严重创伤患者初期复苏后持续纤溶关闭与临床预后的关系  

Relationship between persistent fibrinolysis shutdown after initial resuscitation and clinical outcomes in severe trauma patients

作　　者：张璐平 杨晨[2] 姜俭[1] 高叶 邵荣海 刘励军[2] Zhang Luping;Yang Chen;Jiang Jian;Gao Ye;Shao Ronghai;Liu Lijun(Emergency Department,Taicang Hospital Affiliated to Soochow University(First People's Hospital of Taicang),Taicang 215400,China;Intensive Care Unit,Second Affiliated Hospital of Soochow University,Suzhou 215004,China;Intensive Care Unit,Taicang Hospital Affiliated to Soochow University(First People's Hospital of Taicang),Taicang 215400,China)

机构地区：[1]苏州大学附属太仓医院(太仓市第一人民医院)急诊科,太仓215400 [2]苏州大学附属第二医院急重症医学科,苏州215004 [3]苏州大学附属太仓医院(太仓市第一人民医院)重症医学科,太仓215400

出　　处：《中华急诊医学杂志》2025年第1期62-69,共8页Chinese Journal of Emergency Medicine

基　　金：苏州市“科教兴卫”青年科技项目(KJXW2020069)。

摘　　要：目的探讨严重创伤患者初期复苏后纤溶状态的动态变化,并分析该变化与临床预后的关系。方法采用前瞻性队列研究方法,选择2021年7月至2022年12月苏州大学附属太仓医院创伤中心收治的严重创伤患者,给予氨甲环酸(Tranexamic acid,TXA)等复苏治疗。在伤者进入复苏单元、初期复苏后1 h和8 h分别检测血栓弹力图;按其血块溶解速率将其纤溶状态分为三种表型,即纤维蛋白溶解关闭(fibrinolysis ahutdown,SD)、生理性纤维蛋白溶解(physiologic fibrinolysis,PY)以及纤维蛋白溶解亢进(hyperfibrinolysis,HF);主要预后指标包括24 h和28 d全因病死率。采用多因素Logistic回归,分析早期纤溶变化与临床预后的关系。结果共纳入132例严重创伤患者,入创伤复苏单元时表现为SD 61例(46.2%),PY 59例(44.7%),HF 12例(9.1%)。经TXA等初期复苏后仍以SD和PY表型为主,HF则进一步减少。相对于SD和PY组,HF组患者24 h病死率(25.0%vs.3.3%vs.3.4%,P<0.05)和28 d病死率(58.3%vs.32.8%vs.11.9%,P<0.05)较高,以大出血为主要死因;SD组患者28 d病死率高于PY组(32.8%vs.11.9%,P<0.05),以脑损伤为主要死因。在不纳入HF的12例患者后,多因素Logistic回归分析结果表明,在校正年龄、格拉斯哥昏迷评分≤8分、凝血酶原时间,以及24 h晶体液输注量后,与始终处于PY状态相比,初期复苏后仍处于SD是严重创伤患者28 d死亡的危险因素(OR=7.009,95%CI:1.141~43.079,P=0.036)。结论严重创伤患者早期及初期复苏后,纤溶状态以SD和PY为主要表型;初期复苏后持续SD是严重创伤患者28 d死亡的危险因素。Objective To evaluate the dynamic changes in fibrinolytic states after initial resuscitation in severe trauma patients,and to analyze the relationship between the changes and clinical outcomes.Methods A prospective cohort study was conducted on severe trauma patients admitted to the trauma center in Taicang Hospital,affiliated with Soochow University,from July 2021 to December 2022.Resuscitation treatments,including tranexamic acid(TXA),were administered.Thromboelastography was performed at three intervals:upon admission,1 hour and 8 hours after initial resuscitation.Fibrinolytic states were categorized into three phenotypes based on clot lysis at 30 minutes:fibrinolysis shutdown(SD),physiologic fibrinolysis(PY),and hyperfibrinolysis(HF).The primary outcomes included all-cause mortality at 24 hours and 28 days.Multivariate logistic regression was used to analyze the association between early fibrinolytic changes and clinical outcomes.Results A total of 132 patients with severe trauma were included.Upon admission,fibrinolytic phenotypes were distributed as follows:SD in 61 patients(46.2%),PY in 59 patients(44.7%),and HF in 12 patients(9.1%).After resuscitation with TXA and other interventions,SD and PY remained predominant,whereas HF further decreased.Compared with the SD and PY groups,the HF group had significantly higher 24-hour mortality(25.0%vs.3.3%vs.3.4%,P<0.05)and 28-day mortality(58.3%vs.32.8%vs.11.9%,P<0.05),with massive hemorrhage being the primary cause of death.Among the non-HF groups,28-day mortality was significantly higher in the SD group than in the PY group(32.8%vs.11.9%,P<0.05),with traumatic brain injury as the leading cause of death.After the exclusion of 12 HF patients,multivariate logistic regression showed that after adjusting for age,Glasgow Coma Scale score≤8,prothrombin time,and 24-hour crystalloid infusion volume,identified persistent SD was a risk factor for 28-day mortality in severe trauma patients,compared with sustained PY status(OR=7.009,95%CI:1.141-43.079,P=0.036).Conclusions In

关 键 词：纤维蛋白溶解关闭 初期复苏 严重创伤 

分 类 号：R641[医药卫生—外科学]