切换至 "中华医学电子期刊资源库"
高级检索
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:
全文 ( ) 下载PDF ( ) 导出引用
引用本文：

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]. 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]. 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
1
Adamik B,Gozdzik W,Jakubczyk D, et al. Coagulation abnormalities identified by thromboelastometry in patients with severe sepsis: the relationship to endotoxemia and mortality[J]. Blood Coagul Fibrinolysis, 2017, 28(2): 163-170.
2
Angus DC,van der Poll T. Severe sepsis and septic shock[J]. N Engl J Med, 2013, 369(9): 840-851.
3
Ganter MT,Hofer CK. Coagulation monitoring: current techniques and clinical use of viscoelastic point-of-care coagulation devices[J]. Anesth Analg, 2008, 106(5): 1366-1375.
4
Velik-Salchner C,Streif W,Innerhofer P, et al. End-otoxinemia-induced changes in coagulation as measured by rotation thrombelastometry technique and conventional laboratory tests: results of a pilot study on pigs[J]. Blood Coagul Fibrinolysis, 2009, 20(1): 41-46.
5
Baratto F,Michielan F,Meroni M, et al. Protein C concentrate to restore physiological values in adult septic patients[J]. Intensive Care Med, 2008, 34(9): 1707-1712.
6
Singer M,Deutschman CS,Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (sepsis-3)[J]. JAMA, 2016, 315(8): 801-810.
7
Angus DC,Linde-Zwirble WT,Lidicker J, et al. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care[J]. Crit Care Med, 2001, 29(7): 1303-1310.
8
Levy MM,Artigas A,Phillips GS, et al. Outcomes of the Surviving Sepsis Campaign in intensive care units in the USA and Europe: a prospective cohort study[J]. Lancet Infect Dis, 2012, 12(12): 919-924.
9
Gando S,Saitoh D,Ogura H, et al. A multicenter, prospective validation study of the Japanese Association for Acute Medicine disseminated intravascular coagulation scoring system in patients with severe sepsis[J]. Crit Care, 2013, 17(3): R111.
10
汪洋,陈上仲,陈昌勤, 等. 序贯器官衰竭估计评分用于脓毒症病情评估的研究进展[J/CD]. 中华危重症医学杂志（电子版）, 2016, 9(6)：422-425.
11
Orbey BC,Cuhruk H,Tulunay M, et al. Can plasma-free DNA concentration be a diagnostic tool in critically ill septic patients[J]. Crit Care, 2007, 11(Suppl 2): P48.
12
Balk RA. Severe sepsis and septic shock. Definitions, epidemiology, and clinical manifestations[J]. Crit Care Clin, 2000, 16(2): 179-192.
13
Lipinska-Gediga M. Coagulopathy in sepsis-a new look at an old problem[J]. Anaesthesiol Intensive Ther, 2016, 48(5): 352-359.
14
