血栓弹力图指导输血在老年骨科大手术患者中的应用

Application of thromboelastography-guided blood transfusion in elderly patients undergoing major orthopedic surgery

目的探讨血栓弹力图(TEG)指导输血在老年骨科大手术患者中的应用价值。方法选取安康市中心医院2017年10月至2018年10月期间实施骨科大手术的老年患者(年龄≥60岁)106例,按随机数表法分为观察组和对照组各53例。观察组患者采用TEG检测指导术中输血,对照组采取常规凝血检测指导术中输血,比较两组患者不同时间点的凝血状态、输注物的使用情况及临床结局。结果观察组患者的新鲜冷冻血浆、冷沉淀纤维蛋白的使用率及使用量分别为39.62%、(286.27±34.59)mL,45.28%、(16.37±4.16)U,均明显低于对照组的81.13%、(41.36±50.17)mL,77.36%、(29.37±7.82)U,血小板的使用率为43.40%,明显低于对照组的64.15%,差异均有统计学意义(P<0.05),但血小板的使用量与对照组比较,差异无统计学意义(P>0.05);输血24 h后观察组和对照组的血小板计数(PLT)、纤维蛋白原(FIB)分别为(125.49±56.37)×109/L、(2.91±0.87)U和(124.28±54.39)×109/L、(2.64±0.93)U,均高于其输血前的(109.35±52.54)×109/L、(1.38±0.41)U和(111.65±58.17)×109/L、(1.36±0.45)U,凝血酶原时间(PT)、活化部分凝血活酶时间(APTT)、凝血酶时间(TT)分别为(11.62±2.67)s、(33.49±6.28)s、(19.11±3.43)s和(13.72±3.12)s、(34.71±6.55)s、(21.78±3.95)s,均低于其输血前的(17.35±3.24)s、(40.98±9.21)s、(25.67±5.19)s和(17.61±3.58)s、(41.35±9.71)s、(25.19±5.32)s,且观察组PT、TT低于对照组,差异均有统计学意义(P<0.05);与输血前比较,输血24 h后观察组患者凝血块形成时间(K值)、凝血反应时间(R值)降低,血块形成速率(α角)、最大血凝块强度(MA值)升高,差异均有统计学意义(P<0.05);观察组患者的术后出血量、再出血发生率分别为(107.09±24.98)mL、7.55%,低于对照组的(129.13±30.52)mL、24.53%,差异均有统计学意义(P<0.05);两组患者的住院时间和病死率比较差异均无统计学意义(P>0.05)。结论应用TEG检测能够优化老年骨科大手术患者的输血方案,更为合理的使用血制品,还能保证临床输血效果,降低术后出血量及再出血发生率。

Objective To explore the application value of thrombelastography(TEG)-guided blood transfusion in elderly patients undergoing major orthopedic surgery.Methods A total of 106 elderly patients(older than 60 years old)undergoing major orthopedic surgery,who admitted to Ankang Central Hospital from October 2017 to October 2018,were enrolled and divided into the observation group and control group by random number table method,with 53 cases in each group.The observation group was given TEG-guided blood transfusion,while the control group was given routine blood coagulation to guide blood transfusion.The blood coagulation status,usage condition of infusion content and clinical outcome were compared between the two groups at different time points.Results The usage rate and usage amount of fresh frozen plasma and cryoprecipitate fibrin in the observation group were lower than those in the control group:39.62%vs 81.13%;(286.27±34.59)mL vs(41.36±50.17)mL;45.28%vs 77.36%;(16.37±4.16)U vs(29.37±7.82)U;all P<0.05,while usage rate of platelets was significantly lower than that in the control group(43.40%vs 64.15%,P<0.05).There was no significant difference in the usage amount of platelets between the two groups(P>0.05).At 24 h after blood transfusion,platelet count(PLT)and fibrinogen(FIB)in the observation group and control group were(125.49±56.37)109/L,(2.91±0.87)U and(124.28±54.39)109/L,(2.64±0.93)U,respectively,which were significantly higher than corresponding(109.35±52.54)109/L,(1.38±0.41)U and(111.65±58.17)109/L,(1.36±0.45)U before blood transfusion(all P<0.05);the prothrombin time(PT),activated partial thromboplastin time(APTT)and thrombin time(TT)were(11.62±2.67)s,(33.49±6.28)s,(19.11±3.43)s and(13.72±3.12)s,(34.71±6.55)s,(21.78±3.95)s,respectively,which were significantly lower than corresponding(17.35±3.24)s,(40.98±9.21)s,(25.67±5.19)s and(17.61±3.58)s,(41.35±9.71)s,(25.19±5.32)s before blood transfusion(all P<0.05);PT and TT in the observation group were significantly lower than those in the control group(all P<0.05).Compared with those before blood transfusion,formation time of blood clots(K value)and reaction time of blood coagulation(R value)were decreased in the observation group at 24 h after blood transfusion,while formation rate of blood clots(αangle)and maximum blood clot strength(MA value)were increased significantly(P<0.05).The postoperative bleeding volume and incidence of rebleeding in the observation group were(107.09±24.98)mL and 7.55%,which were significantly lower than corresponding(129.13±30.52)mL and 24.53%in the control group(all P<0.05).There was no significant difference in hospitalization time or mortality rate between the two groups(P>0.05).Conclusion The application of TEG can optimize blood transfusion scheme for elderly patients undergoing major orthopedic surgery,and use blood products more reasonably.It can also ensure clinical blood transfusion effect,reduce postoperative bleeding volume and incidence of rebleeding.