血栓弹力图联合凝血功能检测在创伤患者输血治疗中的指导作用评估

目的:分析血栓弹力图联合凝血功能检测在创伤患者输血治疗中的指导作用.方法:回顾性分析2019年9月-2021年9月期间本院接收的103例创伤患者的临床资料.根据检测方法不同将患者分为观察组(血栓弹力图联合凝血功能检测,n=53)和对照组(凝血功能检测,n=50).分析比较两组的凝血功能、血制品使用量和输血后并发症发生情况.结果:输血24 h后,观察组PT、APTT、TT均显著短于对照组(P<0.05),血浆FIB显著高于对照组(P<0.05).观察组的新鲜冰冻血浆、血小板、冷沉淀及红细胞使用量均显著少于对照组(P<0.05).观察组的不良反应发生率及病死率与对照组相比无明显差异(P>0.05).结论:血栓弹力图联合凝血功能检测在创伤患者输血治疗中有重要的指导作用,能实时监测创伤患者的凝血功能,降低血制品的使用.     

血栓弹力图在创伤性凝血病中的应用

创伤导致约30%患者在入院时已并发凝血功能障碍。凝血功能障碍筛选试验在严重创伤出血患者中很难预测出血倾向,而血栓弹力图(TEG)可以显示从血凝块开始形成到溶解时所有阶段的变化。其优势是可快速识别纤溶亢进。文章就TEG工作原理、优缺点及其在创伤性凝血病患者中临床应用进行阐述。TEG在创伤患者中的应用有助于早期预测输血、指导大量输血复苏、有助于评估创伤患者预后、联合血小板图鉴别诊断创伤前是否应用抗血小板药物造成的血小板功能的下降、区分机械性出血、加强重组活性凝血因子Ⅶ(rFⅦa)的管理,同时也对是否、何时使用抗纤溶药物等提供依据。     

白细胞促凝物质的实验研究

以新鲜全血制备白细胞冻溶上清液，进行其促血小板聚集和促凝血时间的对照研究。结果发现，临床甲襞微循环检查具有白色微小血栓的患者血小板聚集率明显增高及凝血时间缩短明显（P＜0．001），证实白细胞确有促凝物质的存在并参予了白色微小血栓的形成。     

肝病患者的凝血功能检测分析

目的 探讨肝病患者的凝血功能变化,以来判定肝脏疾病患者肝功能损害程度.方法 收集我院肝病患者共100例,采用凝固比浊法来测定血浆凝血酶原时间(PT)、凝血酶时间(TT)、活化部分凝血活酶时间(APTT)、纤维蛋白原(FIB)的含量,并与正常对照进行比较.结果 急性肝炎组中血浆PT、TT、APTT、FIB含量与正常对照组比较差异无显著性(P＞0.05)无统计学意义;肝硬化组、慢性肝炎组与正常对照组比较血浆PT、TT、APTT、FIB含量均存在着显著性的差异(P<0.05)有统计学意义.结论 监测肝病患者的PT、APTT、TT、FIB血浆水平,能较好地反映肝功能状况并评估肝脏受损程度,对临床的治疗及疗效观察提供了科学的依据.     

肝硬化上消化道出血的输血治疗进展

肝硬化患者常见并发症有上消化道出血,因凝血功能障碍、血小板数量减少及功能异常而易致止血困难,引起失血性休克,甚至死亡。临床医师可通过输注新鲜冰冻血浆、冷沉淀及血小板改善凝血功能、促进止血,并输注红细胞悬液提高携氧能力。合理输血可以提高治疗效果,缩短住院时间,减少不良反应发生率及死亡率。目前国内外对肝硬化上消化道出血的输血启动阈值、输血剂量尚存争议,近年仍在不断研究和探讨,本文现对近年相关研究进行综述,以制定科学的输血治疗方案。     

血栓弹力图在肝脏疾病的应用进展

血栓弹力图(TEG)是一种动态描记凝血形成和纤维蛋白溶解全过程的曲线图,可在短时间内提供凝血、纤维蛋白溶解和血小板功能等多方面的信息,为预测出血风险和优化管理策略提供一有效手段.文章对TEG的设计原理、参数解读及其在肝硬化、肝移植、监测活化重组凝血因子Ⅶa使用及对门静脉高压患者肝储备功能评估等方面的临床应用情况进行综述...     

