服用新型口服抗凝药的创伤患者凝血功能的实验室检测：美国创伤外科学会-麻省理工学院的研究结果
Laboratory measures of coagulation among trauma patients on NOAs: results of the AAST-MIT.
作者信息
Kobayashi Leslie M, Brito Alexandra, Barmparas Galinos, Bosarge Patrick, Brown Carlos V, Bukur Marko, Carrick Matthew M, Catalano Richard D, Holly-Nicolas Jan, Inaba Kenji, Kaminski Stephen, Klein Amanda L, Kopelman Tammy, Ley Eric J, Martinez Ericca M, Moore Forrest O, Murry Jason, Nirula Raminder, Paul Douglas, Quick Jacob, Rivera Omar, Schreiber Martin, Coimbra Raul
机构信息
Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California San Diego, San Diego, California, USA.
Department of Surgery, University of California San Diego, San Diego, California, USA.
出版信息
Trauma Surg Acute Care Open. 2018 Oct 15;3(1):e000231. doi: 10.1136/tsaco-2018-000231. eCollection 2018.
BACKGROUND
Warfarin is associated with poor outcomes after trauma, an effect correlated with elevations in the international normalized ratio (INR). In contrast, the novel oral anticoagulants (NOAs) have no validated laboratory measure to quantify coagulopathy. We sought to determine if use of NOAs was associated with elevated activated partial thromboplastin time (aPTT) or INR levels among trauma patients or increased clotting times on thromboelastography (TEG).
METHODS
This was a post-hoc analysis of a prospective observational study across 16 trauma centers. Patients on dabigatran, rivaroxaban, or apixaban were included. Laboratory data were collected at admission and after reversal. Admission labs were compared between medication groups. Traditional measures of coagulopathy were compared with TEG results using Spearman's rank coefficient for correlation. Labs before and after reversal were also analyzed between medication groups.
RESULTS
182 patients were enrolled between June 2013 and July 2015: 50 on dabigatran, 123 on rivaroxaban, and 34 apixaban. INR values were mildly elevated among patients on dabigatran (median 1.3, IQR 1.1-1.4) and rivaroxaban (median 1.3, IQR 1.1-1.6) compared with apixaban (median 1.1, IQR 1.0-1.2). Patients on dabigatran had slightly higher than normal aPTT values (median 35, IQR 29.8-46.3), whereas those on rivaroxaban and apixaban did not. Fifty patients had TEG results. The median values for R, alpha, MA and lysis were normal for all groups. Prothrombin time (PT) and aPTT had a high correlation in all groups (dabigatran p=0.0005, rivaroxaban p<0.0001, and apixaban p<0.0001). aPTT correlated with the R value on TEG in patients on dabigatran (p=0.0094) and rivaroxaban (p=0.0028) but not apixaban (p=0.2532). Reversal occurred in 14%, 25%, and 18% of dabigatran, rivaroxaban, and apixaban patients, respectively. Both traditional measures of coagulopathy and TEG remained within normal limits after reversal.
DISCUSSION
Neither traditional measures of coagulation nor TEG were able to detect coagulopathy in patients on NOAs.
LEVEL OF EVIDENCE
Level IV.
背景
华法林与创伤后不良预后相关，这种影响与国际标准化比值（INR）升高有关。相比之下，新型口服抗凝药（NOA）没有经过验证的实验室指标来量化凝血病。我们试图确定创伤患者使用NOA是否与活化部分凝血活酶时间（aPTT）或INR水平升高相关，或者血栓弹力图（TEG）上的凝血时间是否增加。
方法
这是一项对16个创伤中心的前瞻性观察性研究的事后分析。纳入使用达比加群、利伐沙班或阿哌沙班的患者。在入院时和逆转后收集实验室数据。比较各药物组的入院实验室检查结果。使用Spearman等级系数进行相关性分析，将传统的凝血病指标与TEG结果进行比较。还分析了各药物组逆转前后的实验室检查结果。
结果
2013年6月至2015年7月共纳入182例患者：50例使用达比加群，123例使用利伐沙班，34例使用阿哌沙班。与阿哌沙班（中位数1.1，四分位间距1.0 - 1.2）相比，使用达比加群（中位数1.3，四分位间距1.1 - 1.4）和利伐沙班（中位数1.3，四分位间距1.1 - 1.6）的患者INR值轻度升高。使用达比加群的患者aPTT值略高于正常（中位数35，四分位间距29.8 - 46.3），而使用利伐沙班和阿哌沙班的患者则没有。50例患者有TEG结果。所有组的R、α、MA和溶解的中位数均正常。所有组中凝血酶原时间（PT）和aPTT高度相关（达比加群p = 0.0005，利伐沙班p < 0.0001，阿哌沙班p < 0.0001）。在使用达比加群（p = 0.0094）和利伐沙班（p = 0.0028）的患者中，aPTT与TEG上的R值相关，但与阿哌沙班无关（p = 0.2532）。分别有14%、25%和18%使用达比加群、利伐沙班和阿哌沙班的患者发生逆转。逆转后，传统的凝血病指标和TEG均保持在正常范围内。
讨论
传统的凝血指标和TEG均无法检测出使用NOA患者的凝血病。
证据级别
四级。
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