肝脏切除围手术期凝血和纤溶分子标志物变化规律的研究  

Study on changes of molecular markers of coagulation and fibrinolysis in perioperative period of hepatectomy

作　　者：岳锦熙[1] 万晓红[1] 万林骏[1] 黄青青[1] 毛海 Yue Jinxi;Wan Xiaohong;Wan Linjun;Huang Qingqing;Mao Hai(Department of Critical Care Medicine,the Second Affiliated Hospital of Kunming Medical University,Kunming 650101,Yunnan,China)

机构地区：[1]昆明医科大学第二附属医院重症医学科,云南昆明650101

出　　处：《中国中西医结合急救杂志》2022年第1期36-40,共5页Chinese Journal of Integrated Traditional and Western Medicine in Intensive and Critical Care

基　　金：云南省卫生科技计划项目(2018NS0319)。

摘　　要：目的 结合常规凝血检测指标与凝血和纤溶分子标志物凝血酶原激活片段1+2(F1+2)、纤溶酶(PLA)、纤溶酶-α2抗纤溶酶复合物(PAP)、纤溶酶原激活物抑制物-1(PAI-1),观察肝切除术患者围手术期凝血和纤溶功能的变化规律及影响因素.方法 回顾性研究,选择2019年9月1日至2020年11月30日昆明医科大学第二附属医院行肝切除术的75例患者为研究对象.分析患者的各项临床资料、手术过程中常规凝血指标如凝血酶原时间(PT)、活化部分凝血活酶时间(APTT)、纤维蛋白原(FIB)、纤维蛋白降解产物(FDPs)、D-二聚体(DD)、抗凝血酶Ⅲ(ATⅢ)及特异性凝血和纤溶分子标志物如F1+2、PAP、PLA、PAI-1水平变化情况,术中失血量、氨甲环酸使用情况及术后住院时间等.结果 肝切除术患者术前凝血异常以ATⅢ降低最为常见,术后进一步显著降低;术毕和术后1 d时PT、APTT、DD、FDPs较术前明显升高.FIB在术毕时较术前明显下降(g/L:2.0±0.6比3.7±1.5,P<0.05);多因素Logistic回归分析显示,术毕时FIB低与术前FIB水平低、术前肝功能分级高、术中出血量多相关〔优势比(OR)值分别为27.326、0.001、0.986,P值分别为0.002、0.023、0.008〕.患者术前F1+2、PLA、PAP、PAI-1均高于参考范围〔F1+2(nmol/L):644.1±126.1,PLA(μg/L):3612.7±573.4,PAP(ng/L):246.5±41.1,PAI-1(ng/L):797.7±139.8〕,围手术期变化无统计学意义.共有53例(占70.7%)患者术中使用氨甲环酸,术毕时未使用氨甲环酸的对照组22例患者FDPs、DD均较使用氨甲环酸组高〔FDPs(mg/L):5.5(2.4,13.1)比2.7(1.6,4.3),DD(mg/L):1.8(0.7,4.1)比1.0(0.6,2.1),均P<0.05〕,两组间凝血和纤溶分子标志物差异无统计学意义.结论 肝脏切除术患者术后凝血和纤溶活性都增强,并未表现出低凝状态;FIB在术后降低显著,与术前FIB低、术中出血量多、肝功能下降有关,因此肝脏切除术围手术期应加强FIB监测,术后出血需及时补充FIB;术中使用氨�Objective To observe the changing rules and influencing factors of coagulative and fibrinolytic functions in peri-operative period of patients havi ng un dergone hepatectomy hy combi ning routine detection of coagulatio n indexes and special molecular markers of coagulation and fibrinolysis,including thrombin activated fragment 1+2(Fl+2),plasmin(PLA),plasmin-a 2-antiplasmin complex(PAP),plasminogen activator inhibitors-1(PAI-1).Methods A retrospective study was conducted,including 75 patients who underwent hepatectomy in the Second Affiliated Hospital of Kunming Medical University from September 1,2019 to November 31,2020 were selected as the study subjects.The clinical characteristics,the changes of routine coagulation tests including prothrombin time(PT),activated partial thromboplastin time(APTT),fibrinogen(FIB),fibrin degradation products(FDPs),D-dimer(DD),anti-thrombin Ⅲ(AT Ⅲ)and specific molecular markers of coagulation and fibrinolysis including Fl+2,PAP,PLA,PAI-1 during operation,amount of intraoperative blood loss,usage situation of tranexamic acid,postoperative hospital stay,etc.were analyzed.Results In patients with hepatectomy,the reduction of AT Ⅲ was the most common preoperative coagulation abnormality and it was decreased further more after surgery;PT,APTT,DD,FDPs elevated significantly at the end of operation and on postoperative clay 1;FIB at the end of operation decreased significantly as compared with preoperation(g/L:2.0±0.6 vs.3.7±1.5,P<0.05).Multivariate Logistic regression analysis showed that low FIB level at the end of operation was correlated with low preoperative FIB level,the preoperative liver function grade being high,and high intraoperative blood loss[odds ratio(OR)values were 27.326,0.001,0.986,P values were 0.002.0.023,0.008,respectively].The patients had higher preoperative levels of F1+2,PLA,PAP and PAI-1 levels than their reference values[F1+2(mmol/L):644.1±126.1,PLA(μg/L):3612.7±573.4.PAP(ng/L):246.5±41.1.PAI-1(ng/L):797.7±139.8],but there were no statistical sign

关 键 词：肝切除术 凝血 凝血酶片段1+2 纤溶酶-α2抗纤溶酶复合物 纤溶酶 纤溶酶原激活剂抑制物-1 氨甲环酸 

分 类 号：R73[医药卫生—肿瘤]