摘要目的 探讨血栓弹力图(TEG)相关指标判断多发伤患者预后的价值.方法 采用回顾性病例对照研究分析2015年9月 —2017年12月解放军第九十四医院收治的155例多发伤患者的临床资料,其中男118例,女37例;年龄18～88岁[(49.0±1.3)岁].损伤严重度评分(ISS)为(26.4±11.0)分.143例伤后90 d生存(生存组),12例伤后90 d死亡(死亡组).收集患者刚入院时的ISS、急性生理与慢性健康评估Ⅱ(APACHEⅡ)评分、格拉斯哥昏迷评分(GCS)、收缩压(SBP)、呼吸频率(RR)和伤后90 d结局;入ICU 2 h内的血小板计数(PLT)、红细胞计数(RBC)、血红蛋白(Hb)、血浆凝血酶原时间(PT)、活化部分凝血活酶时间(APTT)、纤维蛋白原(FIB)、国际标准化比值(INR)、凝血酶时间(TT),以及TEG的凝血反应时间(R)、血块形成速率(K)、血块形成动力学(α角)、血块最大强度(MA)、凝血综合指数(CI)、血凝块强度(G)、弹性常数(E)和血块溶解时间(CLT).比较组间TEG相关指标的变化,并进行Logistic回归分析和受试者工作特征(ROC)曲线分析.结果 与生存组比较,死亡组ISS和APACHEⅡ评分明显升高,而GCS、SBP、RR、RBC和Hb明显降低(P均<0.05).与生存组PT[(16.5±4.3)s]和FIB[(2.7±1.7)g/L]比较,死亡组PT[(21.1±9.1)s]显著延长,且FIB[(1.7±1.5)g/L]明显降低(P均<0.05).与生存组K[2.9(2.1,4.2)min]比较,死亡组K[5.2(1.8,8.0)min]显著延长(P<0.05).与生存组G(6366.5±3886.1)、E(127.3±77.7)、α角[(49.4±16.6)°]、MA[(52.0±13.3)mm]、CI[-2.9(-5.9,-0.7)]和CLT[46.4(32.7,60.8)min]比较,死亡组G(3762.4±3346.7)、E(75.3±67.0)、α角[(38.4±19.7)°]、MA[(37.4±17.5)mm]、CI[-6.8(-9.5,1.5)]和CLT[39.2(32.5,46.9)min]显著降低(P均<0.05).两组间PLT、APTT、INR、TT和R差异均无统计学意义(P>0.05).Logistic回归分析显示,MA与多发伤患者的预后显著相关(OR=1.15,95％CI 1.04～1.28,P<0.05).MA的ROC曲线下面积为0.756(P<0.05).取MA界值为43.1 mm时,预测患者生存的敏感度、特异度、阳性预测值和阴性预测值分别为77.5％、76.9％、76.1％和97.3％.结论 TEG指标MA能够判断多发伤患者的预后,且MA<43.1 mm时多发伤患者的病死率会显著升高.

abstractsObjective To investigate the value of thromboelastography ( TEG) in evaluating the prognosis of polytrauma patients. Methods A retrospective case control study was conducted to analyze the clinical data of 155 polytrauma patients admitted to 94th Hospital of People's Liberation Army from September 2015 to December 2017. There were 118 males and 37 females, aged 18-88 years [(49. 0 ± 1. 3)years]. Injury severity score (ISS) was (26. 4 ± 11. 0)points. According to the prognosis of patients 90 days after injury, the patients were divided into survival group ( 143 patients ) and death group (12 patients). The ISS on admission, acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ), Glasgow coma score ( GCS ) , systolic blood pressure ( SBP ) , respiratory rate ( RR ) and outcome of 90 days after injury were collected. Red blood cells( RBC) , hemoglobin( Hb) , plasma prothrombin time ( PT) , activated partial thromboplastin time ( APTT) , fibrinogen ( FIB) , international normalized ratio ( INR) , thrombin time ( TT) , platelet count ( PLT) and TEG-related indicators within 2 hours after ICU admission were collected. TEG-related indicators including TCG clotting reaction time ( R ) , clot formation rate (K), clot formation kinetics (α angle), maximum amplitude (MA), coagulation index (CI), blood clotting strength (G), elasticity constant (E) and clot lysis time (CLT) were collected within 2 hours after admission to ICU. The changes of TEG-related indicators were compared between the two groups, and logistic regression analysis and receiver operating characteristic ( ROC) curve analysis were performed. Results Compared with the survival group, ISS and APACHE II scores in the death group were significantly higher, while GCS, SBP, RR, RBC and Hb were significantly lower (P<0. 05). Compared with the survival group, death group showed significantly prolonged PT [(21. 1 ± 9. 1) s vs. (16. 5 ± 4. 3)s] as well as reduced FIB [(1. 7 ± 1. 5)g/L vs. (2. 7 ± 1. 7)g/L] (P<0. 05). Compared with the survival group, the K value in the death group was significantly prolonged [5. 2(1. 8,8. 0)min vs. 2. 9(2. 1,4. 2)min] (P<0. 05). Compared with the survival group, death group showed significant decrease in G value (3762. 4 ± 3346. 7 vs. 6366. 5 ± 3886. 1), E value (75. 3 ± 67. 0 vs. 127. 3 ± 77.7),αangle[(38.4±19.7)°vs. (49.4±16.6)°],MA[(37.4±17.5)mmvs.(52.0±13.3)mm], CI [-6. 8(-9. 5, 1. 5) vs. -2. 9 ( -5. 9, -0. 7)] and CLT [39. 2 (32. 5, 46. 9) min vs. 46. 4 (32. 7, 60.8) min] (P<0. 05). There were no significant differences in APTT, TT, INR, PLT and R between the two groups (P>0. 05). Logistic regression analysis showed that MA was significantly associated with the prognosis of polytrauma patients (OR=1. 15, 95％ CI 1. 04-1. 28, P<0. 05). The area under the ROC curve of MA was 0. 756 (P <0. 05). When the MA threshold was 43. 1 mm, the sensitivity, specificity, positive predictive value and negative predictive value of predicted survival were 77. 5％, 76. 9％, 76. 1％ and 97. 3％, respectively. Conclusion TEG index MA can determine the prognosis of polytrauma patients, and the mortality rate is significantly increased at MA<43. 1 mm.