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血栓性脉管炎体现 阳普医疗血栓弹力求,心外科围术期办理专家

来源:网络 2021年11月09日 07:01   作者:fashion 血栓性脉管炎表现 血栓 弹力

心外科手术因为其杂乱性、高危险性等特色,使围术期凝血功用办理、输血办理和抗凝药物作用监测等临床活动面对巨大应战。血栓弹力求作为一种新式的根据检测血液粘弹性特性的凝血功用监测体系,在自其发作以来的数十年间,在围术期办理与输血办理方面现已显示出其优胜于传统凝血功用检测的特性。血栓弹力求体系的各项组合均或许运用于心外科的相关手术中。

血栓弹力求仪(TEG)可实时检测手术期间患者的凝血功用状况,帮忙外科医师和麻醉师对患者输血医治的时刻、输注血液制品的品种以及输注量等随时做出恰当的决议,特别对那些高出血危险或凝血妨碍的手术患者,具有更重要的运用价值。在曩昔的几十年里,血栓弹力求仪的运用领域首要会集在围术期患者的输血辅导和办理[1-4]

一、血栓弹力求概述

于 1948 年由德国人 Hartert 创造。其原理是在模仿人体内环境下凝血-纤溶整个进程的一起,经过物理办法将血块弹性强度转换成图形表明,经过输出一系列参数从而能直观判别凝血状况并剖析成因。


图 1. 血栓弹力求检测成果示意图

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二、血栓弹力求在心外科的运用

(1)输血办理

出血是心脏外科手术的严峻并发症之一,而导致患者出血的原因多种多样,包含手术的杂乱性、术前抗血小板和/或抗凝医治、术后肝素的继续作用、凝血因子和血小板的耗费与稀释等[5]。此外,心脏外科手术中运用体外循环、抗凝剂和血液制品等也会导致或加剧凝血功用妨碍,对患者的预后发作晦气的影响[6-8]。Besser 等报导,英国的胸怀外科手术大约耗费英国国家血液中心 10% 的血液制品,其间 90% 运用于大约仅 10% 的患者[8]。血栓弹力求是一种新式的适用于床旁检测的血液粘弹性检测体系(Viscoelastic Coagulation Assay, VCA),运用全血标本,监测血液凝结和纤溶的全进程,比传统凝血功用检测更契合现代以细胞学为根底的凝血反响机制。从上世纪 50 时代后期血栓弹力求被用于心脏外科手术以来,很多的临床数据证明血栓弹力求现已成为心脏外科手术中一项必备的辅佐检测手法,特别是在监控心外科手术患者围术期凝血功用、辅导血液制品的输注方面具有重要的临床意义[9-20]。一般来讲,患者的血样要以鱼精蛋白中和肝素,并调整到最佳温度、pH 值和离子强度后,再进行血栓弹力求检测;不过在高出血危险手术时(如再次手术、循环辅佐、心脏移植等),能够更体系地运用血栓弹力求检测。

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(2)围术期凝血功用办理

血栓弹力求运用于围术期凝血功用办理的前史由来已久。早在 1985 年,血栓弹力求已在肝移植术中进行凝血功用监测[42],且历经 30 多年开展,血栓弹力求在围术期的运用越来越遍及[43-45]。心外科手术因为其危险大、难度高,其围术期的凝血功用状况更为杂乱和危险。据统计,在 40 岁以上人群非择期手术的事例中,发作术后心梗(Preioperative Myocardial Infarction, PMI)或逝世的概率高达 2.5%,而在心血管手术中这个份额高达 6.2%[46]。EACTS(European Journal of Cardio-Thoracic Surgery)指南中明确指出心外科手术的围术期办理内容包含[47]

  • 断定患者是否具有术后出血的危险;

  • 围术期输血办理及贫血的医治;

  • 术后血栓危险的评价及抗血栓医治的作用监测。

早在 1987 年,已有血栓弹力求运用于心外科手术的报导[48]。2012 年时学者 McCrath 的总述汇总了其时现已宣布的 16 个研究报告,成果表明血栓弹力求比传统凝血功用检在猜测手术出血、削减二次手术机率方面愈加具有优胜性[49]。正因如此,2014 年时 NICE(The National Institute for Health and Care Excellence)引荐运用血栓弹力求检测进行心外科手术的围术期办理[50]

(3)抗血小板药物作用监测

无论是急性的仍是择期的心外科手术,术后的抗血小板药物医治简直必不可少(表 4)。服用抗血小板药物的意图是防备术后血栓构成,但抗血小板药物的危险在于出血,因而临床上关于正在服用抗血小板药物的患者有必要进行严密的凝血功用监测。

表 4. 抗血小板药物在心外科的引荐等级

以往临床上常用血小板功用剖析仪/集合剖析仪(PFA-100,VerifyNow 等)监测血小板对药物的反响,但检测费时、重复性差等成果导致临床期望更有用的手法检测抗血小板药物作用。血栓弹力求里的血小板图试剂盒为临床供给了新的根据血小板反响性的个性化检测办法[52, 53]。此外,参数 MA 还可用于根据医治窗的个体化抗血小板医治,在氯吡格雷运用进程中,MA(ADP)规模维持在 31~47 中被认为是一个合理的安全规模,能够有用平衡药效和合理的安全[54]。血小板图实验中参数 MA 还能协助评价整体的血小板功用,猜测再缺血事情的发作危险[55],还能协助预估停药时刻[56],而对入院时已在服用氯吡格雷的非紧迫手术的患者,还能够协助猜测最佳的手术时刻[57]。血小板图试剂盒有三组合:AA、ADP、AA+ADP。用以监测独自或联合运用 AA 途径(阿司匹林)或 ADP 途径(氯吡格雷)的抗小板药物作用。成果以血小板抑制率表明(表 5):

表 5. 血小板图实验成果解读

三、血栓弹力求的局限性

据报导[7],在 CPB(Cardio Pulmonary Bypass)时,患者体温常低于 35℃,均匀 32℃,此温度下凝血因子和血小板的活性大大受到影响。但血栓弹力求的检测是将血液标本复温到 37℃ 再进行检测,此刻现已不能反映患者实在的凝血功用状况。且因为检测原理所限,血栓弹力求也不能反映血管内皮的功用状况。这些原因均或许影响了血栓弹力求在心外科中的运用。不过,临床活动中状况杂乱,凝血功用检测办法品种虽多,但各有不足之处,现在很难讲哪个办法是最好,而是需要在临床活动中将不同的检测办法和成果参数进行有序有理的组合,才干协助临床医师应对「难缠」的凝血反常问题。

TIPS:

四、参考文献

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五、联络咱们

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