董永光

【摘要】?目的?探討大量成分輸血對患者凝血機(jī)制的干預(yù)。方法?73例大量成分輸血患者, 輸注懸浮紅細(xì)胞量平均11 U, 輸注冰凍血漿量平均8 U。輸血前、輸血后4 h檢測凝血指標(biāo)。 結(jié)果?73例患者輸血前后凝血因子差異有統(tǒng)計(jì)學(xué)意義(P均<0.01)；血小板顯著下降, 差異有統(tǒng)計(jì)學(xué)意義(P<0.01)。結(jié)論?大量成分輸血對凝血功能有重要影響, 應(yīng)及時檢測凝血因子及血小板, 并通過血液加溫以及針對性的補(bǔ)充血小板和凝血因子來減少出血風(fēng)險。

【關(guān)鍵詞】?成分輸血；凝血指標(biāo)；血小板

Intervention analysis of a large number of component blood transfusion on blood coagulation mechanism DONG Yong-guang.Pingdu Blood Donor Services of Qingdao Blood Station,Qingdao 266700, China

【Abstract】?Objective?To analyze intervention of a large number of component blood transfusion on blood coagulation mechanism. Methods?Retrospectively analyzed clinical data of 73 patients with a large number of component blood transfusion. The infusion of suspension red blood cell volume average of 11 U, infusion of average frozen plasma volume of 8 U. Blood clotting index 4 h before and after blood transfusion was detected. Results?73 cases of patients before and after blood transfusion blood coagulation factor had significant changes, the difference was statistically significant(P<0.01), blood platelet reducted significantly, the difference was statistically significant(P<0.01). Conclusion?A large number of component blood transfusion has important influence on blood coagulation function, blood platelet and clotting factors should be timely detected, and through blood heat and corresponding platelet and blood coagulation factor supplementary to reduce risk of bleeding.

【Key words】?Component blood transfusion; Blood coagulation indexes; Blood platelet大量成分輸血是外科手術(shù)中比較常見的輔助治療手段, 主要包括：①24 h內(nèi)輸血量大于等于患者有效循環(huán)血量［1］； ②24 h內(nèi)輸入超過10 U的懸浮紅細(xì)胞［2］；③一次連續(xù)性輸血大于等于患者總血容量的1.5倍［3］。主要用于搶救急性失血所致血溶量急驟減少, 血壓快速下降的急危重癥患者。大量成分輸血對機(jī)體的凝血功能具有重要影響, 可造成電解質(zhì)紊亂、低體溫、酸中毒、凝血功能障礙等嚴(yán)重并發(fā)癥, 甚至發(fā)生彌散性血管內(nèi)凝血(DIC), 若處理不當(dāng)可造成患者死亡。其主要機(jī)理是, 凝血因子以及血小板發(fā)生消耗性和稀釋性減少［4］。本研究對73例大量成分輸血患者進(jìn)行回顧性分析, 探討患者輸血前后凝血指標(biāo)的變化情況, 以期為臨床輸血提供可借鑒的依據(jù)。

1 資料與方法

1. 1 一般資料選取2013年1月~2014年1月來源于本地區(qū)三級綜合醫(yī)院的大量成分輸血患者輸血病歷資料73例進(jìn)行回顧性分析, 排除內(nèi)科血液疾病、肝功能衰竭及藥物原因造成的凝血障礙。其中, 男38例, 女35例, 平均年齡(49.7±18.8)歲；按照失血原因分類, 婦產(chǎn)科出血18例, 外科手術(shù)失血外傷性失血35例, 消化系統(tǒng)出血13例, 呼吸系統(tǒng)出血7例。

1. 2輸血情況

1. 2. 1成分輸血單位計(jì)算由200 ml新鮮全血制備1 U懸浮紅細(xì)胞, 平均容積(150.7±9.5)ml； 由200 ml新鮮全血制備1 U冰凍血漿, 容積為100 ml。

