Rotational thromboelastometry predicts thromboembolic complications after major non-cardiac surgery
Rotational thromboelastometry predicts thromboembolic complications after major non-cardiac surgery
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DOI：
10.1186/s13054-014-0549-2
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发表时间：
2014-01-01
期刊：
影响因子：
15.1
通讯作者：
Wagener, Gebhard
中科院分区：
文献类型：
--
作者：
Hincker, Alexander;Feit, Justin;Wagener, Gebhard
引言：血栓栓塞并发症是围手术期发病率和死亡率的主要原因。常规的实验室检查不能检测出患有获得性或先天性高凝状态的患者，这些患者可能会增加围手术期血栓栓塞的风险。旋转血栓弹性测量（ROTEM）是传统血栓弹性描记术的数字化改进，稳定且技术上易于使用。我们设计了一个前瞻性的观察性研究，以评估术前ROTEM是否可以识别患者术后血栓栓塞并发症的风险增加后，主要非心脏surgery. Methods：术前ROTEM分析使用外源性旋转血栓弹性测定法（EXTEM），内源性旋转血栓弹性测定法（INTEM），和纤维蛋白原旋转血栓弹性测定法（FIBTEM）激活剂进行了313例接受主要非心脏手术。出院后对患者的病历进行了审查，以获得标准凝血研究的结果-部分凝血活酶时间（PTT）、国际标准化比值（INR）、血小板计数-以及住院期间血栓栓塞并发症的证据。血栓栓塞并发症被定义为一个新的动脉或深静脉血栓形成，导管血栓形成，或肺栓塞诊断超声或螺旋胸部computedtomography. Results：10例术后血栓栓塞并发症，其中9人接受标准预防皮下依诺肝素或肝素。PTT、INR或血小板计数均无指征。评估纤维蛋白凝块形成和血小板相互作用的术前EXTEM和INTEM活化剂表明，与无血栓栓塞并发症的患者相比，这些患者的凝块形成时间（CFT）显著较短，α角（α）和最大凝块硬度（MCF）显著较高。除血小板相互作用外，使用FIBTEM激活剂的任何参数均无显著差异。构建这些变量的受试者工作特征（ROC）曲线。INTEM凝块10 min时的硬度（A10）是血栓栓塞并发症的最佳预测因子，ROC曲线下面积为0.751。结论：我们的结果表明术前ROTEM检测包括纤维蛋白凝块和血小板相互作用可以检测出非心脏大手术后血栓栓塞并发症风险增加的患者。未来的研究需要评估术前ROTEM的临床效用和成本效益，并更好地定义ROTEM值和特定高凝状态之间的关联。
Introduction: Thromboembolic complications contribute substantially to perioperative morbidity and mortality. Routine laboratory tests do not detect patients with acquired or congenital hypercoagulability who may be at increased risk of perioperative thromboembolism. Rotational thromboelastometry (ROTEM) is a digitized modification of conventional thromboelastography that is stable and technically easy to use. We designed a prospective observational study to evaluate whether preoperative ROTEM can identify patients at increased risk for postoperative thromboembolic complications after major non-cardiac surgery.Methods: Preoperative ROTEM analysis using extrinsic rotational thromboelastometry (EXTEM), intrinsic rotational thromboelastometry (INTEM), and fibrinogen rotational thromboelastometry (FIBTEM) activators was performed on 313 patients undergoing major non-cardiac surgery. Patients' medical records were reviewed after discharge for results of standard coagulation studies - partial thromboplastin time (PTT), international normalized ratio (INR), platelet count - and evidence of thromboembolic complications during their hospital stay. A thromboembolic complication was defined as a new arterial or deep venous thrombosis, catheter thrombosis, or pulmonary embolism diagnosed by ultrasound or spiral chest computed tomography.Results: Ten patients developed postoperative thromboembolic complications, of whom 9 had received standard prophylaxis with subcutaneous enoxaparin or heparin. There was no indication of by PTT, INR, or platelet count. Preoperative EXTEM and INTEM activators that assess fibrin clot formation and platelet interaction indicated that these patients had significantly lower clot formation time (CFT) and significantly higher alpha angle (a) and maximum clot firmness (MCF), compared to patients without thromboembolic complications. There was no significant difference for any parameter using FIBTEM activator, which excludes platelet interaction. Receiver operating characteristic (ROC) curves were constructed for these variables. INTEM clot firmness at 10 min (A10) was the best predictor of thromboembolic complications, with an ROC area under the curve of 0.751.Conclusions: Our results indicate that preoperative ROTEM assays that include fibrin clot and platelet interaction may detect patients at increased risk for postoperative thromboembolic complications after major non-cardiac surgery. Future studies need to evaluate the clinical utility and cost effectiveness of preoperative ROTEM and better define the association between ROTEM values and specific hypercoagulable conditions.