严重创伤性大出血患者的预后...TEG评估参数的相关性研究_贾昭.pdf

海南医学2023年2月第34卷第4期Hainan Med J,Feb.2023.Vol.34,No.4严重创伤性大出血患者的预后与凝血四项和TEG评估参数的相关性研究贾昭，干金文，魏伟，张建梅，金刚西安航天总医院急诊医学科，陕西西安710100【摘要】目的研究严重创伤性大出血患者的预后状况及其与凝血四项、血栓弹力图(TEG)评估参数的相关性。方法回顾性分析2019年12月至2021年11月在西安航天总医院急诊医学科诊治的58例严重创伤性大出血患者的临床资料。按照创伤严重程度评分(ISS)将患者分为危重伤组(ISS评分1625分，24例)和重伤组(ISS评分25分，34例)。按照诊治结果分为死亡组21例和生存组37例。比较各组患者的凝血四项凝血酶时间(TT)、纤维蛋白原(FIB)、活化部分凝血活酶时间(APTT)、凝血酶原时间(PT)和TEG水平血凝时间(R)、血块成型时间(K)、角、血块强度(MA)，采用Spearman相关性分析凝血四项、TEG水平与预后的关系。结果危重伤组患者的TT、APTT、PT、R、K水平分别为(25.022.11)s、(41.093.47)s、(22.552.16)s、(16.644.25)min、(14.934.48)min，明显高于重伤组的(21.361.98)s、(36.763.59)s、(17.092.14)s、(13.963.79)min、(11.823.26)min，FIB、角、MA水平分别为(2.040.33)g/L、(18.235.38)、(22.646.33)mm，明显低于重伤组的(3.490.30)g/L、(23.377.14)、(28.618.27)mm，差异均有统计学意义(P0.05)；死亡组患者的TT、APTT、PT、R、K水平分别为(30.412.16)s、(47.233.87)s、(25.122.27)s、(18.155.24)min、(16.044.86)min，明显高于存活组的(15.892.31)s、(30.464.21)s、(14.452.03)s、(11.743.21)min、(9.513.02)min，FIB、角、MA水平分别为(1.690.38)g/L、(15.254.11)、(20.015.82)mm，明显低于存活组的(3.940.52)g/L、(26.198.42)、(31.179.05)mm，差异均有统计学意义(P0.05)；经Spearman相关性分析结果显示，TT、APTT、PT、R、K与预后呈正相关(P0.05)，FIB、角、MA与预后呈负相关(P25 points,34 cases).According to the diagnosis and treat-ment results,they were divided into a death group(21 cases)and a survival group(37 cases).The four blood coagulationitems thrombin time(TT),fibrinogen(FIB),activated partial thromboplastin time(APTT),prothrombin time(PT),TEG level blood clotting time(R),clot formation time(K),angle,clot strength(MA)were compared between thecritically injured group and the seriously injured group,and between the death group and the survival group.Spearmancorrelation was selected to analyze the relationship between the four blood coagulation items,TEG level and prognosis.ResultsThe levels of TT,APTT,PT,R,and K in the critically injured group were(25.022.11)s,(41.093.47)s,(22.552.16)s,(16.644.25)min,(14.934.48)min,significantly higher than(21.361.98)s,(36.763.59)s,(17.092.14)s,(13.963.79)min,(11.823.26)min in the seriously injured group;FIB,angle,MA levels were(2.040.33)g/L,(18.235.38),(22.646.33)mm,which were significantly lower than(3.490.30)g/L,(23.377.14),(28.618.27)mmin the seriously injured group;the differences were statistically significant(P25分，34例)。危重伤组中男性16例，女性8例；年龄1863岁，平均(36.137.15)岁；刀伤8例、2例钝器伤2例、术后出血2例、车祸伤12例。