神经外科手术病人快速血栓弹力图指标与术中出血量关系

doi:10.24920/J1001-9294.2017.011

摘要/Abstract

摘要：

目的术中凝血功能障碍与出血量及患者预后密切相关。快速血栓弹力图是一种评估术中凝血功能异常及指导血液制品输注的有效方法。本研究旨在探索快速血栓弹力图指标与出血量的关系。方法本研究纳入了北京协和医院2013年1月15日至4月30日期间行经鼻蝶鞍区占位切除术或开颅手术的患者。所有患者均行术前术后快速血栓弹力图及传统凝血功能检查,并对患者的基本信息及术中出血量（以出血量占估计总体血容量百分比表示）进行记录。我们用Spearman相关性分析法来分析快速血栓弹力图及传统凝血功能检查各指标与术中出血量的关系,并对快速血栓弹力图指标中与术中出血量显著相关的指标进行进一步线性回归分析。结果 181例符合纳入标准的患者入选本研究。反应患者纤维蛋白原水平的α角的术中变化是唯一与出血量显著相关的快速血栓弹力图指标(P=0.013, r= -0.184)。这个结果对出血影响凝血功能的经验性认识提出了挑战。我们发现,随着术中出血量的增加,α角逐渐减小;约每1%术中出血会导致α角减小约0.6°。对传统凝血功能检查结果的分析显示,纤维蛋白原(P=0.015)和血小板数量同样与术中出血量显著相关(P=0.001)。结论围手术期快速血栓弹力图α角的变化与术中出血量显著相关,术中出血对纤维蛋白原水平的影响应该受到更多重视。

关键词: 输血管理, 快速血栓弹力图, 术中出血, 神经外科手术

Abstract:

Objective Intra-operative coagulopathy has a close relationship with blood loss and the prognosis of patients. Rapid-thrombelastography (r-TEG) is a comprehensive assessment of coagulation abnormalities and also an effective way for constructing blood transfusion. This study attempts to investigate the correlation of r-TEG indices with intra-operative hemorrhage.Methods Patients who underwent transphenoidal hypophysectomy and craniotomy from January 15 to April 30, 2013 in Peking Union Medical College hospital were recruited. All patients had pre- and post-operative r-TEG and conventional coagulation tests (CCTs). Patients’ information and intra-operative blood loss as a percentage of estimated blood volume were recorded. Spearman’s correlation analyses were used for discovering the relationship between indices in r-TEG or CCTs and the intra-operative blood loss. The significant correlated index of r-TEG was further investigated using linear regression analysis. Results A total of 181 patients participated in this study. Intra-operative change of α-angle, which reflects the fibrinogen level and function, was the only r-TEG index that correlated with blood loss significantly (P=0.013, r= -0.184), thus challenging the current empirical cognition of the effects of intra-operative hemorrhage on coagulation. As intra-operative blood loss increased, α-angle decreased, and every 1% loss of estimated blood volume (EBV) led to 0.60 degree decrease of α-angle. As for CCT results, changes of fibrinogen and platelet count were also significantly correlated with blood loss (P=0.015 and P=0.001, respectively).Conclusions Peri-operative change of α-angle, as an index of r-TEG, exhibited a significant negative correlation with intra-operative blood loss. The impact of hemorrhage on fibrinogen, instead of clotting factors, should be scrutinized.

Key words: blood transfusion management, rapid-thrombelastography, intra-operative blood loss, neurosurgery

Zhang Xue, Yu Xuerong, Huang* Yuguang. The Correlation of Indices in r-TEG with Intra-operative Blood Loss in Neurosurgical Patients[J].Chinese Medical Sciences Journal, 2017, 32(2): 69-74.

图/表 5

参考文献 20.

