血栓弹力图检测儿童脓毒症凝血紊乱的临床研究  

Clinical study of thromboelastography for assessment of coagulation disorders in children with sepsis

作　　者：项龙[1] 钱娟[1] 张建[1] 任宏[1] 胡肖伟[1] 李璧如[1] 王莹[1] 傅启华[2] 祝益民[3] 宁铂涛[1] Xiang Long Qian Juan Zhang Jian Ren Hong Hu Xiaowei Li Biru Wang Ying Fu Qihua Zhu Yimin Ning Botao(Department of Pediatrics Intensive Care Unit , Department of Clinical Laboratory , Shanghai Children＇s Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai 200127, China Emergency Center of Hunan Provincial Children＇ s Hospital, Changsha 410007, China)

机构地区：[1]上海交通大学医学院附属上海儿童医学中心重症医学科,上海200127 [2]上海交通大学医学院附属上海儿童医学中心检验科,上海200127 [3]湖南省儿童医院急救中心,长沙410007

出　　处：《中华急诊医学杂志》2017年第11期1284-1289,共6页Chinese Journal of Emergency Medicine

基　　金：国家十二五科技支撑计划资助项目（2012BA104801）;上海申康专科疾病临床五新转化项目（16CR3085B）

摘　　要：目的了解血栓弹力图（thromboelastography,TEG）在儿童脓毒症凝血紊乱中的检测意义。方法前瞻性收集2016年2月至2017年1月收入上海交通大学附属上海儿童医学中心PICU诊断为脓毒症和严重脓毒症的患儿共100例，于诊断脓毒症当日检测传统凝血功能指标（conventional coagulation tests, CCTs），包括血小板计数（Plt）、活化部分凝血酶时间（APTT）、凝血酶原时间（PT）、国际标准化比值（INR）、纤维蛋白原（Fib）、D-二聚体（D-dimers）；检测TEG指标，包括凝血反应时间（R）、动力时间（K）、凝固角度（α）、最大幅度（MA）、30 min幅度下降比例（LY30）、综合凝血指数（CI）。另随机纳入体检儿童25例为对照组，组间比较采用秩和检验，以P＜0.05为差异有统计学意义。分析TEG和CCTs检测脓毒症凝血紊乱的特征、ROC曲线下面积法（AUC）考察TEG和CCTs预测严重脓毒症的灵敏度和特异度。结果共纳入脓毒症56例、严重脓毒症44例，男女比例63∶37，中位年龄11.5（3.3~48）个月，合并基础疾病占71%。根据TEG检测结果，发生凝血紊乱72例，其中高凝状态28例，低凝状态44例；根据CCTs检测结果，发生凝血紊乱50例，其中非显性DIC 29例，显性DIC 21例。高凝状态在无DIC组中比例高于非显性DIC组（46% 和17.2%，P=0.016）。低凝状态显性DIC组比例高于非显性DIC组（100% 和44.8%，P＜0.01）。脓毒症高凝组较对照组TEG结果显示：R、K缩短，α增大，MA、CI升高（均P＜0.01）；CCTs结果显示：PT延长（P=0.002），APTT两组间差异无统计学意义（P=0.787）。严重脓毒症组较脓毒症组TEG呈低凝状态：R、K延长，α减小，MA、CI降低（P＜0.01）。TEG与CCTs各指标预测严重脓毒症AUC均＞0.5，其中α的AUC大于Fib（P=0.000 2）；K的AUC大于Fib（P=0.004 1）。结论TEG检测显示脓毒症患儿凝血紊乱占72%，其中脓毒症早期呈高凝状�Objective To study the clinical significance of thromboelastography （TEG） for determining the presence of coagulation disorders in septic children. Methods A total of 100 patients suffering from sepsis or severe sepsis in pediatric intensive care unit （PICU） of Shanghai Children＇s Medical Center from February 2014 to January 2015 were recruited. TEG tests and conventional coagulation laboratory tests （CCTs） including platelet count, fibrinogen, prothrombin time （PT）, activated partial thromboplastin time, D-dimers, and international normalized ratio （INR） were carried out in all patients at the primary diagnosis of sepsis. Another 25 healthy children taking physical examination were enrolled as control group. Rank Sum Test was used to detect the differences in coagulation markers and TEG between the groups and there was statistical significance when P 〈 0. 05. Receiver operating characteristic （ROC） curves were used to evaluate the roles of TEG and CCTs tests in this study. Results Of them, there were 56 patients with sepsis and 44 with severe sepsis. The male to female ratio was 63： 37, the median age was 11.5 （3.3 -48） months, and 71% patients suffered from underlying disease. According to TEG, 72 patients had coagulation disorders, including 28 with hypercoagulation and 44 with hypocoagulation. CCTs tests showed 50 patients had coagulation disorders, including 29 with non-overt DIC and 21 with overt DIC. The rate of hypercoagulability was significantly higher in non-DIC group than in non-overt DIC group （46% vs. 17.2%, P =0. 016）. The rate of hypocoagulability was significantly higher in overt DIC group than in non-overt DIC group （ 100% vs. 44. 8%, P 〈 0. 01 ）. Patients with hypercoagulation disorders had significantly shorter R （coagulation reaction time ） and K （coagulation formation time ） and greater α （angle or）, MA （maximal amplitude） and CI （comprehensive coagulation index） compared with control group （P 〈 0. 01 ）. According to CCTs

关 键 词：血栓弹力图 脓毒症 严重脓毒症 凝血紊乱 儿童 

分 类 号：R720.597[医药卫生—急诊医学]