透析患者全髋关节置换术围手术期下肢深静脉血栓预防策略

Preventive strategy for deep venous thrombosis of lower limb in perioperative period of total hip arthroplasty in hemodialysis patients

目的探讨对于合并肾功能衰竭需要规律透析的患者,在行全髋关节置换术围术期的个体化抗凝指导方案,并作出经验性总结。方法回顾性分析2010至2013年在南方医院关节骨病外科行全髋关节置换术(THA),同时伴有肾功能衰竭并行规律血液透析治疗的患者共17例。所有患者术前4 d、术前1 d分别予无肝素透析;术前准备完善后,在腰麻下行生物型假体THA;术后所有静脉药物均用100 ml液体配制,控制麻醉泵频率低于15 min/次。术后6 h予首剂低分子肝素(LMWH),同时抬高患肢,予以双下肢气动加压抗栓泵治疗及患者主动踝泵锻炼。术后24 h下地活动,术后第3天开始进行规律的LMWH透析。对围术期临床指标及术后关节功能评分等进行统计学分析。结果入院时17例患者平均肾功能指标:血肌酐(CR)(524.5±119.3)μmol/L,血尿素氮(BUN)(19.8±2.2)mmol/L;血钾(5.3±1.0)mmol/L;凝血指标:凝血酶时间(TT)(16.6±2.1)s,部分凝血活酶时间(APTT)(32.0±1.6)s。经两次无肝素透析,透析过程中无透析器及管路内凝血发生。术后第2天复查:CR(241.1±107.9)μmol/L,BUN(12.2±2.7)mmol/L,血钾(4.8±0.6)mmol/L,TT(15.1±2.0)s,APTT(32.6±1.5)s。入院时患者患侧髋关节Harris评分为(39.2±4.7)分,术后随访1年平均Harris评分为(73.6±16.7)分;所有患者均无明显血栓相关不良反应发生,未见假体脱位、假体周围骨折及明显假体松动下沉。结论对于肾衰并行规律透析的THA患者,采用上述抗凝方案,能够安全度过围手术期;术后随访患髋功能恢复良好,无血栓及血栓相关不良事件发生。

Objective To discuss individualized anticoagulant solutions for hemodialysis（ HD）patients with renal failure during the perioperative period of total hip arthroplasty. Methods Retrospective analysis was conducted on 17 cases of total hip arthroplasty（ THA） combined with regular dialysis because of renal failure from 2010 to 2013 in the department of orthopedic surgery in Southern Hospital. All the patients were performed with heparin-free HD on four days and one day before the operation; after the completion of the preoperative preparation,THA with biological prosthesis was performed under spinal anaesthesia. All the postoperative intravenous drugs were mixed with 100 ml fluid,and the anesthesia pump frequency was controlled less than 15 min / time. The first administration of low molecular weight heparin（ LMWH） was given 6h after the operation; meanwhile the injured limb was lifted with bilateral pneumatic antithrombotic pressure pump therapy and ankle pump exercise of the patients. Walking activities started from 24 h after the operation. Regular LMWH HD started on 3rdday after THA. The perioperative clinical indicators and postoperative joint function scores were statistically analyzed. Results Average renal functional parameters at the admission of the 17 cases were as follows： creatinine（ CR）（ 524. 5 ± 119. 3）μmol /L,blood urea nitrogen（ BUN）（ 19. 8 ± 2. 2） mmol /L; K（ 5. 3 ± 1. 0） mmol /L,blood coagulation indexes： thrombin time（ TT）（ 16. 6 ± 2. 1） s,activated partial thromboplastin time（ APTT）（ 32. 0 ± 1. 6）s. There was no blood coagulation in the dialyzer or in the dialysis tubes. Re-examination results on 2nd day after the operation were as follows： CR（ 241. 1 ± 107. 9） μmol / L,BUN（ 12. 2 ± 2. 7） mmol / L,potassium（ 4. 8 ± 0. 6） mmol / L,TT（ 15. 1 ± 2. 0） s,APTT（ 32. 6 ± 1. 5） s. The average Harris hip score of the injured hips of the patients at the admission was（ 39. 2 ± 4. 7）,average Harris hip score at the one-year follow-up was（ 73. 6 ± 16. 7）. None of the patients presented thrombosis-related adverse reactions,prosthesis dislocation,prosthesis periphery fractures,or obvious prosthesis loosening. Conclusion For the THA patients with HD for renal failure,the application of the anticoagulant solution mentioned above can help with a safe perioperative period,with good recovery of the function of the injured hip during the postoperative follow-up,as well as no incidence of thrombosis or thrombosis-related adverse reactions.