人工心脏瓣膜置换术后关节置换的围手术期抗凝治疗策略  

Peri-operative anticoagulation for joint replacement through replacing Warfarin by low molecular weight heparin(LMWH) in patients with previous cardiac valve replacement

作　　者：柴伟[1] 许猛[1] 张国强[1] 倪明[1] 陈继营[1] 林峰[1] 

机构地区：[1]中国人民解放军总医院骨科,北京100853

出　　处：《中国骨与关节外科》2013年第1期21-24,共4页Chinese Journal of Bone and Joint Surgery

基　　金：解放军总医院科技创新苗圃基金(10KMZ01);解放军总医院科技创新苗圃基金(10KMM09)

摘　　要：背景:目前,对于人工心脏瓣膜置换术后关节置换患者围手术期的抗凝治疗尚无统一认识。目的:探讨人工心脏瓣膜置换术后关节置换患者围手术期使用低分子肝素(LMWH)替代华法林抗凝治疗的安全性和有效性。方法:回顾性分析2007年4月至2011年6月行人工心脏瓣膜置换术后关节置换患者19例。术前3天采用LMWH替代治疗。术后出现出血倾向时停用LMWH并输入血浆,补充凝血因子,同时给予夹闭引流,患肢加压包扎等对症治疗。术后鼓励下肢肌肉等长收缩训练,拔出引流后离床活动,并辅以下肢静脉泵和下肢弹力袜治疗。术后7 d开始加用术前用量的华法林,术后10 d左右停用LMWH。记录术中出血量和术后引流量,计算平均国际标准化比值(INR),评价术后出血和血栓情况。结果:19例患者的术中出血量为230～520 ml,平均(347±81)ml;术后引流量为480～820 ml,平均(607±103)ml。19例患者术后INR平均值为2.16±0.43。术后无一例出现重度出血,11例出现轻度出血,给予相应治疗后好转。无一例出现血栓征象。结论:人工心脏瓣膜置换术后关节置换患者围手术期使用LMWH替代华法林抗凝治疗可有效预防血栓形成。出现出血症状后及时停药、输入血浆、补充凝血因子以及对症治疗,同时给予术侧肢体加压包扎、夹闭引流可及时有效控制出血。术后鼓励早期功能锻炼、应用下肢静脉泵和抗血栓袜可协助预防血栓行成,有助于患者快速康复。Background： No consensus has been reached in peri-operative anticoagulation for joint replacement in patients with previ-ous cardiac valve replacement. Objective： To evaluate the safety and efficiency of peri-operative anticoagulation for joint replacement through replacing Warfarin by low molecular weight heparin （LMWH） in patients with previous cardiac valve replacement. Methods： Nineteen patients with artificial cardiac valve who underwent arthroplasty in our institution from April 2007 to June 2011 were retrospectively studied. Warfarin was replaced by continuous LMWH 3 days before operation. In case of postoperative bleeding, intermittent wound drainage, transfusion, and pressure bandaging combined with withdrawal of LM-WH were adopted. Early isometric contraction was encouraged. Compressible limb sleeve and bump were used for enhanc-ing circulation in the lower limb, out-of-bed rehabilitation was allowed once the patient＇s general condition permitted. Warfa- rin was started 7 days after operation accompanied by LMWH for additional 3 days. The intraoperative blood loss and post-operative drainage were recorded, the mean international normalized ratio （INR） was calculated, and the postoperative bleeding and embolism risk were also evaluated. Results： The average intraoperative blood loss was （347± 81）ml, ranging from 230 ml to 520 ml; the average postoperative drainage was （607± 103）ml, ranging from 480 ml to 820 ml; and the average INR was 2.16±0.43. No severe bleeding was record-ed. Eleven cases experienced curable bleeding. No embolism was found by ultrasonography in the valve and surgical limb. Conclusions： Replacing Warfarin with LMWH for perioperative anticoagulation in patients with artificial cardiac valve 3 days before elective joint replacement is associated with effective anticoagulation preventing valve and lower limb embo- lism not at the expense of increasing severe bleeding after operation. In case of curable bleeding, transfusion, intermittent wound drainage, pre

关 键 词：关节置换 抗凝 围手术期 低分子肝素 华法林 

分 类 号：R687.4[医药卫生—骨科学]