抗凝治疗对低风险组下肢骨折患者深静脉血栓形成的影响

Effect of anticoagulant therapy on deep vein thrombosis in patients with lower limb fractures of low risk group

目的研究静脉血栓形成危险度评分量表(RAPT)评分≤5分的低风险组下肢骨折患者下肢深静脉血栓形成(DVT)发生率及预防性应用抗凝药物的安全性和必要性。方法回顾性分析自2014-09—2016-10诊治的348例RAPT评分≤5分的低风险组下肢骨折患者的临床资料,根据是否应用抗凝药物分为抗凝组和对照组,抗凝组每日皮下注射低分子肝素钙(4 100 IU qd),术前12 h停药,术后12 h伤口无明显出血,拔除引流管时再次给药,对照组则不应用抗凝药物,2组均给予足底静脉泵物理治疗;术后2、30 d行双下肢静脉彩色多普勒超声检查,根据超声检查结果统计血栓发生率、分布及转归情况。结果术后发生DVT 17例(4.89%),抗凝组7例,对照组10例。术后2组DVT发生率比较差异无统计学意义(χ~2=0.753,P=0.385);2组术后在DVT分布、累及肢体和静脉差异均无统计学意义(χ~2=0.843,P=0.656;χ~2=2.205,P=0.364;χ~2=0.957,P=0.916)。所有患者获得30 d随访,2例仍存在远端肌间静脉血栓,但无临床症状;复查超声显示血栓未向近端蔓延,均未出现致死性肺栓塞(PE)。结论低风险组下肢骨折患者术后DVT发生率较低,给予基本预防和物理预防即可,临床上应结合RAPT评分充分评估患者并发VTE的危险程度,避免盲目进行抗凝治疗。

Objective To evaluate the incidence of DVT and the safety and necessity to use prophylactic anticoagulant drugs in patients with lower limb fractures in the low-risk group with risk assessment and profile for thromboembolism （RAPT） score ≤5. Methods Retrospective analysis was performed on clinical data of 348 patients with lower limb fractures in the low-risk group with RAPT score ~〈5 from Sept. 2014 to Oct. 2016. Patients were assigned, depending on whether anticoagulant drugs were used, to the anticoagulation group and control group. The anticoagulation group received subcutaneous injection of LMWH calcium （4 100 IU qd）, which was discontinued 12 h preoperatively and resumed 12 h postoperatively at the time of drainage tube removal when there was no significant bleeding in the wound. The control group did not receive anticoagulant therapy. Both groups received physiotherapy with venous foot pump. Venous uhrasonography of both lower limbs was performed at 2 d and 30 d postoperatively, and the incidence, distribution and outcome of thrombosis were summarized based on the ultrasonographie results. Results Seven patients in the anticoagulation group and 10 patients in the control group developed DVT postoperatively, without statistically significant difference between the two groups in the incidence of DVT（x^2= 0.753, P =0.385）; there were no statistically significant differences between the two groups in DVT distribution or involved limbs/veins （x^2=0.843, P =0.656; x^2=2.205, P =0.364; x^2=0.957, P =0.916）. All the patients completed 30d follow-up, where 2 patients were noted to have persistent distal intermuscular thrombus that was asymptomatic and was shown to have not spread to the proximal end upon repeated uhrasonography; neither patient developed fatal PE. Conclusion The incidence of postoperative DVT is low in patients with lower limb fracture in low-risk group, for whom essential and physical prophylaxis is sufficient. In clinical practice, it is desirable to adequately assess the patient＇s risk level of concurrent VTE incorporating the RAPT score, so as to avoid indiscriminate use of anticoagulant therapy.