危重型新型冠状病毒肺炎患者合并肝素抵抗2例

Critical coronavirus disease 2019 complicated with heparin resistance in 2 patients

目的探讨危重型新型冠状病毒肺炎(新冠肺炎)合并肝素抵抗(HR)患者的诊断过程和治疗经验。方法2021年11月连云港市第一人民医院医疗队支援连云港市新冠定点收治医院期间在重症监护病房(ICU)收治了2例危重型新冠肺炎合并HR患者,分析患者的临床表现、实验室检查、影像学特征、治疗经过及预后情况。结果2例危重型新冠肺炎患者均行机械通气支持治疗,其中1例行体外膜肺氧合(ECMO)支持治疗;常规剂量抗凝治疗下均并发下肢深静脉血栓,并出现HR现象。普通肝素每日使用最大剂量超过35000 U(最高达43200 U),抗凝治疗仍未达标,患者病程延长;之后给予阿加曲班0.4μg·kg^(-1)·min^(-1)联合抗凝治疗后达标,其中接受ECMO患者的活化部分凝血活酶时间(APTT)能维持在55~60 s,活化凝血时间(ACT)维持在180~200 s。经ECMO支持或后期序贯性机械通气治疗后,2例患者均康复出院,且深静脉血栓均得到有效控制。结论危重型新冠肺炎患者诊治过程中出现HR现象,应及时调整抗凝方案,联合阿加曲班治疗的抗凝效果明确。

Objective To explore the diagnosis process and treatment experience of severe coronavirus disease 2019(COVID-19)patients with heparin resistance(HR).Methods The medical team of the First People's Hospital of Lianyungang admitted 2 severe COVID-19 patients with HR in intensive care unit(ICU)during their support to the designated hospital for the treatment of COVID-19 patients in Lianyungang City in November 2021.The clinical features,laboratory examinations,imaging features,treatment and prognosis of the two patients were analyzed.Results Both severe COVID-19 patients received mechanical ventilation,1 patient was treated with extracorporeal membrane oxygenation(ECMO)support.Both patients were complicated with lower extremity deep venous thrombosis and HR phenomenon under routine dose anticoagulant therapy.The maximum daily dose of unfractionated heparin exceeded 35000 U(up to 43200 U),the 2 patients failed to meet the standard of anticoagulation treatment,and the course of disease was prolonged.After that,argatroban was given 0.4μg·kg^(-1)·min^(-1)combined with anticoagulant therapy,the activated partial thromboplastin time(APTT)of patients undergoing ECMO could be maintained at 55-60 seconds and the activated coagulation time(ACT)of them could be maintained at 180-200 seconds.After ECMO support or later sequential mechanical ventilation,both patients recovered and were discharged,and deep venous thrombosis was also effectively controlled.Conclusion HR phenomenon often occurs during the treatment of severe COVID-19 patients,the anticoagulation regimen should be adjusted in time,and the anticoagulation effect combined with argatroban is clear.