Lentschener Claude, Flaujac Claire, Ibrahim Firas, Gouin-Thibault Isabelle, Bazin Marie, Sogni Philippe, Samama Charles-Marc
From the Department of Anaesthesia and Intensive Care (CL, MB, C-MS), Department of Biological Haematology (CF, FI, IG-T), and Hepatology Unit (PS), Paris Descartes University, Faculty of Medicine, Assistance Publique Hôpitaux de Paris, Cochin University Hospital, Paris Cedex, France.
Eur J Anaesthesiol. 2016 Feb;33(2):126-33. doi: 10.1097/EJA.0000000000000322.
In patients with cirrhosis, decreased rotational thromboelastometry (ROTEM) parameters suggest hypocoagulability secondary to liver dysfunction. However, observed normal or increased thrombin generation suggests preserved haemostasis and/or a procoagulant state. The correlated levels of both coagulation factors and inhibitors also support preserved haemostasis.
The objective of this study is to investigate the correlation between three specific approaches of haemostasis (ROTEM, thrombin generation and coagulation factors/inhibitors) on the same plasma sample from patients with cirrhosis.
A prospective, observational study.
Single university hospital.
Forty patients with cirrhosis.
Measurement of the following factors: model for end-stage liver disease (MELD) scores; ROTEM maximum clot firmness (ROTEM-MCF) in EXTEM, INTEM, FIBTEM assays; fibrinogen; factors V and VIII; von Willebrand factor; protein C; protein S; antithrombin; and the thrombin generation test (TGT) enabling the calculation of endogenous thrombin potential without and with thrombomodulin, and the ratio of endogenous thrombin potential with-to-without thrombomodulin (regarded as an index of hypercoagulability).
ROTEM-MCF values were distributed within the normal and hypocoagulation ranges; were correlated to variations in factor V, fibrinogen, protein C and S and antithrombin; and were inversely correlated to MELD scores (ρ > 0.5; P < 0.05). Levels of von Willebrand factor were above normal and were not correlated with any other factor levels. After addition of thrombomodulin, endogenous thrombin potential values were distributed within or above normal values. Factor V variation was correlated to the ratio of endogenous thrombin potential with-to-without thrombomodulin.
ROTEM indicated hypocoagulability correlated to liver dysfunction. In contrast, the TGT indicated a preserved or even increased coagulation profile (which was supported by the correlation between coagulant factors and inhibitors) and a potential for hypercoagulability inversely correlated to the degree of liver dysfunction. ROTEM may not be appropriate for haemostasis assessment in patients with liver cirrhosis and could lead to the unnecessary transfusion of fresh frozen plasma.
S.C. 3024 - ID RCB: 2012-A01728-35.
在肝硬化患者中，旋转血栓弹力图（ROTEM）参数降低提示肝功能障碍继发的低凝状态。然而，观察到的凝血酶生成正常或增加提示止血功能保留和/或处于促凝状态。凝血因子和抑制剂的相关水平也支持止血功能保留。
本研究的目的是调查肝硬化患者同一血浆样本中三种特定止血方法（ROTEM、凝血酶生成和凝血因子/抑制剂）之间的相关性。
一项前瞻性观察性研究。
单一大学医院。
40例肝硬化患者。
测量以下因素：终末期肝病模型（MELD）评分；EXTEM、INTEM、FIBTEM检测中的ROTEM最大血凝块硬度（ROTEM-MCF）；纤维蛋白原；因子V和VIII；血管性血友病因子；蛋白C；蛋白S；抗凝血酶；以及凝血酶生成试验（TGT），该试验能够计算有无血栓调节蛋白时的内源性凝血酶潜力，以及有血栓调节蛋白与无血栓调节蛋白时内源性凝血酶潜力的比值（视为高凝指标）。
ROTEM-MCF值分布在正常和低凝范围内；与因子V、纤维蛋白原、蛋白C和S以及抗凝血酶的变化相关；与MELD评分呈负相关（ρ＞0.5；P＜0.05）。血管性血友病因子水平高于正常，且与任何其他因子水平均无相关性。加入血栓调节蛋白后，内源性凝血酶潜力值分布在正常范围内或高于正常。因子V变化与有血栓调节蛋白与无血栓调节蛋白时内源性凝血酶潜力的比值相关。
ROTEM提示与肝功能障碍相关的低凝状态。相比之下，TGT提示凝血功能保留甚至增强（凝血因子和抑制剂之间的相关性支持这一点），以及与肝功能障碍程度呈负相关的高凝可能性。ROTEM可能不适用于肝硬化患者的止血评估，可能导致不必要的新鲜冰冻血浆输注。
S.C. 3024 - ID RCB：2012 - A01728 - 35。
