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目的 探讨血栓弹力图(TEG)在临床重症患者合理用血中的应用价值.方法 回顾性分析2014年7月至2015年8月湖南省中南大学湘雅三医院收治的有潜在大量输血可能的100例重症患者的临床资料,收集血常规指标、常规凝血功能指标及TEG参数,对各指标进行相关性分析,并比较TEG检测前后临床申请的血制品成分及量,同时评价TEG与常规凝血功能指标对出血患者诊断的敏感度和特异度.结果 100例重症患者中男性51例,女性49例;年龄35～70岁,平均(54.0±12.5)岁.凝血酶原时间(PT)、活化部分凝血活酶时间(APTT)与R值呈正相关(r1=0.380、P1=0.010,r2=0.490、P2=0.002);纤维蛋白原(FIB)与MA值呈正相关(r=0.390、P=0.020),与K值呈负相关(r=-0.310、P=0.040);血小板计数(PLT)与α角、MA值呈正相关(r1=0.510、P1=0.002,r2=0.650、P=0.001);D-二聚体与TEG各参数均无相关性.对用血栓弹力图普通杯(TEG-CK)检测后高度怀疑肝素残留的22例患者进行肝素酶杯(TEG-CKH)复测,R值、K值较TEG-CK检测值明显下降[R值(min):11.4±4.9比28.6±22.4,K值(min):4.4±2.7比18.5±14.7,均P＜0.05],α角、MA值较TEG-CK检测值明显增加[α角(°):44.8±17.2比22.6±18.8,MA值(mm):48.7±15.8比28.8±23.2,均P＜0.05];复测后建议输注血制品的例数、成分和用量均有显著差异[需输注血浆、血小板和冷沉淀者分别由18、7和3例增减为5、7、5例,输血浆量(mL)由600.00±256.10减至150.00±70.71,输血小板量(U)由1.00±0.46减至0.50±0.28,输冷沉淀量(U)由4.00±0.99增至8.60±2.07,均P＜ 0.05].78例体内无肝素残留患者的TEG指导用血量较检测前申请用量也有显著差异[输血浆量(mL)由422.66±197.79减至241.67±210.22,输血小板量(U)由0.75±0.38增至1.60±1.00,均P＜0.05].TEG的R值、K值、α角、MA值及PT、APTT、FIB、PLT判断患者出血的敏感度分别为15.94％、17.39％、24.63％、30.43％、46.37％、39.13％、28.98％、47.83％,特异度分别为87.09％、80.65％、77.42％、74.19％、64.52％、74.19％、80.64％、54.84％.结论 TEG参数与常规凝血功能指标显著相关,各有优势,二者不可相互替代;TEG对重症患者临床合理用血具有指导意义,但仍需结合临床及其他实验室检测综合考虑.“,”Objective To discuss the application value of thromboelastogram (TEG) in reasonable use of blood in critical patients.Methods The data of 100 critical patients with potential need for massive blood transfusion admitted to the Third Xiangya Hospital of Central South University from July 2014 to August 2015 were analyzed retrospectively.Their blood samples were collected and routine parameters including coagulation functions and TEG were tested;the correlation among the above parameters was analyzed.Then the components and amount of blood products ordered before and after TEG were compared.The diagnostic sensitivity and specificity of TEG and conventional coagulation test for these patients were assessed.Results There were 51 men and 49 women in the 100 critical patients,and their ages were between 35 to 70 years old with an average of (54.0 ± 12.5) years old.A positive correlation was found between prothrombin time (PT),activated partial thromboplastin time (APTT) and R value (r1 =0.380,P1 =0.010;r2 =0.490,P2 =0.002).Fibrinogen (FIB) was positively correlated with MA value (r =0.390,P =0.020),and negatively correlated with K value (r =-0.310,P =0.040).Blood platelet count (PLT) was positively correlated with α angle and MA value (r1 =0.510,P1 =0.002;r2 =0.650,P2 =0.001).Meanwhile,there was no significant correlated between D-Dimer and TEG results.We performed a TEG-CKH to test 22 samples again which were highly suspected having a residue of heparin after TEG-CK test.The result showed a dramatic decline of R value and K value [R value (minutes):11.4±4.9 vs.28.6±22.4,K value (minutes):4.4±2.7 vs.18.5± 14.7,both P ＜ 0.05],while α angle and MA value were increased [α angle (°):44.8± 17.2 vs.22.6± 18.8,MA value (mm):48.7± 15.8 vs.28.8±23.2,both P ＜ 0.05].There was a significant change in the cases,the components and the amount of blood products after retest [plasma,PLT and cryoprecipitate patients needed were changed from 18,7,3 to 5,7,5,respectively;the amount of plasma (mL) was decreased from 600.00±256.10 to 150.00±70.71 per patient,the PLT (U) was decreased from 1.00 ± 0.46 to 0.50 ± 0.28 per patient,the cryoprecipitate (U) was increased from 4.00 ± 0.99 to 8.60 ± 2.07 per patient,all P ＜ 0.05].There was significant difference in volume of blood products after and before TEG was used to guide blood transfusion in 78 patients without residue of heparin [the amount of plasma (mL) was decreased from 422.66 ± 197.79 to 241.67 ± 210.22 per patient,the PLT (U) was increased from 0.75 ± 0.38 to 1.60 ± 1.00 per patient,both P ＜ 0.05].The sensitivity of R value,K value,α angle,MA value,PT,APTY,FIB and PLT were 15.94％,17.39％,24.63％,30.43％,46.37％,39.13％,28.98％ and 47.83％,respectively,in diagnosis of bleeding,while the specificity were 87.09％,80.65％,77.42％,74.19％,64.52％,74.19％,80.64％ and 54.84％,respectively.Conclusions There was significant correlation between TEG parameters and indicators of conventional coagulation test,but either of them has advantage over the other,and cannot be replaced.TEG can be used to guide reasonable transfusion for critical patients,though other clinical and laboratory tests should be combined.