不同频次应用低分子肝素预防髋部骨折静脉血栓的临床对比研究

发布时间：2018-06-24 05:08

本文选题：低分子肝素 + 静脉血栓　；参考：《河北医科大学》2015年硕士论文

【摘要】：目的:近年来,随着我国老龄化进程的发展,髋部骨折发生率有逐渐增多的趋势,由于高龄、创伤、卧床制动等原因导致老年患者骨折后有着较高的下肢静脉血栓发生率,由于较高的发生率及严重的临床后果,对骨科病人深静脉血栓的预防就显得尤为重要了。目前,主要的预防措施有两种:机械性预防和药物预防。机械性预防即采用物理方法促进静脉血液回流,增加血液流速,减少血液淤积,从而减少血栓的发生,常用的方法有弹力袜和静脉泵装置,其优点在于不增加出血风险,缺点是在创伤患者中应用不便,并且其疗效尚未取得一致意见。药物预防常用的有阿司匹林、肝素、低分子肝素等。阿司匹林可减少血小板聚集从而降低血栓发生率,但不被作为常规用药。肝素因为需严密观察患者凝血功能,有出血风险、过敏反应等并发症而应用受限。目前应用最广的是低分子肝素(LMWH),低分子肝素钙是一种新型的抗凝血酶Ⅲ(ATⅢ)依赖性抗血栓形成药,具有明显的抗凝血因子X a活性,抗凝血因子Ⅱa或抗凝血酶的活性较低。低分子肝素可抑制体内、外血栓和动静脉血栓的形成,但不影响血小板聚集和纤维蛋白原与血小板的结合。在发挥抗栓作用时,出血的可能性较小。低分子肝素能刺激内皮细胞释放组织因子凝血途径抑制物和纤溶酶原活化物,不被第4因子中和,对血小板功能亦无明显影响;对血栓溶解有间接协同作用,可用于治疗已形成的深部静脉血栓。因此,低分子肝素受到广大骨科医师推崇。但是,对于应用方法尚未取得一致意见,各有支持者,有学者认为应加大使用量,每日皮下注射两次,强化预防效果。并且,研究多集中于术后抗凝方案,术前抗凝方案以及对机体失血的影响报道较少。为此,本研究通过前瞻性研究方法,将患者分为两组:A组采用低分子肝素钙5000IU皮下注射,每日一次;B组采用低分子肝素钙5000IU皮下注射,每日两次,对其预防效果、手术失血量及并发症的发生率进行对比,分析其治疗效果,为临床应用提供理论依据。方法:对2014年5月至2015年9月就诊于河北省沧州中西医结合医院并住院治疗的股骨粗隆间骨折患者分为两组,共65例,纳入标准:1、同意加入并签署知情同意书者;2、所有患者均为跌倒所致低能量损伤,无其它部位骨折,无开放性伤口;3、年龄大于60岁;4、入院后即刻行彩色多普勒超声检查DVT阴性;5、既往无血栓栓塞性疾病病史。排除标准:1、中、重度肝肾功能损害者。2、凝血功能障碍者。3、近期有出血性疾病病史者。4、对低分子肝素成分过敏者。5、有消化道溃疡者。6、细菌性心内膜炎者。7、拒绝参加者。A组患者采用低分子肝素钙5000IU皮下注射,每日一次;B组患者采用低分子肝素钙5000IU皮下注射,每日两次。所有患者均行手术治疗,麻醉方法采用椎管内麻醉,于术前12小时停用低分子肝素钙,手术方法均为股骨近端髓内钉进行固定,术后放置引流管,记录其引流量,术后12小时继续按照术前抗凝方案预防DVT,术后第3天复查血常规,观察其血红蛋白变化。术后一周进行双下肢静脉彩色多普勒超声检查,了解有无血栓形成。结果:所有患者于术后一周均无症状性DVT发生,其中A组发生患肢小腿肌间静脉丛血栓5例,发生率15.6%,B组发生患肢小腿肌间静脉丛血栓3例,发生率9.1%。两组DVT发生率差异无统计学意义(X2=0.642,P=0.422)。两组患者术后3天复查血常规显示血红蛋白含量较术前明显下降,差异具有统计学意义。但是,两组间患者血红蛋白含量变化比较不具有统计学意义。所有患者均未出现消化道出血、血肿、伤口渗血增加、硬膜外血肿等并发症。两组患者术后引流量平均分别为(250.8±71.7)、(269.5±60.3)mL,差异无统计学意义(t=0.166,P=0.835)。结论:本研究显示常规剂量低分子肝素每日一次皮下注射和每日两次皮下注射并于术前12小时停用、术后12小时继续应用对手术后失血量影响无明显差异。对于预防效果,两组均无症状性DVT发生,每日两次皮下注射VTE发生率略低,但并无统计学差异,因此,临床应用应根据患者发生血栓风险程度,酌情调整应用频次。
[Abstract]:Objective: in recent years, with the development of the aging process in China, the incidence of hip fracture is increasing gradually. Due to old age, trauma, bed brake and so on, the elderly patients have higher incidence of lower limb venous thrombosis after fracture. The prevention of deep venous thrombosis in Department of orthopedics is the result of high incidence and severe clinical consequences. It is particularly important. At present, there are two main preventive measures: mechanical prevention and drug prevention. Mechanical prevention is the use of physical methods to promote venous blood flow, increase blood flow rate, reduce blood stasis, and reduce the occurrence of thrombus. The common method is elastic socks and venous pump device, its advantage is that it does not increase bleeding. The risk, the disadvantage is the inconvenience in the trauma patients, and its effect has not been agreed. Drug prevention commonly used aspirin, heparin, low molecular weight heparin, etc.. Aspirin can reduce platelet aggregation and reduce the incidence of thrombus, but not as a routine drug. Risk, allergy and other complications are limited. Low molecular weight heparin (LMWH) is the most widely used, low molecular weight heparin calcium is a new antithrombin III (AT III) dependent antithrombotic drug, with obvious anticoagulant factor X a activity and low activity of anticoagulant factor II A or anticoagulant. Low molecular weight heparin can inhibit the body The formation of external thrombus and arteriovenous thrombosis does not affect platelet aggregation and the binding of fibrinogen to platelets. The possibility of bleeding is smaller when antithrombotic action is played. Low molecular weight heparin stimulates endothelial cells to release tissue factor coagulation pathway inhibitors and plasminogen activator, not neutralized by fourth factors, and the function of platelets There is no obvious effect on the thrombolytic effect of thrombolysis, which can be used in the treatment of deep venous thrombosis that has been formed. Therefore, low molecular weight heparin is respected by the doctors in the Department of orthopedics. However, there is no agreement on the application methods, each