血栓弹力图评价重症肺炎患者的凝血功能障碍

Evaluation of coagulation disorder with Thrombelastography in patients with Severe pneumonia

目的比较血栓弹力图(TEG)与常规凝血试验在重症肺炎中的检测结果,探讨TEG对监测重症肺炎凝血功能障碍的价值,以指导临床对重症肺炎患者病情进一步评估。方法回顾性分析2015年5月~2016年9月苏州九龙医院重症医学科43例重症肺炎患者的临床资料,并根据急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分分为APACHEⅡ评分≤18分组(17例)和APACHEⅡ评分>18分组(26例);另选取同时期本院健康体检人员15例作为对照组。取静脉血检测常规凝血指标,同时进行TEG检测,比较三组间各指标的差异,采用Spearman相关性分析重症肺炎患者APACHEⅡ评分与各项指标的相关性。结果在常规凝血实验指标中,与对照组[凝血酶原时间(PT)(12.65±0.52)s,活化部分凝血活酶时间(APTT)(34.90±2.79)s,纤维蛋白原(FBG)(3.82±0.60)g/L,D-二聚体(0.63±0.23)mg/L,血小板(PLT)(214.27±52.07)×109/L]相比,APACHEⅡ评分>18分组的PT(14.43±2.65)s、APTT(44.92±12.89)s及D-二聚体(5.71±3.83)mg/L显著升高,FBG(3.24±0.93)g/L及PLT(98.73±27.37)×109/L降低,差异均具有统计学意义(P<0.05);对照组与APACHEⅡ评分≤18分组相比,各常规凝血指标间的差异无统计学意义;提示常规凝血试验能在一定程度上反映病情较重时的低凝状态,但不能很好地反映病情相对较轻的重症肺炎的高凝状态。TEG参数中,与对照组[凝血反应时间(R值)(6.31±0.62)min,血块生成时间(K值)(1.68±0.39)min,最大宽度值(MA值)(58.83±5.09)mm,凝血综合指数(CI值)(0.54±0.49)]相比,R值和K值在重症肺炎APACHEⅡ评分≤18分组R值(5.02±1.43)min,K值(1.37±0.33)min降低,而在APACHEⅡ评分>18分组R值(7.08±2.10)min,K值(3.19±0.54)min则明显升高;而MA值、CI值在APACHEⅡ评分≤18分组MA值(65.03±4.73)mm,CI值(2.73±1.24)升高,而在APACHEⅡ评分>18分组MA值(47.42±4.04)mm,CI值(-2.86±0.83)则明显降低(P<0.05),提示TEG可反应重症肺炎病情中的低凝及高凝改变。相关性分析结果显示,APACHEⅡ评分与PT、APTT、D—二聚体、R值、K值呈正相关(P<0.05),与FBG、PLT、MA值、CI值呈负相关(P<0.05)。结论对比常规凝血功能检测,TEG能更有效地监测重症肺炎患者凝血功能改变,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 blood coagulation test and to discuss the value of TEG in monitoring blood coagulation dysfunction in the patients with severe pneumonia,in order to evaluate the state of severe pneumonia.Methods Theclinical data of43adult patients with severe pneumonia hospitalized in Intensive Care Unit of Suzhou Kowloon Hospital from May2015to September2016were retrospectively analyzed.These43patients with Severe pneumonia were divided into Acute Physiology And Chronic Health Evaluation(APACHEⅡ)score≤18group(n=17)and APACHEⅡ>18group(n=26).Fifteen healthy volunteers served as control group.The venous blood was collected for conventional blood coagulation test and TEG,and the differences were compared among there groups.Correlations between APACHEⅡand various indexes of patients with severe pneumonia were analyzed by Spearman correlation method.Results As shown in the results of the conventional blood coagulation test,compared with control group[Prothrombin time(PT)(12.65±0.52)s,activated partial thromboplastin time(APTT)(34.90±2.79)s,fibrinogen(FBG)(3.82±0.60)g/L,D-dimer(0.63±0.23)mg/L,platelet count(PLT)(214.27±52.07)×109/L)],PT(14.43±2.65s),APTT(44.92±12.89)s and D-dimer(5.71±3.83)mg/L were significantly higher in the APACHEⅡ>18group,FBG(3.24±0.93)g/Land PLT(98.73±27.37)×109/Lin this group was significantly lower.The difference is statistically significant(P<0.05).There was no significant difference in conventional blood coagulation test between control group and APACHEⅡ≤18group.These results indicated that conventional blood coagulation test might not respond quickly to the change in coagulation status of severe pneumonia.As shown in the results of TEG,compared with control group[value of reaction time(R value)(6.31±0.62)min,kinetics time(K value)(1.68±0.39)min,maximum amplitude(MA value)(58.83±5.09)mm,coagulation index(CI value)0.54±0.49)],the R value and K value in APACHE II≤18group R value(5.02±1.43)min,K value(1.37±0.33)min were lower,while they were higher in APACHEⅡ>18group R value(7.08±2.10)min,K value(3.19±0.54)min.The MA value and CI value in APACHE II≤18group MA value(65.03±4.73)mm,CI value(2.73±1.24)were higher than those of the control group,while they were lower in APACHEⅡ>18groupMA value(47.42±4.04)mm,CI value(-2.86±0.83).The above results indicated that TEG could distinguish quickly the hypercoagulability and hypocoagulability status in severe pneumonia.Correlation analysis results showed that APACHE II score was positively correlated with PT,APTT,D-dimer,R value K value(P<0.05),and it was negatively correlated with FBG,PLT,MA value,CI value(P<0.05).Conclusion TEG can effectively monitor the change in coagulation in patient with severe pneumonia,and distinguish the hypercoagulable and hypocoagulablestatus.TEG may be a valuable tool to evaluate degree and risk of severe pneumonia.