主动脉弓置换术后血小板功能改变及影响因素

Changes in function of platelet after total aortic arch replacement and their influencing factors

目的了解深低温停循环下(DHCA)全主动脉弓置换患者术前及鱼精蛋白中和后的凝血功能和血小板功能,并探讨其影响因素。方法 2014年6月至2015年3月主动脉夹层患者入组,排除标准为:发病时间超过30 d、二次手术、术前7天内服用抗血小板药物、血液系统慢性疾病。记录术前和转机一般临床资料;取麻醉诱导后(T1)、鱼精蛋白中和5 min后(T2)两个时间点的静脉血,用血栓弹力图(TEG)行凝血功能检测,常规实验室方法测定血常规、出凝血。所有数据进行统计分析。结果 50名患者,与T1比较,T2血凝块强度最大振幅值(MA)和纤维蛋白含量(FIB)均明显下降,且差异均有显著性(P<0.001),但中位数均在正常范围内。相比于T1,T2血小板计数和血红蛋白均明显下降且具有统计学意义(P<0.001)。T1 MA水平与T1血小板呈直线相关(r=0.76,P=0.008);T1 MA与发病时间存在二次方曲线关系(R2=0.551、P<0.001),T2MA与T1血小板呈线性关系(r=0.60,P=0.002)。多因素logistics回归显示女性(OR=0.097,P=0.047)、体重指数(BMI)(OR=1.197,P=0.036)是停循环后输血小板的危险因素,而术前血小板功能(OR=0.852,P=0.026)为保护因素。术前MA对预测停循环后是否输血小板的ROC曲线下面积为(0.843±0.093)(95%CI:0.660-1.000,P=0.004),术前MA以59.95 mm为最佳界值点,其敏感性和特异性分别为93%和75%。结论 DHCA全主动脉弓置换患者鱼精蛋白中和后血小板功能及FIB水平明显下降,但多数患者均在正常范围内。女性、BMI偏低和术前MA低于59.95 mm患者可能更需要输血小板。

Objective To evaluate the platelet function and blood coagulation of patients received thoracic aortic procedures with deep hypothermic circulatory arrest （DHCA）,and to investigate their influencing factors.Methods The study consisted of 50 patients scheduled for aorta replacement undergoing DHCA between June 2014 and March 2015.Patients with re-operation,prescription antiplatelet drugs within 7 days before operation,onset time over 30 days and hematological diseases were excluded.Function of platelet and coagulation were tested by thrombelastogram （TEG） at two intervals,namely after anesthesia induction （T1） and 5 mins after protamine neutralization （T2）.Blood routine examination and coagulating time test were also included.Results Compared with before cardiopulmonary bypass （CPB）,MA value and fibrinogen （FIB） significantly reduced on T2（ P〈0.001,P〈0.001）.Platelet count and hemoglobin concentration were both statistically decreased after protamine neutralization（ P〈0.001,P〈0.001）.There was a liner relationship between platelet function and platelet count before CPB （r = 0.76,P = 0.008）.The correlation between function of platelet before operation and onset time was quadratic curve relationship（ R^2= 0.551,P〈0.001）.Multivariate logistic regression analysis revealed that female （OR = 0.097,P = 0.047） and body mass index （OR = 1.197,P = 0.036） were risk factors associated with platelet transfusion at the end of CPB,while the function of platelet（OR = 0.852,P = 0.026） before surgery was a protective factor.The area under the ROC curve of MA before surgery on platelet transfusion was 0.843 （95%CI：0.660-1.000,P = 0.004）.The specificity of MA59.95 mm was 75%,the sensitivity was 93%.Conclusion The levels of FIB and platelet function significantly decreased at the end of CPB,while most of patients＇ platelet functions were at normal range.Blood platelet transfusion might be more reasonable for patients of female,lower BMI and MA 59.95 mm before surgery.