David Jean-Stéphane, Durand Maeva, Levrat Albrice, Lefevre Mathilde, Rugeri Lucia, Geay-Baillat Marie-Odile, Inaba Kenji, Bouzat Pierre
From the Department of Anesthesiology and Critical Care Medicine, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon (M.D.); and Charles Mérieux-Lyon Sud School of Medicine, University Lyon 1, Oullins (J.-S.D., M.D.); Department of Anesthesiology and Critical Care Medicine, Lyon-Sud Hospital, Hospices Civils de Lyon, Pierre Bénite (J.-S.D., M.L.); Intensive Care Unit, Annecy Hospital, Annecy (A.L., L.R.); Haemostasis and Thrombosis Division, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon (M.-O.G.-B.); Division of Trauma and Critical Care, Department of Surgery, LAC + USC Medical Center, University of Southern California, Los Angeles, California (K.I.); and Department of Anesthesiology and Critical Care Medicine, Hôpital Michallon; and INSERM U836, Grenoble (P.B.), France.
J Trauma Acute Care Surg. 2016 Aug;81(2):319-27. doi: 10.1097/TA.0000000000001109.
Thromboelastometry (ROTEM, Pentapharm GmbH, Munich, Germany) is increasingly being used to make a diagnosis of coagulopathy and to guide hemostatic therapy (HT). Although ROTEM parameters and standard laboratory test (SLT) correlated well before administration of HT, it is not known if this correlation persists after hemostatic resuscitation.
A retrospective analysis of prospectively collected data from a trauma registry (2011-2014) was performed. All patients having a ROTEM analysis were included. ROTEM parameters (clotting time and clot amplitude at 5 minutes) were determined after activation with tissue factor (EXTEM) or platelet inhibition with cytochalasin D (FIBTEM). Spearman rank correlation coefficient was calculated for the correlation between SLT and thromboelastometry parameters, and thresholds were determined with receiver operating characteristic (ROC) curve analysis for the diagnosis of an international normalized ratio (INR) greater than 1.5, fibrinogen 1.5 g/L or less, and platelet count of less than 100.10/L.
Of the 358 patients included, 533 thromboelastometry results were obtained (335 at admission, 198 during care). Correlation between INR and EXTEM-clotting time was good at admission (r = 0.617) in the whole cohort but decreased in the subgroup of patients having an Injury Severity Score of less than 25 (r = 0.399) or a base excess of less than 6 mmol/L (r = 0.489). During care, correlation was impaired after the administration of fibrinogen concentrates in the whole cohort (r = 0.430), as well as in the subgroup of patients having an Injury Severity Score greater than 24 (r = 0.465). As well, for the diagnosis of increased INR, sensitivity and the area under the ROC curve decreased from 75% and 0.894 (no treatment) to 20% and 0.653 (fibrinogen concentrate). Areas under the ROC curve for the prediction of a fibrinogen or platelet decrease were not significantly altered regardless of the treatment group.
A decrease in the correlation between SLTs and ROTEM parameters was observed at admission or during care, which could be in relation with injury severity, base deficit, or the administration of blood products, particularly fibrinogen concentrate. Further work will be necessary to better understand which tool is the most suitable for guiding HT.
Therapeutic study, level IV; diagnostic study, level IV.
血栓弹力图检测（ROTEM，德国慕尼黑Pentapharm有限公司）越来越多地用于诊断凝血病和指导止血治疗（HT）。尽管在进行止血治疗前，血栓弹力图参数与标准实验室检测（SLT）相关性良好，但在止血复苏后这种相关性是否持续尚不清楚。
对前瞻性收集的创伤登记数据（2011 - 2014年）进行回顾性分析。纳入所有进行血栓弹力图分析的患者。在用组织因子激活后（EXTEM）或用细胞松弛素D抑制血小板后（FIBTEM）测定血栓弹力图参数（5分钟时的凝血时间和血凝块幅度）。计算SLT与血栓弹力图参数之间的Spearman等级相关系数，并通过受试者工作特征（ROC）曲线分析确定诊断国际标准化比值（INR）大于1.5、纤维蛋白原小于或等于1.5 g/L以及血小板计数小于100×10⁹/L的阈值。
纳入的358例患者共获得533次血栓弹力图检测结果（入院时335次，治疗期间198次）。在整个队列中，入院时INR与EXTEM凝血时间之间的相关性良好（r = 0.617），但在损伤严重度评分小于25分（r = 0.399）或碱剩余小于6 mmol/L（r = 0.489）的患者亚组中相关性降低。在治疗期间，在整个队列中给予纤维蛋白原浓缩物后相关性受损（r = 0.430），在损伤严重度评分大于24分的患者亚组中也是如此（r = 0.465）。同样，对于诊断INR升高，敏感性和ROC曲线下面积从75%和0.894（未治疗）降至20%和0.653（纤维蛋白原浓缩物）。无论治疗组如何，预测纤维蛋白原或血小板减少的ROC曲线下面积均无显著改变。
在入院时或治疗期间观察到SLT与血栓弹力图参数之间的相关性降低，这可能与损伤严重度、碱缺失或血液制品的输注有关，特别是纤维蛋白原浓缩物。需要进一步开展工作以更好地了解哪种工具最适合指导止血治疗。
治疗性研究，IV级；诊断性研究，IV级。