髋关节置换后氨甲环酸关节腔注射及间断夹管:出血量的变化

背景:随着全髋关节置换患者的增多,血源越来越紧张,同时输血感染各种严重疾病的风险也困扰者患者,故寻找一种减少输血并且不增加风险的方法显得很重要。目前国内外已有在全膝、全髋关节置换及脊椎手术中使用氨甲环酸减少出血的报道。目的:探讨关节腔注射氨甲环酸及间断夹管对全髋关节置换后出血量、功能恢复及并发症的影响。方法:选取2011年1月至2014年2月因股骨颈骨折或髋关节骨关节炎行全髋关节置换的患者99例,氨甲环酸组55例,对照组44例。氨甲环酸组于置换缝皮结束后关节腔注射2.0 g氨甲环酸(溶入20 mL生理盐水),置换后间断2 h后放开引流,此后每4 h放10 min。对照组间断夹管引流,置换后48 h均拔出负压引流管。比较两组患者置换后可见失血量、输血例数、输血量、置换后24 h血红蛋白及红细胞比容,置换前、置换后3 h纤维蛋白原、凝血酶原时间及活化部分凝血活酶时间,置换后6个月随访髋关节Harris评分及下肢深静脉血栓或肺栓塞形成情况。结果与结论:两组患者置换后可见失血量、输血例数、输血量、置换后24 h血红蛋白及红细胞比容比较差异均有显著性意义(P0.05),氨甲环酸组明显优于对照组。两组置换前、置换后3 h纤维蛋白原、凝血酶原时间和活化部分凝血活酶时间差异无显著性意义(P0.05)。两组患者置换后6个月髋关节Harris评分差异无显著性意义(P0.05)。99例患者置换后3次(3,10,14 d)行下肢血管多普勒超声检查未发现深静脉血栓形成,置换后6个月随访未发现下肢深静脉血栓或肺栓塞发生。提示关节腔注射氨甲环酸及间断夹管在全髋关节置换后能明显降低患者置换后失血量及输血率,并且未增加下肢深静脉血栓形成的风险。     

肺心病急性加重期患者血液流变学及凝血功能指标监测的临床意义

目的 探讨肺心病急性加重期患者血液流变学及凝血功能的变化.方法 选取2014年6月至2016年1月在我院治疗的51例肺心病急性加重期患者为急性加重组,在我院接受治疗的51例恢复期患者为恢复组和社会招募51例健康受试者为正常组,考察肺心病急性加重期患者血液流变学中红细胞计数、红细胞压积、全血高切黏度、全血低切黏度、血浆黏度、血沉,凝血功能中凝血酶原时间(PT)、活化部分凝血活酶时间(APTT)、纤维蛋白原(FIB)、凝血酶时间(TT)的变化.结果 肺心病急性加重期部分患者的红细胞计数偏离正常值范围,整体肺心病急性加重期患者的红细胞计数与恢复期和正常组受试者差异无统计学意义.肺心病急性加重期患者红细胞压积、全血高切黏度、全血低切黏度、血浆黏度、血沉均较恢复期和正常组受试者的值高,并且差异具有统计学意义(P<0.05).肺心病急性加重期患者的PT、APTT、FIB、TT高出正常值范围,并且与恢复期和正常组相比差异具有统计学意义(P<0.05).结论 肺心病急性加重期的患者血液黏度升高、凝血功能紊乱.因此血液黏度和凝血功能检查,可以作为肺心病急性加重期患者病情判定与评估的一种手段.     

