临床医师对新型冠状病毒肺炎患者凝血相关事件认知的调查

doi:10.3877/cma.j.issn.2096-1537.2022.01.007

目的

评估疫情初期一线医师对新型冠状病毒肺炎（COVID-19）患者凝血相关事件的认知情况。

方法

通过网络调查问卷进行数据收集，分别对受访者一般情况、凝血系统的关注与评估，以及深静脉血栓（DVT）和急性肺栓塞（APE）的评估、诊断和治疗情况进行统计分析。

结果

在回收的70份调查问卷中，所有受访者均认为关注COVID-19患者的凝血系统改变是非常必要的，且大多数受访者认为危重型和重型患者应常规进行凝血指标的检测，分别为100.00%、92.86%。75.71%的受访者进行了弥散性血管内凝血（DIC）评分，其中大部分受访者倾向应用2017中国DIC评分标准（34.29%）。大多数受访者所收治的COVID-19患者DVT和APE发生率均＜5%，分别为84.29%、82.86%。分别有92.86%和82.86%的受访者进行了DVT的评估、筛查，大多数受访者更易选择机械联合药物的方式预防DVT（60.00%），应用最多的预防药物是低分子量肝素（54.29%）。

结论

临床医师已经注意到监测COVID-19患者的凝血系统变化是非常重要的，并且对于DVT和APE的评估与治疗相对规范。多数受访者所收治的患者DVT和APE的发生率很低，但大家对DIC诊断标准的选择差异很大。D-二聚体对于评估凝血系统改变是一项非常重要的指标，但纤溶过程在感染性疾病凝血功能障碍中的作用应重新审视。

关键词: 新型冠状病毒肺炎, 凝血相关事件, 弥散性血管内凝血

Objective

To assess the perceptions of the Chinese frontline senior clinicians regarding coagulation-related events in patients with coronavirus disease 19 (COVID-19).

Methods

This survey assessed the perceptions of the Chinese clinicians regarding the coagulation function in patients with COVID-19 and the evaluation, diagnosis, and treatment of deep vein thrombosis (DVT) and acute pulmonary embolism (APE).

Results

In 70 returned surveys, all respondents agreed that coagulation required attention. Most clinicians believed that COVID-19 patients should be routinely examined for coagulation indicators, with 100% and 92.86% of the doctors reporting a need to monitor patients in critical and severe conditions, respectively. Among the respondents, 75.71% believed the disseminated intravascular coagulation (DIC) score should be routinely measured, with 34.29% of whom preferring the 2017 Chinese DIC Scoring System (2017 CDSS). The DVT and APE incidence rates were＜5% among the patients treated by most of the doctors (84.29%, 82.86%, respectively). DVT assessment and screening were performed by 92.86% and 82.86% of the respondents respectively. Most respondents chose machinery and drugs for DVT prevention (60.00%), and low molecular-weight heparin for treatment(54.29%).

Conclusions

Most doctors believe that coagulation should be routinely monitored in COVID-19 patients, and assessment and treatment of DVT and APE should be standardized. Most respondents think the incidence of DVT and APE (＜5%) yet significant differences are noted in the clinicians' choice of DIC diagnostic criteria. The D-dimer level is a significant factor for assessing coagulation change in COVID-19 patients. However, the role of fibrinolytic processes in coagulation disorders with infectious diseases should be reconsidered.

Key words: COVID-19, Coagulation-related events, Disseminated intravascular coagulation

表1 受访者一般情况

一般情况	例数	百分比（%）
年龄（岁）
30~39	11	15.71
40~49	38	54.29
50~59	16	22.86
≥60	5	7.14
职称
高级	62	88.57
中级	8	11.43
医院等级
三级甲等	66	94.29
三级乙等	4	5.71
科室
ICU	62	88.57
急诊ICU	2	2.86
内科ICU	2	2.86
其他	4	5.71
工作经验（年）
6~10	2	2.86
11~15	13	18.57
16~20	14	20.00
＞20	41	58.57

