肝素诱导的血小板减少伴血栓形成

Heparin-induced thrombocytopenia with thrombosis

1例73岁男性患者因下肢动脉硬化闭塞症行“左髂动脉支架植入术＋左股浅动脉再通术”，给予术中普通肝素4000 U静脉推注。术后当天患者因左肾周血肿致急性肾功能不全、急性心功能不全转入重症监护病房，实验室检查示血红蛋白76 g／L，血小板计数（ PLT）113×10^9／L，血肌酐247μmol／L，尿素氮10.6 mmol／L。术后第2天停止静脉泵入肝素，给予无肝素床边连续性肾脏替代治疗（血液滤过前用肝素盐水预冲管道，血液滤过间期用肝素封深静脉导管）。术后第3天患者PLT降至73×10^9／L；第5天左下肢皮肤温度明显降低，足背动脉搏动消失，给予肝素500-625 U／h持续静脉泵入；第7天PLT骤降至16×10^9／L，左下肢皮肤发绀，足底颜色青紫，床边血管超声检查示左股静脉、右颈内静脉置管处血栓形成，左股浅动脉闭塞。考虑为肝素诱导的血小板减少并血栓形成，立即停用肝素，改为阿加曲班静脉泵入，床边连续性肾脏替代治疗改为盐水冲洗、封管。术后第12天患者虽然PLT升至121×10^9／L，但最终因多器官衰竭死亡。

A 73-year-old male patient underwent stent implanting of left iliac artery and recanalization of left superficial femoral artery due to atherosclerotic obliterans of artery of lower extremity and received IV push of 4 000 U unfractionated heparin（ UFH）during the operation. On the operation day,the patient was transferred into Intensive Care Unit due to acute renal insufficiency caused by left perirenal hematoma and acute cardiac insufficiency. Laboratory examination showed the following values：hemoglobin 147 g/L,platelet count 113 × 10^9/L,serum creatinine 247 μmol/L,blood urea nitrogen 10. 6 mmol/L. On day 2 postoperation,he received non-heparin continuous renal replacement therapy on bed（ the tubes were rinsed with UFH before hemodiafiltration and deep venous catheters were sealed with UFH during the hemodiafiltration）. On day 3 postoperation, the patient＇s PLT dropped to 73 × 10^9/L. On day 5 postoperation,the temperature of his left foot decreased and the pulse of dorsal artery of his left foot disappeared. UFH was given intravenously at the rate of 500-625 U per hour. On day 7 postoperation,the patient＇s PLT suddenly dropped to 16 × 10^9/L,he developed skin cyanosis on his left lower limb and cyanoderma on his plantar. Vascular ultrasonography examination showed that thrombosis occurred on his left femoral vein and right internal jugular vein,occlusion appeared on his left superficial femoral artery. Heparin-induced thrombocytopenia with thrombosis was considered. UFH was stopped immediately and intravenous argatroban was given and tube rinsing and sealing with UFH was replaced with saline in continuous renal replacement therapy. On day 12 postoperation,the PLT count increased to 121 × 10^9/L. However,the patient died of multiple organ failure at last.