血栓弹力图在评估脓毒症患者28 d生存率中的临床价值
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摘要
目的探讨血栓弹力图在评估脓毒症患者28 d生存率中的价值。方法根据患者28 d预后情况,将2017年4月至2017年11月中山大学孙逸仙纪念医院重症医学科收治的50例脓毒症患者分为存活组(34例)和死亡组(16例)。比较两组患者的年龄、性别比、感染的病原菌类型、入ICU内24 h的急性病生理学和长期健康评价(APACHE)Ⅱ评分、序贯器官衰竭估计(SOFA)评分、连续静静脉血液滤过(CVVH)/连续静静脉血液透析(CVVHD)、C反应蛋白、降钙素原、血小板计数、国际标准化比值(INR)、N-端脑钠肽(NT-proBNP)、是否行机械通气、是否行持续性血液净化治疗、是否使用升压药等一般资料和血栓弹力图各指标包括凝血反应时间(R值)、血凝块形成时间(K值)、纤维蛋白凝块形成及加固的速率(α角)以及反应血凝块最大强度和硬度(MA值);采用多因素Cox回归分析各指标对脓毒症患者预后的影响。结果两组脓毒症患者APACHEⅡ评分[(27±6)分vs.(22±6)分,t=2.611,P=0.012]比较,死亡组明显高于存活组。两组脓毒症患者血栓弹力图各指标比较,死亡组脓毒症患者血栓弹力图R值[9.50(8.23,13.30)min vs.6.55(6.03,8.15)min,H=3.381,P=0.001]和K值[3.50(1.95,4.50)min vs. 1.25(1.08,2.05)min,H=4.955,P <0.001]均较存活组明显延长;而α角[47.50(39.90,62.45)°vs. 71.80(62.00,74.70)°,H=4.004,P <0.001]和MA值[58.10(48.70,67.58)°vs. 67.10(60.13,70.65)°,H=2.433,P=0.015]均较存活组显著降低。Cox多因素回归结果显示,血栓弹力图中α角<53°为脓毒症患者28 d生存率的影响因素[HR=3.463,95%CI (1.250,9.599),P=0.017]。结论血栓弹力图中α角对脓毒症患者28 d生存率有一定的预测价值。
Objective To explore the value of thromboelastography in evaluating 28-day survival rate in sepsis patients. Methods Totally 50 patients with sepsis admitted to Department of Critical Care Medicine, Sun Yat-sen Memorial Hospital, Sun Yat-sen University from April2017 to November 2017 were divided into the survival group(34 cases) and death group(16 cases) according to the prognosis of patients at 28 days. The age, sex ratio, and pathogen type of infection were compared between the two groups. The general data, including acute physiology and chronic health evaluation(APACHE) Ⅱ score, sequential organ failure assessment(SOFA)score, continuous veno-venous hemofiltration(CVVH)/continuous veno-venous hemodialysis(CVVHD), C reactive protein, procalcitonin, platelet count, international normalized ratio(INR),N-terminal brain natriuretic peptide(NT-proBNP), and the use of mechanical ventilation, blood purification therapy, and vasopressor drugs, were compared between these two groups, as well as thromboelastography indexes of coagulation reaction time(R value), hemagglutination time(K value), rate of fibrin clot formation and reinforcement(alpha angle) and maximum strength and hardness of reactive blood clot(MA value). Multivariate Cox regression analysis was used to evaluate the prognostic value of each index on sepsis patients. Results The APACHEⅡ scores of sepsis patients [(27 ± 6) vs.(22 ± 6), t = 2.611, P = 0.012] were significantly higher in the death group than in the survival group. The R value [9.50(8.23, 13.30) min vs. 6.55(6.03,8.15) min, H = 3.381, P = 0.001], and K value [3.50(1.95, 4.50) min vs. 1.25(1.08, 2.05) min,Z = 4.955, P < 0.001] of sepsis patients were significantly longer, and the alpha angle [47.50(39.90, 62.45) vs. 71.80(62.00, 74.70), H = 4.004, P < 0.001] and MA value [58.10(48.70,67.58) vs. 67.10(60.13, 70.65), H = 2.433, P = 0.015] were significantly lower in the death group than in the survival group. Cox multivariate regression showed that the alpha angle < 53 ° in the thromboelastography was the influencing factor of 28-day survival rate in sepsis patients [HR =3.463, 95% CI(1.250, 9.599), P = 0.017]. Conclusion The alpha angle in the thromboelastography has a certain predictive value for the prognosis of sepsis patients.
