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中华临床医师杂志(电子版)

中华临床医师杂志(电子版) ›› 2022, Vol. 16 ›› Issue (09) : 881 -886. doi: 10.3877/cma.j.issn.1674-0785.2022.09.012

临床研究

TEG对脓毒症患者DIC诊断及预后的影响
张涛1, 万亚楠1, 卢昕媛1, 赵庆忠1, 韩振1, 宋威1, 万健1,†()   
  1. 1. 201200　上海，上海市浦东新区人民医院急诊与危重症医学科
  • 收稿日期:2022-03-03 出版日期:2022-09-15
  • 通信作者: 万健
  • 基金资助:
    上海市医学重点专科建设项目(ZK2019C08); 上海市浦东新区卫生系统领先人才培养项目(PWRl2018-08)

Role of thromboelastography in diagnosis and prognosis evaluation of disseminated intravascular coagulation in patients with sepsis

Tao Zhang1, Yanan Wan1, Xinyuan Lu1, Qingzhong Zhao1, Zhen Han1, Wei Song1, Jian Wan1,†()   

  1. 1. Department of Emergency and Critical Care Medicine, Shanghai Pudong New Area People's Hospital, Shanghai 201200, China
  • Received:2022-03-03 Published:2022-09-15
  • Corresponding author: Jian Wan
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张涛, 万亚楠, 卢昕媛, 赵庆忠, 韩振, 宋威, 万健. TEG对脓毒症患者DIC诊断及预后的影响[J]. 中华临床医师杂志(电子版), 2022, 16(09): 881-886.

Tao Zhang, Yanan Wan, Xinyuan Lu, Qingzhong Zhao, Zhen Han, Wei Song, Jian Wan. Role of thromboelastography in diagnosis and prognosis evaluation of disseminated intravascular coagulation in patients with sepsis[J]. Chinese Journal of Clinicians(Electronic Edition), 2022, 16(09): 881-886.

目的

探讨血栓弹力图（TEG）各参数对脓毒症患者DIC的诊断和排除价值及其预后的影响。

方法

收集2021年1月1日至2021年12月31日上海市浦东新区人民医院重症医学科符合脓毒症3.0且入院当天测过血栓弹力图并经过脓毒症DIC预警系统筛查的100例，记录患者的一般情况，包括年龄、性别，入科当天的外周血，检测入组患者初始血乳酸、白细胞计数、血小板计数、C反应蛋白、血红蛋白、白蛋白、D-二聚体、纤维蛋白原浓度、凝血酶原时间、国际标准化比率、部分凝血活酶时间及血栓弹力图参数（反应时间（R）、血凝块形成时间（K）和形成速率（α角）、最大振幅（MA））等实验室检查指标，以及SOFA评分、APACHEⅡ评分、及90天生存状态。根据脓毒症DIC预警系统筛查结果分为DIC组与非DIC组。运用受试者工作曲线（ROC）来评估血栓弹力图对脓毒症患者DIC的预测价值，用Kaplan-Meier曲线探讨其对脓毒症患者预后的影响。

结果

比较2组患者凝血指标发现，PT（DIC组 vs 非DIC组；P=0.011）及INR（DIC组 vs 非DIC组；P＜0.001）都有不同程度的延长，并且在血栓弹力图的参数中也发现R（DIC组 vs 非DIC组；P＜0.001）和K（DIC组 vs 非DIC组；P＜0.001）显著延长及α角（DIC组 vs 非DIC组；P=0.001）和MA（DIC组 vs 非DIC组；P＜0.001）明显降低；利用ROC曲线进行分析发现诊断DIC的R和K曲线下面积分别为0.928（95%CI：0.875~0.982）和0.752（95%CI：0.638~0.866），排除DIC的α角与MA曲线下面积分别为0.720（95%CI：0.602~0.837）和0.930（95%CI：0.878~0.979）；ROC分析血栓弹力图参数预测脓毒症患者90天生存率发现MA的曲线下面积为0.707（95%CI：0.578~0.836），而R、K和α角则不能预测；Kaplan-Meier生存曲线分析同样发现MA值是预测脓毒症患者90天生存率的良好指标（P=0.001）。

结论

TEG参数可作为诊断及排除DIC的一种有效方法；MA值可作为预测脓毒症患者90天生存率的良好指标。

关键词: 脓毒症, DIC预警系统, 血栓弹力图, 预后
Objective

To explore the role of thromboelastography (TEG) parameters in the diagnosis and prognosis evaluation of disseminated intravascular coagulation (DIC) in patients with sepsis.

