极危重型蝮蛇伤凝血功能障碍患者血浆置换治疗的临床研究

Clinical studies of Plasma exchange treatment of severe type viper injured patients with blood coagulation dysfunction

目的:研究血浆置换方法在极危重型蝮蛇咬伤(内科常规应用抗蛇毒血清后病情仍继续恶化)患者中的临床意义。方法:1回顾性分析解放军总医院第一附属医院急救部2004-01-2014-01按照急救医学会蛇伤急救学组制订的毒蛇咬伤的严重程度评分标准,确诊为极危重型蝮蛇咬伤即DIC样综合征(得分=3分)且内科常规应用抗蛇毒血清后病情仍继续恶化患者58例。2检测患者伤后24h内临床资料,对比包括行血浆置换治疗前后临床表现、肝肾功能、行血小板检测、普通凝血功能检查及血栓弹力图检测结果;3分析预后情况。结果:1极危重患者PLT下降,FIB明显下降甚至不能测出,D-二聚体明显升高,PT明显延长,甚至出现不凝血状态。2血栓弹力图显示:极危重患者R值与K值均明显增大,MA值与α角度明显减小。3血浆置换前后:凝血功能检测结果对比,PLT、FIB、D-二聚体明显升高,PT均明显改善,差异有统计学意义(P<0.05);肝肾功能检测结果对比,显著低于治疗前水平,差异有统计学意义(P<0.05)。4治愈率为62.1%,显效率为27.5%,有效率为5%,无效率为0。结论:运用传统凝血功能实验及血栓弹力图监测凝血指标能够有效发现极危重蝮蛇咬伤凝血功能障碍;血浆置换可有效治疗及改善病情严重程度,为临床救治提供指导。

Objective：To study the clinical significance of plasma exchange treatment in patients with extremely severe type viper bites（state of an illness continued to deteriorate after the routine application of antivenin）.Method：A retrospective analysis of our hospital emergency department from January 2004 to January 2014 in accordance with the snake wound emergency first aid medical association group of snakebite severity score standards,and were diagnosed with extremely severe type viper bites,which was DIC sample syndrome（score=3points）and internal condition continued to deteriorate after the routine application of antivenin 58 patients.Testing within 24 hours after injury in patients with clinical data,contrast ending of lab examination before and after plasma exchange,such as clinical manifestation,liver and kidney function,platelet detection,normal blood coagulation function and thromboela-stogram test results;Analysis of the prognosis.Result：①The PLT in critical patients decreased,FIB decreased obviously cannot even measure,D-dimer rise obviously,PT significantly extended,appear even no blood coagulation state.②Thrombus elastic graph shows：very R value and the K value in critical patients were significantly increased,MA value with alpha Angle decrease obviously.③Line after plasma exchange function of blood coagulation test results contrast comparison（P〈0.05）,the difference was statistically significant;Liver and kidney function test results contrast,significantly lower than before treatment,the difference was statistically significant（P〈0.05）.④The cure rate was 85%,Significant efficiency is 10%,the effective rate of 5%,inefficient for 0.Conclusion：The use of traditional coagulant function experiment and thrombus elastic graph monitoring blood coagulation index can effectively find extremely critical viper bites blood coagulation disorders;Plasma exchange can effective treatment and improve disease severity,can provide basis for the guidance of clinical treatment.