bloodjourГематология и трансфузиологияRussian journal of hematology and transfusiology0234-57302411-3042ООО Издательский дом «Практика»10.35754/0234-5730-2023-68-1-50-61bloodjour-431Research ArticleОРИГИНАЛЬНЫЕ СТАТЬИORIGINAL ARTICLESТромбоэластометрия для прогнозирования нарушений гемостаза в постперфузионном периоде во время кардиохирургических операцийThromboelastometry for predicting hemostasis disorders after cardiopulmonary bypass during cardiac surgeryhttps://orcid.org/0000-0002-4434-3123АксельродБ. А.AkselrodB. A.

Борис Альбертович Аксельрод, доктор медицинских наук, профессор,заведующий отделением

отделение анестезиологии-реанимации II (кардиоанестезиологии и реанимации)

119435

Москва

Boris A. Akselrod, Dr. Sci. (Med.), Professor, Head of the Department

Department of Anesthesiology and Intensive Care II

119435

Moscow

7403797@mail.ruhttps://orcid.org/0000-0003-2008-6350ДымоваО. В.DymovaO. V.

Ольга Викторовна Дымова, кандидат медицинских наук, заведующаялабораторией

научно-клиническая лаборатория

119435

Москва

Olga V. Dymova, Cand. Sci. (Med.)., Head of Laboratory

Clinical Diagnostic Laboratory

119435

Moscow

dimovaolga@gmail.comhttps://orcid.org/0000-0001-6974-8402ГуськовД. А.GuskovD. A.

Денис Александрович Гуськов, кандидат медицинских наук, доцент, врач анестезиолог-реаниматолог

отдел научных программ и подготовки кадров

группа профессорско-преподавательского состава

отделение анестезиологии-реанимации II (кардиоанестезиологии и реанимации)

119435

Москва

Denis A. Guskov, Cand. Sci. (Med.), Associate Professor

Department of Scientific Programs and Personnel Training

Teaching Staff Group 

119435

Moscow

levismen@yandex.ruhttps://orcid.org/0000-0003-1414-8500ГончароваА. В.GoncharovaA. V.

Алевтина Викторовна Гончарова, врач

клинико-диагностическая лаборатория

119435

Москва

Alevtina V. Goncharova, Physician

Clinical Diagnostic Laboratory

119435

Moscow

mamasha-alya@yandex.ruhttps://orcid.org/0000-0002-3703-0911ГладышеваВ. Г.GladyshevaV. G.

Вера Геннадьевна Гладышева, врач

клинико-диагностическая лаборатория

119435

Москва

Vera G. Gladysheva, Physician

Clinical Diagnostic Laboratory

119435

Moscow

veglad@rambler.ruhttps://orcid.org/0000-0001-5333-3026ТолстоваИ. А.TolstovaI. A.

Ирина Александровна Толстова, кандидат медицинских наук, доцент, врач анестезиолог-реаниматолог

отдел научных программ и подготовки кадров

группа профессорско-преподавательского состава

отделение анестезиологии-реанимации II (кардиоанестезиологии и реанимации)

119435

Москва

Irina A. Tolstova, Cand. Sci. (Med.), Associate Professor

Department of Scientific Programs and Personnel Training

Teaching Staff Group 

119435

Moscow

7135198@gmail.comhttps://orcid.org/0000-0001-8714-7432ЛинникД. В.LinnikD. V.

Дарья Викторовна Линник, врач-ординатор

отделение анестезиологии-реанимации II (кардиоанестезиологии и реанимации)

119435

Москва

Daria V. Linnik, Resident

Department of Anesthesiology and Intensive Care II

119435

Moscow

linnikdaria1998@gmail.ruФГБНУ «Российский научный центр хирургии имени академика Б. В. Петровского»РоссияPetrovsky National Research Centre of SurgeryRussian Federation2023120520236815061Copyright © Аксельрод Б.А., Дымова О.В., Гуськов Д.А., Гончарова А.В., Гладышева В.Г., Толстова И.А., Линник Д.В., 20232023Аксельрод Б.А., Дымова О.В., Гуськов Д.А., Гончарова А.В., Гладышева В.Г., Толстова И.А., Линник Д.В.Akselrod B.A., Dymova O.V., Guskov D.A., Goncharova A.V., Gladysheva V.G., Tolstova I.A., Linnik D.V.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.htjournal.ru/jour/article/view/431

