血栓弹力图联合常规凝血功能在术前创伤患者深静脉血栓形成的预测价值

Predictive value of thromboelastography combined with conventional coagulation tests for deep vein thrombosis in preoperative trauma patients

目的分析急性创伤骨折患者术前深静脉血栓形成(deep vein thrombosis,DVT)与常规凝血功能检验(conventional coagulation tests,CCTs)及血栓弹力图(thromboelastography,TEG)各参数间的关系,建立一种风险模型筛选出术前DVT形成的高危患者。方法回顾性收集2021年1月至2021年6月上海市第六人民医院急诊重症监护室收住的急性创伤骨折患者临床资料,根据术前是否发生DVT,分为DVT组和非DVT组。分析两组患者同一时间内CCTs及TEG各参数间差异,利用Logistic回归分析筛选DVT形成的独立危险因素,采用受试者工作特征曲线分析,评估各参数在急性创伤患者DVT形成的预测价值。结果123例急性创伤骨折患者中,术前抗凝治疗101例,发生DVT 51例。DVT与非DVT组患者在部分凝血活酶时间、纤维蛋白原(fibrinogen,Fib)、D二聚体(D-Dimer)、纤维蛋白(原)降解产物(fibrinogen degradation products,FDPs)、凝块反应时间、凝块形成时间、凝固角(alpha angle,α)、血栓最大振幅(maximum amplitude,MA)、凝血指数差异有统计学意义。D-Dimer和MA是创伤骨折术前DVT形成的独立危险因素。利用Logistic回归方程得到预测模型:预测因子=0.101×(D-Dimer值)+0.241×(MA值)+(-18.190)。TEG的α角(AUC=0.833,P<0.001)、MA(AUC=0.904,P<0.001)、凝血指数(AUC=0.914,P<0.001)相对于CCTs的Fib(AUC=0.684,P=0.001)、D-Dimer(AUC=0.685,P<0.001)、FDPs(AUC=0.656,P=0.003)在创伤骨折患者下肢DVT形成诊断效能更高,其中凝血指数最佳。而综合D-Dimer与MA形成的预测因子具有更优的预测价值(AUC=0.926,P<0.001),其截断值为0.32、敏感度为90.2%、特异度为79.8%。结论相较于CCTs指标,TEG在预测急性创伤骨折患者术前DVT更具优势,而综合D-Dimer与MA得到的预测因子有助于筛选DVT形成高危患者,具有较好临床应用价值。

Objective To analyze the relationship between preoperative deep vein thrombosis(DVT)and parameters of conventional coagulation tests(CCTs)and thromboelastography(TEG)in patients with acute trauma,and to establish a prediction model to screen out high-risk patients with preoperative DVT.Methods The clinical data of patients with acute traumatic fracture admitted to the Emergency Intensive Care Unit of Shanghai Sixth People’s Hospital from January 2021 to June 2021 were retrospectively collected.According to whether preoperative DVT occurred,the patients were divided into the DVT group and non-DVT group.The differences of CCTs and TEG parameters at the same time were compared between the two groups.Logistic regression analysis was applied to identify independent risk factors for DVT after trauma.The receiver-operating characteristic curve analysis was employed to analyze the clinical value of those parameters to predict preoperative DVT.Results Among 123 patients with acute traumatic fracture,101 patients were treated with anticoagulation before operation,and 51 patients were diagnosed with DVT.There were significant differences in activated partial thromboplastin time,fibrinogen(Fib),D-Dimer,fibrinogen degradation products(FDPs),reaction time,clotting time,αangle,maximum amplitude(MA)and coagulation index between the DVT and non-DVT groups.D-Dimer and MA were independent risk factors for preoperative DVT in patients with traumatic fracture.Logistic regression equation was used to establish a prediction model:the predicting index=0.101×D-Dimer+0.241×MA+(-18.190).Theαangle(AUC=0.833,P<0.001),MA(AUC=0.904,P<0.001),coagulation index(AUC=0.914,P<0.001)of TEG versus Fib(AUC=0.684,P=0.001),D-Dimer(AUC=0.685,P<0.001)and FDPs(AUC=0.656,P=0.003)of CCTs had a higher diagnostic efficacy in developing DVT of lower extremity in patients with traumatic fracture,and of all the coagulation index was the best.However,the predictor of D-Dimer combined with MA had a better predictive value(AUC=0.926,P<0.001),and the best cut-off value was 0.32 with a sensitivity and specificity of 90.2%and 79.8%,respectively.Conclusions Compared with CCTs,TEG has more advantages in predicting preoperative DVT in patients with traumatic fracture,and the predictor of D-Dimer combined with MA can screen out patients with high risk of DVT,which can be recommended for clinical application.