创伤性肺损伤相关凝血病的预警指标及其临床价值分析

Analysis of warning indicators of coagulopathy related to traumatic lung injury and its clinical value

目的探讨创伤性肺损伤(TLI)相关凝血病的预警指标及其临床价值。方法回顾性分析2015年9月-2019年11月解放军联勤保障部队第908医院重症医学科收治的159例TLI患者的基础资料及入科时的血红蛋白(HGB)、血小板计数(PLT)、纤维蛋白原(FIB)、活化部分凝血活酶时间(APTT)、凝血酶原时间(PT)、国际标准化比值(INR)、凝血酶时间(TT)、D-二聚体(D-D)、抗凝血酶Ⅲ(AT-Ⅲ)、纤维蛋白降解产物(FDP)和血栓弹力图(TEG)参数。依据TLI患者90 d预后分为生存组(n=141)与死亡组(n=18),采用多因素Cox回归分析和ROC曲线分析筛选出危险因素INR,并根据INR截断值分为INR≥1.36组(n=49)与INR<1.36组(n=110),进行组间比较及生存分析。结果生存组INR、乳酸(Lac)、创伤严重程度(ISS)评分明显低于死亡组(Z=–4.493、–3.481、–3.177,P<0.01),APTT、PT、R时间、K时间明显短于死亡组(Z=–3.275、–4.325、–3.300、–2.278,P<0.01),氧合指数、PLT、HGB、AT-Ⅲ、血块最大强度(MA)、血块形成动力学(Angle)、凝血综合指数(CI)明显高于死亡组(Z/t=–4.053、–2.764、0.269、–2.159、–3.058、–3.294、–3.016,P<0.01)。多因素Cox回归分析结果显示,INR与TLI患者死亡明显相关(RR=4.882,95%CI 1.263~18.870,P=0.022)。ROC曲线分析结果显示,INR判断TLI患者死亡的曲线下面积(AUC)为0.826(P<0.0001),敏感度为0.788,特异度为0.752,截断值为1.36。INR<1.36组生存率明显高于INR≥1.36组(P<0.0001)。与INR<1.36组比较,INR≥1.36组Lac、ISS评分均明显升高(P<0.05),APTT、PT、K时间均明显延长(P<0.05),氧合指数、PLT、HGB、AT-Ⅲ、MA、Angle、CI均明显降低(P<0.05)。结论INR≥1.36可作为TLI相关凝血病发生的预警指标,TLI相关凝血病患者的死亡风险明显增加。

Objective To study the warning indicators and clinical value of coagulopathy related to traumatic lung injury(TLI).Methods The data of 159 patients with TLI from September 2015 to November 2019 in the intensive care unit of the 908th Hospital of Chinese PLA Logistical Support Force were analyzed retrospectively,including their hemoglobin(HGB),platelet(PLT),fibrinogen(FIB),activated partial thromboplastin time(APTT),prothrombin time(PT),international normalized ratio(INR),thrombin time(TT),D-dimer(D-D),antithrombinⅢ(AT-Ⅲ),fibrin degradation product(FDP)and thromboelastography.According to the 90-d prognosis of patients with TLI,they were divided into survival group(n=141)and death group(n=18).COX regression analysis and ROC curve analysis were carried out,and the risk factors INR were screened out.The patients were divided into INR≥1.36 group(n=49)and INR<1.36 group(n=110)for analysis.Results In survival group,INR,lactate(Lac),and injury severe score(ISS)score were significantly lower than those in death group(Z=–4.493,–3.481,–3.177,P<0.01);APTT,PT,R time and K time were much shorter than death group(Z=–3.275,–4.325,–3.300,–2.278,P<0.01);Oxygenation index,PLT,HGB,AT-Ⅲ,blood clots maximum intensity(MA),blood clot formation dynamics(Angle)and coagulation index(CI)were significantly better than those in death group(Z/t=–4.053,–2.764,0.269,–2.159,–3.058,–3.294,–3.016,P<0.01).Cox regression analysis showed that INR(RR=2.18,95%CI 1.07-4.43,P=0.031)were significantly correlated with the death of TLI patients.ROC curve analysis showed that the area under the curve for INR to judge the death of TLI patients was 0.826(P<0.0001),the cut-off value was 1.36(P<0.0001)and the sensitivity and specificity were 0.788 and 0.752,respectively.The survival rate in INR<1.36 group was significantly higher than that in INR≥1.36 group(P<0.0001).Compared with INR<1.36 group,in INR≥1.36 group,the Lac and ISS score significantly increased(P<0.05);APTT,PT and K time significantly prolonged(P<0.05);the oxygenation index,PLT,HGB,AT-Ⅲ,MA,Angle and CI decreased significantly(P<0.05).Conclusions TLI patients with INR≥1.36 can be used as an early warning indicator of TLI-related coagulopathy,and the risk of death of TLI related coagulation disease patients is significantly increased.