关节置换术后低分子量肝素抗凝罕见合并症肝素诱导性血小板减少症的诊断与处理  

Diagnosis and treatment of rare anticoagulation complication thrombocytopenia induced by low- molecular-weight heparin after joint replacement

作　　者：周磊[1] 翁习生[1] 金今[1] 唐宁[1] 王炜[1] 盛林[1] 赵丽娟[1] 

机构地区：[1]中国医学科学院北京协和医学院北京协和医院骨科,北京100730

出　　处：《中国医师进修杂志》2013年第5期1-4,共4页Chinese Journal of Postgraduates of Medicine

摘　　要：目的探讨关节置换术后低分子量肝素（LMWH）抗凝所致肝素诱导性血小板减少症（HIT）的早期诊断与处理。方法回顾性分析4例行全膝关节置换术（TKA）后LMWH抗凝所致HIT患者的临床表现、处理及预后。结果关节置换术后LMWH抗凝所致HIT的发病率为0．3％（4／1376）。4例患者于术后第4—9天发现血小板计数（PLT）低于70×10＾9／L，最低降至16×10＾9／L。出现不同程度的心肺窘迫症状及下肢深静脉血栓（DVT）。确诊为HIT，立即停用LMWH，换用阿加曲班、磺达肝癸钠、利伐沙班或华法林替代抗凝治疗。3例经治疗后DVT变小或消失，治愈出院；1例发生脑出血，行开颅血肿清除去骨瓣减压术，并确诊合并多发肺栓塞（PE），治疗1个月效果不佳，无法苏醒，呈植物人状态。结论HIT较罕见，发病隐匿凶险，可继发DVT、PE和脑出血等严重后果；早期确诊和及时处理可以降低致残率和病死率。Objective To investigate the diagnosis and treatment of anticoagulation complication, heparin-induced thrombocytopenia （HIT）,induced by low-molecular-weight heparin （LMWH） after joint replacement. Methods Retrospectively analyzed the clinical manifestations, treatment and prognosis of 4 patients after total knee arthroplasty （TKA） suffered from HIT induced by LMWH. Results The morbidity rate of HIT induced by LMWH was 0.3%（4/1376）. Platelets were found less than 70 ×10^9/L after 4-9 d, minimum to 16 × 10^9/L. Different level of cardiorespiratory distress and lower extremity deep venous thrombosis all appeared. Once diagnosed, patients were immediately stopped using LMWH and replaced with argatroban, fondaparinux or rivaroxaban and warfarin. Deep vein thrombosis gradually disappeared and cured in 3 patients after treatment. One patient suffered cerebral hemorrhage and multiple pulmonary embolism, received craniotomy hematoma removal and decompressive craniectomy. But the patient didn＇t wake up after 1-month treatment, became a vegetative one. Conclusions HIT is rare but dangerous, which can result in deep vein thrombosis, pulmonary embolism, cerebral hemorrhage and other serious consequences. Early diagnosis and timely treatment can reduce the rate of disability and mortality.

关 键 词：肝素 低分子量 关节成形术 置换 诊断 肝素诱导性血小板减少症 

分 类 号：R687[医药卫生—骨科学] R5[医药卫生—外科学]