重伤组中男性22例，女性12例；年龄1965岁，平均(37.027.41)岁；刀伤10例、钝器伤3例、术后出血3例、车祸伤18例。按照患者预后结果分为死亡组21例和生存组37例。本研究经医院医学伦理委员会批准。1.2检测方法收集所有患者空腹静脉血6 mL，选择枸橼酸钠109 mmol/L实施抗凝处理，抗凝剂与血样的比例91，用于进行凝血四项与TEG测定，具体操作方法：(1)凝血四项测定：选取2.7 mL抗凝处理后的全血，离心10 min，取出上层血浆，借助全自动血凝仪检测。(2)TEG测定：在室温环境中注射1 mL抗凝处理后的全血于高岭土激活剂瓶内，颠倒混匀5次后静置5 min，然后激活，依据操作规范将普通杯正确安装于托架上，将测定杯推入检测通道内，并将 20 L0.2 mol/L-CaCl2注入普通杯中，吸取高岭土瓶中340 L已激活血样轻柔置入普通杯，电脑收集数据后用专业分析软件分析，描绘并记录TEG图像与参考值。1.3观察指标(1)比较危重伤组与重伤组患者的凝血四项(TT、FIB、APTT、PT)和TEG参数(包括R、K、角、MA)水平。(2)比较死亡组与存活组患者的凝血四项和TEG参数水平。(3)分析凝血四项和TEG参数与预后的相关性。1.4统计学方法应用SPSS20.0统计软件进行数据统计分析。计量资料以均数标准差(x-s)表示，组间比较采用t检验；选择Spearman相关性分析凝血四项和TEG参数与预后的相关性。以P0.05为差异有统计学意义。2结果2.1危重伤组与重伤组患者的凝血四项水平比较危重伤组患者的TT、APTT、PT水平明显高于重伤组，FIB水平明显低于重伤组，差异均有统计学意义(P0.05)，见表1。2.2死亡组与存活组患者的凝血四项水平比较死亡组患者的TT、APTT、PT水平明显高于存活组，FIB水平明显低于重伤组，差异均有统计学意义(P0.05)，见表2。group;the levels of FIB,angle,and MA were(1.690.38)g/L,(15.254.11),(20.015.82)mm,which were signifi-cantly lower than(3.940.52)g/L,(26.198.42),(31.179.05)mm of the survival group(P0.05).Spearman correla-tion analysis showed that TT,APTT,PT,R,K were positively correlated with prognosis(P0.05),while FIB,angle,MA were negatively correlated with prognosis(P0.05).ConclusionThe four items of blood coagulation and TEG in-dexes are related to the prognosis of patients with severe traumatic hemorrhage.The combined detection of them is con-ducive to the accurate clinical judgment of the disease and can help to provide a reasonable treatment plan.【Key words】Severe traumatic hemorrhage;Thrombin time;Fibrinogen;Activated partial thromboplastin time;Prothrombin time;Clotting time;Clot formation time;angle;Clot strength表1危重伤组与重伤组患者的凝血四项水平比较(x-s)Table 1Comparison of four blood coagulation items between the criticallyinjured group and the seriously injured group(x-s)组别危重伤组重伤组t值P值例数2434TT(s)25.022.1121.361.986.6730.001APTT(s)41.093.4736.763.594.6140.001PT(s)22.552.1617.092.149.5180.001FIB(g/L)2.040.333.490.3017.1070.001547海南医学2023年2月第34卷第4期Hainan Med J,Feb.2023.Vol.34,No.42.3危重伤组与重伤组患者的TEG参数水平比较危重伤组患者的R、K明显高于重伤组，角、MA明显低于重伤组，差异均有统计学意义(P0.05)，见表3。2.4死亡组与存活组患者的 TEG 参数水平比较死亡组患者的R、K明显高于存活组，角、MA明显低于存活组，差异均有统计学意义(P0.05)，见表4。2.5凝血四项和TEG参数与预后的相关性经Spearman相关性分析结果显示，TT、APTT、PT、R、K同预后呈正相关，FIB、角、MA同预后呈负相关(P0.05)，见表5。3讨论创伤性失学休克指的是由于创伤导致人体失血过多，使血液有效循环率下降、缺乏组织灌注，进而引发的一系列生理病理过程。