r-TEG监测对术中患者凝血机制及其干预的价值
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摘要
目的：
随着我国医学事业的发展,血液制品资源稀缺的问题日益凸显,血液制品的合理应用越来越多的引起关注和重视。然而,纠正凝血功能相关血液制品的输注指征仍多以临床医生的经验判断为主要指导依据,找到更快速、准确、全面监测凝血功能指标的方法,来指导纠正凝血功能相关血液制品的使用是十分必要的。快速血栓弹力图与传统凝血功能检测相比存在更加整体和全面、更加快速等诸多优点,未来很可能成为纠正凝血功能相关血液制品输注指征的重要参考依据。然而其在我国的临床应用还基本为空白,其指标与出血量的关系也不清楚。本研究拟在拟行神经外科择期手术且基础凝血功能正常的成人患者中研究快速血栓弹力图指标变化与出血量的关系,并比较其与传统凝血功能检测指标在反应患者术中出血对凝血功能影响中的作用,为快速血栓弹力图未来用于指导临床凝血功能监测与纠正凝血相关血液制品输注提供参考依据。
方法：
选择北京协和医院神经外科行择期经单鼻蝶入路鞍区占位病变切除术或开颅颅内病变切除术的患者,入选标准为年龄15-65岁,ASA Ⅰ-Ⅱ级,术前凝血功能、肝肾功能不存在有临床意义的异常,术前无影响凝血功能相关药物使用史,同意加入此研究者。通过术前访视、术中记录和术后随访,详细记录入选患者术前基本信息及一般情况、术前凝血功能及全血细胞分析指标、术中出血量、术后凝血功能及全血细胞分析指标、术后引流量,并进行术前术后两次快速血栓弹力图检测和指标记录。最后根据需要对病例进行分组,采用IBM SPSS Statistics20进行统计学分析。
结果：
1.神经外科手术患者中,性别、年龄及BMl对r-TEG结果有影响,高龄、女性、高BMI患者呈现高凝状态,与CCT有较好的一致性。2.神经外科手术患者出血导致的凝血功能变化主要与FBG及PLT的降低有关,r-TEG指标中仅K与a角两个指标与出血量占EBV百分比显著相关,而与凝血因子的消耗关系不大。目前临床上对神经外科手术患者出血对凝血功能影响的经验性认识是不够准确的,出血对纤维蛋白原及血小板的影响应该得到更多重视。3. r-TEG有助于快速找到出血对凝血功能影响的具体原因,并予以及时纠正。4. PT、APTT、INR可能帮助预测此类手术病人术后出血量。5.术前r-TEG及CCT指标难以准确帮助预测神经外科手术病人术中出血。
结论：
快速血栓弹力图能够快速准确的即时反应患者凝血功能整体情况,其多个指标与术中出血量有很好的相关性,是替代经验性判断,指导临床纠正凝血功能相关血液制品输注的重要方法。
Objectives:
As medical career is rapidly developing in China, the scarcity of blood products and their rational use become important problems worth paying close attention to. However, blood products used for correcting coagulational function are still used according to clinical doctors' experience. As a result, it's essential to find a method for testing patients' coagulational function that is fast, accurate and comprehensive. Rapid thrombelastography is more comprehensive and rapid than conventional coagulation tests, and probably becomes an important reference for future transfusion of blood products related to coagulational function correction. Unfortunately, it's not widely used in China, and the relationship between rapid thrombelastography indices and blood loss is still unclear. This research intends to analyze the relationship between rapid thrombelastography indices changes and blood loss in patients with normal coagulational function undergoing neurosurgery, and to compare rapid thrombelastography indices with conventional coagulation tests indices on their ability of reflecting the influence of intraoperative bleeding to coagulational function.
Methods:
We selected patients undergoing single transsphenoidal sellar lesion resection or resection of intracranial lesion through craniotomy in the department of neurosurgery, Peking Union Medical College Hospital. The inclusion criteria were age between15and65, ASA grade I or II, normal preoperative coagulational function, liver function and renal function, no history of using preoperative coagulation-related drugs, and agree to take part in the research. We recorded detailly the patients' basic information, general circumstances, preoperative and postoperative coagulational function tests, whole blood cell analysis and rapid thrombelastography indices, intraoperative blood loss volume, and postoperative drainage in detail. Then cases were grouped as needed and IBM SPSS20was used for statistical analysis.
Results:
1. Among neurosurgery patients, sex, age and body mass index have impact on the rapid thrombelastography indices. Senior patients, women and fat patients presented with a hypercoagulable state, and the result is in great agreement with conventional coagulation tests.2. The coagulational function changes caused by intraoperative bleeding in neurosurgical patients are mostly related to fibrinogen and platelets loss. Only two indicators, K and a, are significantly associated with the amount of bleeding. The current empirical knowledge of the effect of bleeding on coagulational function is not accurate. The influence of bleeding on fibrigonen and platelets should get more attention.3. Rapid thrombelastography is able to help finding the specific reason that affect patient's coagulation state and fastly correcting the coagulational abnormity.4. Prothrombin time, activated partial thromboplastin time, and international normalized ratio may help predict postoperative blood loss in patients.5. Neither preoperative rapid thrombelastography nor conventional coagulation tests are good indicators of intraoperative blood loss.
