Coagulation monitoring Recommendation 12 We recommend that routine practice include the early and repeated monitoring of coagulation, using either a traditional laboratory determination [prothrombin time (PT), activated partial thromboplastin time (APTT) platelet counts and fibrinogen] (Grade 1A) and/or a viscoelastic method. (Grade 1C)

凝血监测建议¹²我们建议常规实践包括早期和重复监测凝血，使用传统的实验室测定[凝血酶原时间（PT），活化部分凝血活酶时间（APTT）血小板计数和纤维蛋白原]（1A级）和/或 粘弹性方法。 （1C级）

Rationale

Standard coagulation monitoring comprises the early and repeated determination of PT, APTT, platelet counts and fibrinogen. Increasing emphasis focuses on the importance of fibrinogen and platelet measurements. It is often assumed that the conventional coagulation screens [international normalised ratio (INR) and APTT] monitor coagulation, however these tests monitor only the initiation phase of blood coagulation, and represent only the first 4 % of thrombin production [178]. It is therefore possible that the conventional coagulation screen appears normal, while the overall state of blood coagulation is abnormal [13, 179–183]. In addition, the delay in detection of traumatic coagulopathy can influence outcome, and the turnaround time of thromboelastometry has been shown to be significantly shorter than conventional laboratory testing, with a time saving of 30–60 min [181, 184, 185]. Viscoelastic testing may also be useful in the detection of coagulation abnormalities associated with the use of direct thrombin inhibitors such as dabigatran, argatroban, bivalirudin or hirudin. Furthermore, (early) variables of clot firmness assessed by viscoelastic testing have been shown to be good predictors for the need for massive transfusion, the incidence of thrombotic/thromboembolic events and for mortality in surgical and trauma patients [181, 186–195]. Therefore, complete and rapid monitoring of blood coagulation and fibrinolysis using viscoelastic methods may facilitate a more accurate targeting of therapy compared to conventional laboratory tests alone.

合理

标准凝血监测包括早期和重复测定PT，APTT，血小板计数和纤维蛋白原。越来越重视纤维蛋白原和血小板测量的重要性。通常认为常规凝血筛选[国际标准化比率（INR）和APTT]监测凝血，但这些检测仅监测血液凝固的起始阶段，并且仅代表凝血酶产生的前4％[178]。可能的是，传统的凝血筛可能看起来正常，而凝血的总体状态是异常的[13,179-183]。此外，创伤性凝血病的检测延迟可能影响预后，并且血栓弹力测定的周转时间已经显示出比传统的实验室检测短得多，节省时间30-60分钟[181,184,185] 。粘弹性测试也可用于检测与使用直接凝血酶抑制剂（诸如达比加群，阿加曲班，比伐卢定或水蛭素等）相关的凝血异常。此外，通过粘弹性测试评估的（早期）凝块硬度变量已被证明是大量输血需求、血栓/血栓栓塞事件的发生率以及手术和创伤患者死亡率的良好预测因子[181,186-195]。因此，与单独的常规实验室测试相比，使用粘弹性方法完全和快速地监测血液凝固和纤维蛋白溶解可以促进更准确的治疗。

Tools such as thromboelastometry and portable coagulometers have been developed to detect coagulopathy in the emergency room or at the bedside, improving the availability of real-time data to guide patient management. Portable coagulometers that provide INR or APTT seem to provide acceptable accuracy for point-ofcare INR testing in the emergency department compared with laboratory-based methods [196–198], however others have observed a lack of agreement with conventional laboratory determinations [199]. The usefulness of the parameters measured is therefore limited.

已经开发出诸如血栓弹力测定法和便携式凝血计之类的工具来检测急诊室或床边的凝血病，从而提高实时数据的可用性以指导患者管理。 与基于实验室的方法[196-198]相比，提供INR或APTT的便携式血凝仪似乎为急诊科的临床INR检测提供了可接受的准确度[196-198]，但其他人观察到与常规实验室测定不一致[199]。 因此，测量的参数的有用性是有限的。

Viscoelastic methods provide a rapid assessment of coagulation to support clinical decision-making, generating a growing confidence in these methods and increased use [200, 201]. Case series using viscoelastic testing to assess trauma patients have been published. One study applied rotational thrombelastography to 23 patients, but without a comparative standard [179]. Johansson et al. [180] implemented a haemostatic resuscitation regime [early platelets and fresh frozen plasma (FFP)] guided using thrombelastography in a before-and-after study (n = 832), which showed improved outcomes. In a retrospective study of cardiovascular surgery patients (n = 3865) the combined use of thromboelastometry and portable coagulometry resulted in a reduction in blood product transfusion and thromboembolic events, but did not influence mortality [202]. Rapid thrombelastography is a new variant of viscoelastic testing in which coagulation is initiated by the addition of kaolin and tissue factor that appears to reduce the measurement time compared with conventional thrombelastography [203].

