血栓弹力图对脓毒症患者弥散性血管内凝血的诊断价值及预后的影响

Diagnostic value and prognostic effect of thromboelastometry on disseminated intravascular coagulation in patients with sepsis

目的:探讨血栓弹力图各参数对脓毒症患者弥散性血管内凝血(DIC)的诊断和排除价值及对其预后的影响。方法:收集2020年1月1日-2021年6月31日上海市浦东新区人民医院急诊与危重症医学科符合脓毒症3.0诊断标准且入院当天测过血栓弹力图的100例患者为研究对象,同时对入组患者进行中国DIC诊断积分系统(CDSS)积分,筛查出合并DIC的患者,分为DIC组和非DIC组;记录患者90 d的生存状态,分为存活组与死亡组。运用受试者工作特征曲线(ROC)来评估血栓弹力图对脓毒症患者DIC的预测价值及对其预后的影响。结果:存活组(n=60例)和死亡组(n=40例)比较发现:死亡组血小板计数、白蛋白降低,而C反应蛋白、初始乳酸、序贯器官衰竭评分(SOFA)和急性生理学及慢性健康状况评分Ⅱ(APACHEⅡ)明显升高(P<0.05);凝血指标中凝血酶原时间、部分凝血活酶时间、国际标准化比率、D-二聚体、凝血反应时间(R)升高,但最大振幅(MA)降低(P<0.05);利用ROC曲线分析MA预测脓毒症患者90 d的生存率,发现曲线下面积为0.678(95%CI 0.569~0.788),诊断阈值为68.9,灵敏度为47.5%,特异度为83.3%。DIC组(n=38)与非DIC组(n=62)相比发现:DIC组R、血凝块形成时间(K)升高,血凝块形成速率(α角)及MA降低(P<0.05);ROC曲线分析发现R诊断DIC的曲线下面积为0.869(95%CI 0.794~0.943),诊断阈值为6.9,灵敏度为78.9%,特异度为88.5%;K诊断DIC的曲线下面积为0.965(95%CI 0.930~0.999),诊断阈值为3.5,灵敏度为94.7%,特异度为93.5%;排除DIC的MA曲线下面积为0.805(95%CI 0.719~0.890),诊断阈值为64.2,灵敏度为78.9%,特异度为75.8%;α角不能排除DIC诊断。结论:血栓弹力图参数可作为诊断及排除DIC的一种有效方法。MA值对预测脓毒症患者的病死率有参考价值。

Objective: To analyze the effect of thromboelastography(TEG) parameters on the diagnosis and exclusion value and prognosis of disseminated intravascular coagulation(DIC) in patients with sepsis. Methods: A total of 100 patients were collected from January 1, 2020 to June 31, 2021 in the Department of Critical Care Medicine of Shanghai Pudong New Area People’s Hospital who met the criteria of sepsis 3.0 and had thromboelastography measured on the day of admission. At the same time, the enrolled patients were scored by the Chinese disseminated intravascular coagulation diagnostic scoring system(CDSS) to screen out patients with DIC who were recorded the 90-day survival status, in the meanwhile. Receiver operating curve(ROC) was used to evaluate the predictive value and prognostic impact of thromboelastometry on patients occurred DIC with sepsis. Results: Compared with the survival group(n=60 cases) and the death group(n=40 cases), it was found that the platelet count and albumin in the death group were decreased, while the C-reactive protein, initial lactate, sequential organ failure assessment(SOFA) score and APACHE Ⅱ score were significantly increased(P<0.05);in coagulation indexes, prothrombin time, partial thromboplastin time, international normalized ratio, D-dimer, coagulation reaction time(R) increased, but the maximum amplitude(MA) decreased(P<0.05);using ROC curve analysis to predict the 90-day survival rate of patients with sepsis, the area under the curve was 0.678(95%CI 0.569-0.788), the diagnostic threshold was 68.9,the sensitivity was 47.5%,and the specificity was 83.3%. Compared with the non-DIC group(n=62) in the DIC group(n=38), it was found in that the DIC group the coagulation reaction time(R),the blood clot formation time(K), and the blood clot formation rate(α angle) were increased and the maximum amplitude(MA) was decreased(P<0.05);ROC curve analysis found that the area under the curve of R to diagnose DIC was 0.869(95%CI 0.794-0.943),the diagnostic threshold was 6.9, the sensitivity was 78.9%, and the specificity was 88.5%;the area under the curve of K to diagnose DIC was 0.965(95%CI 0.930-0.999),the diagnostic threshold was 3.5,and the sensitivity was 94.7%, specificity 93.5%;area under the MA curve to exclude DIC was 0.805(95%CI 0.719-0.890), diagnostic threshold was 64.2, sensitivity was 78.9%,specificity was 75.8%;alpha angle could not exclude DIC diagnosis. Conclusion: TEG parameters can be used as an effective method to diagnose and exclude DIC. The MA value has a reference value for predicting the mortality of sepsis patients.