不同剂量低分子肝素对胸外科手术患者术后凝血功能的影响

The Influence of Different Doses of Low Molecular Weight Heparin on Coagulation Function in Patients after Thoracic Surgery

目的对比不同剂量低分子肝素对胸外科手术患者术后凝血功能的影响。方法选取2009年1月至2010年3月在华中科技大学附属同济医院行外科手术治疗的82例患者（肺癌、食管癌、胸腺瘤和胸膜间皮瘤等）,按入院的先后顺序不同分为3组,对照组：24例,男14例,女10例;年龄43.5±21.3岁;术后不给予低分子肝素。Ⅰ组：32例,男18例,女14例;年龄45.2±18.6岁;术后1~7 d每日皮下注射低分子肝素0.2 ml（2 125 U）。Ⅱ组：26例,男15例,女11例;年龄43.8±20.1岁;术后1~7 d每日皮下注射低分子肝素0.4 ml（4 250 U）。观察3组患者术前和术后凝血酶原时间（PT）、活化部分凝血活酶时间（APTT）、纤维蛋白原（Fib）、D-二聚体（D-D）、血小板计数（PLT）以及抗-Ⅹa因子活性等凝血功能变化。结果术前3组PT、APTT、Fib、D-D和PLT值均在正常范围内,3组间比较差异无统计学意义（P〉0.05）。术后3组PT延长,APTT逐渐减少,Fib、D-D升高,PLT术后3 d降低,而7 d升高,抗-Ⅹa因子活性术后逐渐升高,与术前比较差异均有统计学意义（P〈0.05）。术后Ⅱ组Fib明显低于Ⅰ组（术后5 d 4.7±2.5 g/L vs.7.0±3.3g/L,P〈0.05）,Ⅱ组D-D低于对照组（术后5 d 891.3±891.3μg/L vs.1 583.2±984.7μg/L,P〈0.05）和Ⅰ组（术后5 d891.3±891.3μg/L vs.1 452.6±1 052.9μg/L,P〈0.05）,术后Ⅱ组抗-Ⅹa因子活性高于Ⅰ组（术后5 d 0.54±0.05 U/mlvs.0.29±0.04 U/ml,P〈0.05）。结论在一定的体重范围内,固定剂量（4 250 U）的低分子肝素对改善术后高凝状态、避免静脉血栓栓塞症的发生具有重要意义,并不会增加出血等并发症发生的风险。

Objective To compare the influence of different doses of low molecular weight heparin on blood coagulation system of patients who have received thoracic surgery. Methods Eighty-two patients（with lung cancer,esophageal cancer,thymoma,pleural endotheliomas or other diseases） who were treated in Tongji Hospital of Huazhong University of Science and Technology from January 2009 to March 2010 were divided into three groups,based on the time of hospitalization.In the control group,there were 24 patients including 10 females and 14 males with an average age of 43.5±21.3 years.No low molecular weight heparin was given after operation.There were 32 patients in group I,including 14 females and 18 males,with an average age of 45.2±18.6 years.An amount of 0.2 ml（2 125 U） low molecular weight heparin was subcutaneously injected daily during the first 7 days after operation.In group Ⅱ,there were 26 patients including 11 females and 15 males with an average age of 43.8±20.1 years.An amount of 0.4 ml（4 250 U）low molecular weight heparin was subcutaneously injected daily during the first 7 days after operation.The differences of preoperative and postoperative coagulation factors including prothrombin time（PT）,activated partial thromboplastin time（APTT）,fibrinogen（Fib）,D dimer（D-D）,platelet count（PLT） and anti-Ⅹa activity were observed. Results The preoperative average values of PT,APTT,Fib,D-D,PLT of all the three groups were in the normal range and showed no significant difference（P〈0.05）.For all three groups,after operation,PT prolonged,APTT shortened,the amount of Fib,D-D increased,PLT reduced on the 3rd day and then increased on the 7th day and anti-Ⅹa activity increased,all of which showed a significant difference from preoperative values（P〈0.05）.The amount of Fib in group Ⅱ was significantly lower than that in group Ⅰ after operation（the 5th day after operation： 4.7±2.5 g/L vs.7.0±3.3 g/L,P〈0.05）;the amount of D-D in group Ⅱ was significantly lower than that in the control group（the 5th day after operation： 891.3±891.3 μg/L vs.1 583.2±984.7 μg/L,P 0.05） and group Ⅰ（the 5th day after operation： 891.3±891.3 μg/L vs.1 452.6±1 052.9 μg/L,P〈0.05）; and the anti-Ⅹa activity of group Ⅱ was significantly higher than that in group Ⅰ（the 5th day after operation： 0.54±0.05 U/ml vs.0.29±0.04 U/ml,P〈0.05）. Conclusion In a certain weight range,fixed-dose（4 250 U） of low molecular weight heparin is able to improve postoperative hypercoagulable state and avoid the occurrence of venous thrombo-embolism without increasing risk of complications like bleeding.