大量输血对车祸多发伤患者凝血四项指标变化的影响

目的:探究大量输血对输血科车祸多发伤患者凝血四项指标变化的影响。方法:选取2017年1月至2019年8月我院输血科收治的车祸多发伤患者105例作为研究对象,根据输血量分为大量输血组(输血量>2000 ml,n=57)与少量输血组(输血量≤2000 mL,n=48)。比较两组临床资料、输血前、输血后1 d、5 d凝血四项指标:纤维蛋白原(Fibrinogen,FIB)、凝血酶原时间(Prothrombin time,PT)、凝血酶时间(Thrombin time,TT)、活化部分凝血活酶时间(Activated partial thromboplastin time,APTT)以及血小板(Platelet,PLT)变化趋势。结果:输血后1 d大量输血组FIB、PLT低于输血前及少量输血组,PT、APTT、TT长于输血前及少量输血组(P<0.05);输血后5 d两组FIB、PLT高于输血后1 d,PT、APTT、TT短于输血后1 d(P<0.05),组间无明显差异(P>0.05);大量输血组凝血障碍发生率高于少量输血组(P<0.05)。结论:大量输血应用于车祸多发伤患者可显著增加凝血功能障碍风险,需密切监测凝血四项指标,适时合理补充PLT,以促进凝血功能恢复。     

重症肝病患者凝血和纤溶指标观察

重症肝病患者因肝细胞的严重损害,致使肝脏功能减退,全身各系统受损,凝血系统发生不同程度的异常改变。本文报道48例重症肝病（包括慢性重症肝炎和肝硬化）患者血浆凝血酶原时间（PT）、活化部分凝血活酶时间（APTT）、纤维蛋白原（Fib）、凝血酶时间（TT）、D-二聚体（D-D）、抗凝血酶-Ⅲ（AT—Ⅲ）、纤溶酶原（PLG）和血小板计数（PLT）的检测结果,观察重症肝病患者凝血、抗凝和纤溶功能变化。     

Transfusion practice in orthotopic liver transplantation

Liver transplant procedures require the most blood components, despite the fact that blood use in liver transplantation has declined dramatically over the last decade. Liver transplant recipients present unique challenges, not only in terms of blood supply, but also requirements for specialized blood components, serologic problems, and immunologic effects of transfusion on both the allograft and the recipient. The cause of intraoperative blood loss in liver transplantation is multifactorial, due to both technical factors and poor coagulation control. This procedure carries the risk of massive blood loss, which requires massive transfusions and is associated with postoperative infections, reduced graft survival, multi-organ dysfunction, and higher risk of mortality. Efforts to reduce intraoperative bleeding leading to limitation of blood transfusions are desirable to improve results and also to control costs.Method of literature search:

1. The name of topic is typed and searched in Google search.
2. The name of topic is typed and searched in PubMed search. Related articles were also searched.
3. Some standard books in Transfusion Medicine were also referred.

     

Transfusion and recipient immune function

For some time it has been known that allogeneic blood transfusions have immunologic effects on animal and human recipients. These effects include increased numbers of suppressor T cells, decreased natural killer-cell function, decreased function of macrophages and monocytes, induction of anti-idiotypic antibodies that suppress allogeneic antigen recognition, and decreases in alloreactivity of mononuclear cells in mixed lymphocyte cultures. The meaning of these changes is not clearly understood, nor is the exact clinical importance of these alterations known. However, these decreases in immunologic function may explain a number of clinical consequences some investigators believe are the sequelae of homologous blood transfusions. Clinically important outcomes that are associated with transfusions are improved survival of renal allografts and increased risks of bacterial infection and cancer recurrence after perioperative transfusions. Transfusion of plasma-rich blood components (eg, whole blood) has been specifically associated with earlier cancer recurrence and better renal allograft survival in some patient groups. The new hypothesis that transfusion of stored plasma is a major factor in altering host immune defenses is supported by the observation that patients infected with human immunodeficiency acquired immunodeficiency syndrome more rapidly if they have been transfused with large amounts of plasma. Contrary to previous belief, the transfusion of homologous stored blood plasma may have as great or greater effects on immunity than transfusion of white blood cells. We believe investigation into the immunologic effects of transfusions is likely to have a significant impact on transfusion medicine research and practice over the coming years.     