表1 受访者一般情况

一般情况	例数	百分比（%）
年龄（岁）
30~39	11	15.71
40~49	38	54.29
50~59	16	22.86
≥60	5	7.14
职称
高级	62	88.57
中级	8	11.43
医院等级
三级甲等	66	94.29
三级乙等	4	5.71
科室
ICU	62	88.57
急诊ICU	2	2.86
内科ICU	2	2.86
其他	4	5.71
工作经验（年）
6~10	2	2.86
11~15	13	18.57
16~20	14	20.00
＞20	41	58.57

表2 受访者对COVID-19患者凝血指标和DIC诊断标准的选择情况

内容	例数	百分比（%）
需要常规监测凝血指标的人群（人次）
轻型	15	21.13
普通型	37	52.86
重型	65	92.86
危重型	70	100.00
凝血指标选择（人次）
D-D	69	98.57
PLT	57	81.43
Fib	52	74.29
PT/INR	41	58.57
APTT	39	55.71
FDP	38	54.29
APL	22	31.43
ATⅢ	21	30.00
Hb	13	18.57
Anti-factorⅩa	6	8.57
APC/APS	6	8.57
DIC标准选择
2017CDSS	24	34.29
JAAM	13	18.57
ISTH	13	18.57
SIC	3	4.29
临床经验	17	24.29

表2 受访者对COVID-19患者凝血指标和DIC诊断标准的选择情况

内容	例数	百分比（%）
需要常规监测凝血指标的人群（人次）
轻型	15	21.13
普通型	37	52.86
重型	65	92.86
危重型	70	100.00
凝血指标选择（人次）
D-D	69	98.57
PLT	57	81.43
Fib	52	74.29
PT/INR	41	58.57
APTT	39	55.71
FDP	38	54.29
APL	22	31.43
ATⅢ	21	30.00
Hb	13	18.57
Anti-factorⅩa	6	8.57
APC/APS	6	8.57
DIC标准选择
2017CDSS	24	34.29
JAAM	13	18.57
ISTH	13	18.57
SIC	3	4.29
临床经验	17	24.29

表3 受访者对COVID-19患者DVT、APE发生和治疗情况

内容	例数	百分比（%）
DVT发生率（%）
0	20	28.57
＜5	39	55.71
5~10	8	11.43
＞10	3	4.29
APE发生率（%）
0	27	38.57
＜5	31	44.29
5~10	9	12.86
＞10	3	4.29
DVT风险评估
是	65	92.86
否	5	7.14
DVT筛查
是	58	82.86
否	12	17.14
DVT预防选择
机械+药物	42	60.00
药物	22	31.43
机械	6	8.57
DVT治疗
LMWH	38	54.29
肝素	15	21.43
IVCF+LMWH	6	8.57
其他	11	15.71

表3 受访者对COVID-19患者DVT、APE发生和治疗情况

内容	例数	百分比（%）
DVT发生率（%）
0	20	28.57
＜5	39	55.71
5~10	8	11.43
＞10	3	4.29
APE发生率（%）
0	27	38.57
＜5	31	44.29
5~10	9	12.86
＞10	3	4.29
DVT风险评估
是	65	92.86
否	5	7.14
DVT筛查
是	58	82.86
否	12	17.14
DVT预防选择
机械+药物	42	60.00
药物	22	31.43
机械	6	8.57
DVT治疗
LMWH	38	54.29
肝素	15	21.43
IVCF+LMWH	6	8.57
其他	11	15.71

