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血栓弹力图在非创伤性出血性休克诊疗中的应用
原作者: John Greenwood, 步涨 翻 文章来源: 《中华急诊医学杂志》编辑部 发布日期:2014-08-05

Title: Thrombelastography for Management of Non-Traumatic Hemorrhagic Shock
题目:血栓弹力图在非创伤性出血性休克诊疗中的应用
Author 作者: John Greenwood
翻译:步涨 校对:陈都,肖锋

The use of thrombelastography (TEG, ROTEM) has traditionally been utilized and studied in the management of acute coagulopathy of trauma (ACoT) developed by patients in hemorrhagic shock secondary to trauma.
血栓弹力图(TEG,ROTEM)已经在由创伤引起的出血性休克所导致创伤性凝血病(ACoT)的诊疗及研究中得到常规应用。
Functional coagulation tests such as the TEG may provide valuable information when resuscitating the hemorrhaging patient, especially if there is any concern for an underlying coagulopathy.  
凝血功能检测如血栓弹力图(TEG)可能为出血病人的复苏提供了有价值的资料,尤其是在有凝血障碍的情况下。

The following is a TEG recently returned during the resuscitation of a 60 y/o male with a history of HCV cirrhosis presenting with hemorrhagic shock secondary to a massive upper GIB.  The University's Massive Transfusion Protocol was promptly activated and at this point, the patient had received approximately 4 units of PRBCs & FFP along with 1 liter of crystalloid.  His Hgb was 5, PT/PTT/INR were undetectable, and his fibrinogen was 80.
下图显示的是一位正在进行抢救复苏的60岁男性患者的血栓弹力图。该患者既往有丙肝肝硬化,因上消化道大量出血引起的失血性休克而入院。入院后立即启用了大量输血方案,患者立即得到了大约4单位的悬浮红细胞及新鲜冰冻血浆及1000ml的晶体液。他的血色素为5g/dl;PT/PTT/INR都无法测出,纤维蛋白原为80.


 
Below is a table that simplifies the treatment, based on the test's abnormalities:
下表是根据异常检验结果制定的简化治疗方案。
•Prolonged R:  Fresh frozen plasma
•Prolonged K or reduced α angle: Cryoprecipitate
•Low MA: Platelets, desmopressin (DDAVP)
•Elevated LY 30%: Consider antifibrinolytics (aminocaproic acid, TXA)

•R期延长:冰冻血浆
•K期延长或alpha角减小:冷沉淀
•MA低:血小板,精氨酸加压素
•LY升高30%:考虑抗纤溶蛋白药物 ,如氨基己酸 TXA

After reviewing the initial TEG, all perameters were abnormal in addition to the presence of significant fibrinolysis.  The patient was given an additional 4 units of FFP, DDAVP, cryoprecipitate, a unit of platelets, and aminocaproic acid.  The patient still required significant resuscitation, however bleeding had significantly decreased as well has his pressor requirement.  Below is the patient's follow-up TEG 2 hours later.
回顾最初的血栓弹力图(TEG),除了显著的纤溶之外,所有参数都不正常,该患者又输注了4个单位的新鲜冰冻血浆,精氨酸加压素,冷沉淀,一个单位血小板和氨基己酸。患者仍然需要加强复苏,但是其血压已经回升而出血明显减少。下图则是该患者2小时后复查的血栓弹力图(TEG)。
 
There is growing enthusiasm for the use of functional coagulopathy testing in the patient with hemorrhagic shock.  Early resuscitation with blood products as your fluid of choice with limited fluid administration while arranging for definitive source control are critical, but also consider early thrombelastography to detect additional causes for uncontrolled hemorrhage.
现在,越来越积极地在出血性休克的患者中使用功能性血凝检查。尽管在进行原发疾病治疗的同时使用包含血制品的限制性液体输入进行早期复苏是非常重要的,同时对难以控制的出血,要考虑早期进行血栓弹力图检查以发现其它原因。

References 参考文献:
1.Walsh M, Thomas SG, Howard JC, et al. Blood component therapy in trauma guided with the utilization of the perfusionist and thromboelastography. Journal of Extra-Corporeal Technology. 2011 Sep; 43(3):162-7.
2.The Use of TEG & Goal Directed Blood Component Therapy.  MarylandCCProject.org
 

文章来源:《中华急诊医学杂志》编辑部