危重症儿童体外膜肺氧合期间并发肝素诱导的血小板减少症临床分析

Clinical analysis of critically ill children with heparin-induced thrombocytopenia during extracorporeal membrane oxygenation

目的调查危重症儿童体外膜肺氧合(ECMO)支持治疗期间肝素诱导的血小板减少症(HIT)的发生率,并探讨ECMO期间并发HIT的临床特征及预后情况。方法纳入2019年3月1日至2020年12月31日收治于复旦大学附属儿科医院重症监护室施行ECMO支持治疗并且运行时间超过96 h的危重症患儿22例;将4T评分≥6同时肝素/血小板第4因子抗体阳性的患儿定义为HIT组(n=6),其余患儿定义为非HIT组(n=16),进行分组比较临床结局及血栓事件发生情况。结果危重症患儿ECMO支持治疗期间HIT的发生率为27%。HIT组ECMO管路血栓发生率较非HIT组高(100%比63%,P=0.133),且HIT组发生首次ECMO管路血栓时间早于非HIT组(3.70 d比5.44 d,P=0.06),但差异均无统计学意义。在ECMO支持治疗的最初14 d内,血栓事件发生例次≥2次的患儿比例在HIT组中较高(67%比19%,P=0.054)。ECMO撤机后28 d存活率在两组间差异无统计学意义(33%比50%,P=0.664)。结论危重症患儿ECMO支持期间HIT的发生率偏高。ECMO期间并发HIT的患儿可能具有更早期、更广泛的血栓形成倾向。未发现HIT对ECMO支持患儿生存率有显著影响;仍需进行更大样本量的前瞻性临床研究探讨。

Objective To prospectively investigate the prevalence of heparin-induced thrombocytopenia(HIT)in critically ill children during extracorporeal membrane oxygenation(ECMO)and explore the clinical characteristics and prognosis of HIT during ECMO.Methods A total of 22 critically ill children,who had received ECMO support for more than 96 hours in the Intensive Care Unit at the Children′s Hospital of Fudan University from March 2019 to December 2020,were enrolled.According to the 4T score and the heparin/platelet factor 4(PF4)antibody,children whose 4T scores were not less than 6 and heparin/PF4 antibodies were positive,were classified into HIT group(n=6),and non-HIT group(n=16).The clinical outcomes and the incidence of thrombotic events were compared between two groups.Results The incidence of HIT during ECMO in critically ill children was 27%in this study.The incidence of thrombosis in the ECMO circuit in the HIT group was higher(100%vs.63%,P=0.133),and the average time to the first thrombosis in ECMO circuit in the HIT group was shorter than that in the non-HIT group(3.70 d vs.5.44 d,P=0.06).During the first 14 days of ECMO,the proportion of children with thrombotic events no less than twice was higher in the HIT group(67%vs.19%,P=0.054).There was no significant difference regarding the survival rate at 28 days after ECMO withdrawal between two groups(33%vs.50%,P=0.664).Conclusion The prevalence of HIT during ECMO in critically ill children is high.Thrombosis events tend to occur earlier and more extensively in children with HIT during ECMO.No significant effect of HIT on the survival rate of children during ECMO is found.Whether HIT has effect on the survival rate of children with ECMO requires a prospective and large clinical study.