创伤后大出血患者血细胞比容和酸碱度与凝血功能的相关性研究
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摘要
目的探讨创伤性失血患者血细胞比容(Hct)和酸碱度(pH)对凝血功能的影响。方法从2015年1月—2017年1月来本院急诊科和ICU救治的创伤后大出血的多发伤危重病例中,选择符合创伤评分和大量失血标准以及排除标准的108例。用血液分析仪检测并分别统计Hct(%)≤10、10—20和>20—30,以及pH≤7.20、>7.20—7.35、>7.35—7.45和>7.45的患者所占比例;用血凝仪(凝固法)检测各不同Hct组和pH组患者的凝血酶原时间(PT)、活化部分凝血活酶时间(APTT)、凝血酶时间(TT)、纤维蛋白原(Fib),用血栓弹力图(TEG)仪检测R、Angle和MA值,收集患者各预后指标做相关法分析。结果 Hct(%)各组中,20—30的患者比例最高48.2%(52/108),≤10所占者比例最低14.8%(16/108);各pH组中,7.20—7.35和≤7.20的患者比例占前2位,分别为40.7%(44/108),和30.6%(33/108)。随着Hct降低,PT(s)、APTT(s)、TT(s)和R(min)值逐渐增高,分别从16.86±5.55,46.13±23.26,21.21±9.72,10.21±3.91上升到25.01±9.84,94.44±43.84,27.83±11.07,17.6±4.86(P<0.05或<0.01),Fib(g/L)、Angle(°)和MA(mm)值却逐渐降低,分别从1.43±0.97,43.74±9.05,46.52±10.27下降到0.83±0.63,32.52±8.46,26.88±10.21(P<0.05或<0.01);pH<7.45时,随着酸度增加,PT、APTT、TT逐渐增高,分别从14.84±3.79,35.06±16.68,16.24±4.11上升到25.1±10.38,86.9±39.61,29.5±12.75,MA、Angle值逐渐降低,分别从46.77±14.21,43.74±9.05下降到33.3±11.07,30.52±9.46(P<0.01或<0.05)。相关性分析:pH和Hct呈正相关(P<0.01);R值、PT、APTT及预后指标与Hct、pH呈负相关(P<0.05或<0.01),Angle和MA值与Hct、pH呈正相关(P<0.05或<0.01);Fib与pH呈正相关(P<0.01),TT与pH呈负相关(P<0.01)。结论随着创伤性失血患者Hct和pH的下降,其凝血功能障碍逐渐加重,且Hct水平越低其酸中毒越严重,预后越差;Hct和pH都是影响创伤后大出血患者凝血功能的重要因素。
Objective To investigate the effect of Hct and pH on the coagulability function in the patients with traumatic hemorrhage. Methods A total of oose 352 cases were documented between January 2015—January 2017 in our hospital emergency department and ICU treatment as traumatic hemorrhage. 108 of the 352 cases were selected according to their traumatic ranks,blood loss,etc. These cases were divided into 3 groups by Hct: 1. ≤ 10% 2. 10%—20% 3. 20%—30%.Meanwhile PH based group were also formed at pH<7. 2,7. 2—7. 35,7. 35—7. 45 and pH>7. 45. Prothrombin time( PT),activated partial thromboplastin time( APTT),thrombin time( TT) and Fbgrinogen( Fbg) were measured in the blood plasm. The thrombelastography( TEG) index R,Angle,MA and someprognostic indicators were also tested in the whole blood samples. Results In the Hct( %) groups,group3 was the highest at 48. 2%( 52/108),and group 1 was the lowest at 14. 8%( 16/108). As for the pH groups,patients between PH of 7. 20 and 7. 35 and PH no more than 7. 20 accounted for40. 7%( 44/108) and 30. 6%( 33/108) respectively. With the decreasing Hct,PT,APTT,TT and R values increased from 16. 86±5. 55,46. 13± 23. 26,21. 21 ± 9. 72,10. 21 ± 3. 91 to 25. 1 ± 10. 38,86. 9 ± 39. 61,29. 5 ± 12. 75,( P < 0. 05 or <0. 01),Fbg,Angle and MA values gradually decreased from 1. 43±0. 97,43. 74±9. 05,46. 52±10. 27 to 0. 83±0. 63,32. 52±8. 46,26. 88±10. 21( P< 0. 05 or < 0. 01). pH < 7. 45,with the increase of acidity,PT,APTT,TT gradually increased from 14. 84± 3. 79,35. 06± 16. 68,16. 24± 4. 11 to 25. 1± 10. 38,86. 9± 39. 61,29. 5± 12. 75,MA,Angle value gradually decreased from 46. 77± 14. 21,43. 74 ± 9. 05 to 33. 3 ± 11. 07,30. 52 ± 9. 46( P < 0. 01 or < 0. 05); Correlation analysis found that pH values were positively correlated with Hct and the correlation coefficient was 0. 453( P<0. 01). Under the condition of pH<7. 45,PT,APTT and the prognostic indicators were negatively correlated with Hct and pH( P<0. 05 or P<0. 01),while Angle and MA had opposite results. Fbg was positively correlated while TT had opposite correlation( P<0. 01). Conclusions With the decrease of Hct and pH,the patient' s coagulability function gradually deteriorate and the lower the Hct level,the worse the patient' s acidosis,the worse the prognosis. Both Hct and pH values are important factors affecting the coagulability function of post-traumatic hemorrhage.