1.	American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies. Practice guidelines for perioperative blood transfusion and adjuvant therapies: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies. Anesthesiology. 2006; 105:198-208.
2.	Dara SI, Rana R, Afessa B, et al.Fresh frozen plasma transfusion in critically ill medical patients with coagulopathy. Crit Care Med 2005; 33: 2667-71. doi: 10.1097/01.CCM.0000186745.53059.F0.
3.	Sarani B, Dunkman WJ, Dean L, et al.Transfusion of fresh frozen plasma in critically ill surgical patients is associated with an increased risk of infection. Crit Care Med 2008; 36:1114-8. doi:10.1097/CCM.0b013e318168f89d.
4.	Khan H, Belsher J, Yilmaz M, et al.Fresh-frozen plasma and platelet transfusions are associated with development of acute lung injury in critically ill medical patients. Chest 2007; 131:1308-14. doi:10.1378/chest. 06-3048.
5.	Cotton BA, Faz G, Hatch QM, et al.Rapid thrombelastography delivers real-time results that predict transfusion within 1 hour of admission. J Trauma. 2011; 71: 407-17. doi:10.1097/TA.0b013e31821e1bf0.
6.	Jeger V, Zimmermann H, Exadaktylos AK.Can Rapid TEG accelerate the search for coagulopathies in the patient with multiple injuries? J Trauma 2009; 66:1253-7. doi:10. 1097/TA.0b013e31819d3caf.
7.	Reikvam H, Steien E, Hauge B, et al.Thrombelastography. Transfus Apher Sci 2009; 40:119-23. doi:10.1016/j. transci.2009.01.019.
8.	Schöchl H, Nienaber U, Maegele M, et al.Transfusion in trauma: thromboelastometry-guided coagulation factor concentrate-based therapy versus standard fresh frozen plasma-based therapy. Crit Care 2011; 15:R83. doi:10. 1186/cc10078.
9.	Wikkelsoe AJ, Afshari A, Wetterslev J, et al.Monitoring patients at risk of massive transfusion with thrombelastography or thromboelastometry: a systematic review. Acta Anaesthesiol Scand 2011; 55:1174-89. doi:10. 1111/j.1399-6576.2011.02534.x.
10.	Kunio NR, Differding JA, Watson KM, et al.Thrombelastography-identified coagulopathy is associated with increased morbidity and mortality after traumatic brain injury. Am J Surg 2012; 203: 584-8. doi:10.1016/j.amjsurg. 2011.12.011.
11.	Windeløv NA, Welling KL, Ostrowski SR, et al.The prognostic value of thrombelastography in identifying neurosurgical patients with worse prognosis. Blood Coagul Fibrinolysis 2011; 22:416-9. doi:10.1097/MBC. 0b013e3283464f53.
12.	Cotton BA, Minei KM, Radwan ZA, et al.Admission rapid thrombelastography predicts development of pulmonary embolism in trauma patients. J Trauma Acute Care Surg 2012; 72:1470-5. doi:10.1097/TA.0b013e31824d56ad.
13.	Kaye AD, Riopelle JM.Intravascular fluid and electrolyte physiology. In: Miller RD. Miller’s Anesthesia. 7th ed. Philiadephia: Chuichill Livingstone; 2010. p. 1728-30.
14.	Fries D.The early use of fibrinogen, prothrombin complex concentrate, and recombinant-activated factor VIIa in massive bleeding. Transfusion 2013; 53:91S-95S. doi:10. 1111/trf.12041.
15.	Gerlach R, Tölle F, Raabe A, et al.Increased risk for postoperative hemorrhage after intracranial surgery in patients with decreased factor XIII activity: implications of a prospective study. Stroke 2002; 33:1618-23. doi:10. 1161/01.STR.0000017219.83330.FF.
16.	Charbit B, Mandelbrot L, Samain E, et al.The decrease of fibrinogen is an early predictor of the severity of postpartum hemorrhage. J Thromb Haemost 2007; 5: 266-73. doi:10.1111/j.1538-7836.2007.02297.x.
17.	Blome M, Isgro F, Kiessling AH, et al.Relationship between factor XIII activity, fibrinogen, haemostasis screening tests and postoperative bleeding in cardiopulmonary bypass surgery. Thromb Haemost 2005; 93:1101-7. doi:10.1160/TH04-12-0799.
18.	Levy JH, Welsby I, Goodnough LT.Fibrinogen as a therapeutic target for bleeding: a review of critical levels and replacement therapy. Transfusion 2014; 54: 1389-405. doi:10.1111/trf.12431.
19.	Plotkin AJ, Wade CE, Jenkins DH, et al.A reduction in clot formation rate and strength assessed by thrombelastography is indicative of transfusion requirements in patients with penetrating injuries. J Trauma 2008; 64:S64-8. doi:10.1097/TA.0b013e318160772d.
20.	Kashuk JL, Moore EE, Le T, et al.Noncitrated whole blood is optimal for evaluation of postinjury coagulopathy with point-of-care rapid thrombelastography. J Surg Res 2009; 156:133-8. doi:10.1016/j.jss.2009. 03.046.

Categories	r-TEG indices				CCT indices
Categories	ACT (sec)	K-time (min)	α-angle (degree)	MA (mm)	PT(s)	APTT(s)	INR	FBG (g/L)	PLT (×10⁹/L)
Pre-operative	112.07±10.23	1.65±0.59	70.70±6.04	59.71±6.15	11.32±0.78	28.00±13.31	0.99±0.08	2.94±0.67	238.48±54.96
Post-operative	114.54±10.71	1.79±0.67	69.69±6.04	57.12±6.04	12.54±0.89	30.71±6.09	1.12±0.09	2.11±0.72	198.92±48.18
Peri-operative changes	2.45±8.32	0.14±0.34	-0.99±2.64	-2.58±4.53	1.22±0.74	2.72±13.84	0.13±0.09	-0.83±0.63	-39.56±34.83
P value	<0.01	<0.01	<0.01	<0.01	<0.01	<0.01	<0.01	<0.01	<0.01

d(index)* of r-TEG	r_s	P value
ACT	0.005	0.948
K	0.095	0.203
α-angle	-0.184	0.013^**
MA	-0.104	0.164

Subgroup no.	Number of patients	d(α-angle) (degree)	Blood loss of EBV (%)
1	1	-8<dα≤-7	42.2
2	3	-7<dα≤-6	16.2±5.1
3	7	-6<dα≤-5	6.1±3.5
4	11	-5<dα≤-4	13.2±8.5
5	9	-4<dα≤-3	13.8±12.1
6	32	-3<dα≤-2	9.0±9.1
7	33	-2<dα≤-1	7.1±5.2
8	30	-1<dα≤0	7.0±4.2
9	23	0<dα≤1	6.6±3.2
10	16	1<dα≤2	6.4±3.6
11	7	2<dα≤3	5.1±2.9
12	6	3<dα≤4	11.5±7.6
13	1	4<dα≤5	0.5
14	0	5<dα≤6	-
15	1	6<dα≤7	3.8
16	1	7<dα≤8	3.7

d (index)* of CCT	r_s	P value
PT	0.076	0.307
APTT	0.093	0.212
INR	0.041	0.587
FBG	-0.180	0.015^**
PLT	-0.253	0.001^**

优先出版

当期目次

过刊浏览

虚拟专题

作者中心

评阅者中心