中华急诊医学杂志
中華急診醫學雜誌
중화급진의학잡지
CHINESE JOURNAL OF EMERGENCY MEDICINE
2015年
5期
493-497
,共5页
鲁力%胡平%文玉明%马渝
魯力%鬍平%文玉明%馬渝
로력%호평%문옥명%마투
多发伤%血小板增多%血栓栓塞%抗凝治疗%预后
多髮傷%血小闆增多%血栓栓塞%抗凝治療%預後
다발상%혈소판증다%혈전전새%항응치료%예후
Multiple trauma%Thrombocytosis%Thromboembolism%Anticoagulation%Prognosis
目的 总结分析严重多发伤并发继发性血小板增多症的发病特征及对预后的影响,探讨适宜的干预措施.方法 回顾性分析重庆市急救医疗中心创伤数据库中2010年3月至2013年3月共680例存活超过72 h的严重多发伤患者临床资料.总结严重多发伤并发继发性血小板增多症(血小板计数＞450×109 L-1)的发病率、时间特征及相关因素,分析其对严重多发伤患者总住院病死率、总住院时间及血栓栓塞事件(包括静脉血栓栓塞事件和动脉血栓栓塞事件)等预后指标的影响.计量资料间比较采用t检验或秩和检验,百分数或率的比较采用x2检验或Fisher精确检验.结果 本组严重多发伤并发继发性血小板增多症的发病率为14.56％,血小板计数中位数为584×109 L-1(最低478×109 L-1,最高1 072×109 L-1);血小板增多均发生在病程1周以后,中位时间点为第27天(最早8d,最晚304 d),持续时间(18.62±4.38)d.继发性血小板增多组的脾切除比例、使用血管活性药物超过48 h、使用刺激骨髓造血药物及7d后预防性抗凝治疗比例显著高于血小板正常组(14.14％ vs.7.06％,P=0.03;62.63％ vs.39.07％,P＜0.01; 28.28％vs.6.71％,P＜0.01;90.91％ vs.19.45％,P＜0.01).血小板增多组患者血小板增多期间最高血浆D-二聚体(mg/L)显著高于血小板正常组患者1周后的最高水平[(11.68±11.90) vs.(5.05±5.11),P=0.004].两组的总住院病死率(8.08％ vs.8.78％,P=0.82)、总住院时间[34 d(28.5,54.5)d vs.45 d(23,67)d,P=0.41]、总血栓栓塞事件(10.10％ vs.10.50％,P=0.91)及静脉血栓栓塞事件(7.07％ vs.7.92％,P=0.77)差异无统计学意义;血小板增多患者动脉血栓栓塞事件有增多趋势(4.04％ vs.3.10％,P=0.62),但差异无统计学意义.结论 严重多发伤并发继发性血小板增多症的发生率较高.创伤后脾切除、较长时间使用血管活性药物及使用刺激骨髓造血药物等因素可能诱发继发性血小板增多.在没有充分抗凝治疗情况下,继发性血小板增多可能增加严重多发伤患者的血栓栓塞事件;对于存在动脉血栓风险患者可考虑联合抗血小板治疗.
目的 總結分析嚴重多髮傷併髮繼髮性血小闆增多癥的髮病特徵及對預後的影響,探討適宜的榦預措施.方法 迴顧性分析重慶市急救醫療中心創傷數據庫中2010年3月至2013年3月共680例存活超過72 h的嚴重多髮傷患者臨床資料.總結嚴重多髮傷併髮繼髮性血小闆增多癥(血小闆計數＞450×109 L-1)的髮病率、時間特徵及相關因素,分析其對嚴重多髮傷患者總住院病死率、總住院時間及血栓栓塞事件(包括靜脈血栓栓塞事件和動脈血栓栓塞事件)等預後指標的影響.計量資料間比較採用t檢驗或秩和檢驗,百分數或率的比較採用x2檢驗或Fisher精確檢驗.結果 本組嚴重多髮傷併髮繼髮性血小闆增多癥的髮病率為14.56％,血小闆計數中位數為584×109 L-1(最低478×109 L-1,最高1 072×109 L-1);血小闆增多均髮生在病程1週以後,中位時間點為第27天(最早8d,最晚304 d),持續時間(18.62±4.38)d.繼髮性血小闆增多組的脾切除比例、使用血管活性藥物超過48 h、使用刺激骨髓造血藥物及7d後預防性抗凝治療比例顯著高于血小闆正常組(14.14％ vs.7.06％,P=0.03;62.63％ vs.39.07％,P＜0.01; 28.28％vs.6.71％,P＜0.01;90.91％ vs.19.45％,P＜0.01).血小闆增多組患者血小闆增多期間最高血漿D-二聚體(mg/L)顯著高于血小闆正常組患者1週後的最高水平[(11.68±11.90) vs.(5.05±5.11),P=0.004].兩組的總住院病死率(8.08％ vs.8.78％,P=0.82)、總住院時間[34 d(28.5,54.5)d vs.45 d(23,67)d,P=0.41]、總血栓栓塞事件(10.10％ vs.10.50％,P=0.91)及靜脈血栓栓塞事件(7.07％ vs.7.92％,P=0.77)差異無統計學意義;血小闆增多患者動脈血栓栓塞事件有增多趨勢(4.04％ vs.3.10％,P=0.62),但差異無統計學意義.結論 嚴重多髮傷併髮繼髮性血小闆增多癥的髮生率較高.創傷後脾切除、較長時間使用血管活性藥物及使用刺激骨髓造血藥物等因素可能誘髮繼髮性血小闆增多.在沒有充分抗凝治療情況下,繼髮性血小闆增多可能增加嚴重多髮傷患者的血栓栓塞事件;對于存在動脈血栓風險患者可攷慮聯閤抗血小闆治療.