has its supporters, and some scholars believe that the dosage should be increased two times a day to strengthen the preventive effect. In addition, the study focused on postoperative anticoagulant regimens, and there were few reports on preoperative anticoagulant schemes and the effect on blood loss in the body. To this end, the patients were divided into two groups by prospective study methods: group A was subcutaneously injected with low molecular heparin calcium 5000IU daily, and group B was subcutaneously injected with low molecular weight heparin calcium 5000IU every day. The effects of prevention, blood loss and complications were compared, and the therapeutic effect was analyzed. Methods: two groups were divided into two groups of 65 cases of intertrochanteric fracture of femur, which were treated in Cangzhou and Western Medicine Hospital of Hebei province from May 2014 to September 2015, and were included in the standard: 1, agreed to join and sign. 2, all patients were low energy damage caused by fall, no other parts of fracture, no open wound, 3, age greater than 60 years old; 4, DVT negative after admission, 5, history of thrombotic thromboembolic disease. 1, moderate, severe liver and kidney dysfunction,.2,.3,.3 .4, a person with a history of hemorrhagic disease, was allergic to low molecular weight heparin (.5),.6 of peptic ulcers, and.7 for bacterial endocarditis. The patients in group.A were refused subcutaneous injection of low molecular weight heparin calcium 5000IU daily, and the B group was subcutaneously injected with low molecular heparin calcium 5000IU two times a day. All patients were treated with surgical treatment. Treatment, anesthesia was used in spinal canal anesthesia and low molecular weight heparin calcium was stopped 12 hours before operation. The operation method was fixed for proximal femoral nail. Drainage tube was placed after operation to record its flow rate. After 12 hours of operation, DVT was prevented by preoperative anticoagulant scheme. Blood routine was reviewed on third days after operation, and the hemoglobin changes were observed. One week after operation, the changes of hemoglobin were observed. Two lower extremities venous color Doppler ultrasound examination was carried out to understand the formation of thrombus. Results: all patients had no symptomatic DVT in one week after operation, among which group A had 5 cases of limb intermuscular venous plexus thrombosis, the incidence rate was 15.6%, group B had 3 cases of limb intermuscular venous plexus thrombosis, and there was no difference in the incidence of DVT in group 9.1%. two. Significance (X2=0.642, P=0.422). Two groups of patients after 3 days reexamination of blood routine showed that the hemoglobin content was significantly lower than before the operation, the difference was statistically significant. However, the hemoglobin content changes in the two groups were not statistically significant. All patients had no gastrointestinal bleeding, hematoma, increased osmotic bleeding, epidural hematoma, and so on. Complications. The average flow rate of the two groups was (250.8 + 71.7) and (269.5 + 60.3) mL respectively. The difference was not statistically significant (t=0.166, P=0.835). Conclusion: This study showed that the routine dose of low molecular weight heparin was subcutaneous injection once a day and two subcutaneous injections daily and stopped for 12 hours before the operation. The blood loss after operation was continued 12 hours after the operation. There was no significant difference in the effect. For the prevention effect, the two groups were asymptomatic DVT, and the incidence of two subcutaneous injection of subcutaneous injection was slightly lower, but there was no statistical difference. Therefore, the clinical application should be based on the degree of thrombus risk and adjust the frequency of application.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R687.3

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