Conclusion:
Rapid thrombelastography can reflect the overall situation of coagulation rapidly, and some of its indices are strongly related to blood loss. So it can be an important alternative method for directing the transfusion of blood products.
随着我国医学事业的发展,血液制品资源稀缺的问题日益凸显,血液制品的合理应用越来越多的引起关注和重视。然而,纠正凝血功能相关血液制品的输注指征仍多以临床医生的经验判断为主要指导依据,找到更快速、准确、全面监测凝血功能指标的方法,来指导纠正凝血功能相关血液制品的使用是十分必要的。快速血栓弹力图与传统凝血功能检测相比存在更加整体和全面、更加快速等诸多优点,未来很可能成为纠正凝血功能相关血液制品输注指征的重要参考依据。然而其在我国的临床应用还基本为空白,其指标与出血量的关系也不清楚。本研究拟在拟行神经外科择期手术且基础凝血功能正常的成人患者中研究快速血栓弹力图指标变化与出血量的关系,并比较其与传统凝血功能检测指标在反应患者术中出血对凝血功能影响中的作用,为快速血栓弹力图未来用于指导临床凝血功能监测与纠正凝血相关血液制品输注提供参考依据。
方法：
选择北京协和医院神经外科行择期经单鼻蝶入路鞍区占位病变切除术或开颅颅内病变切除术的患者,入选标准为年龄15-65岁,ASA Ⅰ-Ⅱ级,术前凝血功能、肝肾功能不存在有临床意义的异常,术前无影响凝血功能相关药物使用史,同意加入此研究者。通过术前访视、术中记录和术后随访,详细记录入选患者术前基本信息及一般情况、术前凝血功能及全血细胞分析指标、术中出血量、术后凝血功能及全血细胞分析指标、术后引流量,并进行术前术后两次快速血栓弹力图检测和指标记录。最后根据需要对病例进行分组,采用IBM SPSS Statistics20进行统计学分析。
结果：
1.神经外科手术患者中,性别、年龄及BMl对r-TEG结果有影响,高龄、女性、高BMI患者呈现高凝状态,与CCT有较好的一致性。2.神经外科手术患者出血导致的凝血功能变化主要与FBG及PLT的降低有关,r-TEG指标中仅K与a角两个指标与出血量占EBV百分比显著相关,而与凝血因子的消耗关系不大。目前临床上对神经外科手术患者出血对凝血功能影响的经验性认识是不够准确的,出血对纤维蛋白原及血小板的影响应该得到更多重视。3. r-TEG有助于快速找到出血对凝血功能影响的具体原因,并予以及时纠正。4. PT、APTT、INR可能帮助预测此类手术病人术后出血量。5.术前r-TEG及CCT指标难以准确帮助预测神经外科手术病人术中出血。
结论：
快速血栓弹力图能够快速准确的即时反应患者凝血功能整体情况,其多个指标与术中出血量有很好的相关性,是替代经验性判断,指导临床纠正凝血功能相关血液制品输注的重要方法。
Objectives:
As medical career is rapidly developing in China, the scarcity of blood products and their rational use become important problems worth paying close attention to. However, blood products used for correcting coagulational function are still used according to clinical doctors' experience. As a result, it's essential to find a method for testing patients' coagulational function that is fast, accurate and comprehensive. Rapid thrombelastography is more comprehensive and rapid than conventional coagulation tests, and probably becomes an important reference for future transfusion of blood products related to coagulational function correction. Unfortunately, it's not widely used in China, and the relationship between rapid thrombelastography indices and blood loss is still unclear. This research intends to analyze the relationship between rapid thrombelastography indices changes and blood loss in patients with normal coagulational function undergoing neurosurgery, and to compare rapid thrombelastography indices with conventional coagulation tests indices on their ability of reflecting the influence of intraoperative bleeding to coagulational function.
Methods:
We selected patients undergoing single transsphenoidal sellar lesion resection or resection of intracranial lesion through craniotomy in the department of neurosurgery, Peking Union Medical College Hospital. The inclusion criteria were age between15and65, ASA grade I or II, normal preoperative coagulational function, liver function and renal function, no history of using preoperative coagulation-related drugs, and agree to take part in the research. We recorded detailly the patients' basic information, general circumstances, preoperative and postoperative coagulational function tests, whole blood cell analysis and rapid thrombelastography indices, intraoperative blood loss volume, and postoperative drainage in detail. Then cases were grouped as needed and IBM SPSS20was used for statistical analysis.
