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中华危重症医学杂志(电子版)

中华危重症医学杂志(电子版) ›› 2018, Vol. 11 ›› Issue (04) : 233 -237. doi: 10.3877/cma.j.issn.1674-6880.2018.04.004

所属专题： 文献；

论著

血栓弹力图在评估脓毒症患者28 d生存率中的临床价值
况芳1, 何志捷1,†(), 周明根1, 邹子俊1, 黄灿霞1, 陈纯2   
  1. 1. 510120　广州，中山大学孙逸仙纪念医院重症医学科
    2. 510120　广州，中山大学孙逸仙纪念医院儿科
  • 收稿日期:2018-02-04 出版日期:2018-08-01
  • 通信作者: 何志捷
  • 基金资助:
    广东省公益研究与能力建设专项资金项目（社会发展领域）(2014A020212095)

Value of thromboelastography in evaluating the 28 d survival rate in sepsis patients

Fang Kuang1, Zhijie He1,†(), Minggen Zhou1, Zijun Zou1, Canxia Huang1, Chun Chen2   

  1. 1. Department of Critical Care Medicine, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China
  • Received:2018-02-04 Published:2018-08-01
  • Corresponding author: Zhijie He
  • About author:
    Corresponding author: He Zhijie, Email:
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况芳, 何志捷, 周明根, 邹子俊, 黄灿霞, 陈纯. 血栓弹力图在评估脓毒症患者28 d生存率中的临床价值[J/OL]. 中华危重症医学杂志(电子版), 2018, 11(04): 233-237.

Fang Kuang, Zhijie He, Minggen Zhou, Zijun Zou, Canxia Huang, Chun Chen. Value of thromboelastography in evaluating the 28 d survival rate in sepsis patients[J/OL]. Chinese Journal of Critical Care Medicine(Electronic Edition), 2018, 11(04): 233-237.

目的

探讨血栓弹力图在评估脓毒症患者28 d生存率中的价值。

方法

根据患者28 d预后情况，将2017年4月至2017年11月中山大学孙逸仙纪念医院重症医学科收治的50例脓毒症患者分为存活组（34例）和死亡组（16例）。比较两组患者的年龄、性别比、感染的病原菌类型、入ICU内24 h的急性病生理学和长期健康评价（APACHE）Ⅱ评分、序贯器官衰竭估计（SOFA）评分、连续静静脉血液滤过（CVVH）/连续静静脉血液透析（CVVHD）、C反应蛋白、降钙素原、血小板计数、国际标准化比值（INR）、N-端脑钠肽（NT-proBNP）、是否行机械通气、是否行持续性血液净化治疗、是否使用升压药等一般资料和血栓弹力图各指标包括凝血反应时间（R值）、血凝块形成时间（K值）、纤维蛋白凝块形成及加固的速率（α角）以及反应血凝块最大强度和硬度（MA值）；采用多因素Cox回归分析各指标对脓毒症患者预后的影响。

结果

两组脓毒症患者APACHEⅡ评分[（27 ± 6）分vs.（22 ± 6）分，t= 2.611，P= 0.012]比较，死亡组明显高于存活组。两组脓毒症患者血栓弹力图各指标比较，死亡组脓毒症患者血栓弹力图R值[9.50（8.23，13.30）min vs. 6.55（6.03，8.15）min，H= 3.381，P= 0.001]和K值[3.50（1.95，4.50）min vs. 1.25（1.08，2.05）min，H= 4.955，P< 0.001]均较存活组明显延长；而α角[47.50（39.90，62.45）° vs. 71.80（62.00，74.70）°，H= 4.004，P< 0.001]和MA值[58.10（48.70，67.58）° vs. 67.10（60.13，70.65）°，H= 2.433，P= 0.015]均较存活组显著降低。Cox多因素回归结果显示，血栓弹力图中α角< 53°为脓毒症患者28 d生存率的影响因素[HR= 3.463，95%CI（1.250，9.599），P= 0.017]。

结论

血栓弹力图中α角对脓毒症患者28 d生存率有一定的预测价值。

关键词: 脓毒症, 血栓弹力图, α角
Objective

To explore the value of thromboelastography in evaluating 28-day survival rate in sepsis patients.

