急诊危重症患者凝血功能异常对预后的影响

The influence of coagulation dysfunction to the prognosis in the critically ill patients of emergency room

目的探讨凝血功能变化对急诊抢救室危重症患者28d死亡的预测能力，为临床危重症患者预后评估探讨新的思路。方法对2015年6月至2016年5月在首都医科大学附属北京朝阳医院急诊科抢救室救治的所有内科患者进行前瞻性研究。入院后监测血常规、生化全项指标、血气分析、凝血功能等化验室指标，行APACHEⅡ评分，记录28d预后。结果纳入研究患者1992例，按28d预后分为生存组（n=1522）与死亡组（n=470）。两组患者年龄、性别、体质量指数及疾病种类等基础情况差异无统计学意义（P〉0．05）。生存组与死亡组入院即刻APACHEⅡ评分分别为（12．11±4．12）与（21．15±5．55）。死亡组血浆D-二聚体水平高至M（Qr）为265（0，718）μg／L，PⅡ水平低至（208．16±89．87）×109／L-1，与生存组相比差异具有统计学意义（P〈0．05）。入院3d后，死亡组凝血功能进行性恶化，而生存组有所改善。Logistic回归表明APACHEⅡ评分与D-二聚体为危重症患者预后不良的的危险因素。ROC曲线进一步证实D-二聚体的异常升高且对治疗反应不佳提示预后不良。结论急诊危重症患者存在凝血功能异常，其中D-二聚体的异常升高且对治疗反应不佳提示预后不良。

Objective This research investigated the coagulation of critically ill patients for predicting the prognosis of 28 day in a university hospital emergency room. Methods A prospective investigation was done in the emergency room of Beijing Chao-Yang Hospital, Capital Medical University from June 2015 to May 2016, and 28-day mortality was recorded. Whole blood cell analysis, blood gas analysis and clotting test were done and repeated after patients in hospital. Results A total of 1 992 patients were enrolled, and divided into two groups ： survival （ n = 1 522 ） and dead （ n = 470 ） . No significant difference of age, gender, body mass index and disease composition were found between the two groups （P〉0.05） . APACHE Ⅱ of the survival and dead groups were （12. 11±4. 12 ） and （21.15±5.55） respectively. D-dimer and platelet account of the dead group were M （Qr） 265 （0, 718） μg/L and （208. 16 ±89. 87 ） × 109/L-1 respectively, significant differences were found between the two groups （ P 〈 0. 05 ） . Coagulation was found deteriorated progressively in the dead group, whereas improved in the survival group. The risk factors of poor prognosis, which were the increased APACHE Ⅱ and D-dimer, were detected by Logistic analysis and ROC curve, especially the D-dimer. Conclusions Coagulation abnormalities were found in the critically ill patients of emergency room. The increasing of D-dimer is one of the risk factors of poor prognosis.