   Введение. Оценка состояния системы гемостаза в кардиоанестезиологии осуществляется как клинически, так и с помощью тромбоэластографии (ТЭГ), ротационной тромбоэластометрии (РОТЭМ), или их комбинации. ТЭГ и РОТЭМ предназначены для выявления нарушений в системе гемостаза в режиме реального времени.   Цель — оценить информативность РОТЭМ, выполняемой на этапе искусственного кровообращения (ИК) до нейтрализации гепарина протамином, и изучить прогностическое значение данного исследования в оценке риска развития послеоперационного кровотечения во время кардиохирургических вмешательств высокого риска развития кровотечения.   Материалы и методы. Оценка диагностической значимости исследований РОТЭМ на этапе ИК основана на наблюдении за 31 больным, оперированным с июля по октябрь 2018 г. Медиана возраста больных составила 55 лет (31–72 года). Критерии включения больных в исследование — выполнение плановых кардиохирургических вмешательств с высоким риском развития кровотечений: операции на аорте, сочетанные операции (коронарное шунтирование и / или операция на клапане (клапанах), многоклапанная коррекция), в том числе повторные операции. Для оценки диагностических и прогностических возможностей исследования РОТЭМ во время ИК на фоне высоких доз гепарина использовали методы описательной статистики, корреляционного и сравнительного анализов, ROC-анализ.   Результаты. Отмечена статистически достоверная линейная корреляция между показателями А5 и MCF в тестах EXTEM, FIBTEM и PLTEM, выполненных как во время, так и после ИК. Полученные результаты свидетельствуют, что определение причины кровотечения и принятие решения о выборе терапии возможно существенно раньше, чем будет определен показатель MCF, а именно через 5 мин после начала свертывания крови при исследовании РОТЭМ. Показана информативность исследований РОТЭМ, выполненных во время ИК, однако при интерпретации результатов необходимо ориентироваться не только на референсные интервалы, но и на полученные уровни отсечения для параметров РОТЭМ во время ИК для раннего выявления гипофибриногенемии или тромбоцитопении после ИК.   Заключение. РОТЭМ, выполняемая при применении высоких доз гепарина во время ИК, является информативным методом для выбора патогенетически обоснованной терапии возможных кровотечений.

   Introduction. Assessment of the state of the hemostasis system in cardioanesthesiology is carried out both clinically and using standard laboratory tests — thromboelastography (TEG), rotational thromboelastometry (ROTEM), or a combination of both. Both TEG and ROTEM are designed to detect disorders in the hemostasis system in real time.   Aim – to evaluate the informativeness of ROTEM performed at the stage of cardiopulmonary bypass (CPB) before neutralization of heparin with protamine and to study the prognostic value of this study in assessing the risk of postoperative bleeding during cardiac surgery with a high risk of bleeding.   Materials and methods. The assessment of the diagnostic significance of ROTEM studies at the CPB stage is based on the observation of 31 patients operated on from July to October 2018. The median age of these patients was 55 years (31–72 years). The criteria for inclusion of patients in the study were the performance of planned cardiac surgery with a high risk of bleeding: operations on the aorta, combined operations (coronary bypass surgery and/or surgery on the valve(s), multivalve correction), including repeated. Methods of descriptive statistics, correlation and comparative analyses, and ROC-analysis were used to assess the diagnostic and prognostic capabilities of ROTEM research during CPB against the back=-ground of high doses of heparin.   Results. A statistically significant linear correlation was noted between A5 and MCF indicators in EXTEM, FIBTEM and PLTEM tests performed both during and after CPB. The results obtained indicate that determining the cause of bleeding and deciding on the choice of therapy is possible significantly earlier than the MCF indicator is determined, namely 5 minutes after the start of blood clotting in the ROTEM study. The informative value of ROTEM studies performed during CPB is shown, however, when interpreting the results, it is necessary to focus not only on the reference intervals, but also on the obtained cut-off levels for ROTEM parameters during CPB for early detection of hypofibrinogenemia or thrombocytopenia after CPB.   Conclusion. ROTEM performed with the use of high doses of heparin during CPB is informative for the choice of pathogenetically justified therapy for possible bleeding.

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Br J Anaesth. 2017; 118(6):823-833. DOI: 10.1093/bja/aex100.Nakayama Y., Nakajima Y., Tanaka K.A., et al. Thromboelastometry-guided intraoperative haemostatic management reduces bleeding and red cell transfusion after paediatric cardiac surgery. Br J Anaesth. 2015; 114(1):91-102. DOI: 10.1093/bja/aeu339.Nakayama Y., Nakajima Y., Tanaka K.A., et al. Thromboelastometry-guided intraoperative haemostatic management reduces bleeding and red cell transfusion after paediatric cardiac surgery. Br J Anaesth. 2015; 114(1):91-102. DOI: 10.1093/bja/aeu339.Görlinger K., Pérez-Ferrer A., Dirkmann D., et al. The role of evidence-based algorithms for rotational thromboelastometry-guided bleeding management. Korean J Anesthesiol. 2019; 72(4):297-322. DOI: 10.4097/kja.19169.Görlinger K., Pérez-Ferrer A., Dirkmann D., et al. The role of evidence-based algorithms for rotational thromboelastometry-guided bleeding management. Korean J Anesthesiol. 2019; 72(4):297-322. DOI: 10.4097/kja.19169.

The authors declare that there are no conflicts of interest present.