凝血-纤溶失衡与颅脑损伤严重程度的关系及对急性创伤性凝血病的预测价值

毛小强; 金晶; 余国峰

doi:10.16766/j.cnki.issn.1674-4152.002364

凝血-纤溶失衡与颅脑损伤严重程度的关系及对急性创伤性凝血病的预测价值

doi: 10.16766/j.cnki.issn.1674-4152.002364

1.
衢州市人民医院急诊科，浙江衢州 324000
2.
衢州市人民医院普外科，浙江衢州 324000

基金项目:

浙江省医药卫生科技计划项目 2017KY697

详细信息

通讯作者:
金晶，E-mail：594jj@163.com

中图分类号: R651.15
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- 文章访问数: 197
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- PDF下载量: 2
- 被引次数: 0
出版历程
- 收稿日期: 2021-04-06
- 网络出版日期: 2022-08-13

Relationship between coagulation and fibrinolysis imbalance and severity of craniocerebral injury and its predictive value for acute traumatic coagulopathy

1.
Emergency Department of Quzhou People's Hospital, Quzhou, Zhejiang 324000, China

摘要

摘要: 目的分析凝血-纤溶失衡与颅脑损伤严重程度的关系及对急性创伤性凝血病的预测价值。方法选择衢州市人民医院2017年1月—2020年10月接诊的145例颅脑损伤患者作为研究对象，使用格拉斯哥昏迷评分(GCS)评价严重程度，分为重度组(42例)和非重度组(103例)。以凝血酶-抗凝血酶复合物(TAT)与纤溶酶-α2纤溶酶抑制物复合物(PIC)比值评价凝血-纤溶失衡程度，比较2组凝血功能指标及TAT/PIC值，使用ROC曲线评价TAT/PIC值对急性创伤性凝血病的预测效能。结果重度组活化部分凝血活酶时间(APTT)长于非重度组[(33.69±8.16)s vs. (25.43±5.87)s]，D-二聚体水平高于非重度组[(3.57±1.23)mg/L vs. (1.47±0.47)mg/L]，TAT/PIC值低于非重度组[(0.75±0.11)×10^-3 vs. (1.77±0.24)×10^-3]，差异均有统计学意义(均P＜0.05)；经Pearson相关性分析，TAT/PIC值与GCS评分呈正相关关系(P＜0.05)；在145例颅脑损伤患者中，发生急性创伤性凝血病21例，占14.48%；急性创伤性凝血病患者入院后TAT/PIC值有明显降低趋势，入院后12、24 h的TAT/PIC值均较入院时降低，差异均有统计学意义(均P＜0.05)；经多因素logistic回归分析，TAT/PIC值、APTT和D-二聚体均为急性创伤性凝血病的独立预测因素(均P＜0.05)；经ROC曲线分析，TAT/PIC值预测急性创伤性凝血病的AUC为0.918。结论凝血-纤溶失衡与颅脑损伤严重程度呈正相关关系，而TAT/PIC值降低，预示急性创伤性凝血病发生的风险较大。
- 颅脑损伤 /
- 凝血-纤溶失衡 /
- 严重程度 /
- 急性创伤性凝血病 /
- 预测
Abstract: Objective To analyse the relationship between coagulation and fibrinolysis imbalance and the severity of craniocerebral injury and its predictive value in acute traumatic coagulopathy. Methods A total of 145 patients with craniocerebral injury admitted to our hospital from January 2017 to October 2020 were selected as subjects. The severity of the patients was evaluated by Glasgow Coma Scale (GCS), and patients were divided into the severe group and non-severe group. The ratio of thrombin-antithrombin complex (TAT)/plasminolysin-α2 plasminolytic inhibitor complex (PIC) was used to evaluate the degree of coagulation-fibrinolytic imbalance. The coagulation function indexes and the ratio of TAT/PIC were compared between the two groups. The predictive effect of TAT/PIC ratio on acute traumatic coagulopathy was evaluated by area under the receiver operating characteristic (ROC) curve (AUC). Results The activated partial thromboplastin time (APTT) in the severe group was longer than that in the non-severe group[(33.69±8.16) s vs. (25.43±5.87) s], the level of D-dimer was higher than that in the non-severe group[(3.57±1.23) mg/L vs. (1.47±0.47) mg/L], and the TAT/PIC ratio was lower than that in the non-severe group[(0.75±0.11) ×10^-3 vs. (1.77±0.24) ×10^-3], the difference was statistically significant (P < 0.05). Pearson correlation analysis showed that the TAT/PIC ratio was positively correlated with GCS score (P < 0.05). Amongst 145 patients with craniocerebral injury, 21 cases (14.48%) had acute traumatic coagulopathy. The TAT/PIC ratio of the acute traumatic coagulation disease group was significantly decreased after admission, and the TAT/PIC ratio at 12 and 24 h after admission was significantly decreased compared with that at admission, the difference was statistically significant (all P < 0.05). Multivariate logistic regression analysis showed that the TAT/PIC ratio, APTT and D-dimer were independent predictors of acute traumatic coagulation disease (all P < 0.05). Using ROC curve analysis, the AUC of the TAT/PIC ratio in predicting acute traumatic coagulopathy was 0.918. Conclusion Coagulation-fibrinolysis imbalance is positively correlated with the severity of craniocerebral injury, and the decrease of TAT/PIC ratio indicates a greater risk of acute traumatic coagulopathy.
- Craniocerebral injury /
- Coagulation-fibrinolytic imbalance /
- Severity /
- Acute traumatic coagulopathy /
- Predict

