中华危重病急救医学
中華危重病急救醫學
중화위중병급구의학
Chinese Critical Care Medicine
2015年
8期
649-652
,共4页
李玉堂%郭春文%刘辉%元智昊%林辉%王雁%闫红
李玉堂%郭春文%劉輝%元智昊%林輝%王雁%閆紅
리옥당%곽춘문%류휘%원지호%림휘%왕안%염홍
低分子肝素钠%肝素钠%热射病,劳力性%中暑,重症%弥散性血管内凝血,非显性
低分子肝素鈉%肝素鈉%熱射病,勞力性%中暑,重癥%瀰散性血管內凝血,非顯性
저분자간소납%간소납%열사병,로력성%중서,중증%미산성혈관내응혈,비현성
Low molecular weight heparin sodium%Heparin sodium%Exertional heat stroke%Severe heat stroke%Pre-disseminated intravascular coagulation
目的：观察低分子肝素钠（LMWHS）治疗劳力性热射病（EHS）非显性弥散性血管内凝血（DIC）患者的疗效。方法采用前瞻性随机对照临床试验（RCT），选择2012年4月至2014年11月解放军第一八〇医院重症医学科住院治疗的EHS非显性DIC患者36例，按随机数字表法分为肝素钠组（20例）和LMWHS组（16例）。所有患者入院后均接受集束化治疗，包括迅速降温、积极的液体复苏、维护器官功能（呼吸机辅助呼吸、酌情血液净化）、补充凝血底物抗凝等。肝素钠组加用肝素钠注射液12500 U，24 h持续静脉泵入，共5 d；LMWHS组加用希弗全2500 U，皮下注射，每日2次，共5 d。比较两组患者DIC发生率、出血发生率及病死率；观察治疗前后两组患者血小板计数（PLT）、凝血酶原时间（PT）、活化部分凝血活酶时间（APTT）、纤维蛋白原（Fib）和D-二聚体的变化情况。结果 LMWHS组与肝素钠组DIC发生率、病死率比较差异无统计学意义（31.2%比30.0%，χ2＝0.007，P＝0.936；6.2%比5.0%，χ2＝0.026，P＝0.871）；LMWHS组治疗后出血发生率明显低于肝素钠组（12.5%比45.0%，χ2＝4.425，P＝0.035）。LMWHS组和肝素钠组治疗后PLT均较治疗前明显升高（×109/L：140.5±17.5比110.5±16.5，152.6±21.5比120.0±20.0，均P＜0.05），D-二聚体较治疗前明显降低（mg/L：0.5±0.1比3.2±1.2，0.6±0.2比4.4±1.8，均P＜0.05）；肝素钠组治疗后APTT较治疗前明显延长（s：75.3±10.6比44.1±8.2，P＜0.05），而LMWHS组治疗后APTT无明显变化（s：38.6±5.5比42.1±8.4， P＞0.05）；两组治疗前后PT、Fib均无明显变化。结论 LMWHS阻止EHS非显性DIC向DIC发展的疗效与肝素钠相当，但LMWHS治疗后患者出血发生率低，更为安全。
目的：觀察低分子肝素鈉（LMWHS）治療勞力性熱射病（EHS）非顯性瀰散性血管內凝血（DIC）患者的療效。方法採用前瞻性隨機對照臨床試驗（RCT），選擇2012年4月至2014年11月解放軍第一八〇醫院重癥醫學科住院治療的EHS非顯性DIC患者36例，按隨機數字錶法分為肝素鈉組（20例）和LMWHS組（16例）。所有患者入院後均接受集束化治療，包括迅速降溫、積極的液體複囌、維護器官功能（呼吸機輔助呼吸、酌情血液淨化）、補充凝血底物抗凝等。肝素鈉組加用肝素鈉註射液12500 U，24 h持續靜脈泵入，共5 d；LMWHS組加用希弗全2500 U，皮下註射，每日2次，共5 d。比較兩組患者DIC髮生率、齣血髮生率及病死率；觀察治療前後兩組患者血小闆計數（PLT）、凝血酶原時間（PT）、活化部分凝血活酶時間（APTT）、纖維蛋白原（Fib）和D-二聚體的變化情況。結果 LMWHS組與肝素鈉組DIC髮生率、病死率比較差異無統計學意義（31.2%比30.0%，χ2＝0.007，P＝0.936；6.2%比5.0%，χ2＝0.026，P＝0.871）；LMWHS組治療後齣血髮生率明顯低于肝素鈉組（12.5%比45.0%，χ2＝4.425，P＝0.035）。LMWHS組和肝素鈉組治療後PLT均較治療前明顯升高（×109/L：140.5±17.5比110.5±16.5，152.6±21.5比120.0±20.0，均P＜0.05），D-二聚體較治療前明顯降低（mg/L：0.5±0.1比3.2±1.2，0.6±0.2比4.4±1.8，均P＜0.05）；肝素鈉組治療後APTT較治療前明顯延長（s：75.3±10.6比44.1±8.2，P＜0.05），而LMWHS組治療後APTT無明顯變化（s：38.6±5.5比42.1±8.4， P＞0.05）；兩組治療前後PT、Fib均無明顯變化。結論 LMWHS阻止EHS非顯性DIC嚮DIC髮展的療效與肝素鈉相噹，但LMWHS治療後患者齣血髮生率低，更為安全。
목적：관찰저분자간소납（LMWHS）치료로력성열사병（EHS）비현성미산성혈관내응혈（DIC）환자적료효。방법채용전첨성수궤대조림상시험（RCT），선택2012년4월지2014년11월해방군제일팔〇의원중증의학과주원치료적EHS비현성DIC환자36례，안수궤수자표법분위간소납조（20례）화LMWHS조（16례）。소유환자입원후균접수집속화치료，포괄신속강온、적겁적액체복소、유호기관공능（호흡궤보조호흡、작정혈액정화）、보충응혈저물항응등。간소납조가용간소납주사액12500 U，24 h지속정맥빙입，공5 d；LMWHS조가용희불전2500 U，피하주사，매일2차，공5 d。비교량조환자DIC발생솔、출혈발생솔급병사솔；관찰치료전후량조환자혈소판계수（PLT）、응혈매원시간（PT）、활화부분응혈활매시간（APTT）、섬유단백원（Fib）화D-이취체적변화정황。결과 LMWHS조여간소납조DIC발생솔、병사솔비교차이무통계학의의（31.2%비30.0%，χ2＝0.007，P＝0.936；6.2%비5.0%，χ2＝0.026，P＝0.871）；LMWHS조치료후출혈발생솔명현저우간소납조（12.5%비45.0%，χ2＝4.425，P＝0.035）。LMWHS조화간소납조치료후PLT균교치료전명현승고（×109/L：140.5±17.5비110.5±16.5，152.6±21.5비120.0±20.0，균P＜0.05），D-이취체교치료전명현강저（mg/L：0.5±0.1비3.2±1.2，0.6±0.2비4.4±1.8，균P＜0.05）；간소납조치료후APTT교치료전명현연장（s：75.3±10.6비44.1±8.2，P＜0.05），이LMWHS조치료후APTT무명현변화（s：38.6±5.5비42.1±8.4， P＞0.05）；량조치료전후PT、Fib균무명현변화。결론 LMWHS조지EHS비현성DIC향DIC발전적료효여간소납상당，단LMWHS치료후환자출혈발생솔저，경위안전。