我国相关统计数据表明，严重创伤病患中有30%左右会出现大出血，一部分合并凝血功能障碍。出现凝血功能障碍之后，病情急速恶化，出血更难控制，进而增加死亡风险7。国外相关研究表明，若严重创伤病患伴有凝血功能障碍，死亡率会增加34倍8。按照上述国内外研究可知，创伤病患预后同凝血功能障碍可能有一定的相关性。若人体遭受创伤，外源性凝血会启动，利于止血，但是若出血量超过人体代偿能力时，就会使血液系统内的凝血功能失调，最终引发凝血功能障碍。所以，分析创伤性大出血患者凝血四项、TEG参数同预后的相关性是必要的。TT能够反映纤维蛋白原变换成纤维蛋白的能力，它的延长大部分是由于存在肝素类物质或肝素增加9。严重创伤病患出现凝血功能障碍之后，人体的抗凝能力被抑制，分泌的肝素增加，进一步加重凝血功能障碍，形成恶性循环10。FIB能够加快血小板聚集、收缩与增殖内皮细胞、平滑肌，创伤性大出血之后，FIB表达降低，减弱了血小板聚集，使病情进一步恶化11。PT属于外源性凝血指标，创伤会激活人体外源性凝血通路，合并出血，消耗的凝血因子显著上升，导致纤溶系统亢进，使病情恶化。APTT属于内源性凝血指标，使病患病情加重的机制基本与PT一致，相关研究也证实创伤是APTT表达提升的主要因素12。本研究表明，危重度创伤性大出血患者的TT、APTT、PT明显高于重度创伤性大出血患者，FIB明显低于重度创伤性大出血患者，差异均有统计学意义(P0.05)。提示凝血功能不正常是病情恶化的促进因素。创伤性大出血死亡患者的TT、APTT、PT明显高于创伤性大出血存活患者，FIB明显低于创伤性大出血存活患者，这进一步表明凝血功能障碍会使病患的死亡风险增加。经Spearman相关性分析显示，TT、APTT、PT同预后呈正相关，FIB同预后呈负相关，提示TT、APTT、PT、FIB水平的变化会影响创伤性大出血患者的预后状况，表明凝血功能障碍会使病患的死亡风险增加。TEG对血液最初的激活凝血物质、到形成纤维蛋白、再到交互连接纤维蛋白与凝缩血块、最后到溶解血块的完整过程进行模拟，进而监测纤维蛋白、血小板、凝血因子参与凝血的整个过程，为评估凝血功能的关键方式13-15。TEG参数主要包括R、K、角、MA，其中R是对启动凝血至形成纤维蛋白凝块过程的反映(凝血因子的功能)，K和角是对形成纤维蛋白原及相互连接速度的反映(纤维蛋白的功能)，MA是对血小板与纤维蛋白原互相链接的动力学特性的直接反映(血小板的功能)，表示纤维蛋白凝块的强度16-17。本研究表明，危重度创伤性大出血患者的R、K明显高于重度创伤性大出血患者，角、MA明显低于重度创伤性大出血患者，差异均有统计学意义(P0.05)，提示TEG参数不正常能加速病情恶化。创伤性大出血死亡患者的R、K明显高于创伤性大出血存活患者，角、MA明显低于创伤性大出血存活患者，这进一步表明TEG参数不正常会使病患的死亡风险增加。Spearman相关性表2死亡组与存活组患者的凝血四项水平比较(x-s)Table 2Comparison of four blood coagulation items between thedeath group and the survival group(x-s)组别死亡组存活组t值P值例数2137TT(s)30.412.1615.892.3123.9880.001FIB(g/L)1.690.383.940.5218.8920.001APTT(s)47.233.8730.464.2115.3590.001PT(s)25.122.2714.452.0317.8640.001表3危重伤组与重伤组患者的TEG参数水平比较(x-s)Table 3Comparison of TEG indexes between the critical injury groupand the seriously injured group(x-s)组别死亡组存活组t值P值例数2434R(min)16.644.2513.963.792.4720.017K(min)14.934.4811.823.262.9020.006角()18.235.3823.377.143.1250.003MA(mm)22.646.3328.618.273.1120.003表4死亡组与存活组患者的TEG参数水平比较(x-s)Table 4Comparison of TEG indexes between death group and survivalgroup(x-s)组别死亡组存活组t值P值例数2137R(min)18.155.2411.743.215.0900.001角()15.254.1126.198.426.6330.001MA(mm)20.015.8231.179.055.7050.001K(min)16.044.869.513.025.5760.001表5凝血四项和TEG参数与预后的相关性Table 5Correlation of four blood coagulation items and TEG indexeswith prognosis指标r值P值TT0.6030.001FIB-0.5610.001APTT0.5470.001PT0.5820.001MA-0.5020.001R0.4710.001K0.4950.001角-0.4610.001548Hainan Med 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