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图 1 TAT/PIC值与GCS评分的关系散点图

Figure 1. Scatter plot of TAT/PIC value and GCS score

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图 2 TAT/PIC值预测急性创伤性凝血病的ROC曲线

Figure 2. ROC curve of TAT/PIC value for predicting acutetraumatic coagulopathy

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表 1 不同程度颅脑损伤患者凝血功能指标比较(x±s)

Table 1. Comparison of coagulation function indexes in patients with different degrees of craniocerebral injury (x±s)

组别	例数	INR	PT(s)	APTT(s)	FIB(g/L)	D-二聚体(mg/L)	PLT(×10⁹/L)
非重度组	103	1.07±0.15	12.48±1.69	25.43±5.87	2.54±1.03	1.47±0.47	171.47±36.85
重度组	42	1.18±0.23	13.54±2.74	33.69±8.16	2.26±1.17	3.57±1.23	159.42±23.67
t值		3.401	2.829	6.827	1.427	14.916	1.959
P值		＜0.001	0.005	＜0.001	0.156	＜0.001	0.052

组别	例数	Hb(g/L)	HCT(%)	TAT(ng/mL)	PIC(μg/mL)	TAT/PIC比值 (×10^-3)
非重度组	103	130.49±31.33	38.91±8.15	2.25±0.63	1.38±0.29	1.77±0.24
重度组	42	125.42±28.79	36.91±7.43	1.54±0.33	2.06±0.47	0.75±0.11
t值		0.904	1.374	6.917	10.577	26.395
P值		0.367	0.172	＜0.001	＜0.001	＜0.001

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表 2 急性创伤性凝血病与非急性创伤性凝血病颅脑损伤患者TAT/PIC值比较(x±s，×10^-3)

Table 2. Comparison of TAT/PIC values between acute traumatic coagulopathy and non-acute traumatic coagulopathy patientswith craniocerebral injury (x±s, ×10^-3)

组别	例数	入院时	入院后12 h	入院后24 h	F值	P值
急性创伤性凝血病组	21	0.71±0.10	0.62±0.08	0.50±0.06	34.970	＜0.001
非急性创伤性凝血病组	124	1.78±0.29	1.61±0.24	1.50±0.21	39.840	＜0.001
t值		16.699	18.681	21.616
P值		＜0.001	＜0.001	＜0.001

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表 3 急性创伤性凝血病的独立预测因素分析

Table 3. Analysis of independent predictors of acutetraumatic coagulopathy

项目	B	SE	Wald χ²	P值	OR值	95% CI
INR	-0.041	0.036	1.425	0.245	0.998	1.025~2.658
PT	-0.009	0.027	0.258	0.623	1.005	1.452~2.784
APTT	1.952	0.781	5.452	0.039	0.858	0.030~1.192
D-二聚体	1.371	0.623	7.658	0.032	3.947	1.182~9.126
TAT	-0.008	0.048	0.019	0.892	0.942	0.962~1.231
PIC	0.061	0.076	0.612	0.425	1.024	1.247~2.583
TAT/PIC比值	0.475	0.158	12.946	＜0.001	1.471	1.158~5.650

