Integral Use of Thromboelastography With Platelet Mapping to Guide Appropriate Treatment, Avoid Complications, and Improve Survival of Patients With Coronavirus Disease 2019-Related Coagulopathy.
Integral Use of Thromboelastography With Platelet Mapping to Guide Appropriate Treatment, Avoid Complications, and Improve Survival of Patients With Coronavirus Disease 2019-Related Coagulopathy.
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DOI：
10.1097/cce.0000000000000287
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发表时间：
2020-12
影响因子：
--
通讯作者：
Pepe PE
中科院分区：
文献类型：
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作者：
Hranjec T;Estreicher M;Rogers B;Kohler L;Solomon R;Hennessy S;Cibulas M;Hurst D;Hegazy M;Lee J;Perez D;Doctor N;Kiffin C;Pigneri D;LaGuardia H;Shaw K;Arenas J;Rosenthal A;Katz RS;Sawyer RG;Pepe PE
2019冠状病毒病的凝血功能障碍在很大程度上被描述为高凝性，但血栓和出血性并发症都会发生。虽然已经推荐了治疗性和预防性抗凝干预措施，但经验性使用抗因子药物（肝素/依诺肝素）可能导致出血性并发症，包括死亡。此外，传统的（抗因子）抗凝并不能解决血小板过度活跃对2019冠状病毒病的影响。该研究的主要目的是评估算法引导的血小板制图的血栓弹性成像是否可以更好地表征个体的冠状病毒病2019相关凝血功能状态，其次是改善结果。2019冠状病毒病患者（n = 100）在入住一家拥有800张床位的三级医院时接受血小板定位测定的血栓弹性成像，由医院血栓弹性成像团队进行前瞻性随访。治疗临床医生可以选择使用预先建立的抗凝算法，包括随访血小板定位分析的血栓弹性成像。分为两组：1)采用血小板定位算法（算法引导的血栓弹性成像）的血栓弹性成像治疗的患者；2)使用血小板制图方案（非算法指导）而没有进行血栓弹性成像治疗的患者。结果包括血栓/出血性并发症、肺衰竭、需要机械通气、急性肾损伤、透析需求和无法生存。有或没有算法引导的血栓弹性成像支持的标准治疗。虽然d-二聚体、c反应蛋白和铁蛋白在危重患者（非幸存者、急性肾损伤、肺衰竭）中显著升高，但它们不能区分凝血障碍和非凝血障碍患者。血小板过度活跃（最大振幅-花生四烯酸/二磷酸腺苷bbb50分钟），伴或不伴血小板增多，与血栓/缺血性并发症相关，而严重血小板减少（血小板计数< 100,000/μL）一致是致命的。出血并发症的发生与因子活性的降低有关（反应时间为8min）。非算法引导的患者随后发生机械通气（相对风险= 10.9,p < 0.0001）、急性肾损伤（相对风险= 2.3,p = 0.0017）、透析（相对风险= 7.8,p < 0.0001）和死亡（相对风险= 7.7,p < 0.0001）的风险增加，28例非算法引导的患者中有17例（60.7%）死亡，而4例算法引导的血栓弹性成像患者（5.6%）死亡（p < 0.0001）。血小板定位引导的抗血小板治疗的血栓弹性成像降低了82%的死亡率（p = 0.0002），而非算法引导（与算法引导的血小板弹性成像相比）使用抗因子治疗（肝素/依诺肝素）导致死亡风险增加10.3倍（p = 0.0001）。血小板制图的血栓弹性成像更好地表征2019冠状病毒病凝血相关异常的频谱，并可能指导2019冠状病毒病感染者更有针对性的患者特异性治疗。
Coagulopathy of coronavirus disease 2019 is largely described as hypercoagulability, yet both thrombotic and hemorrhagic complications occur. Although therapeutic and prophylactic anticoagulant interventions have been recommended, empiric use of antifactor medications (heparin/enoxaparin) may result in hemorrhagic complications, including death. Furthermore, traditional (antifactor) anticoagulation does not address the impact of overactive platelets in coronavirus disease 2019. The primary aim was to evaluate if algorithm-guided thromboelastography with platelet mapping could better characterize an individual’s coronavirus disease 2019-relatedcoagulopathic state and, secondarily, improve outcomes. Coronavirus disease 2019 patients (n = 100), receiving thromboelastography with platelet mapping assay upon admission to an 800-bed tertiary-care hospital, were followed prospectively by a hospital-based thromboelastography team. Treating clinicians were provided with the option of using a pre-established algorithm for anticoagulation, including follow-up thromboelastography with platelet mapping assays. Two groups evolved: 1) patients managed by thromboelastography with platelet mapping algorithm (algorithm-guided-thromboelastography); 2) those treated without thromboelastography with platelet mapping protocols (non-algorithm-guided). Outcomes included thrombotic/hemorrhagic complications, pulmonary failure, need for mechanical ventilation, acute kidney injury, dialysis requirement, and nonsurvival. Standard-of-care therapy with or without algorithm-guided-thromboelastography support. Although d-dimer, C-reactive protein, and ferritin were elevated significantly in critically ill (nonsurvivors, acute kidney injury, pulmonary failure), they did not distinguish between coagulopathic and noncoagulopathic patients. Platelet hyperactivity (maximum amplitude-arachidonic acid/adenosine diphosphate > 50 min), with or without thrombocytosis, was associated with thrombotic/ischemic complications, whereas severe thrombocytopenia (platelet count < 100,000/μL) was uniformly fatal. Hemorrhagic complications were observed with decreased factor activity (reaction time > 8 min). Non-algorithm-guided patients had increased risk for subsequent mechanical ventilation (relative risk = 10.9; p < 0.0001), acute kidney injury (relative risk = 2.3; p = 0.0017), dialysis (relative risk = 7.8; p < 0.0001), and death (relative risk = 7.7; p < 0.0001), with 17 of 28 non-algorithm-guided patients (60.7%) dying versus four algorithm-guided-thromboelastography patients (5.6%) (p < 0.0001). Thromboelastography with platelet mapping–guided antiplatelet treatment decreased mortality 82% (p = 0.0002), whereas non-algorithm-guided (compared with algorithm-guided-thromboelastography) use of antifactor therapy (heparin/enoxaparin) resulted in 10.3-fold increased mortality risk (p = 0.0001). Thromboelastography with platelet mapping better characterizes the spectrum of coronavirus disease 2019 coagulation-related abnormalities and may guide more tailored, patient-specific therapies in those infected with coronavirus disease 2019.