The Influence of Perioperative Coagulation Status on Postoperative Blood Loss in Complex Cardiac Surgery: A Prospective Observational Study
The Influence of Perioperative Coagulation Status on Postoperative Blood Loss in Complex Cardiac Surgery: A Prospective Observational Study
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DOI：
10.1213/ane.0b013e3181db7991
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发表时间：
2010-06-01
影响因子：
5.7
通讯作者：
Crowther, Mark A.
中科院分区：
文献类型：
--
作者：
Karkouti, Keyvan;McCluskey, Stuart A.;Crowther, Mark A.
引言：凝血障碍导致失血过多是心脏手术的严重并发症。在这项前瞻性队列研究中，我们测量了患者的凝血状态之前和之后的心肺转流（CPB），并检查其与术后bloodloss.METHODS的关系：患者接受复杂的心脏手术与CPB谁没有预先存在的凝血功能障碍是合格的。前瞻性收集所有患者的详细临床和凝血数据。在CPB前后进行凝血试验，包括凝血酶生成、凝血因子消耗和稀释、凝块稳定和纤维蛋白溶解的测量。变量与CPB后失血量（从CPB到重症监护室入院和24小时胸管引流的估计失血量）的相关性采用斯皮尔曼秩相关检验和多变量线性回归进行评估。结果：101例研究患者的中位失血量为952 mL（四分位距，601-1553 mL）。与失血量增加独立相关的变量如下：既往胸骨切开术（P = 0.01），CPB前凝血酶原片段F1 + 2水平较低（凝血酶生成的测量; P = 0.001），CPB后血小板计数较低（P = 0.01），纤维蛋白原水平下降百分比较大（P = 0.05），CPB后可溶性纤维蛋白单体水平较高（凝血酶活性和凝块稳定性的测量; P < 0.0001）（模型R-2 = 0.43）。在复杂的心脏手术中，失血量直接受到CPB前凝血酶生成速率降低、CPB后消耗增加和凝血因子稀释的影响，以及CPB后血凝块稳定性不足。这些信息有助于识别失血过多的高风险患者，并测试旨在减少这种并发症负担的新干预措施。这些发现的有效性和普遍性需要通过其他研究进行评估。（Anesth Analg 2010; 110：1533- 1540）
INTRODUCTION: Coagulopathy leading to excessive blood loss is a serious complication of cardiac surgery. In this prospective cohort study, we measured patients' coagulation status before and after cardiopulmonary bypass (CPB) and examined their relationships with postoperative blood loss.METHODS: Patients undergoing complex cardiac surgery with CPB who did not have preexisting coagulopathy were eligible. Detailed clinical and coagulation data were prospectively collected on all patients. Coagulation testing was performed before and after CPB, and included measures of thrombin generation, clotting factor consumption and dilution, clot stabilization, and fibrinolysis. The associations of variables with post-CPB blood loss (estimated loss from CPB to intensive care unit admission and 24-hour chest tube drainage) were assessed with the Spearman rank correlation test and multivariable linear regression.RESULTS: The median blood loss among the 101 study patients was 952 mL (interquartile range, 601-1553 mL). Variables independently associated with increasing blood loss were as follows: previous sternotomies (P = 0.01), lower pre-CPB prothrombin fragment F1 + 2 levels (measure of thrombin generation; P = 0.001), lower post-CPB platelet counts (P = 0.01), larger percent decrease in fibrinogen levels (P = 0.05), and higher post-CPB soluble fibrin monomer levels (measure of thrombin activity and clot stabilization; P < 0.0001) (model R-2 = 0.43).CONCLUSIONS: In complex cardiac surgery, blood loss is directly influenced by reduced pre-CPB thrombin generation rate, increased post-CPB consumption and dilution of clotting factors, as well as inadequate post-CPB clot stabilization. This information can aid in identifying patients at high risk for excessive blood loss and testing new interventions aimed at reducing the burden of this complication. The validity and generalizability of these findings need to be assessed by other studies. (Anesth Analg 2010; 110: 1533-40)