儿童活体肝移植术后血栓的防治措施探讨

Preventive measures for thrombus after receiving living donor liver transplantation in children

目的：通过对儿童活体肝移植术后凝血功能的调控,探讨儿童肝移植术后血栓的防治措施。方法：采用自身前后对照研究,监测20例活体肝移植患儿术前及术后1、3、5、7 d的凝血功能并进行分析,术后用肝素5~20 U/（kg·h）持续泵入,低分子右旋糖酐5 ml/（kg·d）调节凝血功能;前列腺素E1 5 ng/（kg·min）,持续泵入2 h,每天3次扩张肝血管。将凝血酶原时间（prothrombin time,PT）延长为正常值的1~2倍,如果过长,则减少或停用肝素,或输入新鲜冰冻血浆或冷沉淀。结果：与术前相比,术后第1天[（18.72±4.40）s,P=0.001]、第3天[（16.96±3.03）s,P=0.043]PT明显延长,而第5天[（16.42±4.75）s,P=0.101]、第7天[（15.50±5.94）s,P=0.332]延长不明显;活化部分凝血活酶时间（activated partial thromboplastin time,APTT）及凝血酶时间（thrombin time,TT）在术后第1天、第3天、第5天和第7天均无明显变化[APTT术前（44.21±24.16）s,术后第1天（55.74±20.47）s,术后第3天（55.19±23.80）s,术后第5天（54.59±23.84）,术后第7天（40.35±12.63）,F=1.810,P=0.1334,TT术前（19.44±8.29）,术后第1天（18.80±4.74）s,术后第3天（20.58±4.54）s,术后第5天（19.81±3.56）s,术后第7天（18.62±4.16）s,F=0.44,P=0.779],纤维蛋白原（fibrinogen,Fib）在术后第1天[（1.48±0.54）g/L,P=0.005]、第5天[（1.37±0.63）g/L,P=0.001]及第7天[（1.56±0.46）g/L,P=0.012]明显降低,而第3天变化不明显[（1.73±0.75）g/L,P=0.071],血小板在术后第1天（107.70±51.82）×109个/L、第3天（132.00±70.25）×109个/L、第5天（175.70±73.89）×109个/L及第7天（158.40±60.83）×109个/L明显下降（F=15.43,P=0.000）,所有患儿没有引起严重的凝血功能紊乱,没有血栓形成。结论：儿童活体肝移植术后凝血功能是可用药物调控的,调控的目的是控制出血倾向,防止高凝状态、避免血栓形成;同时彩色多普勒检查是诊断肝脏血管血栓形成的有效方法。

Objective：To explore the prevention measures for thrombus after receiving living donor liver transplantation in children through regulating coagulation function. Methods：Before-after self-controlled study was used among 20 children who had undergone living donor liver transplantation in our hospital. Coagulation function was monitored and analyzed before the operation and on the 1st,3rd,5th,7th d after the operation. Continuous intravenous injection of heparin 5-20 U/（kg·h）and low molecular dextran 5 ml/（kg·d）was administered. Prostaglandin E1 5 ng/（kg·min）,was continuously injected for 2 hours and hepatic vascular was expanded 3 times a day. Prothrombin time（PT）was extended 1-2 times than the normal value. Reducing heparin dosages or stopping heparin injection or injecting fresh frozen plasma or doing cryoprecipitate was administrated if PT lasted too long. Results：Compared with levels before the operation,PT was extended on the 1st d（（18.72 ±4.40） s,P =0.001） and the 3rd d（（16.96 ±3.03） s,P =0.043）after the operation;but there was no difference between the 5th d（（16.42±4.75）s,P=0.101）and the 7th d（（15.50±5.94）s,P=0.332）. There was no difference in levels of activated partial thromboplastin time（APTT）and thrombin time（TT）on the 1st,3rd,5th,7th d after the operation（APTT：before the operation（44.21±24.16）s,the 1st d after the operation（55.74±20.47）s,the 3rd d after the operation（55.19±23.80）s,the 5th d after the operation（54.59±23.84）s,the 7th d after the operation（40.35±12.63）s,F=1.810,P=0.1334;TT：before the operation（19.44±8.29）s,the 1st d after the operation（18.80±4.74）s,the 3rd d after the operation（20.58±4.54）s,the 5th d after the operation（19.81±3.56）s,the 7th d after the operation（18.62 ±4.16） s,F =0.44,P =0.779）. Significant decrease in fibrinogen level was observed on the 1st d（（1.48 ±0.54）g/L,P=0.005）,the 5th d（（1.37±0.63）g/L,P=0.001）and the 7th d（（1.56±0.46）g/L,P=0.012）but not on the 3rd d（（1.73±0.75）g/L,P=0.071）after the operation. Significant decrease in platelet level was found on the 1st d（107.70±51.82）×109 units/L,the 3rd d（132.00±70.25）×109 units/L,the 5th d（175.70±73.89）×109 units/L and the 7th d（158.40±60.83）×109 units/L after the liver transplantation（F=15.43,P=0.000）. No case of serious blood clotting disorders and thrombosis was observed. Conclusion：Coagulation function can be regulated through medicine after the operation in pediatric recipients of live donor liver transplants. The purpose of the regulation is to control the bleeding tendency,prevent the hypercoagulable state,avoid thrombosis. Meanwhile,color Doppler examination is an effective method for diagnosis of hepatic vascular thrombosis.