炎症指标联合血栓弹力图在脓血症患者中的应用价值
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摘要
目的探讨炎症指标联合血栓弹力图(thrombelastograph,TEG)检测结果对于评估脓血症患者凝血功能和预后的意义。方法选取2016年3月—2018年1月收治于原济南军区总医院ICU的72例患者为研究对象。分析入院第一天的临床实验室数据。根据血栓弹力图检测结果将患者分为正常凝血组(A组),低凝组(B组)和高凝组(C组)。检测常规血液学指标,凝血功能指标:活化部分凝血活酶时间(APTT)、凝血酶原时间(PT)、纤维蛋白原(FIB)、D-二聚体(DD),描绘TEG血凝时间(R值)、血块成型时间(K值)、α角、血块强度(MA)。结果低凝组患者,R值和K值都明显延长,α角和MA值明显缩短。高凝组患者R值和K值明显缩短,而α角和MA值则明显延长。低凝组患者血小板计数明显低于正常组和高凝组(P<0.05),低凝组患者PCT及内毒素水平明显高于正常组和高凝组(P<0.05),高凝组患者D-二聚体明显高于其他两组。脓血症患者SOFA评分与炎症指标PCT及血清内毒素水平明显正相关(P<0.05),与D-二聚体水平也呈明显正相关。SOFA评分与R值、K值呈明显正相关(P<0.05),与α角、MA值呈明显负相关(P<0.05)。血液呈现低凝状态的脓血症患者有较高的病死率。结论炎症指标联合TEG检测可以更早期真实地判断脓血症患者的凝血状态,可以更好地评估病情严重程度,低凝状态的脓血症患者具有较高的病死率。
Objective To explore the significance of inflammatory indicators combined with thrombelastograph(TEG) in the detection of coagulation function and prognosis in patients with sepsis. Methods Seventy two patients admitted in ICU of author's Hospital from March 2016 to January 2018 were selected as the study subjects,the clinical laboratory data on the first day of admission were analysed. All the patients were divided into normal coagulation group(group A),low coagulation group(group B) and high coagulation group(group C)according to the test results of thrombelastograph. The routine hematology indexes,blood coagulation function index:activated partial thromboplastin time(APTT),prothrombin time(PT) and fibrinogen(FIB),D dimer(DD),depicting the TEG blood clotting time(R value),blood clots forming time(K value) and alpha Angle,blood clot strength(MA) were detected. Results In group B,the R value and K value were significantly longer,and the αangle and MA value were significantly shorter. In group C,the R value and K value were significantly shortened,while the α angle and MA value were significantly prolonged. Platelet count in the patients of group B was obviously lower than group A and group C(P<0.05),PCT and endotoxin level of the patients in group B was obviously higher than that of group A and group C(P<0.05);D-dimer in the patients in group C was obviously higher than the other two groups. SOFA score in sepsis patients was positively correlated with inflammatory markers PCT and serum endotoxin level(P<0.05),which was also positively correlated with D-dimer level. SOFA score showed significant positive correlation with R value and K value(P <0.05),and significant negative correlation with α angle and MA value(P<0.05). Patients with sepsis in group B had a higher mortality rate.Conclusion The combination detection of inflammatory indicators and TEG can accurately determine the coagulation status of sepsis patients at early stage and better assess the severity of the disease. Sepsis patients with low coagulation have high mortality rate.
Objective To explore the significance of inflammatory indicators combined with thrombelastograph(TEG) in the detection of coagulation function and prognosis in patients with sepsis. Methods Seventy two patients admitted in ICU of author's Hospital from March 2016 to January 2018 were selected as the study subjects,the clinical laboratory data on the first day of admission were analysed. All the patients were divided into normal coagulation group(group A),low coagulation group(group B) and high coagulation group(group C)according to the test results of thrombelastograph. The routine hematology indexes,blood coagulation function index:activated partial thromboplastin time(APTT),prothrombin time(PT) and fibrinogen(FIB),D dimer(DD),depicting the TEG blood clotting time(R value),blood clots forming time(K value) and alpha Angle,blood clot strength(MA) were detected. Results In group B,the R value and K value were significantly longer,and the αangle and MA value were significantly shorter. In group C,the R value and K value were significantly shortened,while the α angle and MA value were significantly prolonged. Platelet count in the patients of group B was obviously lower than group A and group C(P<0.05),PCT and endotoxin level of the patients in group B was obviously higher than that of group A and group C(P<0.05);D-dimer in the patients in group C was obviously higher than the other two groups. SOFA score in sepsis patients was positively correlated with inflammatory markers PCT and serum endotoxin level(P<0.05),which was also positively correlated with D-dimer level. SOFA score showed significant positive correlation with R value and K value(P <0.05),and significant negative correlation with α angle and MA value(P<0.05). Patients with sepsis in group B had a higher mortality rate.Conclusion The combination detection of inflammatory indicators and TEG can accurately determine the coagulation status of sepsis patients at early stage and better assess the severity of the disease. Sepsis patients with low coagulation have high mortality rate.