粘弹性方法提供凝血的快速评估，以支持临床决策，从而增加对这些方法的信心和使用[200,201]。已发表使用粘弹性测试评估创伤患者的病例系列。一项研究对23名患者应用旋转血栓弹力描记术，但没有比较标准[179]。约翰逊等人。 [180]实施了一项止血复苏方案[早期血小板和新鲜冰冻血浆（FFP）]，在前后研究中使用血栓弹力描记术（n = 832），显示出预后改善的结果。在心血管手术患者（n = 3865）的回顾性研究中，联合使用血栓弹力测定法和便携式凝血测定法可以减少血液输注和血栓栓塞事件，但不会影响死亡率[202]。快速血栓弹性描记术是粘弹性测试的一种新变种，其中通过添加高岭土和组织因子引发凝血，与常规血栓弹力图相比，这似乎可以减少测量时间[203]。

Despite the widespread use of viscoelastic methods, the usefulness has recently been questioned. In a recent systematic review Hunt et al. [204] found no evidence of the accuracy of thrombelastography and very little evidence to support the accuracy of thromboelastometry and were therefore unable to offer any advice about the use of these methods [204]. In another systematic review Da Luz et al. [205] concluded that only limited evidence from observational studies support the use of viscoelastic tests to diagnose early traumatic coagulopathy, but while these tests may predict bloodproduct transfusion, mortality and other patientimportant outcomes may be unaffected [205]. A number of other limitations to the use of viscoelastic methods have been described. Larsen et al. [206] found that thrombelastography was unable to distinguish coagulopathies caused by dilution from thrombocytopenia, whereas thromboelastometry was indeed capable of distinguishing these two different types of coagulopathy and suggesting the correct treatment [206]. The use of thrombelastography may thus lead to unnecessary transfusion with platelets, whereas the application of thromboelastometry may result in goal-directed fibrinogen substitution. Although use is rapidly increasing, controversy remains at present regarding the utility of viscoelastic methods for the detection of posttraumatic coagulopathy.

尽管粘弹性方法得到广泛使用，但其有用性最近遭受质疑。在一篇重要的系统评价中，Hunt等人。 [204]没有发现血栓弹力图准确性的证据，也没有证据支持血栓栓塞术的准确性，因此无法就使用这些方法提供任何建议[204]。在另一个系统评价中，Da Luz等人。 [205]得出结论，只有来自观察性研究的有限证据支持使用粘弹性试验来诊断早期创伤性凝血病，但是虽然这些试验可以预测血液 - 产品输血，但死亡率和其他患者的重要结果可能不受影响[205]。已经描述了使用粘弹性方法的许多其他限制。拉森等人。 [206]发现血栓弹力描记术无法区分由血小板减少症引起的凝血功能障碍，而血栓弹力测定法确实能够区分这两种不同类型的凝固球菌，并提示正确的治疗方法[206]。因此，使用血栓弹性描记术可能导致不必要的血小板输注，而血栓弹力测定法的应用可能导致目标导向的纤维蛋白原替代。虽然使用迅速增加，但目前仍存在关于粘弹性方法检测创伤后凝血病的效用的争议。

The agreement between viscoelastic methods and standard coagulation test also remains a matter of debate. Some studies find acceptable agreement [207–209], however a number of other studies found significant discrepancies [25, 199, 210, 211] even among different viscoelastic methods (thrombelastography and thromboelastometry). Hagemo et al. [212] found that the correlation was highly variable at different stages of the clotting process and between centres, highlighting the need for clarification and standardisation of these techniques. One limitation of viscoelastic tests is the lack of sensitivity to detect and monitor platelet dysfunction due to antiplatelet drugs. If platelet dysfunction is expected, point-of-care platelet function tests, for example whole blood impedance aggregometry, should be used in addition to viscoelastic tests [213, 214]. More research is required in this area, and in the meantime physicians should use their own judgement when developing local policies.

粘弹性方法与标准凝血试验之间的一致性仍然存在争议。一些研究发现可接受的一致性[207-209]，然而许多其他研究发现即使在不同的粘弹性方法（血栓弹性成像和血栓弹力测定法）中也存在显着差异[25,199,210,211]。哈格莫等人。 [212]发现在凝血过程的不同阶段和中心之间的相关性是高度可变的，凸显这些技术的澄清和标准化的必要性。粘弹性试验的一个限制是缺乏检测和监测抗血小板药物引起的血小板功能障碍的敏感性。如果出现血小板功能障碍，除了粘弹性试验外，还应使用即时血小板功能测试，例如全血阻抗聚集测定[213,214]。在这方面需要进行更多的研究，与此同时，医生在制定地方政策时应该使用自己的判断。

It is theoretically possible that the pattern of change in measures of coagulation such as D-dimers may help to identify patients with ongoing bleeding. However, a single publication showed that the positive predictive value of D-dimers is only 1.8 % in the postoperative and/or post-traumatic setting [215], therefore traditional methods of detection for ongoing bleeding, such as serial clinical evaluation of radiology (ultrasound, CT or angiography) should be used.

从理论上讲，凝血功能的改变模式如D-二聚体可能有助于确定持续出血的患者。然而，一个单一的出版物显示，D-二聚体在术后和/或创伤后设置中的阳性预测值仅为1.8%（215），因此应该使用传统的检测持续出血的方法，如放射学（超声、CT或血管造影）的系列临床评价。