Objective To explore the value of thromboelastography in evaluating 28-day survival rate in sepsis patients. Methods Totally 50 patients with sepsis admitted to Department of Critical Care Medicine, Sun Yat-sen Memorial Hospital, Sun Yat-sen University from April2017 to November 2017 were divided into the survival group(34 cases) and death group(16 cases) according to the prognosis of patients at 28 days. The age, sex ratio, and pathogen type of infection were compared between the two groups. The general data, including acute physiology and chronic health evaluation(APACHE) Ⅱ score, sequential organ failure assessment(SOFA)score, continuous veno-venous hemofiltration(CVVH)/continuous veno-venous hemodialysis(CVVHD), C reactive protein, procalcitonin, platelet count, international normalized ratio(INR),N-terminal brain natriuretic peptide(NT-proBNP), and the use of mechanical ventilation, blood purification therapy, and vasopressor drugs, were compared between these two groups, as well as thromboelastography indexes of coagulation reaction time(R value), hemagglutination time(K value), rate of fibrin clot formation and reinforcement(alpha angle) and maximum strength and hardness of reactive blood clot(MA value). Multivariate Cox regression analysis was used to evaluate the prognostic value of each index on sepsis patients. Results The APACHEⅡ scores of sepsis patients [(27 ± 6) vs.(22 ± 6), t = 2.611, P = 0.012] were significantly higher in the death group than in the survival group. The R value [9.50(8.23, 13.30) min vs. 6.55(6.03,8.15) min, H = 3.381, P = 0.001], and K value [3.50(1.95, 4.50) min vs. 1.25(1.08, 2.05) min,Z = 4.955, P < 0.001] of sepsis patients were significantly longer, and the alpha angle [47.50(39.90, 62.45) vs. 71.80(62.00, 74.70), H = 4.004, P < 0.001] and MA value [58.10(48.70,67.58) vs. 67.10(60.13, 70.65), H = 2.433, P = 0.015] were significantly lower in the death group than in the survival group. Cox multivariate regression showed that the alpha angle < 53 ° in the thromboelastography was the influencing factor of 28-day survival rate in sepsis patients [HR =3.463, 95% CI(1.250, 9.599), P = 0.017]. Conclusion The alpha angle in the thromboelastography has a certain predictive value for the prognosis of sepsis patients.
引文
1 Adamik B,Gozdzik W,Jakubczyk D,et al.Coagulation abnormalities identified by thromboelastometry in patients with severe sepsis:the relationship to endotoxemia and mortality[J].Blood Coagul Fibrinolysis,2017,28(2):163-170.
2 Angus DC,van der Poll T.Severe sepsis and septic shock[J].N Engl J Med,2013,369(9):840-851.
3 Ganter MT,Hofer CK.Coagulation monitoring:current techniques and clinical use of viscoelastic point-of-care coagulation devices[J].Anesth Analg,2008,106(5):1366-1375.
4 Velik-Salchner C,Streif W,Innerhofer P,et al.Endotoxinemia-induced changes in coagulation as measured by rotation thrombelastometry technique and conventional laboratory tests:results of a pilot study on pigs[J].Blood Coagul Fibrinolysis,2009,20(1):41-46.
5 Baratto F,Michielan F,Meroni M,et al.Protein C concentrate to restore physiological values in adult septic patients[J].Intensive Care Med,2008,34(9):1707-1712.
6 Singer M,Deutschman CS,Seymour CW,et al.The third international consensus definitions for sepsis and septic shock(sepsis-3)[J].JAMA,2016,315(8):801-810.
7 Angus DC,Linde-Zwirble WT,Lidicker J,et al.Epidemiology of severe sepsis in the United States:analysis of incidence,outcome,and associated costs of care[J].Crit Care Med,2001,29(7):1303-1310.
8 Levy MM,Artigas A,Phillips GS,et al.Outcomes of the Surviving Sepsis Campaign in intensive care units in the USA and Europe:a prospective cohort study[J].Lancet Infect Dis,2012,12(12):919-924.
9 Gando S,Saitoh D,Ogura H,et al.A multicenter,prospective validation study of the Japanese Association for Acute Medicine disseminated intravascular coagulation scoring system in patients with severe sepsis[J].Crit Care,2013,17(3):R111.
10汪洋,陈上仲,陈昌勤,等.序贯器官衰竭估计评分用于脓毒症病情评估的研究进展[J/CD].中华危重症医学杂志(电子版),2016,9(6):422-425.
11 Orbey BC,Cuhruk H,Tulunay M,et al.Can plasmafree DNA concentration be a diagnostic tool in critically ill septic patients[J].Crit Care,2007,11(Suppl 2):P48.
12 Balk RA.Severe sepsis and septic shock.Definitions,epidemiology,and clinical manifestations[J].Crit Care Clin,2000,16(2):179-192.
13 Lipinska-Gediga M.Coagulopathy in sepsis-a new look at an old problem[J].Anaesthesiol Intensive Ther,2016,48(5):352-359.
14 Zeerleder S,Hack CE,Wuillemin WA.Disseminated intravascular coagulation in sepsis[J].Chest,2005,128(4):2864-2875.
15 Sivula M,Pettila V,Niemi TT,et al.Thromboelastometry in patients with severe sepsis and disseminated intravascular coagulation[J].Blood Coagul Fibrinolysis,2009,20(6):419-426.