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参考文献(18)

[1]	王俊杰, 张祖勇. 不同病情程度颅脑损伤患者血清皮质醇浓度动态变化及临床意义的研究[J]. 中华全科医学, 2018, 16(3): 410-412. doi: 10.16766/j.cnki.issn.1674-4152.000114 WANG J J, ZHANG Z Y. Clinical significance of dynamic serum cortisol level in patients with different severity of brain injury[J]. Chinese Journal of General Practice, 2018, 16(3): 410-412. doi: 10.16766/j.cnki.issn.1674-4152.000114
[2]	WADA T, GANDO S, MAEKAW K, et al. Disseminated intravascular coagulation with increased fibrinolysis during the early phase of isolated traumatic brain injury[J]. Crit Care, 2017, 21(1): 219. doi: 10.1186/s13054-017-1808-9
[3]	魏捷, 张东梅, 吕菁君, 等. 119例脓毒症凝血, 抗凝和纤溶功能的临床研究[J]. 中华急诊医学杂志, 2018, 27(8): 905-911. doi: 10.3760/cma.j.issn.1671-0282.2018.08.017 WEI J, ZHANG D M, LYU J J, et al. A clinical study of sepsis-related coagulation disorder[J]. Chinese Journal of Emergency Medicine, 2018, 27(8): 905-911. doi: 10.3760/cma.j.issn.1671-0282.2018.08.017
[4]	中国研究型医院学会卫生应急学专业委员会, 中国中西医结合学会灾害医学专业委员会. 急性创伤性凝血功能障碍与凝血病诊断和卫生应急处理专家共识(2016)[J]. 中华卫生应急电子杂志, 2016, 2(4): 197-203. https://www.cnki.com.cn/Article/CJFDTOTAL-YJWS201604001.htm Health Emergency Committee of Chinese Research Hospital Association, Disaster Medicine Professional Committee of Chinese Association of Integrated Traditional Chinese and Western Medicine. Expert Consensus on Diagnosis and health emergency management of acute Traumatic coagulopathy and coagulopathy (2016)[J]. Chinese Journal of Hygiene Rescue (Electronic Edition), 2016, 2(4): 197-203. https://www.cnki.com.cn/Article/CJFDTOTAL-YJWS201604001.htm
[5]	LIRAS I N, CAPLAN H W, STENSBALLE J, et al. Prevalence and impact of admission acute traumatic coagulopathy on treatment Intensity, resource use, and mortality: An evaluation of 956 severely injured children and adolescents[J]. J Am Coll Surg, 2017, 224(4): 625-632. doi: 10.1016/j.jamcollsurg.2016.12.046
[6]	吕学文, 杨永康, 张小雷, 等. 创伤性颅脑损伤患者凝血功能及炎性因子的变化研究[J]. 临床外科杂志, 2019, 27(3): 247-249. https://www.cnki.com.cn/Article/CJFDTOTAL-LCWK201903023.htm LYU X W, YANG Y K, ZHANG X L, et al. Changes of coagulation function and inflammatory factors in patients with traumatic craniocerebral injury[J]. Journal of Clinical Surgery, 2019, 27(3): 247-249. https://www.cnki.com.cn/Article/CJFDTOTAL-LCWK201903023.htm
[7]	李力卓, 何松柏, 赵格晶娃. 中老年人群急性单发性创伤性颅脑损伤相关性凝血病的临床分析[J]. 首都医科大学学报, 2018, 39(4): 537-540. doi: 10.3969/j.issn.1006-7795.2018.04.011 LI L Z, HE S B, ZHAO G J W. Clinical analysis of acute isolated traumatic brain injury-associated coagulopathy in middle aged and older populations[J]. Journal of Capital Medical University, 2018, 39(4): 537-540. doi: 10.3969/j.issn.1006-7795.2018.04.011
[8]	LEE K, BAKER L, MALLETT S, et al. Hypercoagulability progresses to hypocoagulability during evolution of acetaminophen-induced acute liver injury in pigs[J]. Sci Rep, 2017, 7(1): 9347. doi: 10.1038/s41598-017-09508-3