Objective To investigate the effect of Hct and pH on the coagulability function in the patients with traumatic hemorrhage. Methods A total of oose 352 cases were documented between January 2015—January 2017 in our hospital emergency department and ICU treatment as traumatic hemorrhage. 108 of the 352 cases were selected according to their traumatic ranks,blood loss,etc. These cases were divided into 3 groups by Hct: 1. ≤ 10% 2. 10%—20% 3. 20%—30%.Meanwhile PH based group were also formed at pH<7. 2,7. 2—7. 35,7. 35—7. 45 and pH>7. 45. Prothrombin time( PT),activated partial thromboplastin time( APTT),thrombin time( TT) and Fbgrinogen( Fbg) were measured in the blood plasm. The thrombelastography( TEG) index R,Angle,MA and someprognostic indicators were also tested in the whole blood samples. Results In the Hct( %) groups,group3 was the highest at 48. 2%( 52/108),and group 1 was the lowest at 14. 8%( 16/108). As for the pH groups,patients between PH of 7. 20 and 7. 35 and PH no more than 7. 20 accounted for40. 7%( 44/108) and 30. 6%( 33/108) respectively. With the decreasing Hct,PT,APTT,TT and R values increased from 16. 86±5. 55,46. 13± 23. 26,21. 21 ± 9. 72,10. 21 ± 3. 91 to 25. 1 ± 10. 38,86. 9 ± 39. 61,29. 5 ± 12. 75,( P < 0. 05 or <0. 01),Fbg,Angle and MA values gradually decreased from 1. 43±0. 97,43. 74±9. 05,46. 52±10. 27 to 0. 83±0. 63,32. 52±8. 46,26. 88±10. 21( P< 0. 05 or < 0. 01). pH < 7. 45,with the increase of acidity,PT,APTT,TT gradually increased from 14. 84± 3. 79,35. 06± 16. 68,16. 24± 4. 11 to 25. 1± 10. 38,86. 9± 39. 61,29. 5± 12. 75,MA,Angle value gradually decreased from 46. 77± 14. 21,43. 74 ± 9. 05 to 33. 3 ± 11. 07,30. 52 ± 9. 46( P < 0. 01 or < 0. 05); Correlation analysis found that pH values were positively correlated with Hct and the correlation coefficient was 0. 453( P<0. 01). Under the condition of pH<7. 45,PT,APTT and the prognostic indicators were negatively correlated with Hct and pH( P<0. 05 or P<0. 01),while Angle and MA had opposite results. Fbg was positively correlated while TT had opposite correlation( P<0. 01). Conclusions With the decrease of Hct and pH,the patient' s coagulability function gradually deteriorate and the lower the Hct level,the worse the patient' s acidosis,the worse the prognosis. Both Hct and pH values are important factors affecting the coagulability function of post-traumatic hemorrhage.
引文
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[5]刘红升,王曼,苏琴等.急性重症创伤患者凝血功能异常的临床意义.创伤外科杂志,2014,16(5):399-402.
[6]Jamal S,Marwa K,Ron F,et al.Blood flow versus hematocritin optimization of oxygen transfer to tissue during fluid resuscitation.Cardiovascular Engin Technol,2015,6(4):474-484.
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[8]Curry NS,Davenport RA,Hunt BJ,et al.Transfusion strategies for traumatic coagulopathy.Blood Rev,2012,26(5):223-232.
[9]Pohlman TH,Walsh M,Aversa J,et al.Damage control resuscitation.Blood reviews.2015,29(4):251-262.
[10]刘威,乐爱平.创伤患者大量输血研究进展.中国输血杂志,2017,30(2):208-212.
[11]Campbell JE,Aden JK,Cap AP.Acute traumatic coagulopathy:Whole blood thrombelastography measures the tip of the iceberg.J Trauma Acute Care Surg,2015,78(5):955-961.
[12]刘海波.创伤性凝血功能障碍机制及诊断方法进展.重庆医科大学硕士学位论文,2014,5:13.
[2]Mac Leod JB,Winkler AM,McCoy CC,et al.Early trauma induced coagulopathy(ETIC):prevalence across the injury spectrum.Injury,2014,45(5):910-915.
[3]Gissel M,Brummel-Ziedins KE,Butenas S,et al.Effects of an acidic environment on coagulation dynamics.J Thromb Haemost,2016,14(10):2001-2010.
[4]Shenkman B,Budnik I,Einav Y,et al.Model of trauma-induced coagulopathy including hemodilution,fibrinolysis,acidosis,and hypothermia:Impact on blood coagulation and platelet function.J Trauma Acute Care Surg,2017,82(2):287-292.
[5]刘红升,王曼,苏琴等.急性重症创伤患者凝血功能异常的临床意义.创伤外科杂志,2014,16(5):399-402.
[6]Jamal S,Marwa K,Ron F,et al.Blood flow versus hematocritin optimization of oxygen transfer to tissue during fluid resuscitation.Cardiovascular Engin Technol,2015,6(4):474-484.
[7]Ziegler AK,Grand J,Stangerup I,et al.Time course for the recovery of physical performance,blood hemoglobin,and ferritin content after blood donation.Transfusion,2015,55(4):898-905.
[8]Curry NS,Davenport RA,Hunt BJ,et al.Transfusion strategies for traumatic coagulopathy.Blood Rev,2012,26(5):223-232.
[9]Pohlman TH,Walsh M,Aversa J,et al.Damage control resuscitation.Blood reviews.2015,29(4):251-262.
[10]刘威,乐爱平.创伤患者大量输血研究进展.中国输血杂志,2017,30(2):208-212.
[11]Campbell JE,Aden JK,Cap AP.Acute traumatic coagulopathy:Whole blood thrombelastography measures the tip of the iceberg.J Trauma Acute Care Surg,2015,78(5):955-961.
[12]刘海波.创伤性凝血功能障碍机制及诊断方法进展.重庆医科大学硕士学位论文,2014,5:13.