严重创伤与脓毒症患者凝血功能紊乱的比较研究

Comparation of coagulation dysfunction between severe trauma and sepsis patients

目的应用血栓弹力图(TEG)和凝血分子标志物评估创伤与脓毒症患者凝血功能紊乱的特征。方法回顾性分析解放军联勤保障部队第九○八医院重症医学科2018年6月至2019年6月住院治疗的创伤患者49例(创伤组)与脓毒症患者79例(脓毒症组)入科时的基础资料,统计入院30 min内的血栓调节蛋白(TM)、凝血酶-抗凝血酶复合物(TAT)、纤溶酶-α2纤溶酶抑制物复合物(PIC)、组织纤溶酶原激活物/纤溶酶原激活物抑制剂-1复合物(tPAI-C)、血浆凝血酶原时间(PT)、活化部分凝血活酶时间(APTT)、纤维蛋白原(FIB)、凝血酶原时间(TT)、纤维蛋白降解产物(FDP)、D二聚体(DD)以及TEG指标,并进行统计学分析。结果与脓毒症组患者的TM[13.0(10.1,20.2)TU/mL]、TAT[9.4(5.6,21.1)ng/mL]、PIC[1.33(0.72,2.46)μg/mL]、FDP[13.2(6.9,27.3)μg/mL]、DD[3.7(2.0,7.7)μg/mL]、FIB[2.8(2.1,3.8)g/L]和TEG的MA[57.9(50.6,64.5)mm]相比,创伤组患者的TAT[41.1(16.2,120)ng/mL]、PIC[4.12(1.06,9.09)μg/mL]、FDP[52.9(13.2,137.2)μg/mL]和DD[10.5(3.8,30.7)μg/mL]明显升高(P<0.05),TM[9.7(7.8,12.1)TU/mL]、FIB[1.5(1.0,2.2)g/L]和TEG的MA[47.5(38.7,55.3)mm]明显降低(P<0.05)。创伤患者的TAT、PIC与FDP和DD呈强相关(P<0.05)。结论严重创伤相关凝血紊乱主要表现为血小板功能障碍和纤溶功能亢进,脓毒症相关凝血紊乱主要表现为内皮细胞功能障碍,联合应用TM、TAT和PIC可区分创伤与脓毒症相关的凝血障碍。

Objective To evaluate the hematological differences between sepsis and trauma patients using the rotational thromboelastography(TEG)and plasma biomarkers.Methods This retrospective study includes all sepsis or severe trauma patients transported to our intensive care unit who underwent TEG and coagulation parameters from Jun 2018 to Jun 2019,including thrombin antithrombin complex(TAT),a 2-plasmininhibitor-plasmin complex(PIC),soluble thrombomodulin(sTM),tissue plasminogen activator-inhibitor complex(tPAIC).All 128 patients(79 sepsis and 49 severe trauma)were included in primary analysis.All the demographics,clinical characteristics,laboratory data were statistically analyzed between sepsis and severe trauma patients.Results Compared with the TM[13.0(10.1,20.2)TU/mL],TAT[9.4(5.6,21.1)ng/mL],PIC[1.33(0.72,2.46)μg/mL],FDP[13.2(6.9,27.3)μg/mL],DD[3.7(2.0,7.7)μg/mL],FIB[2.8(2.1,3.8)g/L]and MA[57.9(50.6,64.5)mm]of sepsis group,the TAT[41.1(16.2,120)ng/mL],PIC[4.12(1.06,9.09)μg/mL],FDP[52.9(13.2,137.2)μg/mL]and DD[10.5(3.8,30.7)μg/mL]of the trauma group was significantly higher(P<0.05);TM[9.7(7.8,12.1)TU/mL],the FIB[1.5(1.0,2.2)g/L]and MA[47.5(38.7,55.3)mm]became significantly lower(P<0.05).TAT and PIC were significantly associated with FDP or DD(P<0.05).Conclusion Coagulation disorder in severe trauma is mainly manifested as platelet dysfunction and hyperfibrinolysis.Sepsis-induced coagulopathy mainly manifested as endothelial cell dysfunction.The combination of TM,TAT andPIC can distinguish coagula-tion disorder of trauma from sepsis.