亚低温对重型颅脑损伤患者凝血功能及预后的影响

The effects of mild-hypothermia therapy on coagulation and prognosis in patients with severe traumatic brain injury

目的：探讨亚低温治疗对重型颅脑损伤（sTBI）患者凝血功能及预后的影响。方法将40例格拉斯哥昏迷评分（GCS）3～8分的急性sTBI患者按随机原则分为常温治疗组（NT组）和亚低温治疗组（HT组），每组20例。NT组给予常规治疗，HT组在常规治疗的同时给予亚低温治疗。动态监测两组颅脑损伤患者治疗期间凝血酶原时间（PT）、活化部分凝血活酶时间（APTT）、凝血酶时间（TT）及纤维蛋白原（Fg）、D-二聚体浓度。统计两组患者迟发性血肿、纤溶亢进、脑梗死3种常见凝血功能相关并发症的发生率；于伤后3个月应用格拉斯哥预后评分（GOS）标准评估预后。结果 NT组伤后PT、APTT、TT显著缩短，12 h达谷值〔PT（s）：10.6＆#177;0.8比11.6＆#177;1.2，APTT（s）：16.7＆#177;1.2比20.8＆#177;1.4，TT（s）：9.8＆#177;0.8比13.6＆#177;0.8〕，Fg、D-二聚体水平于伤后显著上升，12 h达峰值〔Fg（g/L）：3.2＆#177;0.9比2.5＆#177;0.8，D-二聚体（μg/L）：4126.7＆#177;1170.3比873.5＆#177;140.2〕，表明NT组伤后12 h内呈现高凝状态，12 h后向纤溶亢进转变。HT组PT、APTT、TT在给予亚低温治疗后缓慢延长，于伤后12 h达峰值〔PT（s）：14.4＆#177;0.9比10.9＆#177;1.0，APTT（s）：45.4＆#177;1.0比20.2＆#177;1.0，TT （s）：25.3＆#177;1.2比13.0＆#177;0.6〕，Fg逐渐下降，12 h达谷值（g/L：1.8＆#177;0.7比2.3＆#177;0.6），然后趋于正常水平；D-二聚体逐渐上升，12 h达峰值（μg/L：3079.8＆#177;947.6比795.6＆#177;120.7），72 h趋于正常水平，且HT组上述指标早于NT组恢复正常水平。NT组迟发性血肿的发生率高于HT组（10%比5%），但差异无统计学意义（P＞0.05）， HT组纤溶亢进（5%比35%，P＜0.05）和脑梗死（0比25%，P＜0.05）的发生率低于NT组。HT组良好率较NT组明显升高（30%比5%，P＜0.05），病死率明显高于HT组（25%比10%，P＜0.05）。结论亚低温治疗可减轻sTBI患者凝血功能紊乱，降低凝血功能相关并发症的发生率，改善sTBI患者的预后。

Objective To evaluate the effects of mild-hypothermia therapy on coagulation and prognosis in patients with severe traumatic brain injury（sTBI）. Methods Forty sTBI patients with Glasgow coma score（GCS） 3-8 were randomly divided into normal temperature-treatment control group（NT group）and hypothermia-treatment group（HT group）,each 20 cases. Both groups were given conventional therapy,and HT group was additionally given mild-hypothermia therapy. The values of prothrombin time（PT）,activated partial thromboplastin time（APTT）, thrombin time（TT） and concentrations of plasma fibrinogen（Fg）,D-dimer（DD）in two groups were monitored dynamically. The incidences of frequently seen blood coagulation related complications,such as delayed hematoma, hyper-fibrinolysis,cerebral infarction were counted,and 3 months after injury,the standard glasgow outcome scale （GOS）was applied to assess the prognosis. Results The values of PT,APTT and TT were significantly shorter and reached their valley values after 12 hours in NT group〔PT（s）：10.6＆#177;0.8 vs. 11.6＆#177;1.2,APTT（s）：16.7＆#177;1.2 vs. 20.8＆#177;1.4,TT（s）：9.8＆#177;0.8 vs. 13.6＆#177;0.8〕,the concentrations of plasma Fg,DD were obviously increased and reached their peak values after 12 hours〔Fg（g/L）：3.2＆#177;0.9 vs. 2.5＆#177;0.8,DD（μg/L）：4 126.7＆#177;1 170.3 vs. 873.5＆#177;140.2〕,which showed that hypercoagulability appeared in the first 12 hours after injury in NT group,and after 12 hours turned into hyper-fibrinolysis. However,the values of PT,APTT,TT extended slowly until 12 hours reaching to their peak values〔PT（s）：14.4＆#177;0.9 vs. 10.9＆#177;1.0,APTT（s）：45.4＆#177;1.0 vs. 20.2＆#177;1.0,TT（s）：25.3＆#177;1.2 vs. 13.0＆#177;0.6〕,the concentration of plasma Fg declined gradually until 12 hours to its valley value（g/L：1.8＆#177;0.7 vs. 2.3＆#177;0.6）and then back to normal,the concentration of DD rose gradually until 12 hours reaching to its peak value（μg/L：3 079.8＆#177;947.6 vs. 795.6＆#177;120.7）and then back to normal at 72 hours in HT group. The time of recovery for above indexes in HT group was earlyer than that in NT group. The incidence of delayed hematoma in NT group was higher than that of HT group（10%vs. 5%）,but there was no statistical significant difference between the two groups（P＆gt;0.05）,and the incidences of hyper-fibrinolysis（5% vs. 35%,P＆lt;0.05）and cerebral infarction （0 vs. 25%,P＆lt;0.05）in HT group were obviously lower than those in NT group. The rate of good therapeutic effect was higher（30% vs. 5%,P＆lt;0.05）,and mortality lower（10% vs. 25%,P＆lt;0.05）in HT group than that of NT group. Conclusion Mild-hypothermia therapy can ameliorate coagulation dysfunction, reduce morbidity of coagulation related complications,and can improve the prognoses of patients with sTBI.