围术期膝髋关节置换患者静脉血栓栓塞症的临床特点分析

Analysis of clinical feature about perioperative venous thromboembolism in patients with total knee and hip arthroplasty

目的 探讨围术期膝髋关节置换患者静脉血栓栓塞症（VTE）的发生率及临床特点分析.方法 前瞻性观察2015年1月—2016年6月在北京协和医院骨科关节病房行膝髋关节置换术患者982例,围术期经多普勒超声检查诊断VTE,分析VTE危险因素分布情况、围术期VTE发生率、血栓好发部位及诊断时间、不同时间点D-二聚体（D-dimer）变化特征、VTE患者主诉和生命体征变化.结果 982例患者术前诊断DVT 12例,术后诊断症状性DVT 15例和症状性肺栓塞3例.单因素分析显示,卧床、肥胖、下肢静脉曲张、狼疮抗凝物阳性和COPD与VTE发生有关（χ2值分别为5.816、6.900、21.650、4.206、5.682;P〈0.05）.Logistic回归分析显示,下肢静脉曲张是发生VTE的影响因素（P〈0.05）.小腿肌间静脉是DVT好发部位,VTE诊断时间主要集中在术后1周内.术前诊断VTE患者D-dimer高于非VTE患者（Z=-3.654,P〈0.05）.症状性DVT患者主要表现为小腿肿胀和疼痛,症状性肺栓塞患者主要表现为SpO2下降和突然出现短暂性意识丧失.结论 下肢静脉曲张是围术期膝髋关节置换患者发生VTE的影响因素,DVT好发于小腿肌间静脉,术后1周内是VTE高发时期且D-dimer波动变化大.护士应密切关注患者主诉、生命体征变化以及D-dimer变化,对早期识别和防范症状性VTE至关重要.

Objective To explore the incidence and clinical characteristics of perioperative venous thromboembolism （VTE） in patients with total knee or hip arthroplasty. Methods A total of 982 patients who underwent total knee or hip arthroplasty at Orthopedics Department, Peking Union Medical College Hospital, Chinese Academy of Medical Science were prospectively observed from January 2015 to June 2016 and VTE was diagnosed by Doppler ultrasonography peri-operatively. Distribution of VTE risk factor, incidence of perioperative VTE, location and diagnostic time of thrombosis, variation of D-dimer at different time as well as complaint and vital sign of VTE patients were analyzed. Results A number of 12 patients were diagnosed with deep vein thrombosis （DVT） pre-operation, and 15 symptomatic DVT and 3 symptomatic pulmonary embolism （PE） were diagnosed post-operation. Univariate analysis showed that bed rest, obesity, varicose veins of lower limb, positive of lupus anticoagulant and chronic obstructive pulmonary disease（COPD） were associated with VTE（χ2=5.816, 6.900, 21.650, 4.206, 5.682;P〈0.05）. Logistic regression analysis indicated that varicose veins of lower limb was the influence factor of VTE （P〈0.05）. Venous plexus of calf muscle was the predilection site of DVT. Diagnostic time of VTE was more common during one week after operation. D-dimer of VTE patients was higher than non VTE patients pre-operation （Z=-3.654,P〈0.05）. Swelling and pain of calf muscle were the main complaints of symptomatic DVT patients. SpO2decreasing and transient loss of consciousness were the main complaints of symptomatic PE patients. Conclusions Varicose veins of lower limb is the influence factor of VTE in perioperative for patients with total knee and hip arthroplasty. Venous plexus of calf muscle is the predilection site of DVT. VTE occurs mostly within one week post-operation with D-dimer having a large variation. Nurses should closely monitor patients＇ complaints, vital signs, and D-dimer which is crucial to identify and prevent symptomatic VTE in early stage.