活化凝血时间和活化部分凝血活酶时间在成人体外膜肺氧合支持期间抗凝的作用探讨
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摘要
目的在成人体外膜肺氧合(ECMO)治疗期间,活化凝血时间(ACT)已成为抗凝检测的主要指标,本研究回顾了ECMO治疗期间ACT与活化部分凝血活酶时间(APTT)两种监测指标的相关性。方法在ECMO治疗期间应用肝素抗凝的患者纳入到本研究,主要的研究终点是配对的ACT及APTT的关系。结果 22例患者纳入到本研究,皮尔森(Pearson)分析显示ECMO治疗期间,总体ACT与APTT呈弱相关性(r=0.114,P=0.003),静脉-静脉(V-V) ECMO治疗期间,二者呈弱相关(r=0.229,P=0.001),V-V ECMO治疗期间APTT(51.1±27.5) s,ACT(196.1±35.7) s,静脉-动脉(V-A) ECMO患者APTT(46.1±27.7) s,ACT(205.4±33.1) s,两组间ACT差异有统计学意义(P=0.013),APTT差异无统计学意义。此外,试验分析了非生存组与生存组血小板的变化,非生存组血小板数量明显降低(P <0.001)。结论 ECMO治疗期间ACT与APTT两种指标呈弱相关性,不同ECMO治疗模式凝血指标存在差异,危重患者血小板数量明显下降,且与预后相关。
Objective Activated clotting time( ACT) has been the preferred monitoring index in extracorporeal membrane oxygenation( ECMO) patients for long. This retrospective study sought to evaluate the relationship between activated clotting time( ACT)and activated partial thromboplastin time( APTT) when they were used to monitor anticoagulation in patients undergoing extracorporeal membrane oxygenation( ECMO). Methods Patients administered with heparin during ECMO were included in this study. The primary endpoint was the relationship between paired ACT and APTT samples. Results Twenty-two patients who met the criteria for the study were included. Pearson analysis found weak correlation between ACT and APTT( r = 0.114,P = 0.003),and weak correlation between ACT and APTT was also founded in patients who benefited from venovenous ECMO( r = 0. 229,P = 0. 001). The levels of APTT( 51.1±27.5 s) and ACT( 196.1±35.7 s) in V-V ECMO group were different from those in V-A ECMO group( 46.1±27.7 s for APTT and 205.4±33.1 s for ACT,respectively) with a statistical difference in ACT( P = 0.013). Compared with survivours,platelet count declined significantly( P <0.001) in nonsurvivors. Conclusion There was a weak correlation between ACT and APTT in patients supported with ECMO. The coagulation indices of different ECMO modes were different. Platelet count declined significantly during the treatment of ECMO in critical patients and was related to their prognosis.
Objective Activated clotting time( ACT) has been the preferred monitoring index in extracorporeal membrane oxygenation( ECMO) patients for long. This retrospective study sought to evaluate the relationship between activated clotting time( ACT)and activated partial thromboplastin time( APTT) when they were used to monitor anticoagulation in patients undergoing extracorporeal membrane oxygenation( ECMO). Methods Patients administered with heparin during ECMO were included in this study. The primary endpoint was the relationship between paired ACT and APTT samples. Results Twenty-two patients who met the criteria for the study were included. Pearson analysis found weak correlation between ACT and APTT( r = 0.114,P = 0.003),and weak correlation between ACT and APTT was also founded in patients who benefited from venovenous ECMO( r = 0. 229,P = 0. 001). The levels of APTT( 51.1±27.5 s) and ACT( 196.1±35.7 s) in V-V ECMO group were different from those in V-A ECMO group( 46.1±27.7 s for APTT and 205.4±33.1 s for ACT,respectively) with a statistical difference in ACT( P = 0.013). Compared with survivours,platelet count declined significantly( P <0.001) in nonsurvivors. Conclusion There was a weak correlation between ACT and APTT in patients supported with ECMO. The coagulation indices of different ECMO modes were different. Platelet count declined significantly during the treatment of ECMO in critical patients and was related to their prognosis.
引文
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[7]Maul TM,Wolff EL,Kuch BA,et al.Activated partial thromboplastin time is a better trending tool in pediatric extracorporeal membrane oxygenation[J].Pediatr Crit Care Med,2012,13(6):e363-e371.
