损伤控制性外科中凝血功能障碍的治疗

Postinjury coagulopathy management in damage control sugery

损伤后进行性凝血功能障碍是损伤控制性外科的基本问题之一,但其具体发生的机制尚未完全明确。近年来提出的基于"细胞凝血模型"的理论对传统的内外源性凝血途径作出了有益的修正,也为临床损伤后凝血功能障碍的检测及治疗带来改变。具体表现为:首先,在凝血功能的检测上,血栓弹力图相对于传统的基于内外源性凝血途径的PT、APTT等检测手段,更能全面反映凝血全貌,同时也更为精确、快速;其次,在血栓弹力图指导下的目标导向性复苏策略,相对于按比例成分输血等损伤控制性复苏策略,能更为及时有效地纠正凝血功能障碍,减少输血量,改善病人预后;此外,合理、有效、及时地补充重组活化因子Ⅶ,对控制急性威胁生命的损伤出血病人有益。

Postinjury coagulopathy remains one of the fundamental rationale for damage control surgery and the exact mechanism remains to be clarified. Recently, the classic description of the intrinsic and extrinsic coagulation cascades has recently been revised by the ＂cell-based model＂ of coagulation. The new innovation of coagulation has changed the testing and management of coagulation disorders. As modeling in vivo coagulation, thromboelastography （TEG） is the only single test that can provide information on the balance between thrombosis and lysis, while the traditional coagulation tests, including PT, APTT and so on are based on isolated, static end points. And TEG could be more accurate and rapid. Compared with current resuscitation protocol such as transfusion of fresh-frozen plasma and packed red blood cells in a certain ration, component blood product therapy guided by TEG enables timely correction of coagulation dysfunction, reduction of transfusion volumes and improvement in survival.Furthermore, using recombinant activated factor VII properly would be effectively hemostatic properties in patients with uncontrolled hemorrhage refractory.