劳力性热射病并发弥散性血管内凝血的治疗

Treatment of disseminated intravascular coagulation as a complication of exertional heat stroke

目的:就我们2005年以来收治的并发有弥散性血管内凝血、多器官功能障碍综合征的严重劳力性热射病进行总结。方法:共6例重症热射病患者,每日监测全血细胞计数、血生化、肌酸激酶、血/尿肌红蛋白浓度及凝血功能等指标。治疗:快速降温、大量输液改善微循环、连续血液净化等支持治疗。DIC治疗:补充凝血因子,低分子肝素抗凝。全部6例中仅例1治疗过程未使用肝素。结果:所有患者在起病3～30h住院,表现为意识障碍、昏迷、低血压、休克、皮肤及黏膜出血。实验室检查:血小板计数呈进行性下降,最低值(3.0～3.4)×109/L,均有转氨酶、总胆红素和直接胆红素、血肌酐、肌红蛋白升高,起病72h左右达到高峰。随着治疗大多在2～3周后恢复正常。全部患者入院时D-二聚体均已升高,起病6h后纤维蛋白原水平低于正常,PT、APTT延长,均符合弥散性血管内凝血诊断。凝血功能在1～4周恢复正常。例1治疗中未用肝素,最终死于多器官功能衰竭及弥散性血管内凝血。结论:连续血液净化可以有效清除肌红蛋白、炎性递质等代谢产物,迅速纠正电解质及酸碱失衡,同时起到补充液体及凝血因子的作用。使用肝素抑制过度活跃的凝血系统,阻止微血栓的形成,对于改善组织缺血和缺氧、治疗弥散性血管内凝血、多器官功能障碍综合征,提高治愈率起到关键的作用。

Objective：We summarize the clinical findings and treatments in a series patient with exertional heat stroke（EHS）.Method： Six patients with EHS complicated with multiple organ failure syndrome,rhabdomyolysis and disseminated intravascular coagulation（DIC） were studied retrospectively.The measurements included whole blood cell count,hepatic function,renal function,electrolytes,creatine kinase,serum/urinary myoglobin levels and coagulatory function.The treatments included endotracheal intubation,mechanical ventilation,cooling,transfusion,blood purification,intensive supportive measures and supplement of coagulation factors.All patients except one received heparin or low-molecular weight heparin for the treatment of DIC.Result：：All patients had elevated ALT,AST,CK,myoglobin,and creatinine levels.Coagulatory abnormalities were universal.Continuous blood purification and the treatment of DIC with heparin could effectually improve the prognosis of EHS.Conclusion：EHS always occurrs with rhabdomyolysis,renal dysfunction and DIC.Blood purification and heparin for anti-coagulation treatment both play significant role in the treatment of EHS.