[罂粟摘要]血栓弹力图6s预测小儿心脏手术中补充纤维蛋白原的价值

血栓弹力图6s预测小儿心脏手术中补充纤维蛋白原的价值

贵州医科大学   麻醉与心脏电生理课题

翻译:  马艳燕    编辑:  严旭  审校: 曹莹

背景：目前研究建议在心脏手术期间实施床旁检查，以便提供特定的抗凝替代方案。由于纤维蛋白原是心脏手术中最先消耗的凝血因子，因此纤维蛋白原的测定和相应的替代方案备受关注。然而，血栓弹力图（TEG）6s的预测效能在儿科患者中还没有得到评估。本研究的目的是描述心脏手术期间接受纤维蛋白原替代治疗患儿的特征，并评估TEG6s在体外循环(CPB)后的预测效能。

方法：在2017年1月至2019年7月期间，纳入279例在体外循环下行先天性心脏病手术的患儿。收集患儿手术当天至次日凌晨六点的围术期数据。用TEG6s评估止血能力。通过敏感度和特异度分析，评价TEG功能纤维蛋白原最大波幅(TEG-FF-MA)测量对术中出血以及由此引起的冷沉淀需求的预测效能。

结果：在174例TEG-FF-MA患儿中，147例(84%)在术中接受了冷沉淀治疗。冷沉淀治疗与较小的年龄[66(10-132)天比98(45-204)天(p=0.044)]，较高的RACHS-1分级和较多的术中出血[21(11-47)比5(3-13)ml/kg，p<0.001，平均差为29ml/kg（CI：8-50)]相关。输入冷沉淀的患儿的TEG-FF-MA中位数值更低[7.6(5.3-11.0)mm比10.5(7.3-13.4)mm，p=0.004，平均差为2.4 mm（CI：4.1-0.73)]。冷沉淀的用量与体外循环持续时间，TEG-FF-MA值，特别是术中出血量有关。TEG-FF-MA阈值为10.0 mm时，预测术中出血(>10ml/kg)及需要输入冷沉淀的敏感性为74%，特异性为56%，阳性预测值为80%，阴性预测值为47%。

结论：患儿的纤维蛋白原替代治疗与较小的年龄和较高的RACHS-1分级相关。我们评估了TEG6s的预测价值，冷沉淀输注与TEG-FF-MA值有关，但也与体外循环时间、手术复杂性，特别是术中出血过多相关。在接受先天性心脏病手术的患儿中，TEG-FF-MA的确切阈值很难确定。

原始文献来源  ：

Lindhardt RB, Kronborg JR, Wanscher M, Andersen LW, Gjedsted J, Ravn HB. Evaluation of Thromboelastography 6s prognostication of fibrinogen supplementation in pediatric cardiac surgery. Acta Anaesthesiol Scand. 2022 Aug 27. doi: 10.1111/aas.14144.

英文原文：

Evaluation of Thromboelastography 6s prognostication of fibrinogen supplementation in pediatric cardiac surgery 

Background: Implementation of point-of-care tests is recommended to provide tailored substitution during cardiac surgery. The measurement and substitution of fibrinogen have gained particular interest since it is the first coagulation factor to become depleted during cardiac surgery. However, the prognostic ability of thromboelastography (TEG) 6s has not been evaluated in pediatric patients.The aim of the present study was to describe patient characteristics of infants receiving fibrinogen substitution during cardiac surgery and evaluate the prognostic ability of TEG6s after weaning off cardiopulmonary bypass (CPB).

Methods：Infants undergoing congenital cardiac surgery with CPB were retrospectively included (n = 279) between January 2017 to July 2019. Patient and perioperative data were collected on the day of surgery until 6:00 AM the next morning. Hemostatic capacity was assessed with TEG6s. The efficacy of TEG-functional fibrinogen-maximal amplitude (TEG-FF-MA) measurements for the prediction of intraoperative bleeding, and thereby cryoprecipitate need, was evaluated by a sensitivity and specificity analysis.

Results: Among 174 children with TEG-FF-MA data, 147 (84%) received cryoprecipitate intraoperatively. Cryoprecipitate administration was associated with younger age 66 (10–132) versus 98 (45–204) days (p = .044), higher RACHS-1 classification, and intraoperative bleeding 21 (11–47) versus 5 (3–13) ml/kg (p < .001, mean difference 29 ml/kg [CI: 8–50]). Median TEG-FF-MA values were lower in transfused children 7.6 (5.3–11.0) versus 10.5 (7.3–13.4) mm (p = .004, mean difference ? 2.4 mm [CI: ?4.1 to ? 0.73]). The volume of cryoprecipitate was associated with bypass time, TEG-FF-MA values, and in particular intraoperative bleeding volumes. A TEG-FF-MA threshold of 10.0 mm, resulted in sensitivity: 74%, specificity: 56%, positive predictive value: 80%, and a negative predictive value of 47% for the prediction of intraoperative bleeding (>10 ml/kg) and consequently a need of cryoprecipitate transfusion.

Conclusion: Fibrinogen substitution in infants was associated with younger age and higher RACHS-1 category. The prognostic value of TEG6s was evaluated, and cryoprecipitate transfusion was related to TEG-FF-MA values, but also CPB-time, surgical complexity, and in particular excessive intraoperative bleeding. A clear-cut threshold for TEG-FF-MA is difficult to establish in infants undertaken congenital heart surgery.