抗凝治疗可以改善高凝脓毒症患者的脏器功能

Anticoagulation therapy can improve organ function in septic patients with hypercoagulation

目的:研究血栓弹力图(TEG)显示高凝(R值<5 min)的脓毒症患者抗凝治疗的疗效。方法:连续收集收治的脓毒症患者,进行TEG检测,将TEG显示高凝者76例,随机分为观察组(38例)和对照组(38例)。对照组给予脓毒症常规治疗,观察组在常规治疗基础上同时使用低分子肝素钙皮下注射(4100 IU每12h 1次,肾功能损害者根据肌酐清除率调整剂量),抗凝治疗7 d,随访28 d。比较2组院内死亡率、住院时间、院内弥散性血管内凝血(DIC)、脓毒症诱发凝血病(SIC)发生率和出血发生率、治疗前与治疗7 d后序贯器官衰竭评分(SOFA)和凝血功能变化情况;采用Kaplan-Meier法绘制生存曲线,用Log-rank法比较2组间生存曲线差异。结果:观察组院内DIC及SIC发生率低于对照组(P均<0.05);2组住院时间、院内死亡率和出血发生率比较,差异无统计学意义(P均>0.05)。重复测量方差分析显示,治疗7 d后,观察组血小板计数(PLT)较治疗前升高,而凝血酶原时间(PT)和SOFA评分较治疗前下降(P均<0.05);对照组PLT较治疗前升高(P<0.05)。治疗7 d后观察组PT、SOFA评分低于对照组,PLT高于对照组(P均<0.05)。Kaplan-Meier曲线分析发现,2组28 d预后比较,生存分布比较,差异无统计学意义(P>0.05)。结论:TEG显示高凝的脓毒症患者进行抗凝治疗,可以降低DIC及SIC发生率,改善脏器功能,且不增加出血发生率,但不能改善患者的院内死亡率及28 d生存情况。

Objective:To evaluate the efficacy of anticoagulation therapy in septic patients with hypercoagulation(R<5 min)indicated by thromboelastograpy(TEG).Methods:All patients with sepsis underwent TEG test and 76 patients with hypercoagulation were randomly divided into observation group(n=38)and control group(n=38).Patients in the control group were treated with routine treatment and those in the observation group were given low molecular weight heparin subcutaneously(4100 IU,once every 12 h and adjusted according to the creatinine in patients with renal impairment)on the basis of routine treatment,7 days for a course of treatment.The in-hospital mortality,length of hospital stays,incidence of disseminated intravascular coagulation(DIC),sepsis-induced coagulopathy(SIC)and bleeding events,and the changes in sequential organ failure assessment(SOFA)score and coagulation index were compared between the two groups.Kaplan‐Meier estimator was used to estimate the survival curve of patients in different groups,and the differences in survival curves were assessed using log‐rank test.Results:The incidence of DIC and SIC was both significantly lower(P<0.05)in the observation group than that in the control group.There were no significant differences in length of hospital stays,in-hospital mortality and incidence of bleeding events between the two groups(P>0.05).In the observation group,the platelet count(PLT)significantly increased 7 days later,while the SOFA score and prothrombin time(PT)significantly decreased(P<0.05).In the control group,the PLT also significantly increased 7 days later(P<0.05).The PT and SOFA score were lower in the observation group than those in the control group after 7 days of treatment,while the PLT was significantly higher(P<0.05).Kaplan-Meier survival analysis showed that the 28-day survival rate was not significantly different between the two groups(P>0.05).Conclusion:Anticoagulation therapy can reduce the incidence of DIC and SIC and improve organ function in septic patients with hypercoagulation indicated by TEG,without increasing the risk of bleeding.But anticoagulation therapy has no effect on 28-day mortality and in-hospital mortality.