16 Cortegiani A,Marino L,Montalto F,et al.Use of thromboelastography in severe sepsis:a case-control study[J].Crit Care,2011,15(Suppl 1):P444.
17张德厚,陈义坤,刘大东.脓毒症患者早期血小板功能变化及预后分析[J/CD].中华危重症医学杂志(电子版),2017,10(1):28-33.
18 Haase N,Ostrowski SR,Wetterslev J,et al.Thromboelastography in patients with severe sepsis:a prospective cohort study[J].Intensive Care Med,2015,41(1):77-85.
19何婧瑜,周晓超,刑绣荣,等.血栓弹力图对脓毒症患者预后预测价值的研究[J].中国临床医生杂志,2017,45(7):45-49.
20 Adamzik M,Langemeier T,Frey UH,et al.Comparison of thrombelastometry with simplified acute physiology scoreⅡand sequential organ failure assessment scores for the prediction of 30-day survival:a cohort study[J].Shock,2011,35(4):339-342.
2 Angus DC,van der Poll T.Severe sepsis and septic shock[J].N Engl J Med,2013,369(9):840-851.
3 Ganter MT,Hofer CK.Coagulation monitoring:current techniques and clinical use of viscoelastic point-of-care coagulation devices[J].Anesth Analg,2008,106(5):1366-1375.
4 Velik-Salchner C,Streif W,Innerhofer P,et al.Endotoxinemia-induced changes in coagulation as measured by rotation thrombelastometry technique and conventional laboratory tests:results of a pilot study on pigs[J].Blood Coagul Fibrinolysis,2009,20(1):41-46.
5 Baratto F,Michielan F,Meroni M,et al.Protein C concentrate to restore physiological values in adult septic patients[J].Intensive Care Med,2008,34(9):1707-1712.
6 Singer M,Deutschman CS,Seymour CW,et al.The third international consensus definitions for sepsis and septic shock(sepsis-3)[J].JAMA,2016,315(8):801-810.
7 Angus DC,Linde-Zwirble WT,Lidicker J,et al.Epidemiology of severe sepsis in the United States:analysis of incidence,outcome,and associated costs of care[J].Crit Care Med,2001,29(7):1303-1310.
8 Levy MM,Artigas A,Phillips GS,et al.Outcomes of the Surviving Sepsis Campaign in intensive care units in the USA and Europe:a prospective cohort study[J].Lancet Infect Dis,2012,12(12):919-924.
9 Gando S,Saitoh D,Ogura H,et al.A multicenter,prospective validation study of the Japanese Association for Acute Medicine disseminated intravascular coagulation scoring system in patients with severe sepsis[J].Crit Care,2013,17(3):R111.
10汪洋,陈上仲,陈昌勤,等.序贯器官衰竭估计评分用于脓毒症病情评估的研究进展[J/CD].中华危重症医学杂志(电子版),2016,9(6):422-425.
11 Orbey BC,Cuhruk H,Tulunay M,et al.Can plasmafree DNA concentration be a diagnostic tool in critically ill septic patients[J].Crit Care,2007,11(Suppl 2):P48.
12 Balk RA.Severe sepsis and septic shock.Definitions,epidemiology,and clinical manifestations[J].Crit Care Clin,2000,16(2):179-192.
13 Lipinska-Gediga M.Coagulopathy in sepsis-a new look at an old problem[J].Anaesthesiol Intensive Ther,2016,48(5):352-359.
14 Zeerleder S,Hack CE,Wuillemin WA.Disseminated intravascular coagulation in sepsis[J].Chest,2005,128(4):2864-2875.
15 Sivula M,Pettila V,Niemi TT,et al.Thromboelastometry in patients with severe sepsis and disseminated intravascular coagulation[J].Blood Coagul Fibrinolysis,2009,20(6):419-426.
16 Cortegiani A,Marino L,Montalto F,et al.Use of thromboelastography in severe sepsis:a case-control study[J].Crit Care,2011,15(Suppl 1):P444.
17张德厚,陈义坤,刘大东.脓毒症患者早期血小板功能变化及预后分析[J/CD].中华危重症医学杂志(电子版),2017,10(1):28-33.
18 Haase N,Ostrowski SR,Wetterslev J,et al.Thromboelastography in patients with severe sepsis:a prospective cohort study[J].Intensive Care Med,2015,41(1):77-85.
19何婧瑜,周晓超,刑绣荣,等.血栓弹力图对脓毒症患者预后预测价值的研究[J].中国临床医生杂志,2017,45(7):45-49.
20 Adamzik M,Langemeier T,Frey UH,et al.Comparison of thrombelastometry with simplified acute physiology scoreⅡand sequential organ failure assessment scores for the prediction of 30-day survival:a cohort study[J].Shock,2011,35(4):339-342.