心脏手术患者肝素诱导血小板减少症

Heparin-induced thrombocytopenia in patients undergoing cardiac surgery

目的本研究旨在总结心脏手术患者发生肝素诱导血小板减少症(HIT)的临床特点。方法检索报道心脏手术患者围术期发生HIT的中、英文献,以英文检索词"heparin"、"thrombocytopnia"、"cardiac surgery"、"cardiopulmonary bypass"检索PUBMED,以中文检索词"肝素"、"血小板减少"、"体外循环"及"心脏手术"检索万方、中国知网和维普数据库。统计分析文献信息、患者基本情况、肝素使用情况、临床表现、实验室检查、处理及预后。结果最终纳入26篇文献(33例患者),其中中文文献13篇(15例患者),英文文献13篇(18例患者)。其中,15例患者既往无肝素暴露史,其余18例患者有肝素暴露史。有25篇文献(31例患者)记录了HIT相关临床:20例血栓形成(6例发生在静脉血管,14例发生在动脉血管),4例有出血症状(2例表现为皮肤瘀斑),1例肠梗阻,有5例出现梗塞症状(2例脑梗塞、3例肺梗塞)。31例患者中有16例患者进行了F4-H抗体检测,均显示升高,有2例患者进行了D-二聚体含量测定,均显示升高。一经怀疑HIT诊断后,单纯停用肝素(6例),停用肝素同时阿加曲班代替(7例)、磺达肝癸钠代替(3例)、阿加曲班与磺达肝癸钠联合用药(2例)、利伐沙班代替(1例)、重组水蛭素代替(2例)、华法林替代(4例)、血液透析治疗(4例)。有4例患者同时应用了糖皮质激素,1例患者使用了免疫球蛋白,1例患者使用了重组白介素-11等免疫调节剂。结论 HIT是在肝素应用后排除其它原因的血小板急剧减少。使用肝素抗凝时,应监测血小板计数情况,必要时测定PF4-H抗体含量。

Objective This study aims to summarize the clinical features of heparin-induced thrombocytopenia（ HIT） in patients undergoing cardiac surgery. Methods The Chinese and English literatures reporting perioperative occurrence of HIT in patients undergoing cardiac surgery were searched. The English and Chinese keywords of ＂ heparin＂, ＂ thrombocytopnia＂, ＂ cardiac surgery＂, ＂cardiopulmonary bypass＂ were used to search in PUBMED,WANFANG,CNKI and VIP databases. Patient characteristics,heparin use,clinical manifestations,laboratory tests,management and prognosis were collected,recorded and analyzed. Results 26 articles（ 33 patients） were included in our study,with 13 articles（ 15 cases） in Chinese and 13 articles（ 18 cases） in English. Among them,15 cases had no history of heparin exposure while the other 18 cases did. Clinical manifestations of HIT were reported in 25 articles（ 31 patients）. Among them,20 cases had thrombosis（ six cases occurred in veins,14 in arteries）,Four case had bleeding symptoms（ two cases had skin ecchymosis）,one case had intestinal obstruction,and five cases had infarct symptom（ two cases of cerebral infarction and three cases of pulmonary infarction）. F4-H antibody was detected in 16 out of the 31 patients,and all of them showed elevated F4-H antibody. D-dimer content was measured in two patients and both of them showed elevated levels. Once the diagnosis of HIT was suspected,heparin discontinuation as sole treatment was reported in 6 patients. Heparin was replaced by argatroban in seven patients,fondaparinux in three patients,argatroban combined with fondaparinux in two patients,rivaroxaban in one patient,recombinant hirudin in two patients,and warfarin in four patients,respectively. Four patients were treated with hemodialysis. Four patients were treated with glucocorticoid and one patient was treated with immunoglobulins. One patient was treated with recombinant Interleukin-11. Conclusion HIT,characterized by acute thrombocytopenia after heparin administration,is a differential diagnosis after excluding other causes.Once suspected,platelet count should be monitored continuously,and sometimes PF4-H antibody should be measured.