急性中毒患者血栓弹力图和常规凝血指标的相关性及应用

The correlation and application of thromboelastography and routine coagulation detection in the patients with acute poisoning

目的探讨急性中毒患者血栓弹力图(TEG)和常规凝血指标检测之间的一致性。方法回顾性分析2018年7月~2020年9月在南阳市中心医院急诊内科就诊的急性中毒患者102例,收集其TEG检测参数(R值、K值、Angle值、MA值、CI值和G值)和常规凝血指标参数(PT、APTT、TT和FIB)。采用Spearman秩相关分析TEG与常规凝血指标之间的相关性,用Kappa值(κ)判断两者在评估急性中毒患者凝血状态时的一致性。选用ROC曲线评估常规凝血指标对TEG异常结果的预测价值。结果(1)中毒后继发肝功能损害组的R值显著高于非肝功能损害组(6.77±4.28 vs.5.03±1.36,P=0.009),继发心肌损伤组的MA值和G值均显著高于非心肌损伤组(61.75±6.83 vs.57.52±8.93,P=0.017,8.50±2.55 vs.7.30±2.69,P=0.019)。(2)PLT值与MA值、CI值和G值均呈正相关(r分别为0.397、0.234、0.401,P均<0.05),APTT值与R值呈正相关(r=0.323,P=0.001),与CI值呈负相关(r=-0.201,P=0.043),TT值与Angle值、MA值、CI值和G值均呈负相关(r分别为-0.197、-0.246、-0.232、-0.242,P均<0.05),FIB值与MA值和G值均呈正相关(r分别为0.335、0.332,P=0.001)。(3)在评估患者低凝状态时,PLT值和MA值、PLT值与CI值具有一致性(κ分别为0.243、0.203,P均<0.05),TT值和CI值具有一致性(κ=0.224,P=0.020),FIB值和K值、FIB值和MA值具有一致性(κ分别为0.193、0.213,P均<0.05)。FIB值和Angle值、FIB值和MA值在评估患者高凝状态时具有一致性(κ分别为0.214、0.274,P均<0.05)。(4)PLT值判断MA值<50 mm的敏感度和特异度分别为99.0%、81.5%,AUC为0.933,FIB值判断MA值<50 mm的敏感度和特异度分别为70.0%、70.7%,AUC为0.678。以PLT值和FIB值判断MA值>70 mm表示的高凝状态时,AUC分别为0.474、0.419。结论TEG和常规凝血指标在急性中毒患者中的相关性较弱,两者在评估患者低凝状态时的一致性较好。常规凝血指标对预测TEG检测的低凝结果价值较大,但不能取代TEG检测,两者联合应用将有助于更好的评估急诊中毒患者的凝血状态,预防出血事件。

Objective To explore the consistency between thromboelastography(TEG) and routine coagulation detection in the patients with acute poisoning.Methods 102 patients with acute poisoning were involved in the emergency medical department of Nanyang Central Hospital from July 2018 to September 2020.The TEG parameters(R value,K value,Angle value,MA value,CI value and G value) and routine coagulation parameters(PT,APTT,TT and FIB) were collected for analysis.Spearman correlation was used to analyze the correlation between TEG and routine coagulation tests,and the Kappa value(κ) was used to evaluate the consistency of coagulation status.The ROC curve was used to assess the predictive value of routine coagulation parameters for abnormal TEG results.Results(1)R value of the secondary liver damage group after poisoning was significantly higher than that of the non-hepatic damage group(6.77 ± 4.28 vs.5.03 ± 1.36,P = 0.009);MA and G values of the secondary myocardial damage group were significantly higher than those of the non-myocardial damage group(61.75 ± 6.83 vs.57.52 ± 8.93,P = 0.017;8.50 ± 2.55 vs.7.30 ± 2.69,P = 0.019).(2)There was a positive correlation of PLT with MA,CI and G values(r = 0.397,0.234,0.401,respectively,all P < 0.05);APTT value was positively correlated with R value(r = 0.323,P = 0.001),while negatively correlated with CI value(r =-0.201,P = 0.043);TT value was negatively correlated with Angle,MA,CI and G values(r =-0.197,-0.246,-0.232,-0.242,respectively,all P <0.05);FIB value was positively correlated with MA and G values(r = 0.335,0.332,respectively,P =0.001).(3) When assessing patient’ s hypocoagulable status,there were consistency between PLT and MA value,PLT and CI value(κ = 0.243,0.203,all P < 0.05);There were consistency between TT value and CI value(κ = 0.224,P = 0.020),FIB and K value,FIB and MA value(κ = 0.193,0.213,respectively,all P < 0.05).The FIB value and Angle value,FIB value and MA value were consistent in evaluating the hypercoagulable status of patients(κ = 0.214,0.274,all P < 0.05).(4)The sensitivity and specificity of the PLT value to judge the MA value < 50 mm were 99.0% and 81.5%,respectively,and AUC was 0.933.The sensitivity and specificity of FIB value to judge MA value < 50 mm were70.0% and 70.7% respectively,and AUC was 0.678,and when the PLT value and FIB value were used to judge the hypercoagulable state(MA value > 70 mm),the AUC were 0.474 and 0.419,respectively.Conclusions There was weak correlation between TEG and routine coagulation detections in patients with acute poisoning,while had better consistency in evaluating patients’ hypocoagulable status.Routine coagulation detection was of great value in predicting the hypocoagulation results of TEG,while couldn’t replace each other.The combined application of two detections would help to better assess the coagulation status of acute poisoning patients and prevent bleeding events.