血栓弹力图在急性上消化道出血患者凝血功能评估中的应用

Application of thromboelastography in evaluation of coagulation function in patients with acute upper gastrointestinal hemorrhage

目的探讨血栓弹力图(TEG)在评估急性上消化道出血患者凝血功能中的应用。方法选择宁德师范学院附属宁德市医院2018年11月—2019年5月收治的129例急性上消化道出血患者作为急性上消化道出血组,另外选择48例无血液系统疾病且未使用抗凝药物的内科住院患者作为对照组。所有患者进行常规凝血试验〔凝血酶原时间(PT)、国际标准化比值(INR)、活化部分凝血活酶时间(APTT)、凝血酶时间(TT)、纤维蛋白原(Fib)、D-二聚体〕,以及TEG检测〔反应时间(R)、血凝块形成时间(KT)、凝固角(α)、最大振辐(MA)、凝血综合指数(CI)、血凝块强度(G)〕,比较两组上述指标的差异。根据入院时血红蛋白(Hb)水平将患者分为高Hb组(Hb>90 g/L,29例)、中Hb组(60 g/L<Hb≤90 g/L,76例)、低Hb组(Hb≤60 g/L,24例),比较不同Hb水平组急性上消化道出血患者与对照组的常规凝血试验及TEG检测结果。结果急性上消化道出血组的PT、INR均明显高于照组〔PT(s):13.28±3.07比11.53±0.85,INR:1.15±0.26比1.00±0.07,均P<0.05〕,APTT、Fib均明显低于对照组〔APTT(s):24.84±5.03比26.94±2.29,Fib(g/L):1.88±0.80比2.76±0.75,均P<0.05〕,急性上消化道出血组与对照组TT、D-二聚体水平比较差异均无统计学意义〔TT(s):18.36±4.43比17.88±1.02,D-二聚体(mg/L):0.44(0.17,1.22)比0.34(0.14,0.49),均P>0.05〕;急性上消化道出血组R值、α角、MA、G值均明显低于对照组〔R(min):4.42±1.29比5.06±0.88,α角(°):63.78±8.88比66.13±3.83,MA(mm):54.34±10.01比61.75±3.77,G(×10^(3)):7.42±3.22比8.20±1.33,均P<0.05〕,KT明显高于对照组(min:2.22±1.41比1.71±0.32,P<0.05)。不同Hb水平3组PT、INR均明显高于对照组,且随Hb下降呈上升趋势;Fib水平均低于对照组,且随Hb下降呈下降趋势;3组APTT水平均低于对照组,且低Hb组的D-二聚体水平明显低于高、中Hb组。不同Hb水平3组R值、MA均明显小于对照组,K值均明显高于对照组,但3组间比较差异均无统计学意义。结论急性上消化道出血患者存在凝血因子激活,出血达到一定程度时会出现凝血功能减弱,需同时进行凝血常规和TEG检测,才能更准确地评估患者凝血状况。

Objective To explore the application of thromboelastography(TEG)in the evaluation of coagulation function in patients with acute upper gastrointestinal hemorrhage.Methods From November 2018 to May 2019,129 patients with acute upper gastrointestinal hemorrhage admitted to Ningde Hospital Affiliated to Ningde Normal University were selected as acute upper gastrointestinal hemorrhage group,and 48 hospitalized patients in department of internal medicine without hematological diseases or anticoagulant treatment were selected as control group.All patients underwent routine coagulation test[prothrombin time(PT),international normalized ratio(INR),activated partial thromboplastin time(APTT),thrombin time(TT),fibrinogen(Fib),D-dimer],and TEG test[reaction time(R),kinetics time(KT),Alpha angle(α),maximal amplitude(MA),coagulation index(CI),and blood clot strength(G)]were recorded.According to the hemoglobin(Hb)level at admission,the patients were divided into high Hb group(Hb>90 g/L,29 cases),medium Hb group(60 g/L<Hb≤90 g/L,76 cases)and low Hb group(Hb≤60 g/L,24 cases).The routine coagulation test and TEG results of patients with acute upper gastrointestinal hemorrhage with different Hb levels and control group were compared.Results The PT and INR levels of acute upper gastrointestinal hemorrhage group were higher than those of control group[PT(s):13.28±3.07 vs.11.53±0.85,INR:1.15±0.26 vs.1.00±0.07,both P<0.05],the levels of APTT and Fib were lower than those of control group[APTT(s):24.84±5.03 vs.26.94±2.29,Fib(g/L):1.88±0.80 vs.2.76±0.75,both P<0.05],there were no significant differences in TT and D-dimer levels between acute upper gastrointestinal hemorrhage group and control group[TT(s):18.36±4.43 vs.17.88±1.02,D-dimer(mg/L):0.44(0.17,1.22)vs.0.34(0.14,0.49),both P>0.05].The R value,αangle,MA,and G value of acute upper gastrointestinal hemorrhage group were lower than those in control group[R(minutes):4.42±1.29 vs.5.06±0.88,αangle(°):63.78±8.88 vs.66.13±3.83,MA(mm):54.34±10.01 vs.61.75±3.77,G(×10^(3)):7.42±3.22 vs.8.20±1.33,all P<0.05],KT was higher than that of control group(minutes:2.22±1.41 vs.1.71±0.32,P<0.05).The levels of PT and INR in three groups with different Hb levels were higher than those of control group and showed an upward trend with the decrease of Hb.The Fib levels were lower than that of control group and showed a downward trend with the decrease of Hb.The levels of APTT in three groups were lower than that of the control group,the D-dimer of the low Hb group was significantly lower than those of control group and high and medium Hb groups.The R value and MA of the three groups with different Hb levels were lower than those of control group,and KT levels were higher than that of control group.There was no statistically significant difference among the three groups.Conclusions There is activation of coagulation factors in patients with acute upper gastrointestinal hemorrhage,when the bleeding reaches a certain degree,the coagulation function will be weakened.It is necessary to perform routine coagulation test and TEG test at the same time,so as to evaluate the coagulation status of patients more accurately.