Prakash Shivesh, Verghese Santosh, Roxby David, Dixon Dani, Bihari Shailesh, Bersten Andrew
Department of Critical Care Medicine, Flinders Medical Centre, Bedford Park, SA 5042, Australia.
Department of Critical Care Medicine, Flinders Medical Centre, Bedford Park, SA 5042, Australia.
J Crit Care. 2015 Apr;30(2):264-70. doi: 10.1016/j.jcrc.2014.10.014. Epub 2014 Oct 22.
We hypothesized that the thromboelastometry (ROTEM; Pentapharm GmbH, Munich, Germany) fibrinolysis parameter "maximum lysis" (ML) would have an independent inverse association with the severity of organ failure in sepsis.
Selected adult patients with sepsis (n = 77) were recruited within 24 hours of antibiotic commencement. Patients with Sequential Organ Failure Assessment score higher than 1 (n = 57) were followed for 72 hours. Prothrombin fragments 1 + 2, plasminogen activator inhibitor-1 (aPAI-1), ROTEM, and routine coagulation tests were measured daily along with Sequential Organ Failure Assessment scores.
The activity of functional aPAI-1 increased with increasing severity of organ failure (P = .01) and was higher as compared with healthy controls (95% confidence interval, -65.4 to -29.9; P < .001). There was a decreasing trend in ML with increased organ failure (P = .001); however, there was no trend in d-dimer. Among all tests, only the lower ML (ß = -0.38, P < .001) and higher international normalized ratio (INR; ß = 0.32, P = .002) values significantly contributed to greater severity of organ failure (R(2) = 0.35, F2,73 = 19.29, P < .001). Despite an increase in INR, the prothrombin fragment remained unchanged (P = .89). Strong correlations were observed between early (24 hours) increase in fibrinolysis and recovery of organ failures for 48 hours (ML: r = 0.679, P = .001; aPAI-1: r = 0.694, P < .001).
Lower ML and higher INR values predicted greater severity of organ failure at presentation. Further studies are required, as ROTEM could aid selection of patients and guide interventions aimed at fibrinolysis in severe sepsis.
我们假设血栓弹力图（ROTEM；德国慕尼黑Pentapharm GmbH公司）纤溶参数“最大溶解率”（ML）与脓毒症器官功能衰竭的严重程度呈独立负相关。
选取成年脓毒症患者（n = 77），在开始使用抗生素后24小时内纳入研究。序贯器官衰竭评估评分高于1分的患者（n = 57）随访72小时。每天测量凝血酶原片段1 + 2、纤溶酶原激活物抑制剂-1（aPAI-1）、ROTEM和常规凝血指标，同时记录序贯器官衰竭评估评分。
功能性aPAI-1的活性随器官功能衰竭严重程度的增加而升高（P = 0.01），与健康对照组相比更高（95%置信区间，-65.4至-29.9；P < 0.001）。随着器官功能衰竭加重，ML呈下降趋势（P = 0.001）；然而，D-二聚体无此趋势。在所有检测指标中，只有较低的ML（β = -0.38，P < 0.001）和较高的国际标准化比值（INR；β = 0.32，P = 0.002）显著导致器官功能衰竭更严重（R(2)=0.35，F2,73 = 19.29，P < 0.001）。尽管INR升高，但凝血酶原片段保持不变（P = 0.89）。观察到纤溶早期（24小时）增加与器官功能在48小时内恢复之间存在强相关性（ML：r = 0.679，P = 0.001；aPAI-1：r = 0.694，P < 0.001）。
较低的ML和较高的INR值预示着初始时器官功能衰竭更严重。由于ROTEM有助于选择患者并指导针对严重脓毒症纤溶的干预措施，因此需要进一步研究。