[8]Bembea MM,Schwartz JM,Shah N,et al.Anticoagulation monitoring during pediatric extracorporeal membrane oxygenation[J].ASAIO J,2013,59(1):63-68.
[9]Bembea MM,Annich G,Rycus P,et al.Variability in anticoagulation management of patients on extracorporeal membrane oxygenation:an international survey[J].Pediatr Crit Care Med,2013,14(2):e77-e84.
[10]Atallah S,Liebl M,Fitousis K,et al.Evaluation of the activated clotting time and activated partial thromboplastin time for the monitoring of heparin in adult extracorporeal membrane oxygenation patients[J].Perfusion,2014,29(5):456-461.
[11]Cunningham D,Besser MW,Giraud K,et al.Agreement between ACT and a PTT during extracorporeal membrane oxygenation shows intra-and inter-individual variation[J].Perfusion,2016,31(6):503-507.
[12]Casan J,Andrews RK,Gardiner EE,et al.Mechanisms of platelet dysfunction in patients with implantable devices[J].Semin Thromb Hemost,2018,44(1):12-19.
[13]Glick D,Dzierba AL,Abrams D,et al.Clinically suspected heparin-induced thrombocytopenia during extracorporeal membrane oxygenation[J].J Crit Care,2015,30(6):1190-1194.
[14]Esper SA,Levy JH,Waters JH,et al.Extracorporeal membrane oxygenation in the adult:a review of anticoagulation monitoring and transfusion[J].Anesth Analg,2014,118(4):731-743.
[2]Stocker CF,Horton SB.Anticoagulation strategies and difficulties in neonatal and paediatric extracorporeal membrane oxygenation(ECMO)[J].Perfusion,2016,31(2):95-102.
[3]Bolliger D,Zenklusen U,Tanaka KA.Point-of-care coagulation management algorithms during ECMO support:are we there yet[J]?Minerva Anestesiol,2016,82(9):1000-1009.
[4]Ontaneda A,Annich GM.Novel surfaces in extracorporeal membrane oxygenation circuits[J].Front Med(Lausanne),2018,5:321
[5]Coughlin MA,Bartlett RH.Anticoagulation for Extracorporeal Life Support:Direct Thrombin Inhibitors and Heparin[J].ASAIO J,2015,61(6):652-655.
[6]Eytan D,Bitterman Y,Annich GM.VV extracorporeal life support for the Third Millennium:will we need anticoagulation[J]?JThorac Dis,2018,10(Suppl 5):S698-S706.
[7]Maul TM,Wolff EL,Kuch BA,et al.Activated partial thromboplastin time is a better trending tool in pediatric extracorporeal membrane oxygenation[J].Pediatr Crit Care Med,2012,13(6):e363-e371.
[8]Bembea MM,Schwartz JM,Shah N,et al.Anticoagulation monitoring during pediatric extracorporeal membrane oxygenation[J].ASAIO J,2013,59(1):63-68.
[9]Bembea MM,Annich G,Rycus P,et al.Variability in anticoagulation management of patients on extracorporeal membrane oxygenation:an international survey[J].Pediatr Crit Care Med,2013,14(2):e77-e84.
[10]Atallah S,Liebl M,Fitousis K,et al.Evaluation of the activated clotting time and activated partial thromboplastin time for the monitoring of heparin in adult extracorporeal membrane oxygenation patients[J].Perfusion,2014,29(5):456-461.
[11]Cunningham D,Besser MW,Giraud K,et al.Agreement between ACT and a PTT during extracorporeal membrane oxygenation shows intra-and inter-individual variation[J].Perfusion,2016,31(6):503-507.
[12]Casan J,Andrews RK,Gardiner EE,et al.Mechanisms of platelet dysfunction in patients with implantable devices[J].Semin Thromb Hemost,2018,44(1):12-19.
[13]Glick D,Dzierba AL,Abrams D,et al.Clinically suspected heparin-induced thrombocytopenia during extracorporeal membrane oxygenation[J].J Crit Care,2015,30(6):1190-1194.
[14]Esper SA,Levy JH,Waters JH,et al.Extracorporeal membrane oxygenation in the adult:a review of anticoagulation monitoring and transfusion[J].Anesth Analg,2014,118(4):731-743.