危重患儿凝血功能障碍及弥散性血管内凝血临床分析

Analysis of critically ill children with abnormal coagulation and disseminated intravascular coagulation

目的了解危重患儿凝血功能障碍及弥散性血管内凝血(DIC)患病率及病死率,总结DIC诊断及临床应用肝素预防和治疗的体会。方法对所有PICU住院患儿进行小儿危重评分或美国PICU入出院指南评估及凝血功能监测,确诊DIC者根据临床出血情况应用不同剂量肝素。凝血功能障碍者应用小剂量肝素。结果PICU危重患儿病死率为8.6%。凝血功能异常发生率28.6%,病死率25.7%。其中DIC发生率10.6%,病死率45.2%。凝血功能障碍发生率18.0%,病死率14.1%。原发病为脓毒症者73.8%。在DIC早、中期阶段,使用肝素200～240U/(kg·d),有较好疗效。凝血功能障碍者应用肝素60～120/(kg·d),极少发展为DIC。结论DIC是导致危重患儿死亡的重要原因之一,其主要病因是严重感染性疾病。早期合理应用肝素治疗有效,晚期治疗非常困难。小剂量肝素用于危重患儿可能具有预防DIC的作用。

Objectives To understand the morbidity and mortality of abnormal coagulation and disseminated intravascular coagulation （DIC） in pediatric critically ill patients and summarize experiences of early diagnosis and prophylaxis of using heparin in DIC. Methods A total of 589 patients admitted to PICU ward from January 2005 to April 2007 were evaluated with Pediatric Critical Illness Score and Guidelines for Developing Admission and Discharge Policies for Pediatric Intensive Care Unit of America and monitored with coagulation function tests. Patients with DIC were treated with different doses of heparin according to their bleeding condition, Patients with dysfunction of coagulation, presented abnormal coagulation but not reach to the criterion of DIC, were treated with low dose heparin. Results The mortality of pediatric critically ill patients is 8.6% with morbidity of 28.6% and mortality of 25.7% among abnormal coagulation. The morbidity and mortality of DIC was 10.6% and 45.2% , respectively; and the morbidity and mortality of dysfunction of coagulation was 18.0% and 14.1%. The main primary cause was sepsis which accounted for 73.8%. Earlier treatment with 200 - 240 U/（kg·d） heparin showed better therapeutic effects on patients with DIC. Patients with dysfunction of coagulation who had been treated with 60 - 120 U/（kg·d） heparin seldom developed to DIC. Conclusions DIC is one of the fatal causes of pediatric critical ill patients. The main primary disease is severe infection. Treating earlier with individualized heparin dosage showed better therapeutic effect. Small dosage of heparin in treating critical ill patients may play a role in preventing from DIC.