ObjectiveTo study the effect of low molecular weight heparin sodium (LMWHS) therapy for exertional heat stroke (EHS) patients with pre-disseminated intravascular coagulation (pre-DIC).Methods A prospective randomized controlled trial (RCT) was conducted. Thirty-six patients with EHS with pre-DIC admitted to Department of Critical Care Medicine of 180th Hospital of Chinese PLA from April 2012 to November 2014 were divided into heparin sodium group (n = 20) and LMWHS group (n = 16) in accordance with the random number table. All patients received bundle treatment after being admitted to the hospital, including rapid cooling, fluid resuscitation, organ support (mechanical ventilation, hemopurification if necessary), supplement of pro-coagulation factors, etc. The patients in heparin sodium group were treated with continuous heparin sodium 12 500 U throughout 24 hours with intravenous pump for 5 days, and the patients in LMWHS group were given LMWHS 2 500 U subcutaneously, twice a day for 5 days.The incidence of DIC, incidence of bleeding and mortality of two groups were compared.The platelet count (PLT), prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen (Fib) and D-dimer of each patient between pre and post treatment times were compared.Results No significant difference was found in the incidence of DIC and mortality between LMWHS group and heparin sodium group (31.2% vs. 30.0%,χ2 =0.007,P = 0.936; 6.2% vs. 5.0%,χ2 = 0.026,P = 0.871). Incidence of bleeding during treatment in LMWHS group was significantly lower than that in heparin sodium group (12.5% vs. 45.0%,χ2 = 4.425,P = 0.035). After treatment,PLT in both LMWHS group and heparin sodium group was significantly increased compared with that before treatment (×109/L: 140.5±17.5 vs. 110.5±16.5, 152.6±21.5 vs. 120.0±20.0, bothP< 0.05) and D-dimer was significantly decreased (mg/L: 0.5±0.1 vs. 3.2±1.2, 0.6±0.2 vs. 4.4±1.8, bothP< 0.05). APTT after treatment in heparin sodium group was significantly prolonged compared with that before treatment (s: 75.3±10.6 vs. 44.1±8.2,P< 0.05) while no change in APTT was found in LMWHS group (s: 38.6±5.5 vs. 42.1±8.4,P> 0.05). No significant difference was found in PT and Fib between pre and post treatment in all the patients.Conclusion When LMWHS was applied in EHS patients in pre-DIC stage, it could not only prevent DIC as efficiently as heparin sodium, but also results in lower incidence of bleeding. So LMWHS is safer.
