纤维蛋白溶解大于 3% 是启动抗纤维蛋白溶解治疗的临界值。
Fibrinolysis greater than 3% is the critical value for initiation of antifibrinolytic therapy.
机构信息
From the Department of Surgery (M.P.C., C.R.R., J.N.H., T.L.C., J.R.S., A.S., A.B.), University of Colorado-Denver; Denver Health Medical Center (M.P.C., E.E.M., C.R.R., A.G., J.N.H., T.L.C., J.R.S., A.S.); Medical College of Georgia (M.P.C.); and Bonfils Blood Center (C.C.S.), Denver, Colorado.
出版信息
J Trauma Acute Care Surg. 2013 Dec;75(6):961-7; discussion 967. doi: 10.1097/TA.0b013e3182aa9c9f.
BACKGROUND
The acute coagulopathy of trauma is present in up to one third of patients by the time of admission, and the recent CRASH-2 and MATTERs trials have focused worldwide attention on hyperfibrinolysis as a component of acute coagulopathy of trauma. Thromboelastography (TEG) is a powerful tool for analyzing fibrinolyis, but a clinically relevant threshold for defining hyperfibrinolysis has yet to be determined. Recent data suggest that the accepted normal upper bound of 7.5% for 30-minute fibrinolysis (LY30) by TEG is inappropriate in severe trauma, as the risk of death rises at much lower levels of clot lysis. We wished to determine the validity of this hypothesis and establish a threshold value to treat fibrinolysis, based on prediction of massive transfusion requirement and risk of mortality.
METHODS
Patients with uncontrolled hemorrhage, meeting the massive transfusion protocol (MTP) criteria at admission (n = 73), represent the most severely injured trauma population at our center (median Injury Severity Score [ISS], 30; interquartile range, 20-38). Citrated kaolin TEG was performed at admission blood samples from this population, stratified by LY30, and evaluated for transfusion requirement and 28-day mortality. The same analysis was conducted on available field blood samples from all non-MTP trauma patients (n = 216) in the same period. These represent the general trauma population.
RESULTS
Within the MTP-activating population, the cohort of patients with LY30 of 3% or greater was shown to be at much higher risk for requiring a massive transfusion (90.9% vs. 30.5%, p = 0.0008) and dying of hemorrhage (45.5% vs. 4.8%, p = 0.0014) than those with LY30 less than 3%. Similar trends were seen in the general trauma population.
CONCLUSION
LY30 of 3% or greater defines clinically relevant hyperfibrinolysis and strongly predicts the requirement for massive transfusion and an increased risk of mortality in trauma patients presenting with uncontrolled hemorrhage. This threshold value for LY30 represents a critical indication for the treatment of fibrinolysis.
LEVEL OF EVIDENCE
Prognostic study, level III.
背景
创伤后急性凝血病在患者入院时可达三分之一，最近的 CRASH-2 和 MATTERs 试验引起了全球对创伤后急性凝血病中纤维蛋白溶解亢进的关注。血栓弹性描记术（TEG）是分析纤维蛋白溶解的有力工具，但尚未确定定义纤维蛋白溶解亢进的临床相关阈值。最近的数据表明，TEG 中 30 分钟纤维蛋白溶解的可接受正常上限 7.5%（LY30）在严重创伤中并不合适，因为在较低的血凝块溶解水平时，死亡风险会增加。我们希望确定这一假设的有效性，并根据对大量输血需求和死亡率的预测，建立一个治疗纤维蛋白溶解的阈值。
方法
我们中心的最严重创伤患者（中位创伤严重程度评分 [ISS]为 30，四分位距 [IQR]为 20-38），无控制出血并符合入院时的大量输血方案（MTP）标准（n=73）。从该人群的入院血样中进行枸橼酸高岭土 TEG，按 LY30 分层，并评估输血需求和 28 天死亡率。在同一时期，对所有非 MTP 创伤患者（n=216）的可用现场血样进行了相同的分析。这些代表一般创伤人群。
结果
在激活 MTP 的人群中，LY30 为 3%或更高的患者组需要大量输血的风险更高（90.9% vs. 30.5%，p=0.0008），死于出血的风险更高（45.5% vs. 4.8%，p=0.0014），而 LY30 低于 3%的患者组则不然。在一般创伤人群中也出现了类似的趋势。
结论
LY30 为 3%或更高定义了临床上相关的纤维蛋白溶解亢进，并强烈预测创伤患者出现无控制出血时需要大量输血和死亡率增加的风险。LY30 的这一阈值代表了纤维蛋白溶解治疗的一个关键指征。
证据水平
预后研究，III 级。
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