凝血功能障碍出血患者的血栓弹力描记术和旋转血栓弹力描记术：东部创伤外科学会的实践管理指南。
Thromboelastography and rotational thromboelastometry in bleeding patients with coagulopathy: Practice management guideline from the Eastern Association for the Surgery of Trauma.
机构信息
From the Division of Trauma and Acute Care Surgery (N.B.), Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts; Department of Surgery (J.J.C.), MetroHealth Medical Center, Cleveland, Ohio; Department of Surgery A (G.G.), Soroka Medical Center, Beer Sheva, Israel; Department of Surgery (J.J.F.), TCU and UNTHSC School of Medicine, Fort Worth, Texas; Maine Medical Center (J.S.S.), Portland, Maine; Division of Trauma and Critical Care Surgery (C.J.V.), Department of Surgery, Duke University School of Medicine, Durham, North Carolina; University of Florida College of Medicine-Jacksonville (B.K.Y.), Jacksonville, Florida; Case Western University School of Medicine (L.A.K.), Cleveland, Ohio; Division of Trauma, Surgical Critical Care, and Acute Care Surgery (N.M.G.), Department of Surgery, Brody School of Medicine, East Carolina University, Greenville; Weill Cornell University (H.A.A.), Doha, Qatar; Department of Surgery (P.A.P.), College of Medicine, University of Central Florida, Orlando; Division of Trauma and Acute Care Surgery (E.J.M.), Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts; 2D Medical Battalion, 2D Marine Logistics Group (Z.W.B.), Camp LeJeune, North Carolina; Department of Surgery (Z.W.B.), Uniformed Services University of the Health Sciences, Bethesda; and Division of Trauma and Critical Care Surgery (G.K.), Department of Surgery, Duke University School of Medicine, Durham, North Carolina.
出版信息
J Trauma Acute Care Surg. 2020 Dec;89(6):999-1017. doi: 10.1097/TA.0000000000002944.
BACKGROUND
Assessment of the immediate need for specific blood product transfusions in acutely bleeding patients is challenging. Clinical assessment and commonly used coagulation tests are inaccurate and time-consuming. The goal of this practice management guideline was to evaluate the role of the viscoelasticity tests, which are thromboelastography (TEG) and rotational thromboelastometry (ROTEM), in the management of acutely bleeding trauma, surgical, and critically ill patients.
METHODS
Systematic review and meta-analyses of manuscripts comparing TEG/ROTEM with non-TEG/ROTEM-guided blood products transfusions strategies were performed. The Grading of Recommendations Assessment, Development and Evaluation methodology was applied to assess the level of evidence and create recommendations for TEG/ROTEM-guided blood product transfusions in adult trauma, surgical, and critically ill patients.
RESULTS
Using TEG/ROTEM-guided blood transfusions in acutely bleeding trauma, surgical, and critically ill patients was associated with a tendency to fewer blood product transfusions in all populations. Thromboelastography/ROTEM-guided transfusions were associated with a reduced number of additional invasive hemostatic interventions (angioembolic, endoscopic, or surgical) in surgical patients. Thromboelastography/ROTEM-guided transfusions were associated with a reduction in mortality in trauma patients.
CONCLUSION
In patients with ongoing hemorrhage and concern for coagulopathy, we conditionally recommend using TEG/ROTEM-guided transfusions, compared with traditional coagulation parameters, to guide blood component transfusions in each of the following three groups: adult trauma patients, adult surgical patients, and adult patients with critical illness.
LEVEL OF EVIDENCE
Systematic Review/Meta-Analysis, level III.
背景
评估急性出血患者对特定血液制品的即时需求具有挑战性。临床评估和常用的凝血检测既不准确又耗时。本实践管理指南的目的是评估血栓弹力图（TEG）和旋转血栓弹性测定（ROTEM）等粘弹性检测在急性出血创伤、手术和重症患者管理中的作用。
方法
对比较 TEG/ROTEM 与非 TEG/ROTEM 指导的血液制品输注策略的文献进行系统评价和荟萃分析。应用推荐评估、制定与评价分级方法（Grading of Recommendations Assessment, Development and Evaluation，GRADE）评估 TEG/ROTEM 指导成人创伤、手术和重症患者血液制品输注的证据水平，并制定推荐意见。
结果
在急性出血创伤、手术和重症患者中使用 TEG/ROTEM 指导输血与所有人群中血液制品输注量减少趋势相关。TEG/ROTEM 指导的输血与手术患者中额外侵入性止血干预（血管栓塞、内镜或手术）的数量减少相关。TEG/ROTEM 指导的输血与创伤患者的死亡率降低相关。
结论
对于持续出血且怀疑存在凝血功能障碍的患者，我们有条件地推荐在以下三组患者中使用 TEG/ROTEM 指导输血，而非传统凝血参数，以指导血液成分输注：成人创伤患者、成人手术患者和患有重症的成人患者。
证据等级
系统评价/荟萃分析，III 级。
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