Risk of post-transfusion infection with the hepatitis delta virus. A multicenter study

Hepatitis delta virus is a defective virus that can replicate only in the presence of hepatitis B virus. To determine the prevalence, circumstances of transmission, and clinical importance of infection with hepatitis delta virus, we obtained data on 262 patients with post-transfusion hepatitis who were positive for the hepatitis B surface antigen (HBsAg) even though they had received blood screened for it. We also studied 94 HBsAg carriers who were receiving repeated blood transfusions for other diseases, and 103 HBsAg carriers with hemophilia who were receiving various forms of coagulation factors. Antibody to hepatitis delta virus was found in 9 of 262 patients (3.5 per cent) with post-transfusion hepatitis, 5 of 234 (2 per cent) with self-limited disease, and 4 of 28 (14.5 per cent) with fulminant disease (P less than 0.05). The absence of IgM antibodies to the hepatitis B core antigen indicated that three of the nine patients with both HBsAg and antibodies to hepatitis delta virus had been carriers of HBsAg at the time of transfusion, and the acute disease represented the combined effects of the two viruses. Antibody to hepatitis delta virus was found in 3 of 94 Italian carriers of HBsAg who were receiving repeated blood transfusions, in none of 24 Brazilian, East German, or Australian hemophiliac carriers infused with clotting factors prepared from single or mini-pool volunteer plasma, and in 27 to 100 per cent of 79 hemophiliac carriers from European and U.S. series who received coagulation factors manufactured from large pools of plasma. We conclude that infection with hepatitis delta virus is likely to be more severe than infection with hepatitis B virus alone and that screening for HBsAg provides a high degree of safety in preventing infection with hepatitis delta virus, but that the risk is considerably greater in patients who are already carriers of HBsAg. We recommend that HBsAg carriers be given only blood derivatives prepared from a single donor or mini-pool donors.     

Unappreciated risk factors for transplant patients: HLA antibodies in blood components

One of the more aggressive approaches in renal transplantation is the use of plasmapheresis (PP) and intravenous immunoglobulin to eliminate donor-directed human leukocyte antigen (HLA) alloantibodies. A potential complication of a PP protocol is iatrogenic hypocoagulability resulting from the removal of coagulation factors. To prevent bleeding, hypocoagulable patients may require transfusions with fresh frozen plasma (FFP) and/or cryoprecipitate (Cryo). Although HLA alloantibodies in these components have been linked to complications, such as transfusion-related acute lung injury (TRALI), whether they cause complications following transfusion into allograft recipients is unknown. The incidence of complications would be dependent, in part, upon the frequency of HLA alloantibodies in the various blood components. In this study, segments from 77 units of FFP, 66 units of Cryo, 106 units of packed red blood cells (RBCs), and 59 units of apheresis platelets (Plts) were tested for antibodies to HLA class I and class II antigens using FlowPRA, an HLA antigen-specific flow cytometric assay. On average, 22% of blood components tested contained HLA alloantibodies, tenfold greater than previously reported. This unappreciated frequency of HLA alloantibodies in blood components may pose a risk to transplant patients requiring transfusions by promoting allograft dysfunction or loss.     

Blood transfusion practices--a case study

Blood transfusion practices of the treating doctors in a district hospital in Haryana were studied through retrospective study of blood bank records for the years 1992 to 1994 and interview of the clinicians of various specialities in the hospital. It was found that utilization of the whole blood was 90%, 89% and 81% respectively of the total blood units utilized during this period. Single unit transfusions out of the total transfusions done were 87% in 1992 and 1993 while these were 89.9% in 1994. Blood was often requested for volume replacement in acute haemorrhage. Only homologous blood transfusions were done at the hospital. This study has highlighted that there is scope for improvement of blood transfusion practices by strictly following the indications for use of blood, promoting the preparation and use of blood components, use of plasma expanders for acute blood loss, avoiding single unit transfusions and promoting the use of autologous blood during routine surgery.     

Plugged-percutaneous liver biopsy in patients with impaired coagulation and ascites

In liver cirrhosis coagulation is impaired due to decreased synthesis of vitamin K-dependent and vitamin K-independent coagulation factors. In such patients routine liver biopsy is contraindicated due to the increased risk of bleeding. Treatment with recombinant factor VIIa or fresh frozen plasma reduces the complication rate of liver biopsy, but both have disadvantages. In this observational study, we evaluated the safety and efficacy of plugged-percutaneous liver biopsy in 36 patients with ascites (n = 9), impaired coagulation (n = 22), or both (n = 5) due to severe chronic liver disease. Among patients with clotting disorders, mean prothrombin time was 16.3 s (range 11.4-20.3) and the mean platelet count was 53 x 10(9)/l (range 19-153). Plugged-percutaneous liver biopsy was in none of the cases associated with bleeding complications (95% confidence interval 0-0.097). All biopsies were adequate for histological interpretation and therefore diagnostically successful. In our experience, plugged-percutaneous liver biopsy seems a safe and reliable method in patients with chronic liver disease associated with impaired coagulation and/or ascites needing histological evaluation.     