1	Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study [J]. Lancet, 2020, 395(10223): 507-513.
2	Wu C, Chen X, Cai Y, et al. Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China [J]. JAMA Intern Med, 2020, 180(7): 934-943.
3	Wichmann D, Sperhake JP, Lütgehetmann M, et al. Autopsy findings and venous thromboembolism in patients with COVID-19 [J]. Ann Intern Med, 2020, 173(12): 1030.
4	Angus DC, van der Poll T. Severe sepsis and septic shock [J]. N Engl J Med, 2013, 369(9): 840-851.
5	Zhou Y, Fu B, Zheng X, et al. Pathogenic T cells and inflammatory monocytes incite inflammatory storm in severe COVID-19 patients [J]. Natl Sci Rev, 2020, 7(6): 998-1002.
6	Tanaka T, Narazaki M, Kishimoto T. Immunotherapeutic implications of IL-6 blockade for cytokine storm [J]. Immunotherapy, 2016, 8(8): 959-970.
7	Klok FA, Kruip MJHA, van der Meer NJM, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19 [J]. Thromb Res, 2020, 191: 145-147.
8	Lodigiani C, Iapichino G, Carenzo L, et al. Venous and arterial thromboembolic complications in COVID-19 patients admitted to an academic hospital in Milan, Italy [J]. Thromb Res, 2020, 191: 9-14.
9	Thrombosis and Hemostasis Group, Hematology Society of Chinese Medical Association. Consensus of Chinese experts on diagnosis of disseminated intravascular coagulation (version 2017) [J]. Zhonghua Xue Ye Xue Za Zhi, 2017, 38(5): 361-363.
10	Gando S, Iba T, Eguchi Y, et al. A multicenter, prospective validation of disseminated intravascular coagulation diagnostic criteria for critically ill patients: comparing current criteria [J]. Crit Care Med, 2006, 34(3): 625-631.
11	Taylor FB, Toh CH, Hoots WK, et al. Towards definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation [J]. Thromb Haemost, 2001, 86(5): 1327-1230.
12	Iba T, Nisio MD, Levy JH, et al. New criteria for sepsis-induced coagulopathy (SIC) following the revised sepsis definition: a retrospective analysis of a nationwide survey [J]. BMJ Open, 2017, 7(9): e017046.
13	China National Health Commission. Diagnosis and treatment of novel coronavirus pneumonia in China (trial version 7) [EB/OL]. [2020-3-3]. URL
14	Liu Q, Wang RS, Qu GQ, et al. Gross examination report of a COVID-19 death autopsy [J]. Fa Yi Xue Za Zhi, 2020, 36(1): 21-23.
15	Jose RJ, Manuel A. COVID-19 cytokine storm: the interplay between inflammation and coagulation [J]. Lancet Respir Med, 2020, 8(6): e46-e47.
16	Xu Y, Zhu R, Sun Y, et al. Antithrombin Ⅲ for early diagnosis of DIC in sepsis patients: a retrospective analysis with 445 patients [J]. Zhonghua Wei Zhong Bing Ji Jiu Yi Xue, 2017, 29(2): 127-132.
17	Tang N, Li D, Wang X, et al. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia [J]. J Thromb Haemost, 2020, 18(4): 844-847.
18	Shorr AF, Thomas SJ, Alkins SA, et al. D-dimer correlates with proinflammatory cytokine levels and outcomes in critically ill patients [J]. Chest, 2002, 121(4): 1262-1268.
19	Owings JT, Gosselin RC, Anderson JT, et al. Practical utility of the D-dimer assay for excluding thromboembolism in severely injured trauma patients [J]. J Trauma, 2001, 51(3): 425-430.
20	Wang Z, Li X, Zhu R, et al. A reevaluation of diagnostic efficacy of International Society of Thrombosis and Haemostasis and Japanese Association for Acute Medicine criteria for the diagnosis of sepsis disseminated intravascular coagulation [J]. Zhonghua Nei Ke Za Zhi, 2019, 58(5): 355-360.
21	Semeraro F, Ammollo CT, Caironi P, et al. D-dimer corrected for thrombin and plasmin generation is a strong predictor of mortality in patients with sepsis [J]. Blood Transfus, 2020, 18(4): 304-311.
22	Zhang L, Yan X, Fan Q, et al. D-dimer levels on admission to predict in-hospital mortality in patients with Covid-19 [J]. J Thromb Haemost, 2020, 18(6): 1324-1329.
