心脏瓣膜置换术后妇科手术的围手术期处理

Perioperative management of patients undergoing gynecological operation after cardiac valve replacement

目的探讨心脏瓣膜置换术后患者行妇科手术的安全性。方法回顾性分析2004年4月～2009年4月同济医院收治的10例心脏瓣膜置换术后因妇科疾病行妇科手术患者的临床资料。患者心功能Ⅰ～Ⅱ级。其中,9例择期手术,1例急诊手术,均口服华法林进行抗凝治疗。择期手术者术前停用华法林2～5d,急诊手术者术前2～4h静脉点滴维生素K110～20mg,术前凝血酶原时间(PT)平均值为13.2s,凝血酶原国际标准化比值(INR)平均值为1.19。结果10例患者手术时间8min～210min,术中出血量10～1000ml,其中1例术中出血1000ml,行输血治疗。术后未发生大出血、血栓、感染性心内膜炎,心力衰竭等并发症。结论心脏瓣膜置换术后的患者术前停用华法林或应用维生素K1并将PT、INR分别控制在15s和1.20左右,结合术中细致操作,加强围手术期管理,进行妇科手术是安全的。

Objective To investigate the safety and management of gynecological operations on patients after cardiac valve replacement. Methods Clinical data of 10 cases subject to cardiac valve replacement undergoing gynecological operations in Tongji Hospital from April 2004 to April 2009 were retrospectively analyzed. All the cases had routine oral warfarin with prothrombin time （PT） of 11.0 s-18.6 s （mean 13.2 s）, international normalized ratio （INR） for prothrombin of 0.95-1.59 （mean 1.19） and heart functional class I - II. Among them, elective gynecological operations were performed on 9 cases and emergency operation on one case. In those subject to elective surgery, warfarin was withdrawn 2-5 days before operation, and 2- 4 h before operation 10-20 mg vitamin K1 was injected intravenously into the patients receiving emergency surgery. ECG, blood pressure, hemoglobin and oxygen saturation were routinely monitored for all the cases intraoperatively and postoperatively. Results Average operation time was 8-210 min, and average blood loss was 10-1000 ml. There were no postoperative complications such as massive hemorrhage, thrombosis, infective endocarditis and heart failure. Conclusion Gynecological operation was safe in the patients with cardiac valve replacement if preoperative PT and INR were adjusted to about 15 s and 1.20 respectively by cessation of warafarin or application of vitamin K, , combined with careful manipulation and strengthened perioperative management.