【摘要】 目的 探讨血栓弹力图预测脓毒症和脓毒性休克患儿病情及预后的价值，并探寻提高脓毒症和脓毒性休克患儿预后预测效能的方法。方法 收集2020年3月—2021年8月丽水市中心医院儿科PICU和浙江大学医学院附属儿童医院PICU诊断为脓毒症和脓毒性休克的患儿共85例，于诊断当日检测传统凝血功能指标、血栓弹力图指标[包括凝血反应时间(R)、动力时间(K)、Angel值、最大幅度(MA)、30 min幅度下降比例(LY30)、凝血综合指数(CI)]。根据诊断标准，分为脓毒症组和脓毒性休克组；根据结局，分为存活组和死亡组。比较各组间血栓弹力图参数。采用受试者工作特征(ROC)曲线预测乳酸联合K预测脓毒症和脓毒性休克患儿预后的能力。结果 脓毒症组R、K、Angel值、LY30、MA、CI、血小板计数(PLT)、活化部分凝血活酶时间(APTT)、凝血酶原时间(PT)、国际标准化比值(INR)、纤维蛋白原(Fib)、D-二聚体分别为[5.30(2.47)]min、[1.80(2.02)]min、[64.40(19.65)]°、[0.00(0.00)]%、[60.25(18.10)]mm、[0.30(4.80)]、[230.50(178.50)]×10~9/L、[32.85(11.13)]s、[12.65(2.53)]s、[1.07(0.21)]、[2.63(2.12)]g/L、[1.60(5.74)]mg/L;脓毒性休克组R、K、Angel值、LY30、MA、CI、PLT、APTT、PT、INR、Fib、D-二聚体分别为[6.80(10.20)]min、[4.10(5.00)]min、[45.20(35.50)]°、[0.00(0.00)]%、[46.40(25.00)]mm、[-3.90(11.00)]、[119.00(233.00)]×10~9/L、[37.30(12.70)]s、[17.20(8.60)]s、[1.45(0.66)]、[1.99(1.35)]g/L、[5.45(12.66)]mg/L。与脓毒症组比较，脓毒症休克组R、K、APTT、PT明显延长，Angel值、MA值、CI、Fib、PLT明显降低，D-二聚体、INR明显升高，差异均有统计学意义(P<0.05)。存活组和死亡组乳酸、降钙素原、K、国内小儿危重病例评分法(PCIS评分)比较，差异均有统计学意义(P<0.05)。当乳酸>3.65 mmol/L,K>4.81 min时，预测脓毒症和脓毒性休克患儿预后的灵敏度为59.13%,特异度为92.11%。结论 血栓弹力图可判断脓毒症和脓毒性休克患儿病情严重程度，K联合血乳酸可作为预测脓毒症和脓毒性休克患儿预后的新手段。更多还原

【Abstract】 Objective To explore the value of thrombelastogram in predicting disease condition and prognosis of children with sepsis and septic shock, analyze the methods to improve the prognostic prediction efficiency of children with sepsis and septic shock.Methods From March 2020 to August 2021, 85 children diagnosed as sepsis and septic shock in PICU of Lishui Central Hospital and Affiliated Children’s Hospital of Zhejiang University School of Medicine were collected, traditional indicators of coagulation function and thrombelastogram indicators [coagulation reaction time(R), dynamic time(K), Angel value, maximum amplitude(MA), 30-minute amplitude reduction ratio(LY30), and coagulation composite index(CI)] on the day of diagnosis were detected.According to the diagnostic criteria, the children were divided into sepsis group and septic shock group; according to the outcome, the children were divided into survival group and death group.Thrombelastogram indicators in different groups were compared.Receiver operating characteristic(ROC) curve was used to predict the ability of lactic acid combined with K in predicting pregnosis of children with sepsis and septic shock.Results R, K, Angel value, LY30, MA, CI, platelet count(PLT), activated partial thrombin time(APTT), prothrombin time(PT), international standardized ratio(INR), fibrinogen(Fib), D-dimer in sepsis group were [5.30(2.47)]minutes, [1.80(2.02)]minutes, [64.40(19.65)]°, [0.00(0.00)]%, [60.25(18.10)]mm, [0.30(4.80)], [230.50(178.50)]×10~9/L, [32.85(11.13)]seconds, [12.65(2.53)]seconds, [1.07(0.21)], [2.63(2.12)]g/L, and [1.60(5.74)]mg/L, respectively; the above-mentioned indicators in septic shock group were [6.80(10.20)]minutes, [4.10(5.00)]minutes, [45.20(35.50)]°, [0.00(0.00)]%, [46.40(25.00)]mm, [-3.90(11.00)], [119.00(233.00)]×10~9/L, [37.30(12.70)]seconds, [17.20(8.60)]seconds, [1.45(0.66)], [1.99(1.35)]g/L, and [5.45(12.66)]mg/L, respectively.Compared with sepsis group, R, K, APTT, and PT prolonged significantly, Angel value, MA, CI, Fib, and PLT decreased significantly, D-dimer and INR increased significantly, there were statistically significant differences(P<0.05).There were statistically significant differences in lactic acid, procalcitonin, K, and PCIS score between survival group and death group(P<0.05).When lactic acid>3.65 mmol/L and K>4.81 minutes, the sensitivity and specificity for predicting prognosis of children with sepsis and septic shock were 59.13% and 92.11%, respectively.Conclusion Thrombelastogram can be used to judge the severity of sepsis and septic shock in children.K combined with blood lactic acid can be used as the new means to predict the prognosis of children with sepsis and septic shock.更多还原