肝臟移植作為終末期肝病的治療，自上個世紀80年代在歐美國家獲得公認以來，已在世界各國得到迅速開展。我國自90年代后期以來，在全國掀起了第二個肝移植的熱潮，迄今已完成1 000余例肝移植，在圍手術期處理、手術技術、介入放射、移植免疫、抗感染治療等各個方面均獲得豐富的經驗，我國肝移植的效果及長期生存率亦逐步趕上國際先進水平。總的來講，適合進行肝移植的病種可分為良性及惡性肝病，鑒于惡性肝病行肝移植后復發率高，長期生存率低，因而其作為肝移植的指征長期以來存在爭議，而良性終末期肝病則是肝移植的主要指征。我院自1999年2月以來連續施行肝移植114例，其中良性肝病為69例，占60.5%。本文僅針對良性肝病肝移植的一些特點談談我們的經驗和體會。
目的:探討腦損傷患者凝血功能水平與顱腦損傷傷情轉歸的相關性。方法:收集70例顱腦損傷患者的臨床資料,傷者抽取靜脈血2 mL,進行凝血功能檢測,分析結果與臨床資料等分別采用SPSS 11.5軟件進行χ2檢驗和logistic回歸分析。結果:在13例凝血功能異常患者中有5例(38%)傷情加重(較入院時腦內血腫體積增大,遲發性血腫等),明顯高于凝血功能正常而傷情加重者(12%,Plt;0.05);單因素和多因素logistic回歸分析提示凝血功能異常時腦損傷傷情加重的危險因素。結論:腦創傷后凝血功能異常時顱腦損傷患者傷情加重的危險因素。
Objective To preliminarily summarize the diagnosis and treatment of coagulopathy in patient with severe hepatic cirrhosis who underwent orthotopic liver transplantation (OLT). Methods Preoperative coagulability, the replacement therapy by coagulation factors and platelet pre-and intraoperatively, intra-operative bleeding amount and blood transfusion amount and the relation to the postoperative course were analyzed retrospectively in 6 patients with severe hepatic cirrhosis who underwent OLT in the last year. Results All of the 6 patients had a Child-c preoperative hepatic function, 2 with prolongation of bleeding time. All of the 6 had a decrease of platelet count, with a mean platelet count of 25.3×１０９／Ｌ. Mean prolongation of prothrombin time was 10.7 seconds as compared with controls. Mean prolongation of activated partial thromboplastin time was 23.1 seconds as compared with controls. Mean fibrinogen was 1.5 g/L. Mean pre- and intra- operative transfusion of fresh frozen plasma was 788 ml, platelet 7.1×１０12， cryopreciptitate 5.5 units, fibrinogen 2.8 grams and lyophilized prothombin complex concentrate (LPCC) 1 700 units. The first 4 cases in the early period had a mean bleeding amount of 8 672.5 ml, with a mean transfusion of 9 215.0 ml. One of the 4 with the most massive intraoperative bleeding was complicated by severe internal milieu disturbance, DIC and fungus infection and died of the infection. Postoperatively the last 2 cases in the late period had a complete preoperative replacement of coagulation factors and platelet and had a only mean bleeding amount of 2 700 ml with a mean transfusion amount of 3 638 ml. Conclusion We initially consider that a preoperative complete replacement of coagulation factors and platelet according to the coagulability tests may lessen intraoperative bleeding and transfusion and make the patient an uneventful postoperative course.
Objective To build a score with the coagulation, inflammation indexes of sepsis patients, named Sepsis-Related Coagulo-Inflammatory Score (SRCIS), and then evaluate the prognostic capability of it in predicting the 28-day mortality of septic patients after the diagnosis. Methods In this prospective nested case-control study, we recruited septic patients according to the Sepsis 3.0 standards, who visited the Emergency Department, West China Hospital of Sichuan University from September 2017 to January 2018. Multiple factor analysis was conducted to confirm which coagulation or inflammation biomarkers were independent risk factors related to the 28-day mortality after their diagnosis. After that, the SRCIS was built based on those independent risk factors. Finally, receiver operating characteristic curve (ROC) analysis was conducted to verify its prognostic capability for the 28-day mortality of septic patients. Results A total of 123 cases were included. Among them, 17 patients died within 28 days, and the mortality rate was 13.8%. There were no significant differences in the demographic characteristics or comorbidities between the survival group and dead group (P>0.05). Multivariate logistic analysis showed that both activated partial thromboplastin time (APTT) [odds ratio (OR)=1.015, 95% confidence interval (CI) (1.017, 1.189), P=0.017] and C-reactive protein (CRP) [OR=1.100, 95%CI (1.006, 1.025), P=0.002] were independent risk factors for predicting the 28-day mortality of septic patients. ROC analysis indicated that the cut-off values of APTT and CRP predicting the 28-day mortality rate of sepsis were 39.25 seconds and 198.05 mg/L, respectively, and the areas under the curve (AUC) of them were 0.618 and 0.671, respectively. The results indicated that the mortality increased from 8.79% to 28.13%, when APTT prolonged to no less than 39.25 seconds (P<0.05). The mortality also increased from 8.89% to 27.27% when CRP elevated to no less than 198.05 mg/L (P<0.05). The AUC of SRCIS in predicting the 28-day mortality of patients with sepsis was 0.707, which was better than that of Sequential Organ Failure Assessment (SOFA) (AUC=0.681) and quick Sequential Organ Failure Assessment (qSOFA) (AUC=0.695). The corresponding 28-day mortality rates for patients with sepsis were 6.94%, 16.22%, and 42.86% (P<0.05), respectively, when the SRCIS score were 0, 1, and 2. Conclusions APTT and CRP are independent risk factors in predicting the 28-day mortality of patients with sepsis. Compared with traditional scoring systems such as SOFA and qSOFA, SRCIS performances better in predicting the 28-day mortality for patients with sepsis.
