外科术后重症病人感染时凝血紊乱及低分子肝素钠干预研究

Clinical intervention study of low molecular heparin (LMH) and coagulopathy in critical post-surgical patients with infection

目的观察研究外科重症病人术后合并感染时凝血指标的变化、低分子肝素钠的治疗作用及术后使用的安全性。方法前瞻性收集2006年10月至2009年8月间昆明医学院第二附属医院外科重症病房(SICU)200例术后合并感染病人为研究组;同期100例非感染病人作为对照组。研究组随机分为感染对照组100例,接受ICU常规治疗;低分子肝素钠组100例,于手术后8h开始加用低分子肝素钠40mg皮下注射,每日两次。所有病人进行ICU常规监测及病情观察,比较三组病人凝血指标:凝血酶原时间(PT)、活化部分凝血活酶时间(APTT)、凝血酶时间(TT)、纤维蛋白原(FIB)的变化及出血等肝素钠治疗的副反应,连续7d。观察期间凡达到ICU转出标准者即可转出ICU。结果(1)术后第1～7天所有合并感染的病人PT、APTT均较非感染病人延长(P<0.01);TT在术后第6～7天较非感染病人稍长,但均在正常范围;FIB第1天三组相近(P>0.05),第2～7天所有感染病人FIB均较对照组增高(P<0.01)。(2)经低分子肝素钠治疗的病人术后第4～7天,PT较感染对照组短;术后第5～7天APTT较感染对照组长;TT无变化;术后第4～7天,FIB较感染对照组低(P<0.01)。(3)观察结束时,经低分子肝素钠治疗的感染病人转出ICU的比例较常规治疗病人高(P<0.01)。住ICU时间差异无统计学意义(P>0.05)。(4)低分子肝素钠治疗的感染病人中,有3例发生注射部位瘀斑。结论外科重症病人术后合并感染时,常伴有凝血活化及纤溶抑制现象;早期使用低分子肝素钠对术后感染病人有一定的改善凝血活化和纤溶抑制的作用,增强了综合治疗效果,具有较好的安全性。

Objective To observe the index of blood coagulation, intervention treatment and safety of low molecular heparin （LMH） in critical post-surgical patients with infection. Methods The clinical data of 200 critical post-surgical patients with infection in the Department nf SICU of Second Affiliated Hospital of Kunming Medical College between October 2006 and August 2009 as study group and 100 non-infection patients as comparative group in synchronization. The study group was randomly divided into infection group that 100 patients were treated regularly of ICU, and LMH treatment group that 100 patients were taken 40rag LMH by a subcutaneous injection twice per day on regular treatment in post-surgieal 8 hours. All patients of study group and eomparalive group were observed regularly by ICU. PT, APTT, TT, FIB and side effect of Heparin such as hemorrhage in 7 days were observed. The patients accorded with the transfer criteria of ICU were gotten out from ICU during observation time. Results （1）PT and APTT in all patients with infection compared with non-infection were time-lapse in post-surgical 1 to 7 days （P 〈 0.01）, and TT was time-lapse a little bit but located in normal range in post-surgical 6 to 7 days. FIB in all groups were similar in the first day （P〉 0.05）. However, FIB in all of infection patients inereased eompared with that of comparative group in 2 to 7 days （P 〈 0.01）. （2） PT in 1,MH treatment group was shorter than infection group＇ s in post-surgical 4 to 7 days. APTT was time-lapse compared with that of infection group in post-surgical 5 to 7 days. TT did not change. FIB in LMH treatment group decreased compared with that of comparative infection group （P 〈 0.01）. （3） The proportion of getting out from ICU in LMH treatment group was higher than that of regular treatment group as observation was over （P 〈 0.01）. The time in ICU was not different （P〉 0.05）. （4） Injection sites of three patients in LMH treatment group presented ecchymosis. Conclusion Critical post-surgical patients with infection usually accompany by phenomenon of coagulation activation and fibrinolytic inhibition. Early treatment by LMH in post-surgical patients with infection might improve coagulation activation and fibrinolytic inhibition, increase effect of combined therapy and have good safety.