骨折后深静脉血栓的早期诊断与处理

Early diagnosis and treatment for deep venous thromboembolism in patients with fracture

目的探讨早期诊断及处理骨折后深静脉血栓栓塞症（VTE）的方法。方法参考Well评分对2004年10月到2007年10月间来我院就诊的急性骨折患者行VTE筛查，并对行彩色多普勒超声（彩超）和深静脉造影检查明确诊断的患者进行抗凝、溶栓等治疗。结果筛查出高危患者1508例，均行D-二聚体筛查，1455例行彩超、53例行深静脉造影检查。共确诊VTE652例（43．2％），其中给予抗凝治疗619例（94。9％），在行抗凝治疗的患者中，加行溶栓治疗者162例（24．8％，162／652）、加行手术取栓治疗25例（3．8％，25／652）；为预防致命性肺栓塞，对146例（22．4％，146／652）患者行腔静脉滤器植入治疗，有抗凝禁忌的33例（5．1％）患者均放置腔静脉滤器。经疗效评价，治愈412例（63．2％），有效240例（36．8％）。结论骨折患者VTE的诊断按照Well评分分组，行D-二聚体和彩超检查进行筛查，适时进行静脉造影加以证实。VTE治疗应在抗凝、溶栓治疗的基础上，进行必要的取栓术和腔静脉滤器植入术。

Objective To explore the measures in early diagnosis and treatment for venous thromboembolism （VTE） in patients with fracture. Methods All the patients with fracture visiting Beijing Jishuitan Hospital in emergency during October 2004 to October 2007 were screened by Well＇ s prediction rides, and anticoagulation and thrombolysis were instituted for those with established diagnosis of VTE by color Doppler ultrasonography and venography. Results Totally, 1 508 patients at high-risk of VTE were identified by D-dimer test, 1 455 by color ultrasonography and 53 by venography. Diagnosis of VTE was established in 652 of them （43.2%）, 619 （ 94. 9% ） received anticoagulant treatment, 162 （24. 8% ） received anticoagulant plus thrombolytic treatment and 25 （3.8%） received anticoagulation plus thrombectomy. In order to prevent fatal pulmonary embolism, vena cava filters （VCFs） were implanted in 146 （22. 4% ） patients, and 33 （5. 1% ） of them were contraindicated to anticoagulation. After treatment, 412 cases were cured and 240 were improved, with no one failed. Conclusions Patients with fracture are at high-risk of VTE and should be screened by D-dimer test and color Doppler ultrasonography based on Well＇ s evaluation, as well as by venography for confirming the diagnosis of VTF as appropriate. Anticoagulation and thrombolysis are still the treatment of choice, with thrombectomy and VCF implantation performed only if necessary.