合并轻度出血性疾病的扁桃体和(或)腺样体切除术患儿围手术期管理

Perioperative management of children with mild bleeding disorders undergoing adenotonsillectomy procedures

目的探讨合并轻度出血性疾病并接受扁桃体和(或)腺样体手术的患者围手术期处理方案,提高围手术期安全。方法回顾分析6例合并诊断为轻度出血性疾病并行扁桃体和(或)腺样体手术患者资料。收集患者的基本信息、出血风险评估、手术方案、围术期控制出血策略等,结合文献复习分析此类患者的诊疗要点。结果6例患者凝血情况:血友病A FVIII:C 4.8%,APTT 57.7s;血友病B:FIX:C 4.2%,APTT 59.3s;血友病B FIX:C 5.9%,APTT 57.2s;FIX:C 64.3%,APTT 52.3s;FVII:C 73.3%;FX:C 66.2%;FIX:C 58.4%;APTT 44s;APTT 35s;PLT 102×10^(9)/L。3例血友病患者给予凝血因子替代治疗+抗纤溶治疗,2例凝血功能障碍患者给予新鲜冰冻血浆治疗,免疫性血小板减少患者治疗无特殊。在血液科、麻醉科、供血科配合下6例患者顺利完成腺样体扁桃体手术,手术的平均手术时间&平均出血量(血友病63.3 min&16.7 mL,凝血功能障碍47.5 min&10 mL,血小板减少15 min&5 mL)。术后2例血友病(33.3%)患者在术后第4~7 d有轻度扁桃体窝渗血,输注新鲜冰冻血浆后未再发现渗血,余患者均无术后出血。血友病患者平均住院时间13.3 d,其他患者住院时间6 d,均痊愈出院,出院后1个月随访无出血。结论对于合并轻度出血性疾病患者行腺扁桃体切除手术,围手术期管理需要多学科协作,做好控制出血策略,手术安全可行并能达到预期手术效果。同时血友病患者围手术期抗纤溶治疗应至少7~14 d。对于凝血功能障碍患者可延长住院时间至1周,血友病患者延长至2周至伤口愈合。

Objective To explore the perioperative management of children with mild bleeding disorders who underwent tonsil and/or adenoid surgery,and to improve the perioperative safety of such cases in the future.Methods We conducted a retrospective analysis of six children with bleeding disorders who underwent tonsil and/or adenoid surgery in our hospital.We collected information on their diagnosis and treatment plans,bleeding risk assessments,surgical plans,and perioperative bleeding control strategies.We also analyzed the key points of diagnosis and treatment of such cases through a literature review.Results The results for the hemagglutination test of the six children were as follows:hemophilia A FVIII:C 4.8%;APTT 57.7 s,hemophilia B FIX:C 4.2%;APTT 59.3 s,hemophilia B FIX:C 5.9%;APTT 57.2 s,FIX:C 64.3%;APTT 52.3 s,FVII:C 73.3%;FX:C 66.2%;FIX:C 58.4%;APTT 44 s,APTT 35s;PLT 102×10^(9)/L.The children with hemophilia were treated with factor replacement and antifibrinolytic therapy,while the two children with coagulopathies were treated with fresh frozen plasma.There was no specific treatment for the child with immune-mediated thrombocytopenia.All six children completed tonsil and/or adenoid surgery successfully with the close cooperation of the hematology,anesthesiology,and blood supply departments.The mean operation time and average bleeding volume were 63.3 min and 16.7 mL for the hemophilia cases,47.5 min and 10 mL for the coagulopathy cases,and 15 min and 5 mL for the child with platelet reduction.During the perioperative period the coagulation function,coagulation factor activity,inhibitor concentration,and platelet function were monitored.Different replacement treatments and anti-fibrinolytic therapies were given for different reasons.Two patients with hemophilia(33.3%)had mild tonsil hemorrhage during the first 4-7 days of their postoperative hospitalization stay.And no bleeding occurred after the transfusion of fresh frozen plasma.However,the remaining children did not show bleeding.The average length of hospitalization for children with hemophilia was 13.3 days,while the other children were hospitalized for 6 days.The patients all healed well and were discharged,and no bleeding was noted during the 1-month follow-up period.Conclusion Children with mild bleeding disorders who need to undergo tonsil and/or adenoid surgery require multi-disciplinary cooperation,and good bleeding control strategies during the perioperative period.The operation is safe and feasible for these cases.However,perioperative antifibrinolytic therapy should be continued for at least 7-14 days.The hospital stay should also be extended to 1 week for children with mild coagulation dysfunction and up to 2 weeks for cases of hemophilia to ensure the wounds are fully healed.