胸外科患者术后大面积肺动脉栓塞的防治

Prevention and treatment of massive pulmonary embolism patients after thoracic surgery

目的:总结预防和治疗胸外科患者术后肺动脉栓塞的经验。方法:收集2019年1月至2020年7月华中科技大学同济医学院附属同济医院胸外科术后确诊为大面积肺动脉栓塞患者共19例。分析肺动脉栓塞的发生与传统的高危因素、术前术后是否使用低分子肝素类药物及其他因素是否相关;总结发生肺动脉栓塞患者给予溶栓治疗的经验及细节。结果:19例大面积肺动脉栓塞患者,17例患者术前存在肺动脉栓塞的高危因素(高龄、吸烟、既往有静脉曲张、糖尿病、房颤等);另外,肿瘤直径>5 cm、病理类型为鳞状细胞癌、瘤体存在坏死的患者发生肺动脉栓塞风险更高。19例确诊为大面积肺动脉栓塞患者中,死亡6例,治愈13例,死亡率31.6%。在17例术前存在肺动脉栓塞的高危因素患者中,10例患者未预防性使用低分子肝素类药物,7例患者术前及术后24 h使用低分子肝素类药物,说明术前及术后预防性使用低分子肝素类药物能够有效降低肺动脉栓塞的发生。19例肺动脉栓塞患者,6例患者使用溶栓治疗,均顺利出院;13例患者未使用溶栓治疗,6人死亡,死亡率46.2%。采用溶栓治疗患者,溶栓过程出血量为(2793.3±267.4)mL。结论:对于术前存在肺动脉栓塞高危因素的患者,预防性使用低分子肝素类药物能够有效降低肺动脉栓塞发生率;及时有效的使用溶栓治疗能够降低患者死亡率,但出血风险高,需严格掌握其用量及速度。

Objective:To summarize the experience of how to prevent and treat massive pulmonary embo⁃lism patients who were treated with thoracic surgery.Methods:Nineteen patients'information of mas⁃sive pulmonary embolism in the Department of Thoracic Surgery,Tongji Hospital,Tongji Medical College of Huazhong University of Science and Technology were collected during the period from Jan⁃uary 2019 to July 2020.We analyzed the relationship between pulmonary embolism and whether to use low molecular weight heparin⁃like drugs preoperatively and postoperatively,furthermore,we sum⁃marized the experience and details of how to treat pulmonary embolism and the key points of the treat⁃ment process.Results:Among the 19 patients,17 patients had the high⁃risk factors of pulmonary em⁃bolism before the operation(age,smoking,previous varicose veins,diabetes,atrial fibrillation,etc.);in addition,the patients with tumor diameter>5 cm,squamous cell cancer in pathological type,and necrosis in tumors,were also in high risk of pulmonary embolism.Among the 19 patients,6 patients were died and 13 patients cured,with a mortality of 31.6%.Among the patients with a high risk of pulmonary embolism pre⁃operation,7 patients received prophylactic use of low molecular weight heparin⁃like drugs(LMWH)perioperatively and 10 patients did not,indicating that prophylactic use of LMWH could reduce the incidence of pulmonary embolism.Among the 19 patients,6 patients re⁃ceived thrombolytic therapy and were successfully discharged;13 patients did not receive thrombolytic therapy and 6 patients died eventually,with a mortality of 46.2%.The average blood loss of the pa⁃tients who used thrombolytic therapy was(2793.3±267.4)mL during the thrombolytic treatment.Conclusion:For patients who have high⁃risk factors of pulmonary embolism before the operation,pro⁃phylactic use of LMWH can effectively reduce its incidence;timely and effective thrombolytic therapy for patients with pulmonary embolism can reduce mortality,but strict control of the amount and speed of thrombolytic drugs is essential to prevent the complication of bleeding.