Methods

Totally 50 patients with sepsis admitted to Department of Critical Care Medicine, Sun Yat-sen Memorial Hospital, Sun Yat-sen University from April 2017 to November 2017 were divided into the survival group (34 cases) and death group (16 cases) according to the prognosis of patients at 28 days. The age, sex ratio, and pathogen type of infection were compared between the two groups. The general data, including acute physiology and chronic health evaluation (APACHE) Ⅱ score, sequential organ failure assessment (SOFA) score, continuous veno-venous hemofiltration (CVVH)/ continuous veno-venous hemodialysis (CVVHD), C reactive protein, procalcitonin, platelet count, international normalized ratio (INR), N-terminal brain natriuretic peptide (NT-proBNP), and the use of mechanical ventilation, blood purification therapy, and vasopressor drugs, were compared between these two groups, as well as thromboelastography indexes of coagulation reaction time (R value), hemagglutination time (K value), rate of fibrin clot formation and reinforcement (alpha angle) and maximum strength and hardness of reactive blood clot (MA value). Multivariate Cox regression analysis was used to evaluate the prognostic value of each index on sepsis patients.

Results

The APACHEⅡ scores of sepsis patients [(27 ± 6) vs. (22 ± 6), t= 2.611, P= 0.012] were significantly higher in the death group than in the survival group. The R value [9.50 (8.23, 13.30) min vs. 6.55 (6.03, 8.15) min, H= 3.381, P= 0.001], and K value [3.50 (1.95, 4.50) min vs. 1.25 (1.08, 2.05) min, Z= 4.955, P < 0.001] of sepsis patients were significantly longer, and the alpha angle [47.50 (39.90, 62.45) vs. 71.80 (62.00, 74.70), H= 4.004, P < 0.001] and MA value [58.10 (48.70, 67.58) vs. 67.10 (60.13, 70.65), H= 2.433, P= 0.015] were significantly lower in the death group than in the survival group. Cox multivariate regression showed that the alpha angle < 53° in the thromboelastography was the influencing factor of 28-day survival rate in sepsis patients [HR= 3.463, 95%CI (1.250, 9.599), P= 0.017].

Conclusion

The alpha angle in the thromboelastography has a certain predictive value for the prognosis of sepsis patients.

Key words: Sepsis, Thromboelastography, Alpha angle
表1 两组脓毒症患者一般资料比较
组别 例数 年龄（岁， ± s) 性别比（例，男/女） 恶性肿瘤[例(%)] APACHEⅡ评分（分， ± s） SOFA评分[分，M(P25,P75)] CVVH/CVVHD[例(%)]
存活组 34 59 ± 18 21/13 14(41.18) 22 ± 6 6.0(4.0,8.0) 1(2.94)
死亡组 16 66 ± 17 13/3 4(25.00) 27 ± 6 7.5(5.0,11.0) 4(25.00)
H/χ2/t值 ? 1.338 1.902 1.244 2.611 1.402 3.687
P值 ? 0.188 0.168 0.266 0.012 0.161 0.055
组别 例数 ? 感染类型[例(%)] 机械通气[例(%)]
革兰阴性菌 革兰阳性菌 真菌 病毒 培养阴性
存活组 34 17(50.00) 5(14.71) 4(11.76) 1(2.94) 7(20.59) 29(85.29)
死亡组 16 4(25.00) 4(25.00) 4(25.00) 0 4(25.00) 16(100.00)
H/χ2/t值 ? 4.020 1.243
P值 ? 0.404 0.145
组别 例数 升压药的应用[例(%)] 降钙素原[μg/L，M(P25,P75)] C反应蛋白[mg/L，M(P25,P75)] 血小板计数（×109/L, ± s) INR[M(P25,P75)] NT-proBNP[μg/L, M(P25,P75)]
存活组 34 9(26.47) 1.01(0.37,3.80) 88.90(20.00,160.30) 198 ± 107 1.21(1.09,1.36) 1.30(0.25,5.38)
死亡组 16 6(37.50) 3.25(0.80,21.67) 113.20(87.26,200.00) 186 ± 100 1.20(1.06,1.33) 4.27(0.44,18.42)
H/χ2/t值 ? 0.208 1.460 1.711 0.377 0.592 1.885
P值 ? 0.643 0.145 0.088 0.703 0.553 0.058
表2 两组脓毒症患者血栓弹力图各指标比较[M（P25，P75）]
组别 例数 R值(min) K值(min) α角（°） MA值(mm)
存活组 34 6.55(6.03,8.15) 1.25(1.08,2.05) 71.80(62.00,74.70) 67.10(60.13,70.65)
死亡组 16 9.50(8.23,13.30) 3.50(1.95,4.50) 47.50(39.90,62.45) 58.10(48.70,67.58)
H值 ? 3.381 4.955 4.004 2.433
P值 ? 0.001 < 0.001 < 0.001 0.015
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