1. 2. 2輸血量及輸血速度本研究中73例患者輸注懸浮紅細(xì)胞量為10~19 U, 平均11 U。同期輸注冰凍血漿量5~11 U, 平均8 U。輸注的血液制品均由本血站提供。按照患者失血情況以及身體耐受性調(diào)整輸血速度, 平均為5~10 ml/min。

1. 3 觀察指標(biāo)73例患者分別于輸血前、輸血后4 h兩個時間節(jié)點(diǎn)檢測以下指標(biāo), 以比較輸血前后凝血功能變化。采用日本希斯美康公司Sysmex CA1500血凝儀測定纖維蛋白原(FIB)、活化部分凝血酶原時間(APTT)、凝血酶原時間(PT)、凝血酶原時間活動度(PT%)、國際標(biāo)準(zhǔn)化比值(INR)、凝血酶時間(TT), 美國貝克曼庫爾特公司貝克曼-庫爾特血細(xì)胞分析儀檢測血小板計(jì)數(shù)(PLT)、血紅蛋白(HGB)、紅細(xì)胞壓積(HCT)。各試驗(yàn)試劑均為儀器配套試劑。

1. 4 統(tǒng)計(jì)學(xué)方法應(yīng)用SPSS17.0統(tǒng)計(jì)分析, 計(jì)量資料以均數(shù) ±標(biāo)準(zhǔn)差( x-±s)表示, 采用t檢驗(yàn), 計(jì)數(shù)資料用 χ2檢驗(yàn), P<0.05為差異有統(tǒng)計(jì)學(xué)意義。

2 結(jié)果

2. 1輸血前后凝血因子比較73例患者輸血前后凝血因子均有顯著改變, 差異有統(tǒng)計(jì)學(xué)意義(P均<0.01), 詳見表1。表明大量成分輸血對凝血功能有重要影響。

2. 2輸血前后血細(xì)胞比較輸血后HGB、HCT得到顯著改善, 差異有統(tǒng)計(jì)學(xué)意義(P均<0.01)；PLT顯著下降, 差異有統(tǒng)計(jì)學(xué)意義(P<0.01), 詳見表2。

表2輸血前后血細(xì)胞比較( x-±s, n=73)

時間 HGB(g/L) HCT PLT(×109/L)

輸血前 58.8±11.7 0.23±0.03 155.8±19.9

輸血后 76.4±17.6a 0.31±0.05a 76.5±15.9a

注：組間比較, aP均<0.01

3討論

成分輸血具有提高血制品各成分的利用度以及較少輸血相關(guān)感染性疾病傳播風(fēng)險的優(yōu)點(diǎn)［5］, 目前臨床用血, 成分輸血已替代了全血輸注, 大出血患者要獲得大量全血已不現(xiàn)實(shí)。然而大量成分輸血對凝血功能的影響值得關(guān)注。大量成分輸血對急、危、重患者的搶救發(fā)揮重要作用, 對于大量失血患者, 及時充足的血液供應(yīng)對搶救起到關(guān)鍵性作用, 調(diào)查顯示大量成分輸血治療后患者死亡率在18%~69%［6］, 其中凝血機(jī)制障礙是導(dǎo)致患者死亡的重要因素［7］。庫存血液特點(diǎn)是血小板及凝血因子FⅤ、FⅧ、FⅪ隨儲存的時間越長破壞越嚴(yán)重, 大量快速輸注庫存血液則有可能導(dǎo)致自身凝血因子的稀釋性降低［8］, 無凝血功能障礙成人輸入超過1200 ml血液可出現(xiàn)凝血功能改變［9］?；颊叽罅枯斎霚囟容^低的庫存血液會引起體溫下降, 如果沒有及時補(bǔ)充凝血因子, 會導(dǎo)致稀釋性凝血因子減少。凝血因子數(shù)量的相對減少是導(dǎo)致凝血功能下降的原因之一［10］。首先降低的凝血成分是FIB, 大量成分輸血時, 胞漿素原被激活成為胞漿素, 造成FIB過度溶解, 導(dǎo)致FIB顯著降低。研究發(fā)現(xiàn)［11］, 當(dāng)輸入5 U紅細(xì)胞后即會出現(xiàn)稀釋性凝血障礙, 輸入12 U紅細(xì)胞可致PT和APTT異常延長, 輸入20 U紅細(xì)胞即可致凝血功能障礙, 有發(fā)生出血的危險［12］。PT和APTT分別反映外源性和內(nèi)源性凝血功能。APTT的延長主要與Ⅷ、Ⅸ、Ⅺ、Ⅻ因子減少有關(guān), PT的延長主要與Ⅶ因子減少有關(guān)。

