低分子肝素治疗经皮肾镜碎石术后肺栓塞并发大量血胸1例

Massive hemothorax following anticoagulation with low-molecular-weight heparin for pulmonary embolism after percutaneous nephro-ureterolithotomy:A case report

低分子量肝素广泛用于肺栓塞及血栓性疾病的治疗,发生严重出血和肝素诱导血小板减少症的风险低[1-3],引起严重出血的主要部位为咯血、消化道、腹壁、腹膜后出血、中枢神经系统、伤口出血、阴道及血管造影相关性腹股沟血肿[4]。既往肺栓塞使用肝素和华法林抗凝治疗有并发大量血胸的报道[5],但单纯使用低分子肝素而引发血胸是极其罕见的,临床资料相对缺乏。

A 59-year-old woman with a background history of percutaneous nephro-ureterolithotomy(left)for urolithiasis 1week ago felt dyspnea and left chest pain.Pulmonary embolism with a small amount of left pleural effusion was confirmed by CTPA.Following 3days of anticoagulant therapy(Dalteparin),the patient developed progressive chest pain followed by a massive left hemothorax detected by CT and thoracoscopy.It has been documented that pleural effusion resulted from pulmonary embolism is always in small amount,sometimes hemorrhagic.The presence of hemothorax is not a contraindication for the administration of anticoagulant therapy.The treatment of pulmonary embolism with low molecular weight heparin is quite safe.Massive hemothorax is a rare phenomenon in conjunction with LMWH.Pulmonary or pleural injury due to percutaneous nephro-ureterolithotomy is uncommon cause of hemothorax.When the thoracic complication is slight or asymptomatic,surgical management is not required.It’s easy to be ignored by physicians.The occult injury of pleura,accompanied with anticoagulant therapy of pulmonary embolism can cause unpredictable,serious bleeding complications.It’s difficult to be identified and treated timely.Anticoagulant therapy of pulmonary embolism rarely causes massive hemothorax.Risk assessment of bleeding in anticoagulant therapy should be carried out carefully and comprehensively.Hence,the bleeding complications will be more predictable.If the chest pain is aggravated during the treatment,spontaneous hemothorax should be considered and the underlying causes of hemothorax should be detected.