Results:
1. Among neurosurgery patients, sex, age and body mass index have impact on the rapid thrombelastography indices. Senior patients, women and fat patients presented with a hypercoagulable state, and the result is in great agreement with conventional coagulation tests.2. The coagulational function changes caused by intraoperative bleeding in neurosurgical patients are mostly related to fibrinogen and platelets loss. Only two indicators, K and a, are significantly associated with the amount of bleeding. The current empirical knowledge of the effect of bleeding on coagulational function is not accurate. The influence of bleeding on fibrigonen and platelets should get more attention.3. Rapid thrombelastography is able to help finding the specific reason that affect patient's coagulation state and fastly correcting the coagulational abnormity.4. Prothrombin time, activated partial thromboplastin time, and international normalized ratio may help predict postoperative blood loss in patients.5. Neither preoperative rapid thrombelastography nor conventional coagulation tests are good indicators of intraoperative blood loss.
Conclusion:
Rapid thrombelastography can reflect the overall situation of coagulation rapidly, and some of its indices are strongly related to blood loss. So it can be an important alternative method for directing the transfusion of blood products.
引文
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[27]Malhotra S, Naggar I, Stewart M, et al. Neurogenic pathway mediated remote preconditioning protects the brain from transient focal ischemic injury[J]. Brain Res. 2011,1386:184-190.
[28]Bernaudin M, Marti HH, Roussel S, et al. A potential role for erythropoietin in focal permanent cerebral ischemia in mice[J]. J. Cereb. Blood Flow Metab. 1999,19:643-651.
[29]Prass K, Scharff A, Ruscher K, et al. Hypoxia-induced stroke tolerance in the mouse is mediated by erythropoietin[J]. Stroke.2003,34(8):1981-1986.
[30]Ehrenreich H, Hasselblatt M, Dembowski C, et al. Erythropoietin therapy for acute stroke is both safe and beneficial[J]. Mol. Med.2002,8:495-505.
[31]Ehrenreich H, Weissenborn K, Prange H, et al. Recombinant human erythropoietin in the treatment of acute ischemic stroke[J]. Stroke.2009, 40(12):e647-656.
[1]李克强.不断深化医改推动建立符合国情惠及全民的医药卫生体制.求是杂志,2011.22：3-10.
[2]毕普民,蒋红卫,方其和等.黄山市基层医药卫生体制综合改革实践.安徽医学,第32卷第9期2011.9：1637-1639.
[3]叶宜德,朱霖,吴晓红等.实施基本药物制度对新型农村合作医疗的影响研究.中国农村卫生事业管理,第31卷第12期2011.12：1221-1224.
[4]马晓华."医改三年”圆桌：基层改革初告捷 公立医院开启攻坚战.第一财经日报,2012年6月29日第A04版.
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[1]R. Weber HC, Diener C, Weimar. Why Do Acute Ischemic Stroke Patients with a Preceding Transient Ischemic Attack Present with Less Severe Strokes?-Insights from the German Stroke Study[J]. Eur Neurol.2011,66:265-270.
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[26]Hu S, Dong H, Zhang H, et al. Noninvasive limb remote ischemic preconditioning contributes neuroprotective effects via activation of adenosine A1 receptor and redox status after transient focal cerebral ischemia in rats[J]. Brain Res.2012, 1459:81-90.
[27]Malhotra S, Naggar I, Stewart M, et al. Neurogenic pathway mediated remote preconditioning protects the brain from transient focal ischemic injury[J]. Brain Res. 2011,1386:184-190.
[28]Bernaudin M, Marti HH, Roussel S, et al. A potential role for erythropoietin in focal permanent cerebral ischemia in mice[J]. J. Cereb. Blood Flow Metab. 1999,19:643-651.
[29]Prass K, Scharff A, Ruscher K, et al. Hypoxia-induced stroke tolerance in the mouse is mediated by erythropoietin[J]. Stroke.2003,34(8):1981-1986.
[30]Ehrenreich H, Hasselblatt M, Dembowski C, et al. Erythropoietin therapy for acute stroke is both safe and beneficial[J]. Mol. Med.2002,8:495-505.
[31]Ehrenreich H, Weissenborn K, Prange H, et al. Recombinant human erythropoietin in the treatment of acute ischemic stroke[J]. Stroke.2009, 40(12):e647-656.
[1]李克强.不断深化医改推动建立符合国情惠及全民的医药卫生体制.求是杂志,2011.22：3-10.
[2]毕普民,蒋红卫,方其和等.黄山市基层医药卫生体制综合改革实践.安徽医学,第32卷第9期2011.9：1637-1639.
[3]叶宜德,朱霖,吴晓红等.实施基本药物制度对新型农村合作医疗的影响研究.中国农村卫生事业管理,第31卷第12期2011.12：1221-1224.
[4]马晓华."医改三年”圆桌：基层改革初告捷 公立医院开启攻坚战.第一财经日报,2012年6月29日第A04版.