Zeerleder S,Hack CE,Wuillemin WA. Disseminated intravascular coagulation in sepsis[J]. Chest, 2005, 128(4): 2864-2875.
15
Sivula M,Pettila V,Niemi TT, et al. Thromboelas-tometry in patients with severe sepsis and disseminated intravascular coagulation[J]. Blood Coagul Fibrinolysis, 2009, 20(6): 419-426.
16
Cortegiani A,Marino L,Montalto F, et al. Use of thromboelastography in severe sepsis: a case-control study[J]. Crit Care, 2011, 15(Suppl 1): P444.
17
张德厚,陈义坤,刘大东. 脓毒症患者早期血小板功能变化及预后分析[J/CD]. 中华危重症医学杂志（电子版）, 2017, 10(1)：28-33.
18
Haase N,Ostrowski SR,Wetterslev J, et al. Thromb-oelastography in patients with severe sepsis: a prospective cohort study[J]. Intensive Care Med, 2015, 41(1): 77-85.
19
何婧瑜,周晓超,刑绣荣, 等. 血栓弹力图对脓毒症患者预后预测价值的研究[J]. 中国临床医生杂志, 2017, 45(7)：45-49.
20
Adamzik M,Langemeier T,Frey UH, et al. Comparison of thrombelastometry with simplified acute physiology score Ⅱ and sequential organ failure assessment scores for the prediction of 30-day survival: a cohort study[J]. Shock, 2011, 35(4): 339-342.
[1] 韩媛媛, 热孜亚·萨贝提, 冒智捷, 穆福娜依·艾尔肯, 陆晨, 桑晓红, 阿尔曼·木拉提, 张丽. 组合式血液净化治疗对脓毒症患者血清炎症因子水平和临床预后的影响[J]. 中华危重症医学杂志(电子版), 2023, 16(04): 272-278.
[2] 孟建标, 张庚, 焦燕娜. 脓毒症合并心功能障碍患者早期肠道微生态改变的探讨[J]. 中华危重症医学杂志(电子版), 2023, 16(04): 279-285.
[3] 陈宇, 冯芳, 张露, 刘健. 基于生物信息学分析筛选脓毒症心肌病关键致病基因[J]. 中华危重症医学杂志(电子版), 2023, 16(04): 286-291.
[4] 莫小乔, 胡喆莹, 廖冬花, 谢天. 脓毒症继发急性肾损伤患者死亡风险预测模型构建及评估[J]. 中华危重症医学杂志(电子版), 2023, 16(03): 198-206.
[5] 张晓燕, 肖东琼, 高沪, 陈琳, 唐发娟, 李熙鸿. 转录因子12过表达对脓毒症相关性脑病大鼠大脑皮质的保护作用及其机制[J]. 中华妇幼临床医学杂志(电子版), 2023, 19(05): 540-549.
[6] 魏徐, 张鸽, 伍金林. 新生儿脓毒症相关性凝血病的监测和治疗[J]. 中华妇幼临床医学杂志(电子版), 2023, 19(04): 379-386.
[7] 姚咏明. 如何精准评估烧伤脓毒症患者免疫状态[J]. 中华损伤与修复杂志(电子版), 2023, 18(06): 552-552.
[8] 窦上文, 邓欢, 刘邦锋, 岳高远志, 朱华财, 刘永达. 术前复查尿培养在预测微通道经皮肾镜取石术相关感染并发症中的作用[J]. 中华腔镜泌尿外科杂志(电子版), 2023, 17(04): 361-366.
[9] 李伟, 卓剑, 黄川, 黄有攀. Lac、HO-1、sRAGE、CRP/ALB表达及脓毒症并发ARDS危险因素分析[J]. 中华肺部疾病杂志(电子版), 2023, 16(04): 514-516.
[10] 苗软昕, 乔晞. Toll样受体在脓毒症性急性肾损伤中的作用[J]. 中华肾病研究电子杂志, 2023, 12(04): 210-214.
[11] 李世明, 黄蔚, 刘玲. HMGB1介导脓毒症相关凝血功能障碍的作用机制及其治疗进展[J]. 中华重症医学电子杂志, 2023, 09(03): 269-273.
[12] 谭睿, 王晶, 於江泉, 郑瑞强. 脓毒症中高密度脂蛋白、载脂蛋白A-I和血清淀粉样蛋白A的作用研究进展[J]. 中华临床医师杂志(电子版), 2023, 17(06): 749-753.
[13] 蔡荇, 郑瑞强. 肝素结合蛋白在脓毒症中的应用及研究进展[J]. 中华临床医师杂志(电子版), 2023, 17(04): 487-490.
[14] 张许平, 刘佳成, 张舸, 杜艳姣, 李韶, 商丹丹, 王浩, 李艳, 段智慧. CYP2C19基因多态性联合血栓弹力图指导大动脉粥样硬化型非致残性缺血性脑血管事件患者抗血小板治疗的效果[J]. 中华脑血管病杂志(电子版), 2023, 17(05): 477-481.
[15] 黎力梦, 陶悦, 刘坚军, 李旭, 王晓俊, 汪涛, 陈斌, 范隆华. 血小板抑制不足与颈动脉支架植入术后不良事件的相关性研究[J]. 中华脑血管病杂志(电子版), 2023, 17(03): 227-231.
阅读次数
全文


摘要

版权所有 中华医学会 中华医学电子音像出版社有限责任公司  京ICP备14006079号-1  网络出版服务许可证：(署)网出证(京)字第075号