[9]	崔婵娟, 崔巍, 高佳, 等. 凝血酶-抗凝血酶复合物和纤溶酶-ɑ2纤溶酶抑制物复合物优于D二聚体用于肿瘤患者血栓的诊断[J]. 中华检验医学杂志, 2019, 42(10): 853-854, 857. doi: 10.3760/cma.j.issn.1009-9158.2019.10.008 CUI C J, CUI W, GAO J, et al. TAT and PIC better than D-dimer in monitoring hypercoagulability of cancer patients[J]. Chinese Journal of Laboratory Medicine, 2019, 42(10): 853-854, 857. doi: 10.3760/cma.j.issn.1009-9158.2019.10.008
[10]	苗树船, 王晓燕, 王恩任, 等. 颅脑损伤患者凝血功能与伤情严重程度及预后的相关性研究[J]. 重庆医学, 2019, 48(18): 3148-3150. doi: 10.3969/j.issn.1671-8348.2019.18.021 MIAO S C, WANG X Y, WANG E R, et al. Correlation of coagulation function with the severity and prognosis of craniocerebral injury[J]. Chongqing Medicine, 2019, 48(18): 3148-3150. doi: 10.3969/j.issn.1671-8348.2019.18.021
[11]	KITAYAMA H, KONDO T, SUGIYAMA J, et al. Venous thromboembolism in hospitalized patients receiving chemotherapy for malignancies at Japanese community hospital: Prospective observational study[J]. BMC Cancer, 2017, 17(1): 351. doi: 10.1186/s12885-017-3326-1
[12]	林宁, 姚国权, 李军, 等. D-二聚体与颅脑损伤后进展性出血性损伤的关系研究[J]. 中华全科医学, 2017, 15(7): 1123-1126. doi: 10.16766/j.cnki.issn.1674-4152.2017.07.009 LIN N, YAO G Q, LI J, et al. Clinical study of D-dimer level in patients with progressive hemorrhagic injury after traumatic brain injury[J]. Chinese Journal of General Practice, 2017, 15(7): 1123-1126. doi: 10.16766/j.cnki.issn.1674-4152.2017.07.009
[13]	CHAUDHARY P K, KIN S, JEE Y, et al. Role of GRK6 in the regulation of platelet activation through selective G Protein-Coupled Receptor (GPCR) desensitization[J]. Int J Mol Sci, 2020, 21(11): 3932. doi: 10.3390/ijms21113932
[14]	GAO Z, PEI X, HE C, et al. Oxygenation impairment in patients with acute aortic dissection is associated with disorders of coagulation and fibrinolysis: A prospective observational study[J]. J Thorac Dis, 2019, 11(4): 1190-1201. doi: 10.21037/jtd.2019.04.32
[15]	武晓灵, 喻莉, 龙鼎. suPAR及D-二聚体对创伤性颅脑损伤患者病情严重程度及预后的判断价值[J]. 实用医学杂志, 2017, 33(2): 234-237. doi: 10.3969/j.issn.1006-5725.2017.02.018 WU X L, YU L, LONG D. Soluble urokinase plasminogen activator receptor and D-dimer for assessment of disease severity and prognosis in traumatic brain injury[J]. The Journal of Practical Medicine, 2017, 33(2): 234-237. doi: 10.3969/j.issn.1006-5725.2017.02.018
[16]	JOSEPH C, ANDERSSON N, BJELAK S, et al. Incidence, aetiology and injury characteristics of traumatic spinal cord injury in Stockholm, Sweden: A prospective, population-based update[J]. J Rehabil Med, 2017, 49(5): 431-436. doi: 10.2340/16501977-2224
[17]	HIFUMI T, KURODA Y, KAWAKITA K, et al. Therapeutic hypothermia in patients with coagulopathy following severe traumatic brain injury[J]. Scand J Trauma Resusc Emerg Med, 2017, 25(1): 120. doi: 10.1186/s13049-017-0465-y
[18]	REED C R, WILLIAMSON H, VATSAAS C, et al. Higher mortality in pediatric and adult trauma patients with traumatic coagulopathy, using age-adjusted diagnostic criteria[J]. Surgery, 2019, 165(6): 1108-1115. doi: 10.1016/j.surg.2019.03.003