23	Gando S, Levi M, Toh CH. Disseminated intravascular coagulation [J]. Nat Rev Dis Primers, 2016, 2: 16037.
24	Valade S, Azoulay E, Galicier L, et al. Coagulation disorders and bleedings in critically ill patients with hemophagocytic lymphohistiocytosis [J]. Medicine (Baltimore), 2015, 94(40): e1692.
25	Gando S, Wada H, Thachil J. Differentiating disseminated intravascular coagulation (DIC) with the fibrinolytic phenotype from coagulopathy of trauma and acute coagulopathy of trauma-shock (COT/ACOTS) [J]. J Thromb Haemost, 2013, 11(5): 826-835.
26	Wada H, Matsumoto T, Yamashita R, et al. Disseminated intravascular coagulation: testing and diagnosis [J]. Clin Chim Acta, 2014, 436: 130-134.
27	Ding R, Wang Z, Lin Y, et al. Comparison of a new criteria for sepsis-induced coagulopathy and International Society on Thrombosis and Haemostasis disseminated intravascular coagulation score in critically ill patients with Sepsis 3.0: a retrospective study [J]. Blood Coagul Fibrinolysis, 2018, 29(6): 551-558.
28	Okamoto K, Tamura T, Sawatsubashi Y. Sepsis and disseminated intravascular coagulation [J]. J Intensive Care, 2016, 4: 23.
29	Zou Y, Guo H, Zhang Y, et al. Analysis of coagulation parameters in patients with COVID-19 in Shanghai, China [J]. Biosci Trends, 2020, 14(4): 285-289.
30	Helms J, Tacquard C, Severac F, et al. High risk of thrombosis in patients with severe SARS-CoV-2 infection: a multicenter prospective cohort study [J]. Intensive Care Med, 2020, 46(6): 1089-1098.
31	Wada H, Nishioka J, Nobori T, et al. Diagnosis of DIC based on evidence [J]. Rinsho Byori, 2006, 54(11): 1172-1177.
32	Gando S, Saitoh D, Ogura H, et al. A multicenter, prospective validation study of the Japanese Association for Acute Medicine disseminated intravascular coagulation scoring system in patients with severe sepsis [J]. Crit Care, 2013, 17(3): R111.
33	Wada H, Matsumoto T, Yamashita Y. Diagnosis and treatment of disseminated intravascular coagulation (DIC) according to four DIC guidelines [J]. J Intensive Care, 2014, 2(1): 15.
34	Iba T, Arakawa M, Nisio MD, et al. Newly proposed sepsis-induced coagulopathy precedes International Society on Thrombosis and Haemostasis overt-disseminated intravascular coagulation and predicts high mortality [J]. J Intensive Care Med, 2020, 35(7): 643-649.
35	Tang N, Bai H, Chen X, et al. Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy [J]. J Thromb Haemost, 2020, 18(5): 1094-1099.
36	White RH. The epidemiology of venous thromboembolism [J]. Circulation, 2003, 107(23 Suppl 1): I4-8.
37	Raskob GE, Angchaisuksiri P, Blanco AN, et al. Thrombosis: a major contributor to global disease burden [J]. Arterioscler Thromb Vasc Biol, 2014, 34(11): 2363-2371.
38	Prichayudh S, Tumkosit M, Sriussadaporn S, et al. Incidence and associated factors of deep vein thrombosis in Thai surgical ICU patients without chemoprophylaxis: one year study [J]. J Med Assoc Thai, 2015, 98(5): 472-478.
39	Kaplan D, Casper TC, Elliott CG, et al. VTE incidence and risk factors in patients with severe sepsis and septic shock [J]. Chest, 2015, 148(5): 1224-1230.
40	Miri M, Goharani R, Sistanizad M. Deep vein thrombosis among intensive care unit patients; an epidemiologic study [J]. Emerg (Tehran), 2017, 5(1): e13.
41	Llitjos JF, Leclerc M, Chochois C, et al. High incidence of venous thromboembolic events in anticoagulated severe COVID-19 patients [J]. J Thromb Haemost, 2020, 18(7): 1743-1746.
42	Fogarty H, Townsend L, Cheallaigh CN, et al. More on COVID-19 coagulopathy in Caucasian patients [J]. Br J Haematol, 2020, 189(6): 1060-1061.
43	Zhang Y, Xiao M, Zhang S, et al. Coagulopathy and antiphospholipid antibodies in patients with Covid-19 [J]. N Engl J Med, 2020, 382(17): e38.

