摘要
目的比较血栓弹力图(TEG)与常规凝血试验在脓毒症患者中的检测结果,探讨TEG对监测脓毒症凝血功能障碍的价值。方法回顾性分析2013年6月至2015年6月广西医科大学第一附属医院重症医学科92例脓毒症患者的临床资料,并根据序贯器官衰竭评分(SOFA)分为SOFA≥12分组(47例)和SOFA〈12分组(45例);另选35例同期非脓毒症且凝血功能正常的患者作为对照。取静脉血检测常规凝血指标、血常规、D-二聚体、降钙素原(PeT),并同时进行TEG检测,比较3组间各指标的差异,采用Spearman秩相关法分析脓毒症患者SOFA与各项检测指标的相关性。结果在常规凝血试验指标中,D-二聚体水平随着患者病情加重而逐渐升高,非脓毒症组、脓毒症SOFA〈12分组和≥12分组分别为0.523(0.273,0.928)、0.863(0.673,4.221)、4.118(2.420,5.653)mg/L(Z=25.163,P=O.000);SOFA≥12分组血小板计数(PLT)明显低于SOFA〈12分组和非脓毒症组[×109/L:28.6(12.8,48.9)比257.3(152.6,339.8)、182.0(118.0,229.0),均P〈O.01];而3组间凝血酶原时间(胛)、国际标准化比值(INR)比较差异均无统计学意义,未能提示脓毒症患者凝血状态改变。TEG参数中,凝血反应时间(R值)和血块生成时间(K值)在脓毒症SOFA〈12分组低于非脓毒症组[R值(min):4.4(3.6,6.1)比6.3(6.0,6.7),P〈0.01;K值(rain):1.1(1.0,1.5)比1.5(1.3,1.8),P〈0.05),在SOFA≥12分组则高于非脓毒症组[R值(min):7.0(5.7,8.7)比6.3(6.0,6.7),P〉O.05;K值(rain):4.2(3.4,7.1)比1.5(1.3,1.8),P〈0.01];血块生成率(仪角)、最大宽度值(MA值)、凝血综合指数(CI值)在SOFA〈12分组均高于非脓毒症组[仅角(。):73.3(68.5,74.7)比66.8(62.2,69.0),P〈0.01;MA值(mm):71.7(61.9,73.3)比60.3(58.2,63.8),P〈0.01;cI值:3.1(-0.1,3.9)比0.9(-0.4,1.3),P〈0.05],而在SOFA〉112分组则低于非脓毒症组[仪角(°):48.1(36.6,53.0)比66.8(62.2,69.0),P〈O.01;MA值(mm):37.8(30.0,45.7)比60.3(58.2,63.8),P〈O.01;CI值:-5.6(-8.4,-3.6)比0.9(-0.4,1.3),P〈O.01],提示TEG各指标可反映脓毒症病程进展中的高凝和低凝状态改变。PCT值在非脓毒症组及脓毒症SOFA〈12分组和≥12分组分别为0.27(0.05,1.80)、0.68(0.10,10.00)、41.10(4.24,100.00)ug/L(z=195.475,P=O.000),提示随病情加重其感染严重程度增加。相关性分析结果显示,脓毒症患者SOFA评分与PLT、仅角、MA值、CI值呈明显负相关(r值分别为-0.853、-0.833、-0.881、-0.859,均P=O.000),与活化部分凝血活酶时间(APTT)、D-二聚体、R值、K值和PCT呈明显正相关(r值分别为0.381、0.561、0.587、0.831、0.775,P〈0.05或P〈0.01),而与胛、纤维蛋白原(F13C)、INR无相关性(r1=0.211、P,=0.233,r2=-0.252、P2=0.142,r3=0.248、PF0.148)。结论TEG能更有效地监测脓毒症患者凝血功能改变,识别高凝、低凝状态,客观评价病情严重程度,指导临床风险评估。
Objective To compare the results of thrombelastography (TEG) and the conventional coagulability test in patients with sepsis, and to discuss the value of TEG in monitoring blood coagulation dysfunction in patients with sepsis. Methods The clinical data of 92 adult patients with sepsis admitted to Department of Critical Care Medicine of the First Affiliated Hospital of Guangxi Medical University were retrospectively analyzed. The patients were divided into sequential organ failure assessment (SOFA) score ≥ 12 group (n = 47) and SOFA 〈 12 group (n = 45). Thirty-five non-sepsis adult patients with normal coagulation function served as control group. The venous blood was collected for conventional blood coagulation test and routine examination of blood, D-dimer, procalcitonin (PCT), and TEG, and the differences were compared among three groups. Correlations between SOFA and various indexes of patients with sepsis were analyzed by Spearman rank correlation method. Results As shown in the results of the conventional blood coagulation test, D-dimer was gradually increased with the aggravation of the disease, the values in non-sepsis, SOFA 〈 12, and SOFA ≥ 12 groups were 0.523 (0.273, 0.928), 0.863 (0.673, 4.221), and 4.118 (2.420, 5.653) mg/L respectively (Z = 25.163, P = 0.000). Platelet count (PLT) in SOFA t〉 12 group was significantly lower than that of the SOFA 〈 12 group and non-sepsis group [×109/L: 28.6 (12.8, 48.9) vs. 257.3 (152.6, 339.8), 182.0 (118.0, 229.0), both P 〈 0.01]. There was no significant difference in prothrombin time (PT) and international normalized ratio (INR) among three groups, and it indicated that the conventional blood coagulation test might not respond quickly to the change in coagulation status of sepsis patients. As shown in the results of TEG, the values of reaction time (R value) and kinetics time (K value) in SOFA 〈 12 group were lower than those of the non-sepsis group [R value (minutes): 4.4 (3.6, 6.1) vs. 6.3 (6.0, 6.7), P 〈 0.01; K value (minutes): 1.1 (1.0, 1.5) vs. 1.5 (1.3, 1.8), P 〈 0.05], while they were higher in SOFA I〉 12 group than those of the non-sepsis group [R value (minutes): 7.0 (5.7, 8.7) vs. 6.3 (6.0, 6.7), P 〉 0.05; K value (minutes): 4.2 (3.4, 7.1) vs. 1.5 (1.3, 1.8), P 〈 0.01]. The ct angle, maximμm amplitude (MA) and coagulation index (CI) in SOFA 〈 12 group were higher than those of the non-sepsis group [ ct angle (° ): 73.3 (68.5, 74.7) vs. 66.8 (62.2, 69.0), P 〈 0.01; MA (mm): 71.7 (61.9, 73.3) vs. 60.3 (58.2, 63.8), P 〈 0.01; CI: 3.1 (-0.1, 3.9) vs. 0.9 (-0.4, 1.3), P 〈 0.05], while they were lower in SOFA ≥12 group than those of the non-sepsis group [ ct angle (°): 48.1 (36.6, 53.0) vs. 66.8 (62.2, 69.0), P 〈 0.01; MA (mm): 37.8 (30.0, 45.7) vs. 60.3 (58.2, 63.8), P 〈 0.01; CI: -5.6 (-8.4, -3.6) vs. 0.9 (-0.4, 1.3), P 〈 0.01]. The above results indicated that TEG could distinguish quickly the hypercoagulability and hypocoagulability status in septic patients. PCT in non-sepsis, SOFA 〈 12, and SOFA ≥ 12 groups were 0.27 (0.05, 1.80), 0.68 (0.10, 10.00), 41.10 (4.24, 100.00) ug/L respectively (Z = 195.475, P = 0.000), which indicate the severity of infectious disease. Correlation analysis results showed that SOFA score was negatively correlated with PLT, ct angle, MA, and CI (r value was -0.853, -0.833, -0.881, and -0.859, respectively, all P = 0.000), and it was positively correlated with activated partial thromboplastin time (APTF), D-dimer, R value, K value, and PCT (r value was 0.381, 0.561, 0.587, 0.831, 0.775, respectively, P 〈 0.05 or P 〈 0.01), and non correlations was founded with PT, fibrinogen (FBG), and INR (r1 = 0.211, P1 = 0.233; r2 = -0.252, P2 = 0.142; r3 = 0.248, P3 = 0.148). Conclusions TEG can effectively monitor the change in coagulation in patients with sepsis, and distinguish the hypercoagulable and hypocoagulable state. TEG may be a valuable tool to evaluate degree and risk of sepsis objectively.
出处
《中华危重病急救医学》
CAS
CSCD
北大核心
2016年第2期153-158,共6页
Chinese Critical Care Medicine
基金
广西壮族自治区自然科学基金(2012GxNsFBA276036)
国家临床重点专科建设项目(2011-873)