Disorders of hemostasis in chronic renal failure and renal transplantation

The presence of end-stage renal disease (ESRD) has been associated with profound clinical effects on hemostasis ranging from thrombosis to bleeding complications. The pathogenesis of uremic bleeding is multifactorial. It has been attributed to platelet dysfunction, the most important feature, particularly platelet-platelet and platelet-vessel wall interactions. Renal replacement therapy has helped reduce bleeding episodes, but the risk of morbidity and mortality due to hemorrhage persists. Abnormalities of blood coagulation and fibrinolysis predispose uremic patients to hypercoagulable state carrying the risk of atherosclerotic cardiovascular disease and thrombotic complications such as thrombosis of the vascular access wall. There are differences in the measurement of various hemostatic parameters in patients with ESRD concerning treatment with either hemodialysis (HD) or continuous ambulatory peritoneal dialysis (CAPD). Hemostatic disturbances are overlapped by changes in the coagulation/fibrinolytic system after renal transplantation (RT). Despite the etiology, renal transplant patients are at an increased risk of thromboembolic events as a consequence of prothrombotic clotting and fibrinolytic abnormalities. This hypercoagulable state is to a large extent associated with immunosuppressive drugs. This review will give a summary of views on hemostasis in patients with ESRD and after RT.     

Appropriate blood component usage

Blood transfusion (which includes FFP, platelets, cryoprecipitate and any other blood-derived product) remains an important modality of treatment across all clinical disciplines. A blood transfusion is deemed appropriate when used in an evidence-based fashion and where the effects of the transfusion are felt to outweigh any potential risks and complications that may arise from the transfusion. In certain cases, it may be the best treatment option available, for example plasma exchange in thrombotic thrombocytopenic purpura. However, blood transfusion can result in acute or delayed complications, as well as the risk of transmission of infectious agents. The inappropriate use of blood and blood products increases the risk of transfusion-related complications and adverse events to recipients. It also contributes to shortages of blood products and the possibility of it not being available when required for other patients in an appropriate setting. It is therefore necessary to reduce the unnecessary transfusions through the appropriate clinical use of blood, avoiding unnecessary transfusions, and use of alternatives to transfusion.     

Evidence for indications of fresh frozen plasma

There continues to be a general but unfounded enthusiasm for fresh frozen plasma (FFP) usage across a range of clinical specialties in hospital practice. Clinical use of plasma has grown steadily over the last two decades in many countries. In England and Wales, there has not been a significant reduction in the use of FFP over the last few years, unlike red cells. There is also evidence of variation in usage among countries--use in England and Wales may be proportionately less per patient than current levels of usage in other European countries and the United States. Plasma for transfusion is most often used where there is abnormal coagulation screening tests, either therapeutically in the face of bleeding, or prophylactically in non-bleeding subjects prior to invasive procedures or surgery. Little evidence exists to inform best therapeutic plasma transfusion practice. Most studies have described plasma use in a prophylactic setting, in which laboratory abnormalities of coagulation tests are considered a predictive risk factor for bleeding prior to invasive procedures. The strongest randomised controlled trial (RCT) evidence indicates that prophylactic plasma for transfusion is not effective across a range of different clinical settings and this is supported by data from non-randomised studies in patients with mild to moderate abnormalities in coagulation tests. There are also uncertainties whether plasma consistently improves the laboratory results for patients with mild to moderate abnormalities in coagulation tests. There is a need to undertake new trials evaluating the efficacy and adverse effects of plasma, both in bleeding and non-bleeding patients, to understand whether the "presumed" benefits outweigh the "real risks". In addition, new haemostatic tests should be validated which better define risk of bleeding.