严重创伤时应用血栓弹力图指导血小板输注指征的临床研究  

Clinical study of thromboelastography in the indication of platelet transfusion in severe trauma

作　　者：曾庆波 宋景春 胡炜 尚峰 林青伟 钟林翠 胡艳晶 余甜 ZENG Qingbo;SONG Jingchun;HU Wei;SHANG Feng;LIN Qingwei;ZHONG Lincui;HU Yanjing;YU Tian(Intensive Care Unit,the 908th Hospital of Chinese People,s Liberation Army,Nanchang 330002,China)

机构地区：[1]解放军第九○八医院重症医学科

出　　处：《中国输血杂志》2019年第10期1004-1007,共4页Chinese Journal of Blood Transfusion

基　　金：江西省科技支撑计划项目(2014BBG70057);江西省卫生健康委员会科技计划(20163016)

摘　　要：目的探讨严重创伤时以血栓弹力图(TEG)为指导的血小板输注指征。方法选取重症医学科2年零3个月收治的155例严重多发伤住院病例,收集患者入重症医学科时的临床资料,包括入科时间<2 h的红细胞计数(RBC)、血红蛋白(Hb)、血小板计数(Plt)以及TEG的血块形成速率(K)、血块形成动力学(α角)、血块最大强度(MA)和凝血综合指数(CI);根据患者伤后90 d的预后分为生存组(n=143)和死亡组(n=12),采用t检验(卡方检验或非参检验)比较2组间血常规和TEG相关指标的变化,采用二分类logistic回归分析和受试者操作曲线(ROC)分析筛选最佳预后判断指标,并根据MA阈值分组,比较组间的Plt和死亡率。结果1)严重创伤患者入科<2 h Plt(×10^9/L):生存组及死亡组分别为79-170.75(121)、54-115.5(103)(P>0.05);K(min):生存组及死亡组分别为2.1-4.2(2.9)、1.8-8(5.2)(P<0.05),α角(°):生存组及死亡组分别为49.37±16.55、38.35±19.65(P<0.05);MA(mm):生存组及死亡组分别为51.95±13.33、37.35±17.49(P<0.05)。2)直线相关分析:Plt与MA、α角呈正相关,与K呈负相关(P<0.05);3)Logistic回归分析:MA与创伤患者的预后明显相关(OR 0.892,95%CI 0.801-0.993;P<0.05)。4)ROC分析:MA取43.1 mm时曲线下面积为0.756(P<0.05)。严重创伤患者MA<43.1 mm组和MA≥43.1 mm组入科<2 h Plt(×10^9/L)分别为49-122(95)、90-180(127)(P<0.05),MA<43.1 mm组和MA≥43.1 mm组的死亡率分别为23.3%、1.8%(P<0.05)。结论严重创伤患者早期即可出现血小板功能障碍,MA<43.1 mm是严重创伤患者启动输注血小板治疗的指征。Objective To explore the indication of platelet transfusion guided by thromboelastography(TEG)in severe trauma.Methods 155 in patients who were admitted to intensive care unit(ICU)due to severe multiple injuries over 27-month period were enrolled in this study.The records of the patients at admission to ICU was collected,including RBC,Hb,Plt,K,αangle,MA and CI.According to the prognosis of patients 90-day after injury,the patients were divided into survival group(n=143)and death group(n=12).T test(chi square test or non participation test)was used to compare the changes of blood routine tests and TEG related indexes between the two groups.The best prognosis indexes were selected by binary logistic regression analysis and ROC analysis.The patients were divided into two groups according to MA threshold to compare Plt and mortality.Results 1)Plt(×10^~9/L)of severe trauma patients within 2 hours after admission:79-170.75(121)in survival group and 54-115.5(103)in death group,respectively(P>0.05);K value(min):2.1-4.2(2.9)in survival group and 1.8-8(5.2)in death group,respectively(P<0.05);αangle:49.37±16.55 in survival group and 38.35±19.65 in death group respectively(P<0.05);MA(mm):51.95±13.33 in survival group and 37.35±17.49 in death group respectively(P<0.05).2)linear correlation analysis:Plt was positively correlated with MA value andαangle,and negatively correlated with K value(P<0.05).3)logistic regression analysis:MA value was significantly correlated with the prognosis of trauma patients(OR 0.892,95%CI 0.801-0.993;P<0.05).4)ROC analysis:when MA value was 43.1 mm,the area under the curve was 0.756(P<0.05).The Plt(×10^9/L)of severe trauma patients within 2 hours after admission in MA<43.1 mm group and MA≥43.1 mm group were 49-122(95)and 90-180(127),respectively(P<0.05).The mortality of MA<43.1 mm group was 23.3%and that of the other group was 1.8%(P<0.05).Conclusion Platelet dysfunction occur in the early stage of severe trauma patients and platelet transfusion should be initiated as MA<43.1 mm in seve

关 键 词：严重创伤 血小板功能障碍 血小板输血 血栓弹力图 血块最大强度 

分 类 号：R446.111[医药卫生—诊断学] P641[医药卫生—临床医学]