血栓弹力图评估创伤后下肢静脉血栓患者凝血功能的价值

Value of thrombelastography in monitoring coagulation state of trauma patients with lower limb venous thrombosis

目的探讨血栓弹力图（TEG）评估创伤后下肢静脉血栓患者凝血功能的价值。方法采用回顾性病例对照研究分析2015年3月-2015年4月手术治疗的骨科创伤患者64例，其中男32例，女32例；年龄17—79岁，平均53．44岁。患者均无明显下肢血管损伤。平均受伤至手术时间8．8d。患者根据术前彩色多普勒诊断下肢静脉是否血栓分为血栓组（10例）和非血栓组（54例）。收集两组TEG参数[反应时间（R值）、血块形成时间（K值）、血块生成率（α角）、最大血栓幅度（MA）]、传统凝血功能检测（CCTs）[凝血酶原时间（肌）、活化部分凝血活酶时间（APTT）、国际标准化比值（INR）]及血小板（PLT）计数，比较两组各参数的差异。分析R值、K值与传统凝血功能指标的相关性，PLT与d角、MA的相关性。分析R值、K值、PT和APTY的受试者工作特征（ROC）曲线下面积（AUC）及其敏感度和特异度。结果血栓组R值为5．55（4．78，5．85）min，比非血栓组的6．20（5．30，7．03）min明显缩短（P〈0．05）。两组间K值、α角、MA变化差异无统计学意义（P〉0．05），且PT、APTT、INR、PLT变化差异无统计学意义（P〉0．05）。R值与胛呈正相关（r=0．65，P〈0．05），与INR值呈正相关（r=0．69，P〈0．05），与APTT值和PLT值无明显相关。K值与PT、APTF、INR、PLT无明显相关，PLT与α角和MA也无明显相关。R值、K值、胛和AFIT的AUC分别为0．73，0．66，0．58，0．60。R值（〈5min）、K值（〈1．00min）、PT（〈11．4S）和APTT（〈27．4s）的敏感度分别为87．04％、79．63％、0．00％和90．74％，特异度分别为40．00％、40．00％、100．00％和20．00％。结论对于创伤后下肢静脉血栓患者，TEG能更准确反映患者的凝血功能，可作为筛查创伤患者下肢静脉血栓的补充手段。

Objective To investigate the efficacy of thrombelastography （TEG） in monitoring the coagulation state of trauma patients with lower limb venous thrombosis. Methods A total of 64 trauma patients surgically treated from March 2015 to April 2015 were analyzed by retrospective case- control study. There were 32 males and 32 females, with an age range of 17-79 years （mean, 53.44 years）. None had significant vascular damage. The average time between injury and surgery was 8.8 days （range, 2-20 days ）. The patients were divided into lower limb venous thrombosis group （thrombosis group, n = 10 ） and non-venous-thrombosis group （ non-thrombosis group, n = 54 ） according to the diagnosis of color Doppler ultrasound. The causes of trauma included tumbling in 33 cases, fall from height in 8, traffic accident in 15, and compression injury in 8. The data were reviewed including variables of TEG [ reaction time （R value ）, clot formation time （K value ）, α angle, maximum amplitude （ MA ） ], platelet （ PLT ） count and variables of conventional coagulation tests （ CCTs ） [plasma prothrombin time （PT）, activated partial thromboplastin time （APTF）, and international normalized ratio （INR） ]. The correlation between R, K and CCTs and the correlation between α angle, MA and PLT were investigated. The variations of the two methods between two groups were investigated by reeeiver operating characteristic curve （ROC）. Area under the curve （AUC） , sensitivity and specificity of R value, K value, PT and APTT were analyzed. Results R value of thrombosis group was lower than that in non-thrombosis group [5.55（4.78, 5.85） min vs. 6.20（5.30, 7.03） mini （P 〈 0.05）. There was no significant difference between the two groups in aspects of K value, α angle, MA, PT, APTT, INR, and PLT （ P 〉 0.05 ）. The R value was positively eorrelated PT （ r = 0.65, P 〈 0.05 ） and INR （ r = 0.69, P 〈 0.05 ） , but had no significant correlation with AP3＂T or PLT count. The K value was not significantly correlated with PT, APTT, INR or PLT count, and PLT was not significantly correlated with α angle or MA. AUC was 0.73 in R value, 0.66 in K value, 0.58 in PT, and 0.60 in APTT. The sensitivity values to detect lower limb venous thrombosis in trauma patients were 87.04% in R value （ 〈 5 min） , 79. 63% in K value （ 〈1.00 rain）, 0.00% in PT （ 〈11.4 s）, and 90.74 in APTT （ 〈27.4 s）. The specificity values were 40.00% in R value （ 〈 5 min）, 40.00% in K value （ 〈 1.00 min） , 100.00% in PT （ 〈 11.4 s）, and 20.00% in APTT （ 〈 27.4 s）. Conclusion TEG is considered to be much more sensitive than CCTs for monitoring the coagulation state, and can be selected as the supplementary screening test for trauma patients with lower limb venous thrombosis.