endprint

綜上所述, 大量成分輸血對凝血功能有重要影響, 應(yīng)及時檢測凝血因子及血小板, 并通過血液加溫以及針對性的補(bǔ)充血小板和凝血因子來減少出血風(fēng)險。

參考文獻(xiàn)

［1］ Stainsby D, MacLennan S, Thomas D, et al. Guidelines on the man-agement of massive blood loss. British J Haematol, 2006, 135(5):634-641.

［2］ Hewitt PE, Machin SJ.ABC of transfusion Massive blood transfusion. BMJ, 1990, 300(6717):107-109.

［3］ Malone DL, Hess JR, Fingerhut A. Massive transfusion practices around the globe and a suggestion for a common massive transfusion protocol. J Trauma, 2006, 60(6):S91-S96.

［4］ Kozek-Langenecker S. Management of massive operative bloodloss.Minerva Anestesiol, 2007, 73(7):401-415.

［5］ Schuster KM, Davis KA, Lui FY, et al. The status of massive trans-fusion protocols in United States trauma centers:massive transfusion or massive confusion. Transfusion, 2010, 50(7):545-1551.

［6］ MacLeod JB, Lynn M, McKenney MG, et al. Early coagulopathy predicts mortality in trauma. J Trauma, 2003, 55(1):39-44.

［7］ Cinat ME, Wallace WC, Nastanski F, et al.Improved survival fol-lowing massive transfusion in patients who have undergone trau-ma. Arch Surg, 1999, 134(9):964-968.

［8］ Riskin DJ, Tsai TC, Riskin L, et al.Massive transfusion protocols:The role of aggressive resuscitation versus product ratio in mortality reduction. J Am Coll Surg, 2009, 209(2):198-205.

［9］ Como JJ, Dutton RP, Scalea TM, et al. Blood transfusion rates in the care of acute trauma. Transfusion, 2004, 44(6):809-813.

［10］Miller RD, Robbins TO, Tong MJ, et al. Coagulation defects associ-ated with massive blood transfusion. Ann Surg, 1971, 174(5):794-801.

［11］Counts RB, Haiscb C, Simon TL, et al. Hemostasis in massively transfused trauma patients. Ann Surg, 1979, 190(1):91-99.

［12］Hardy JF, Moerloose P, Samama M, et al. Massive transfusion and coagulopathy: pathophysiology and implication for clinical manage-ment, Can J Anesth, 2004, 51(4): 293-310.

［收稿日期：2014-04-23］

endprint

綜上所述, 大量成分輸血對凝血功能有重要影響, 應(yīng)及時檢測凝血因子及血小板, 并通過血液加溫以及針對性的補(bǔ)充血小板和凝血因子來減少出血風(fēng)險。

參考文獻(xiàn)

［1］ Stainsby D, MacLennan S, Thomas D, et al. Guidelines on the man-agement of massive blood loss. British J Haematol, 2006, 135(5):634-641.

［2］ Hewitt PE, Machin SJ.ABC of transfusion Massive blood transfusion. BMJ, 1990, 300(6717):107-109.

［3］ Malone DL, Hess JR, Fingerhut A. Massive transfusion practices around the globe and a suggestion for a common massive transfusion protocol. J Trauma, 2006, 60(6):S91-S96.

［4］ Kozek-Langenecker S. Management of massive operative bloodloss.Minerva Anestesiol, 2007, 73(7):401-415.

