共识注册编号：PREPARE-2025CN304
Expert consensus on coagulant function tests in the diagnosis and treatment of pulmonary thromboembolism
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摘要: 目的 制定肺血栓栓塞症(pulmonary thromboembolism，PTE)诊疗全流程出凝血功能检测专家共识(简称《共识》)。方法 充分借鉴急性PTE诊治和管理指南，参考国内外近10年的循证医学依据，并整合现有的最佳临床证据和分别来自全国的84名急诊医学、重症医学、检验医学、呼吸病学以及护理学等不同领域的专家经验。通过系统查阅文献资料、德尔菲专家调查及专家论证会议，共同制定本《共识》。结果 《共识》包括PTE临床表现、出凝血功能检测在PTE诊断和治疗决策中的作用、PTE护理中的关键作用以及出凝血功能检测的准确性评估等。结论 《共识》以其特有的科学性和实用性，为各级医院在PTE的诊治领域，提供基于出凝血功能指标检测的指导和实践性参考。Abstract: Objective To formulate the expert consensus on the coagulant function tests throughout the entire process of pulmonary thromboembolism(PTE)(hereinafter referred to as the "Consensus").Methods The consensus thoroughly draw on the latest evidence-based medical data from both domestic and international sources over the past decade regarding the diagnosis, treatment, and management of acute PTE and integrate the best available clinical evidence with expert consensus from 84 specialists spanning emergency medicine, critical care medicine, laboratory medicine, respiratory medicine, and nursing science across nationwide. This "Consensus" was developed through systematic literature review, Delphi expert survey, and expert argumentation meetings.Results The "Consensus" includes the clinical manifestations of PTE, the role of coagulant function tests in the diagnosis, treatment and nursing of PTE, the assessment of the accuracy of coagulant function tests.Conclusion The "Consensus", with its unique scientific nature and practicality, provides guidance and practical references based on the detection of coagulation function indicators for hospitals at all levels in the field of diagnosis and treatment of PTE.
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表 1 共识推荐分级及其代表意义
推荐分级 代表意义 Ⅰ级(一致推荐或一致不推荐) 投票100%一致，所有专家完全达成共识 Ⅱ级(强推荐或强不推荐) 投票75%~99%一致，绝大多数专家达成共识 Ⅲ级(弱推荐或弱不推荐) 投票50%~74%一致，多数专家达成共识，但少数专家存在分歧 Ⅳ级(专家未达成一致性结论) 投票＜50%一致，专家未达成一致性结论 
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APTT检测 初始剂量及调整剂量 下次APTT测定的时间间隔/h 治疗前基础值 初始计量：80 IU/kg静脉注射，然后按照18 IU/kg/h静脉滴注 4~6 ＜35 s(＜1.2倍基础值) 予80 IU/kg静脉注射，然后增加静脉滴注剂量4 IU/kg/h 6 35~45 s(1.2~1.5倍基础值) 予40 IU/kg静脉注射，然后增加静脉滴注剂量2 IU/kg/h 6 46~70 s(1.5~2.3倍基础值) 无须调整剂量 6 71~90 s(2.3~3.0倍基础值) 减少静脉滴注剂量2 IU/kg/h 6 >90 s(>3倍基础值) 停药1 h，然后减少剂量3 IU/kg/h后恢复静脉滴注 6
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表 3 直接口服抗凝剂在VTE强化治疗和维持治疗期间的用药方法[53]
药物 强化治疗 维持治疗(急性发作治疗至少3~6个月内) 达比加群 胃肠外抗凝≥5 d 150 mg bid (高龄患者可减量) 利伐沙班 15 mg bid，21 d 20 mg qd 阿哌沙班 10 mg bid，7 d 5 mg bid 艾多沙班 胃肠外抗凝≥5 d 60 mg qd
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活动性出血 具体表现 大出血 ①致死性出血；②某些重要部位或器官的出血，如颅内、脊柱内、腹膜后、关节内、心包等，及因出血引起的骨筋膜室综合征；③出血导致血流动力学不稳定，和(或)在24~48 h内引起血红蛋白水平下降20 g/L以上，或需要输至少2个单位全血或红细胞；④手术部位出血需要再次进行切开，关节镜或血管内介入等，或关节腔内出血致活动或伤口恢复推迟，使住院时间延长或伤口加深 临床相关非大出血 ①自发性皮肤出血面积>25 cm2；②自发性鼻出血时间>5 min；③持续24 h肉眼血尿；④便血(厕纸可见出血点)；⑤牙龈出血时间>5 min；⑥因出血住院治疗；⑦出血需要输血但少于2个单位；⑧观察者认为影响临床治疗 小出血 其他类型的出血
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表 5 常见凝血指标及其临床意义参考
凝血指标 正常参考值 延长/升高临床意义 缩短/降低临床意义 PT 11.5~14.5 s 延长>3 s，纤溶亢进，抗凝阶段，存在出血风险 血栓前状态 INR 0.8~1.2 抗凝阶段，>3时存在出血风险 血栓形成状态 APTT 20~40 s 延长>10 s，抗凝阶段，存在出血风险 血栓形成及血液呈高凝状态 TT 11~14 s 延长>3 s，AT升高，FDP/D-Dimer增多，抗凝阶段，存在出血风险 存在微小凝块，可以粗略用于检测肝素抗凝治疗 FIB 2~4 g/L 血栓高凝状态 ＜1.5 g/L，低凝血期及纤溶期，溶栓治疗的监测，存在出血风险 FDP 0~5 mg/L 原发性纤溶亢进，血栓高凝状态 - D-Dimer ＜500 μg/L 继发性纤溶亢进，血栓高凝状态，提示发生PTE的风险增加 对于低可能性的患者，可基本排除PTE AT 80%~120% 血液抗凝活性增强 血栓形成状态，抗凝能力下降及肝素抗凝作用减弱 血小板计数 (125~320)×109/L 血小板易发生黏附、聚集及释放反应，可能形成血小板性血栓 ＜100×109/L，出血风险增加 PC 70%~140% 病理性异常 易形成血栓 PS 63.5%~149% 病理性异常 易形成血栓
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