病态肥胖肺栓塞患者肝素抗凝剂量的探讨（病例报告及文献复习）

How much heparin should be used in morbidly obese patients with pulmonary embolism：a case report and literature review

目的：探讨病态肥胖肺栓塞患者抗凝治疗时普通肝素的治疗剂量。方法报告1例病态肥胖（体质量〉100 kg,体质量指数〉40 kg/m2）的肺栓塞患者,并进行文献复习,结合本患者和文献资料分析肝素抗凝治疗过程中肝素初始剂量、维持剂量与体质量的关系。结果患者男,21岁,身高178 cm,体质量140 kg,因“晕厥3 h”入院,肺动脉 CT 血管造影确诊为急性肺栓塞。立即按校正体质量106 kg [（实际体重＋理想体重）/2]给予负荷剂量普通肝素80 U/kg,续以18 U·kg-1·h-1持续泵入,4 h 后查活化部分凝血活酶时间（APTT）为145 s；暂停肝素泵入1 h,复查 APTT 为96 s；继续暂停肝素泵入1 h,APTT 为56 s；开始以1500 U/h 泵入肝素,根据 APTT 值调整肝素泵入速度,最终肝素维持用量为9.4-14.6 U·kg-1·h-1（按校正体质量计算）,APTT 维持在45-96 s。复习文献：病态肥胖患者肝素按 Raschke 量表负荷和维持治疗,会出现 APTT 超标和达标时间延长。按照校正体质量′[理想体质量＋0.3×（实际体质量-理想体质量）]计算,80 U/kg 为负荷剂量,13 U·kg-1·h-1为维持剂量,可能能减少病态肥胖患者肝素治疗时 APTT 的超标几率,增加安全性。结论肝素抗凝时 Raschke 量表不适合病态肥胖肺栓塞患者,应适当降低肝素的负荷剂量和维持剂量。

Objective To analyze the therapeutic heparin doses in treatment of pulmonary embolism （PE） in morbidly obese patients.Methods We reported a morbidly obese patient who was diagnosed as acute PE and reviewed the literatures to analyze the relation between heparin doses and weight.Results A case of 21-year-old,male,weight 140 kg,height 1 75 cm,was admitted to the hospital after an episode of syncope.The patient was diagnosed as acute PE by pulmonary arterial CT angiography soon after admission.Heparin was initiated with a bolus at 80 U/kg,and then infused with micro-pump at 18 U·kg-1·h-1 ,based on adjusted weight 106 kg[（actual body weight＋ideal body weight）/2].After four hours,activated partial thromboplastin time （APTT） was 145 s.Heparin was stopped right then.APTT was 96 s at the sixth hour and 56 s at the seventh hour.Then heparin was restarted to infuse with micro-pump at a slower speed of 1 500 U/h.The medicated speed was adjusted according to APTT.APTT was 45-96 s and the actual heparin maintenance dose was 9.4-14.6 U·kg-1·h-1 .Literature review：Heparin dosing according to the Raschke nomogram in morbidly obese patients can make APTT obviously prolonged.Heparin dosing according to adjusted weight′[ideal weight ＋ 0.3 ×（actual weight - ideal weight）],with a bolus at 80 U/kg and maintenance dose at 13 U·kg-1·h-1 ,could reduce the possibility of excess APTT in heparin treatment of morbidly obese patients and increase therapeutic security. Conclusions The weight-based heparin dosing nomogram （Raschke nomogram） might not suit morbidly obese patients,and the initial bolus and maintenance dose should be reduced.