［5］ Schuster KM, Davis KA, Lui FY, et al. The status of massive trans-fusion protocols in United States trauma centers:massive transfusion or massive confusion. Transfusion, 2010, 50(7):545-1551.

［6］ MacLeod JB, Lynn M, McKenney MG, et al. Early coagulopathy predicts mortality in trauma. J Trauma, 2003, 55(1):39-44.

［7］ Cinat ME, Wallace WC, Nastanski F, et al.Improved survival fol-lowing massive transfusion in patients who have undergone trau-ma. Arch Surg, 1999, 134(9):964-968.

［8］ Riskin DJ, Tsai TC, Riskin L, et al.Massive transfusion protocols:The role of aggressive resuscitation versus product ratio in mortality reduction. J Am Coll Surg, 2009, 209(2):198-205.

［9］ Como JJ, Dutton RP, Scalea TM, et al. Blood transfusion rates in the care of acute trauma. Transfusion, 2004, 44(6):809-813.

［10］Miller RD, Robbins TO, Tong MJ, et al. Coagulation defects associ-ated with massive blood transfusion. Ann Surg, 1971, 174(5):794-801.

［11］Counts RB, Haiscb C, Simon TL, et al. Hemostasis in massively transfused trauma patients. Ann Surg, 1979, 190(1):91-99.

［12］Hardy JF, Moerloose P, Samama M, et al. Massive transfusion and coagulopathy: pathophysiology and implication for clinical manage-ment, Can J Anesth, 2004, 51(4): 293-310.

［收稿日期：2014-04-23］

endprint

綜上所述, 大量成分輸血對凝血功能有重要影響, 應(yīng)及時檢測凝血因子及血小板, 并通過血液加溫以及針對性的補(bǔ)充血小板和凝血因子來減少出血風(fēng)險。

參考文獻(xiàn)

［1］ Stainsby D, MacLennan S, Thomas D, et al. Guidelines on the man-agement of massive blood loss. British J Haematol, 2006, 135(5):634-641.

［2］ Hewitt PE, Machin SJ.ABC of transfusion Massive blood transfusion. BMJ, 1990, 300(6717):107-109.

［3］ Malone DL, Hess JR, Fingerhut A. Massive transfusion practices around the globe and a suggestion for a common massive transfusion protocol. J Trauma, 2006, 60(6):S91-S96.

［4］ Kozek-Langenecker S. Management of massive operative bloodloss.Minerva Anestesiol, 2007, 73(7):401-415.

［5］ Schuster KM, Davis KA, Lui FY, et al. The status of massive trans-fusion protocols in United States trauma centers:massive transfusion or massive confusion. Transfusion, 2010, 50(7):545-1551.

［6］ MacLeod JB, Lynn M, McKenney MG, et al. Early coagulopathy predicts mortality in trauma. J Trauma, 2003, 55(1):39-44.

［7］ Cinat ME, Wallace WC, Nastanski F, et al.Improved survival fol-lowing massive transfusion in patients who have undergone trau-ma. Arch Surg, 1999, 134(9):964-968.

［8］ Riskin DJ, Tsai TC, Riskin L, et al.Massive transfusion protocols:The role of aggressive resuscitation versus product ratio in mortality reduction. J Am Coll Surg, 2009, 209(2):198-205.

［9］ Como JJ, Dutton RP, Scalea TM, et al. Blood transfusion rates in the care of acute trauma. Transfusion, 2004, 44(6):809-813.

［10］Miller RD, Robbins TO, Tong MJ, et al. Coagulation defects associ-ated with massive blood transfusion. Ann Surg, 1971, 174(5):794-801.

［11］Counts RB, Haiscb C, Simon TL, et al. Hemostasis in massively transfused trauma patients. Ann Surg, 1979, 190(1):91-99.

［12］Hardy JF, Moerloose P, Samama M, et al. Massive transfusion and coagulopathy: pathophysiology and implication for clinical manage-ment, Can J Anesth, 2004, 51(4): 293-310.

［收稿日期：2014-04-23］

endprint