引文
[1] AC J,PINHEIRO I,MENEZES FL. Rethinking the concept of sepsis and septic shock[J]. Eur J Intern Med,2018,54(8):1-5.
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[3] FAYED N,MOURAD W,YASSEN K,et al. Preoperative thromboelastometry as a predictor of transfusion requirements during adult living donor liver transplantation[J]. Transfus Med Hemother,2015,42(2):99-108.
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[7] LYNCH SF,LUDLAM CA. Plasma microparticles and vascular disorders[J]. Br J Haematol,2007,137(1):36-48.
[8] ADAMZIK M,GORLINGER K,PETERS J,et al. Whole blood impedance aggregometry as a biomarker for the diagnosis and prognosis of severe sepsis[J]. Crit Care,2012,16(5):R204.
[9] OSTROWSKI SR,WINDELOV NA,IBSEN M,et al. Consecutive thrombelastography clot strength profiles in patients with severe sepsis and their association with 28-day mortality:a prospective study[J]. J Crit Care,2013,28(3):317 e311-311.
[10] 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.
[11] 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.
[12]钟声健,张春宝,胡军涛,等.血栓弹力图评价脓毒症患者的凝血功能障碍[J].中华危重病急救医学,2016,(2):153-158.
[13] RODELO JR,DELA RG,VALENCIA ML,et al. D-dimer is a significant prognostic factor in patients with suspected infection and sepsis[J]. Am J Emerg Med,2012,30(9):1991-1999.
[2] MULLER MC,MEIJERS JC,VROOM MB,et al. Utility of thromboelastography and/or thromboelastometry in adults with sepsis:a systematic review[J]. Crit Care,2014,18(1):R30.
[3] FAYED N,MOURAD W,YASSEN K,et al. Preoperative thromboelastometry as a predictor of transfusion requirements during adult living donor liver transplantation[J]. Transfus Med Hemother,2015,42(2):99-108.
[4] DELLINGER RP,LEVY MM,RHODES A,et al. Surviving Sepsis Campaign:international guidelines for management of severe sepsis and septic shock,2012[J]. Intensive Care Med,2013,39(2):165-228.
[5] 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.
[6] LANCE MD. A general review of major global coagulation assays:thrombelastography,thrombin generation test and clot waveform analysis[J]. Thromb J,2015,13(1):1.
[7] LYNCH SF,LUDLAM CA. Plasma microparticles and vascular disorders[J]. Br J Haematol,2007,137(1):36-48.
[8] ADAMZIK M,GORLINGER K,PETERS J,et al. Whole blood impedance aggregometry as a biomarker for the diagnosis and prognosis of severe sepsis[J]. Crit Care,2012,16(5):R204.
[9] OSTROWSKI SR,WINDELOV NA,IBSEN M,et al. Consecutive thrombelastography clot strength profiles in patients with severe sepsis and their association with 28-day mortality:a prospective study[J]. J Crit Care,2013,28(3):317 e311-311.
[10] 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.
[11] 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.
[12]钟声健,张春宝,胡军涛,等.血栓弹力图评价脓毒症患者的凝血功能障碍[J].中华危重病急救医学,2016,(2):153-158.
[13] RODELO JR,DELA RG,VALENCIA ML,et al. D-dimer is a significant prognostic factor in patients with suspected infection and sepsis[J]. Am J Emerg Med,2012,30(9):1991-1999.