목적 총결분석엄중다발상병발계발성혈소판증다증적발병특정급대예후적영향,탐토괄의적간예조시.방법 회고성분석중경시급구의료중심창상수거고중2010년3월지2013년3월공680례존활초과72 h적엄중다발상환자림상자료.총결엄중다발상병발계발성혈소판증다증(혈소판계수＞450×109 L-1)적발병솔、시간특정급상관인소,분석기대엄중다발상환자총주원병사솔、총주원시간급혈전전새사건(포괄정맥혈전전새사건화동맥혈전전새사건)등예후지표적영향.계량자료간비교채용t검험혹질화검험,백분수혹솔적비교채용x2검험혹Fisher정학검험.결과 본조엄중다발상병발계발성혈소판증다증적발병솔위14.56％,혈소판계수중위수위584×109 L-1(최저478×109 L-1,최고1 072×109 L-1);혈소판증다균발생재병정1주이후,중위시간점위제27천(최조8d,최만304 d),지속시간(18.62±4.38)d.계발성혈소판증다조적비절제비례、사용혈관활성약물초과48 h、사용자격골수조혈약물급7d후예방성항응치료비례현저고우혈소판정상조(14.14％ vs.7.06％,P=0.03;62.63％ vs.39.07％,P＜0.01; 28.28％vs.6.71％,P＜0.01;90.91％ vs.19.45％,P＜0.01).혈소판증다조환자혈소판증다기간최고혈장D-이취체(mg/L)현저고우혈소판정상조환자1주후적최고수평[(11.68±11.90) vs.(5.05±5.11),P=0.004].량조적총주원병사솔(8.08％ vs.8.78％,P=0.82)、총주원시간[34 d(28.5,54.5)d vs.45 d(23,67)d,P=0.41]、총혈전전새사건(10.10％ vs.10.50％,P=0.91)급정맥혈전전새사건(7.07％ vs.7.92％,P=0.77)차이무통계학의의;혈소판증다환자동맥혈전전새사건유증다추세(4.04％ vs.3.10％,P=0.62),단차이무통계학의의.결론 엄중다발상병발계발성혈소판증다증적발생솔교고.창상후비절제、교장시간사용혈관활성약물급사용자격골수조혈약물등인소가능유발계발성혈소판증다.재몰유충분항응치료정황하,계발성혈소판증다가능증가엄중다발상환자적혈전전새사건;대우존재동맥혈전풍험환자가고필연합항혈소판치료.
Objective To estimate the clinic features of severe multiple trauma with secondary thrombocytosis as a factor influencing the prognosis.Methods A retrospective single-center study was carried out in 680 patients with severe multiple trauma survived longer than 72 hours in Chongqing Emergency Medical Center from March 2010 through March 2013.The variables including age,gender,ISS (injury severity score),APACHE Ⅱ score,splenectomy and the usages of vasopressors,blood products transfusion,hematopoietic medicines and anticoagulant were analyzed.The prognosis indices including total in-hospital mortality after 72 hours,length of hospital stay and morbidity of thrombo-embolism were explored.The clinic characteristics and prognosis of severe multiple trauma with secondary thrombocytosis (platelet count more than 450 × 109 L-1) were evaluated.T test or rank sum test was used for comparison between measurement data and Chi-square test or Fisher' s exact test was used for comparison between enumeration data.Results Thrombocytosis was identified in 99 (14.56％) patients and it occurred one week after injury with median time of 27 days (ranged from 8 days to 304 days),and maintained for (18.62±4.38) d.The median of platelet count was 584 × 109 L-1 (lowest 478 × 109 L-1,highest 1 072 × 109 L-1) in severe multiple trauma patients with thrombocytosis.The proportions of splenectomy,prolonged use of vasopressors and employment of hematopoietic medicines or anticoagulant were significantly higher in patients with thrombocytosis than those in patients without thrombocytosis (14.14％ vs.7.06％,P=0.03;62.63％ vs.39.07％,P＜0.01; 28.28％ vs.6.71％,P＜0.01; 90.91％ vs.19.45％,P＜ 0.01).The highest D-Dimer level presenting in patients with thrombocytosis during the time of platelet increasing was significantly more common than that in patients of non-thrombocytosis group 7 days after trauma [(11.68 ± 11.90) vs.(5.05 ± 5.11),P =0.004].However,the mortality,length of hospital stay and morbidity of thrombo-embolism were not significantly increased in patients with thrombocytosis compared with patients without thrombocytosis [8.08％ vs.8.78％,P=0.82; 34 d (28.5,54.5) d vs.45 d (23,67) d,P =0.41; 10.10％ vs.10.50％,P =0.91].Conclusion There was a higher rate of secondary thrombocytosis in severe multiple trauma patients.The factors such as splenectomy,vasopressors,hematopoietic medicines and so on might induce the reactive thrombocytosis in trauma patients.Thrombocytosis might increase the incidence of thromboembolism in severe multiple trauma patients without appropriate prophylactic anticoagulation.For the sake of prophylaxis,employment of anti-platelet agent might be the appropriately therapeutic strategy for patients suffering from severe multiple trauma with secondary thrombocytosis accompanying risk factors of arterial thrombo-embolism.