[1]	武玺宁, 欧阳云淑, 孟华, 姜玉新, 张一休, 戴晴, 徐钟慧, 李建初. 新型冠状病毒肺炎疫情防控期间北京协和医院产科超声工作量的同比及环比分析[J/OL]. 中华医学超声杂志（电子版）, 2022, 19(09): 990-993.
[2]	李逸群, 王娜, 莫红楠, 兰波, 王佳妮, 温霆宇, 马飞. 早期乳腺癌患者新型冠状病毒肺炎疫苗接种情况及影响因素调查[J/OL]. 中华乳腺病杂志(电子版), 2023, 17(01): 30-35.
[3]	卢鑫, 魏昕, 王志斌. 重组人可溶性血栓调节蛋白治疗脓毒症合并弥散性血管内凝血临床疗效的Meta分析[J/OL]. 中华危重症医学杂志(电子版), 2023, 16(02): 123-129.
[4]	徐保平, 彭怀文, 喻怀斌, 王晓涛. 新型冠状病毒肺炎继发糖尿病酮症酸中毒合并肝门静脉积气一例[J/OL]. 中华实验和临床感染病杂志(电子版), 2024, 18(04): 250-255.
[5]	李振华, 解宝江, 易为, 李丽, 卫雅娴, 周明书, 伊诺. 82例孕产妇对新型冠状病毒肺炎疫情防控认知的心理干预及常态化疫情防控应对要点[J/OL]. 中华实验和临床感染病杂志(电子版), 2023, 17(03): 173-179.
[6]	陈彩玲, 吉金峰, 王玉红, 徐静, 朱湘安, 李伟, 郝喜燕, 李爱琴. 新冠肺炎疫情防控期间急诊腹部多发伤一体化救治管理及对策[J/OL]. 中华普外科手术学杂志(电子版), 2022, 16(05): 560-563.
[7]	刘扬, 左兴华, 陈志航. 新型冠状病毒肺炎疫情常态化下医院人员管理挑战及对策[J/OL]. 中华疝和腹壁外科杂志(电子版), 2022, 16(05): 611-614.
[8]	张彬霞, 王宁, 李端芳, 刘勇, 陈珍珍. 新型冠状病毒肺炎患者分级评估及康复治疗研究进展[J/OL]. 中华肺部疾病杂志(电子版), 2022, 15(06): 912-915.
[9]	刘付蓉, 翁利, 杜斌. 2020年至2022年中国重症医学临床研究进展[J/OL]. 中华重症医学电子杂志, 2024, 10(01): 48-53.
[10]	李雪珠, 谢剑锋, 李晓青, 夏泽燕, 鲁玲, 顾晓霞, 马绍磊, 黄英姿. 循环式筛查与五色区域分类模式在方舱医院管理中的应用[J/OL]. 中华重症医学电子杂志, 2023, 09(03): 316-320.
[11]	李世明, 黄蔚, 刘玲. HMGB1介导脓毒症相关凝血功能障碍的作用机制及其治疗进展[J/OL]. 中华重症医学电子杂志, 2023, 09(03): 269-273.
[12]	刘广杰, 王光林, 樊少青, 王贵英. 局部新型冠状病毒感染疫情下肿瘤患者负性情绪和行为的诱因及应对措施[J/OL]. 中华临床医师杂志(电子版), 2023, 17(01): 93-96.
[13]	葛静萍, 尹媛媛, 李燕. 梯度压力袜联合间歇充气加压在老年新型冠状病毒肺炎患者预防下肢深静脉血栓形成中的应用[J/OL]. 中华介入放射学电子杂志, 2024, 12(01): 70-74.
[14]	孙维杰, 翁跃颂, 沈驰斌, 韩阿祥, 刘旭峰, 徐灵, 陈雪琴. 方舱医院医学检验实验室建设运行探索[J/OL]. 中华临床实验室管理电子杂志, 2022, 10(04): 242-245.
[15]	刘敏, 彭才静, 王金能. 重庆市新型冠状病毒肺炎疫情前后儿童支气管肺炎痰培养结果分析[J/OL]. 中华诊断学电子杂志, 2023, 11(02): 97-103.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

Analysis of the Chinese clinicians' perceptions regarding coagulation-related events in patients with coronavirus disease

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

Analysis of the Chinese clinicians' perceptions regarding coagulation-related events in patients with coronavirus disease