血必净注射液对严重脓毒症患者凝血指标及预后的影响

摘要

Objective To observe the effects of Xuebijing injection on the activated coagulation time, clot rate(CR) of blood, platelet counts (PLT), platelet function (PF) and the outcome of patients with severe sepsis. Methods Forty-six cases with severe sepsis and coagulation dysfunction in intensive care unit (ICU) of Guangzhou General Hospital of Guangzhou Military Command during July 2010 to December 2010 were prospectively included and randomly divided into treatment group (26 cases) and control group (20 cases). The control group was given standard therapy according to the American Surviving Sepsis Campaign in 2008, while the treatment group was received the standard therapy plus Xuebijing injection (100 ml, intravenous drip, 2 times per day for 7 days). The peripheral blood of patients was collecled. Routine coagulation parameters like plasma prothrombin time (PT), activated partial thromboplastin time(APTT), thrombin time(TT), fibrinogen(Fib), international normalized ratio (I1NR), D-dimer and PLT were detected, and new coagulation parameters like gbactivated clotting time (gbACT), CR and PF were assessed at bed-side by American Sonoclot coagulation and platelet function analyzer. Before and after treatment, the changes of acute physiology and chronic health evaluation II (APACHE Q) scores and serum procalcitonin (PCT) levels were evaluated and ICU length of stay, total length of stay in the hospital (LOS) and mortality rate in 28 days were recorded. Results All parameters had no significant differences between the two groups before treatment (all P＞0.05). After treatment for 7 days, PLT ( ×109/L) and PF were significantly increased, while APTT (s) was obviously shortened in both groups (all P＜0.05). gbACT(g)was significantly shortened to normal range in the treatment group, while it was seldom changed in the control group ; all the above indexes were much more improved in the treatment group than those in the control group (PLT : 218.75± 114.15 vs. 151.60+153.03, PF : 3.74±0.71 vs. 2.51 ±0.80, APTT:30.21 ±7.60 vs. 39.27± 15.06, gbACT : 160.47±40.93 vs. 201.10+48.55, all P＜0.05). After treatment, the APACHE II scores and PCT (μg/L) levels were both reduced in the two groups, and the decreasing trend was much more obvious in the treatment group (APACHE Ⅱ: 14.72±3.55 vs. 21.50±4.85, PCT : 7.09±5.51 vs. 19.43±9.98, both P＜0.05). Before and after the treatment, the other parameters like PT, TT, Fib, INR, D-dimer and CR were similar in both groups (all P＞0.05). Compared with control group, the average ICU stay, total LOS and 28-day mortality rate were reduced in the treatment group, however, there were no significant differences (all P＞ 0.05). Conclusions A large dose of Xuebijing injection can facilitate the recovery of the coagulation function in patients with severe sepsis, however, it cannot improve the outcome. The new gbACT+coagulation indexes are more sensitive to the treatment, and can reflect the comprehensive condition of entire coagulation process. When the new ones combined with routine coagulation parameters, they can better guide the treatment to correct the coagulation dysfunction of severe sepsis.%目的 观察血必净注射液对严重脓毒症患者凝血激活时间、凝血速率(CR)、血小板计数(PLT)和血小板功能(PF)等指标及预后的影响.方法 采用前瞻性研究方法,选择2010年7月至12月广州军区广州总医院重症监护病房(ICU)收治的严重脓毒症合并凝血功能障碍患者46例,按入组时间使用简单随机化分组方法分为治疗组(26例)和对照组(20例).对照组按2008国际脓毒症指南的要求给予经典治疗；治疗组在经典治疗基础上加用血必净注射液100 ml静脉滴注,每日2次,连用7d.留取患者外周血,检测常规凝血指标如血浆凝血酶原时间(PT)、活化部分凝血活酶时间(APTT)、凝血酶时间(TT)、纤维蛋白原(Fib)、国际标准化比值(INR)、D-二聚体和PLT,以及新型凝血指标如全血激活时间(gbACT)、CR和PF；记录治疗前后急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分和降钙素原(PCT)水平的变化,以及住ICU时间、总住院时间和28 d病死率.结果 两组治疗前各指标比较差异均无统计学意义(均P＞0.05).与治疗前比较,两组治疗7d后PLT (×109/L)和PF均明显升高,APTT(s)显著缩短(均P＜0.05),对照组gbACT(s)无显著变化,治疗组gbACT显著缩短至正常范围；且治疗组上述指标的改善程度较对照组更明显(PLT:218.75±114.15比151.60±153.03,PF:3.74±0.71比2.51±0.80,APTT:30.21±7.60比39.27± 15.06,gbACT:160.47±40.93比201.10±48.55,均P＜0.05).两组治疗后APACHEⅡ评分(分)和PCT水平(μg/L)均明显降低,且治疗组下降水平较对照组更明显(APACHEⅡ:14.72±3.55比21.50±4.85,PCT:7.09±5.51比19.43±9.98,均P＜0.05).两组治疗前后PT、TT、Fib、INR、D-二聚体、CR比较差异均无统计学意义(均P＞0.05).与对照组比较,治疗组住ICU时间、总住院时间和28 d病死率均有所减少,但差异均无统计学意义(均P＞0.05).结论 大剂量血必净注射液对严重脓毒症患者的凝血功能恢复有一定作用,但不能改善预后.gbACT+凝血指标对治疗的反应性更灵敏,能反映整个凝血级联过程的综合状况,与常规凝血指标结合可以更好地指导临床针对凝血功能障碍的治疗.