在大出血的大手术期间，实验室凝血试验和凝血因子水平对旋转血栓弹性描记术（ROTEM(R)）的影响。
The influence of laboratory coagulation tests and clotting factor levels on Rotation Thromboelastometry (ROTEM(R)) during major surgery with hemorrhage.
机构信息
Institute of Anesthesiology, University Hospital Zurich, CH-8091 Zurich, Switzerland.
出版信息
Anesth Analg. 2013 Aug;117(2):314-21. doi: 10.1213/ANE.0b013e31829569ac. Epub 2013 Jun 18.
BACKGROUND
The aim of this study was to determine the association between standard laboratory tests, coagulation factor concentrations, and Rotation Thromboelastometry (ROTEM® delta, TEM® International GmbH, Munich, Germany) in patients undergoing major surgery with hemorrhage.
METHODS
In 45 patient's fibrinogen, factor VIII, factor XIII, International Normalized Ratio (INR), activated partial thromboplastin time (aPTT), thrombin time, hemoglobin, leukocytes, and platelet count were simultaneously measured intraoperatively with ROTEM (EXTEM, INTEM, FIBTEM, APTEM) measurements. ROTEM parameters were: clotting time (CT), clot formation time (CFT), maximum clot firmness (MCF), and α-angle. Demographic and laboratory data were expressed as mean ± SD and median [range]; nonparametric Spearman rank correlations and multiple linear regressions were performed; P-values ≤0.003 were considered significant.
RESULTS
Significant correlations (P ≤ 0.003) were found for CFT, α-angle, and MCF, in EXTEM, INTEM, and APTEM with platelets, INR, and fibrinogen. Factor VIII (18 measurements) showed a strong correlation (r ≥ 0.7 or r ≤ -0.7; all P ≤ 0.003) with MCF, CFT, and α-angle of EXTEM, INTEM, MCF of FIBTEM excluding CT of EXTEM, INTEM, FIBTEM and strong significant correlation for α-angle of APTEM and moderate for CFT and MCF of APTEM. A significant moderate to strong correlation of factor XIII with MCF of EXTEM, INTEM, FIBTEM, and APTEM was found. Hemoglobin was moderately correlated (r = 0.3-0.7 or r = -0.3 to -0.7) with MCF in APTEM (P = 0.003). A moderate to strong correlation of the standard coagulation tests with all ROTEM parameters was found, in particular the CT. The aPTT correlated significantly moderate to strong with CT, CFT, α-angle, and MCF of INTEM. However, multiple linear regressions were not able to show an influence of INR on ROTEM parameters except for APTEM-MCF. A significant impact of the aPTT on INTEM-CT was found. EXTEM, INTEM, and APTEM are significantly influenced by fibrinogen and platelets.
CONCLUSIONS
The results confirm the clinical assumption that EXTEM, INTEM, and APTEM are associated with fibrinogen and platelets levels; INTEM-CT significantly to aPTT; and FIBTEM significantly to fibrinogen. Factor VIII showed a significant correlation with all ROTEM parameters except CT of EXTEM, INTEM, FIBTEM, and CFT and MCF of APTEM.
背景
本研究旨在确定标准实验室检测指标、凝血因子浓度与旋转血栓弹性描记术（ROTEM® delta，TEM® International GmbH，慕尼黑，德国）在接受大出血大手术患者中的关联。
方法
在 45 例患者中，术中同时进行纤维蛋白原、VIII 因子、XIII 因子、国际标准化比值（INR）、活化部分凝血活酶时间（aPTT）、凝血酶时间、血红蛋白、白细胞和血小板计数的检测，并同时进行 ROTEM（EXTEM、INTEM、FIBTEM、APTEM）检测。ROTEM 参数包括：凝血时间（CT）、凝血形成时间（CFT）、最大凝块硬度（MCF）和 α 角。数据以均数±标准差和中位数[范围]表示；采用非参数 Spearman 秩相关和多元线性回归分析；P 值≤0.003 为差异有统计学意义。
结果
在 EXTEM、INTEM 和 APTEM 中，CFT、α 角和 MCF 与血小板、INR 和纤维蛋白原显著相关（P≤0.003）。VIII 因子（18 次测量）与 EXTEM、INTEM、MCF 的 CFT 和 α 角呈强相关（r≥0.7 或 r≤-0.7；所有 P≤0.003），与 EXTEM、INTEM 的 MCF、FIBTEM 除外的 CFT 和 α 角呈强显著相关，与 APTEM 的 α 角呈强相关，与 APTEM 的 CFT 和 MCF 呈中度相关。XIII 因子与 EXTEM、INTEM、FIBTEM 和 APTEM 的 MCF 有显著中度至强相关。血红蛋白与 APTEM 的 MCF 呈中度相关（r=0.3-0.7 或 r=-0.3 至-0.7；P=0.003）。标准凝血试验与所有 ROTEM 参数均呈中度至强相关，尤其是 CT。APTT 与 INTEM 的 CT、CFT、α 角和 MCF 显著中度至强相关。然而，多元线性回归未能显示 INR 对 ROTEM 参数的影响，除了 APTEM-MCF。APTT 对 INTEM-CT 的影响显著。EXTEM、INTEM 和 APTEM 显著受纤维蛋白原和血小板的影响。
结论
结果证实了临床假设，即 EXTEM、INTEM 和 APTEM 与纤维蛋白原和血小板水平相关；INTEM-CT 与 aPTT 显著相关；FIBTEM 与纤维蛋白原显著相关。VIII 因子与除 EXTEM、INTEM、FIBTEM 的 CT 以及 APTEM 的 CFT 和 MCF 外的所有 ROTEM 参数均呈显著相关。
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