von Rappard Sarah, Hinnen Corina, Lussmann Roger, Rechsteiner Manuela, Korte Wolfgang
Department of Anesthesiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
Department of Anesthesiology, Intensive Care, Rescue and Pain Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland.
Transfus Med Hemother. 2017 Apr;44(2):85-92. doi: 10.1159/000468946. Epub 2017 Mar 22.
Fibrinogen and factor XIII (FXIII) have been shown to critically influence clot firmness in the intraoperative setting and thus likely influence intraoperative bleeding. We were interested to identify potential modulators of postoperative clot firmness in a tertiary care hospital surgical intensive care unit setting, independent of their clinical course during surgery.
272 day-shift consecutive patients were evaluated for whole blood clot firmness evaluated by the ROTEM® EXTEM thrombelastometric assay and various potential modulators of clot firmness upon arrival at the surgical intensive care unit (SICU).
Maximum clot firmness on the SICU was found to be independently influenced by the amount of colloids given during surgery as well as by platelet count, fibrinogen concentration, and FXIII activity at the time of SICU admission. In patients with lowest clot firmness, FXIII activity was the most important independent modulator of clot firmness; in patients with the highest clot firmness, platelet count and fibrinogen concentration were the most important modulators of clot firmness. Deficiencies (i.e., results below normal range) of these modulators of clot firmness were most prevalent for FXIII (activity < 70%: 45% of cases), which was significantly more frequent than thrombocytopenia (<150 × 10/l: 32%) or fibrinogen deficiency (<1.5 g/l: 6%).
Postoperative clot firmness as evaluated by whole blood thrombelastometry (ROTEM EXTEM assay) is independently and frequently modulated though FXIII activity and the platelet count, while fibrinogen concentration is also an independent but much less frequent modulator. Different modulators show different influences, depending on the clot firmness being present. Colloids infused during surgery also independently modulate postoperative clot firmness. Based on our data, strategies can be developed to improving postoperative care of patients with bleedings or at risk for bleeding.
纤维蛋白原和凝血因子 XIII（FXIII）已被证明在术中对血凝块硬度有至关重要的影响，因此可能影响术中出血情况。我们感兴趣的是，在三级医疗医院的外科重症监护病房环境中，确定术后血凝块硬度的潜在调节因素，而不考虑其手术期间的临床过程。
对 272 名白天连续入院的患者进行评估，采用 ROTEM® EXTEM 血栓弹力图测定法评估全血凝块硬度，并在其抵达外科重症监护病房（SICU）时评估各种血凝块硬度的潜在调节因素。
发现 SICU 中的最大血凝块硬度独立受手术期间给予的胶体量以及 SICU 入院时的血小板计数、纤维蛋白原浓度和 FXIII 活性影响。在血凝块硬度最低的患者中，FXIII 活性是血凝块硬度最重要的独立调节因素；在血凝块硬度最高的患者中，血小板计数和纤维蛋白原浓度是血凝块硬度最重要的调节因素。这些血凝块硬度调节因素的缺乏（即结果低于正常范围）在 FXIII 中最为普遍（活性<70%：45%的病例），其发生率明显高于血小板减少症（<150×10⁹/l：32%）或纤维蛋白原缺乏症（<1.5 g/l：6%）。
通过全血血栓弹力图（ROTEM EXTEM 测定法）评估的术后血凝块硬度经常受到 FXIII 活性和血小板计数的独立调节，而纤维蛋白原浓度也是一个独立但频率低得多的调节因素。不同的调节因素根据存在的血凝块硬度表现出不同的影响。手术期间输注的胶体也独立调节术后血凝块硬度。基于我们的数据，可以制定策略来改善出血患者或有出血风险患者的术后护理。