Methods

From January 1, 2021 to December 31, 2021, 100 patients with sepsis meeting Sepsis 3.0 criteria, who underwent thromboelastography on the day of admission and were screened for sepsis by the DIC early warning system, were collected at the Department of Critical Care Medicine, Shanghai Pudong New Area People's Hospital. The general and clinical data of the patients, including age, gender, peripheral blood parameters on the day of admission (initial blood lactate, white blood cell count, platelet count, C-reactive protein, hemoglobin, albumin, D-dimer, fibrinogen concentration, prothrombin time, international normalized ratio, and partial thromboplastin time), and thromboelastography parameters [reaction time, clot formation time and rate of formation (alpha angle), and maximum amplitude (MA)], as well as SOFA score, APACHE II score, and 90-day survival status were recorded. According to the presence of DIC or not, the patients were divided into either a DIC group or a non-DIC group. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the predictive value of thromboelastometry for DIC in patients with sepsis, and the Kaplan-Meier curve was used to explore its impact on the prognosis of patients with sepsis.

Results

Comparing the coagulation indexes of the two groups, it was found that PT (P=0.011) and INR (P＜0.001) were prolonged in the DIC group. Regarding the thromboelastography parameters, reaction time (P＜0.001) and clot formation time (P＜0.001) were significantly prolonged in the DIC group, while α angle (P=0.001) and MA (P＜0.001) were significantly decreased. ROC curve analysis showed that the areas under the curves of reaction time and clot formation time for the diagnosis of DIC were 0.928 (95% confidence interval [CI]: 0.875~0.982) and 0.752 (95%CI: 0.638~0.866), respectively, while those of the alpha angle and MA for excluding DIC were 0.720 (95%CI: 0.602~0.837) and 0.930 (95%CI: 0.878~0.979), respectively. ROC analysis of thromboelastography parameters for predicting 90-day survival in patients with sepsis revealed that the area under the curve for MA was 0.707 (95%CI: 0.578~0.836), while reaction time, clot formation time, and alpha angle were not predictive. Kaplan-Meier survival curve analysis also demonstrated that MA value was a good predictor of 90-day survival in patients with sepsis (P=0.001).

Conclusion

TEG parameters can be used as an effective method to diagnose and exclude DIC. MA value can be used as a good indicator to predict the 90-day survival rate of sepsis patients.

Key words: Sepsis, DIC warning system, Thromboelastography, Prognosis
图1 脓毒症DIC预警系统
表1 DIC组与非DIC组一般资料分析
一般资料 DIC组（n=20） 非DIC组（n=80） t/z值 P值
年龄（岁） 72.15±12.39 70.96±13.33 0.407 0.689
性别（男/女） （12/8） （41/39） -0.744 0.459
白细胞（×109/L） 14.98±6.43 14.06±5.16 0.595 0.553
血小板（×109/L） 150.25±76.78 175.06±84.71 -1.195 0.235
C-反应蛋白 99.17（40.74，164.3） 79.30（32.94，127.85） -1.021 0.307
血红蛋白 107.70±12.62 109.46±16.89 -0.481 0.632
白蛋白 29.32±3.07 30.54±3.46 -1.393 0.167
乳酸 7.57±2.96 5.95±3.02 2.090 0.043
SOFA评分 9.45±2.96 7.48±2.39 3.145 0.002
APACHEⅡ评分 27.15±7.61 20.48±8.89 3.042 0.003
表2 2组患者凝血指标比较
项目 DIC组（n=20） 非DIC组（n=80） t/z值 P值
PT（s） 16.18±2.63 14.45±2.67 2.595 0.011
APTT（s） 42.09±10.37 37.90±8.05 1.960 0.053
INR 139±0.16 1.18±0.22 4.038 ＜0.001
FIB（g/L） 4.17±1.79 4.47±1.59 -0.747 0.457
D-D（mg/L） 13.41（4.13，24.68） 5.81（2.62，14.86） -2.224 0.026
R 8.86±1.32 5.97±1.38 8.438 ＜0.001
K 4.72±1.63 2.90±1.72 4.256 ＜0.001
α 46.98±6.33 52.95±7.48 -3.283 0.001
MA 46.14±7.86 61.26±8.48 -7.567 ＜0.001
表3 血栓弹力图参数与DIC相关性
项目 AUC 敏感性（%） 特异性（%） 95%CI 诊断阈值 P值
R 0.928 95% 80% 0.875~0.982 7.00 ＜0.001
K 0.752 85% 71.2% 0.638~0.866 3.45 0.001
α 0.720 85% 56.2% 0.602~0.837 51.4 0.002
MA 0.930 90% 81.2% 0.880~0.979 55.8 ＜0.001
图2 MA预测脓毒症患者90 d生存率
图3 Kalan-Meier 曲线分析MA预测价值
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