ObjectiveTo evaluate the changes in thrombelastography(TEG) during orthotopic liver transplantation （OLT） in Chinese. MethodsTwentyfive patients with cirrhosis of liver undergoing OLT were studied. They were composed of two groups: cirrhosis group （n=15） and liver neoplasm group （n=10）. Anesthesia was induced with propofol 1.5-2 mg/kg,fentanyl 3-5 μg/kg and vecuronium 0.1 mg/kg and maintained with isoflurane or enflurane inhalation.The operation was divided into three phases: ① before operation and preanhepatic phase （120 min after operation was started）, ② 30 min after liver was removed,③ 5 min before reperfusion and 5 min,15 min,30 min,60 min and 120 min after reperfusion.In 8 patients among the 25 patients heparinasecelite TEG was measured 5 min after reperfusion in addition to celite TEG.If there was significant differences in traces between the two TEG measurements,an intravenous bolus of 50-75 mg protamine was given and the heparinasecelite TEG was repeated.The measured variables included the r （reaction） time,representing the rate of initial fibrin formation K （coagulation） time, alpha angles （α） reflecting fibrinplatelet interaction, MA （maximal amplitude） indicating qualitative platelet function and percent fibrinolysis at 60 min. ResultsIn cirrhosis group changes in TEG occurred after liver was removed and in earlier period after reperfusion, while in liver neoplasm group changes in TEG were found in earlier period after reperfusion as compared with preoperative value.At 5 min after reperfusion there were significant differences in TEG （r，K，α and MA） values between celite and heparincelite TEG （P＜0.01）. ConclusionDuring OLT coagulation disorder occurs mainly at anhepatic and early reperfusion phase.
ObjectiveTo investigate the effect of artificial colloid on coagulation function in pediatric patients weighing less than 5 kg with congenital heart disease during cardiopulmonary bypass in congenital heart disease surgery by using artificial colloid instead of human serum albumin.MethodsA total of 65 pediatric patients with weight less than 5 kg who underwent congenital heart disease surgery in our hospital from September 2016 to December 2017 were included in the study. They were randomly divided into two groups: an artificial colloid group (the experimental group, n=33) and a human serum albumin combined artificial colloid group (the control group, n=32). Perioperative hemoglobin concentration (Hb), blood products and hemostatic drugs used, postoperative coagulation function index and pleural fluid volume 24 hours after surgery were monitored.ResultsThere was no significant difference in perioperative Hb and chest tube drainage between the two groups. The platelet utilization rate in the experimental group was significantly lower than that in the control group (P<0.05). No significant difference was found in the dosage of other blood products and hemostatic drugs between the two groups during the perioperative period. There was no significant difference in coagulation parameters between the two groups before and after surgery (P>0.05).ConclusionThe use of artificial colloid as colloid priming solution during cardiopulmonary bypass has no adverse effect on coagulation function in pediatric patients weighting less than 5 kg with congenital heart disease.
ObjectiveTo explore the use of agkistrodon halys antivenin, and the influence of its infusion time on the coagulation function of the patient bitten by agkistrodon halys. MethodsWe retrospectively analyzed the clinical data of patients suffering from pit viper bites and first diagnosed and treated in the emergency department of our hospital between April 1 and November 30, 2013. According to the allergy test results, patients were divided into two groups: negative and positive. Based on the infusion time, the negative patients were divided into ≤1.5 hours and >1.5 hours groups, and the positive patients were divided into ≤3 hours and >3 hours groups. All patients' gender, age, infusion time, and PT, APTT, TT, FIB, D-DIMER before and after infusion of antivenomous serum were recorded, and blood coagulation indicators before and after infusion of antivenomous serum and the impact of infusion time were compared among different groups. ResultsFor both the negative and positive groups, PT, APTT, TT, FIB, and D-DIMER were statistically improved after infusion of antivenomous serum. The blood coagulation indicators of infusion time ≤1.5 hours group and ≤3 hours group were significantly better than those of infusion time >1.5 hours and >3 hours groups. ConclusionAntivenomous serum can correct coagulation and the faster infusion rate, the more obvious the effect is.