老年髋部骨折患者术前DVT风险评估与处理

Preoperative evaluation and management of risk of deep vein thrombosis in elderly patients with hip fractures

目的探讨老年髋部骨折患者术前下肢深静脉血栓(DVT)形成的危险因素,评估术前小腿肌肉静脉血栓是否需要抗凝治疗。方法回顾性分析自2016-09—2018-09行手术治疗的313例老年髋部骨折,采用单因素分析术前DVT形成的影响因素,再采用多因素Logistic回归分析术前DVT形成的危险因素和保护因素。结果58例术前(18.5%)出现DVT,40例小腿肌肉静脉血栓中25例术前进行抗凝治疗(抗凝组),15例术前未进行抗凝治疗(未抗凝组)。抗凝组与未抗凝组输血率与复发率差异无统计学意义(P>0.05);抗凝组术后血红蛋白减少量大于未抗凝组,差异有统计学意义(P<0.05)。多因素Logistic回归分析结果显示,年龄>65岁、股骨粗隆间骨折、卧床时间>7 d、D-二聚体升高、纤维蛋白原升高、合并高脂血症是老年髋部骨折患者术前DVT形成的独立危险因素,术前使用抗血小板药物是老年髋部骨折患者术前DVT形成的保护因素。结论临床上对于年龄>65岁、股骨粗隆间骨折、卧床时间>7 d、D-二聚体升高、纤维蛋白原升高、合并高脂血症的老年髋部骨折患者需要预防术前DVT形成。术前对小腿肌肉血栓进行抗凝治疗不能降低血栓进展的风险,还可能会加重术后贫血,此类老年髋部骨折患者可直接进行手术治疗。

Objective To investigate preoperative evaluation and management of deep vein thrombosis(DVT)in elderly patients with hip fractures,and evaluate the safety and effective of therapeutic anticoagulation for isolated calf muscular venous thrombosis(ICMVT)prior to hip fracture surgery.Methods A retrospective case-control study was conducted,including 313 hip fracture patients who were admitted to our institution between September 2016 and September 2018.Multivariate logistic regression analysis was used to analyze the risk or protective factors in such patient population.Results Fifty eight patients(18.5%)had preoperative deep vein thrombosis.In 40 ICMVT patients,25 patients received anticoagulant therapy(anticoagulation group)and 15 patients without any therapy(no anticoagulation group).There were no significant differences in the rate of thrombosis extension between anticoagulation and no anticoagulation groups(P>0.05),but significantly decreased postoperative hemoglobin was observed in the anticoagulation group(P<0.05).Multivariate logistic analysis showed that age over 65 years old,intertrochanteric fracture,bed rest time for more than 7 days,D-dimer level and fibrinogen level,hyperlipidemia,were risk factors for thrombosis,while recent use of antiplatelet drugs and anticoagulants were protective factors for thrombosis.Conclusion The patients with age over 65 years old,intertrochanteric fractures,bed rest time for more than 7 days,D-dimer level and fibrinogen level and hyperlipidemia,should prevent preoperative deep vein thrombosis,while the recent use of antiplatelet drug not easy to cause preoperative deep venous thrombosis.Our study suggested that a direct surgery without preoperative use of therapeutic anticoagulation for ICMVT would not reduce the risk of thrombus extension,and the therapeutic use of anticoagulation may worsen postoperative anemia.This kind of elderly hip fracture patients can be operated directly.