Department of Surgery, University of Colorado Denver, Aurora, CO, USA.
Shock. 2013 Jan;39(1):45-9. doi: 10.1097/SHK.0b013e3182787122.
Thromboelastography (TEG) is emerging as the standard in the management of acute coagulopathies in injured patients. Although TEG is sensitive in detecting abnormalities in clot strength, one shortcoming is differentiating between fibrinogen and platelet contributions to clot integrity. Current American algorithms suggest platelet transfusion, whereas European guidelines suggest fibrinogen concentrates for correcting low clot strength. Therefore, we hypothesized that a TEG-based functional fibrinogen (FF) assay would assess the contribution of fibrinogen and platelets to clot strength and provide insight to transfusion priorities. Blood samples were obtained from trauma patients on arrival to the emergency department or who were admitted to the surgical intensive care unit (n = 68). Citrated kaolin TEG, FF, and von Clauss fibrinogen levels (plasma-based clinical standard) were measured. Correlations were assessed using linear regression models. In vitro studies were also performed with adding fibrinogen concentrates to blood collected from healthy volunteers (n = 10). Functional fibrinogen and citrated kaolin TEG parameters were measured. Functional fibrinogen strongly correlated with von Clauss fibrinogen levels (R = 0.87) and clot strength (R = 0.80). The mean fibrinogen contribution to clot strength was 30%; however, there was a direct linear relationship with fibrinogen level and percent fibrinogen contribution to clot strength (R = 0.83). Traditional TEG parameters associated with fibrinogen activity (α angle and kinetic time) had significantly lower correlations with FF (R = 0.70 and 0.35). Furthermore, platelet count had only a moderate correlation to clot strength (R = 0.51). The addition of fibrinogen concentrate in in vitro studies increased clot strength (MA) (60.44 ± 1.48 to 68.12 ± 1.39) and percent fibrinogen contribution to clot strength (23.8% ± 1.8% to 37.7% ± 2.5%). Functional fibrinogen can be performed rapidly with TEG and correlates well with the standard von Clauss fibrinogen assay. Both fibrinogen and platelet contribution of clot strength can be derived from FF. Moreover, FF had a stronger correlation to clot strength, and increased levels were directly associated with increased percent contribution to clot strength. In vitro studies also demonstrated an increase in FF, clot strength, and percent fibrinogen contribution to clot strength with the addition of fibrinogen concentrate. These data suggest that fibrinogen should be addressed early in trauma patients manifesting acute coagulopathy of trauma.
血栓弹力图（TEG）在受伤患者急性凝血病管理中崭露头角，成为标准。尽管 TEG 对检测凝块强度异常很敏感，但它有一个缺点，即无法区分纤维蛋白原和血小板对凝块完整性的贡献。目前的美国算法建议进行血小板输注，而欧洲指南建议使用纤维蛋白原浓缩物纠正低凝块强度。因此，我们假设 TEG 基于的功能性纤维蛋白原（FF）测定法将评估纤维蛋白原和血小板对凝块强度的贡献，并提供有关输血优先级的见解。从到达急诊科的创伤患者或被收入外科重症监护病房的患者中采集血液样本（n=68）。测量枸橼酸盐高岭土 TEG、FF 和基于血浆的临床标准 von Clauss 纤维蛋白原水平。使用线性回归模型评估相关性。还对从健康志愿者采集的血液中添加纤维蛋白原浓缩物进行了体外研究（n=10）。测量功能性纤维蛋白原和枸橼酸盐高岭土 TEG 参数。功能性纤维蛋白原与 von Clauss 纤维蛋白原水平（R=0.87）和凝块强度（R=0.80）呈强相关性。纤维蛋白原对凝块强度的平均贡献为 30%；然而，纤维蛋白原水平与纤维蛋白原对凝块强度的贡献百分比之间存在直接线性关系（R=0.83）。与纤维蛋白原活性相关的传统 TEG 参数（α角和动力学时间）与 FF 的相关性明显较低（R=0.70 和 0.35）。此外，血小板计数与凝块强度的相关性仅为中度（R=0.51）。在体外研究中添加纤维蛋白原浓缩物可增加凝块强度（MA）（60.44±1.48 至 68.12±1.39）和纤维蛋白原对凝块强度的贡献百分比（23.8%±1.8%至 37.7%±2.5%）。FF 可以通过 TEG 快速进行，与标准的 von Clauss 纤维蛋白原测定法相关性良好。纤维蛋白原和血小板对凝块强度的贡献都可以从 FF 中得出。此外，FF 与凝块强度的相关性更强，并且增加的水平与增加的纤维蛋白原对凝块强度的贡献百分比直接相关。体外研究还表明，添加纤维蛋白原浓缩物可增加 FF、凝块强度和纤维蛋白原对凝块强度的贡献百分比。这些数据表明，在表现出创伤性急性凝血病的创伤患者中，应尽早解决纤维蛋白原问题。
