CAJ | 학술논문

目的探讨肝硬化患者人工全髋关节置换(total hip arthroplasty,THA)围手术期深静脉血栓(deep veinthrombosis, DVT)的风险,评价个体化抗凝治疗的安全性和可行性.方法 2009年1月至2014年12月围手术期接受个体化抗凝治疗合并肝硬化的25例THA患者进行前瞻性研究,男17例,女8例;年龄平均为(57.9±9.2)岁;股骨头缺血性坏死18例、骨关节炎7例,均为单侧.围手术期应用低分子肝素.随机选择2008年1月至2008年12月行THA的非肝硬化患者30例的相关动态指标作为参照,监测肝功能和凝血指标.对出血量大或消化道出血病例暂缓抗凝,适当补充凝血酶原复合物、新鲜冰冻血浆,维持出血/凝血平衡.结果所有患者手术均顺利完成并获随访,随访时间(34±15.7)个月.术前Harris评分(32.4±10.2)分,末次随访为(82.9±6.1)分,差异有统计学意义.围手术期及随访期间均无脱位、假体周围骨折及假体周围感染发生.个体化抗凝治疗保持围手术期患者出血/凝血平衡,凝血指标动态曲线未明显偏离参照曲线.1例术后48 h下肢肌间血肿形成,予暂停抗凝,补充凝血酶原复合物、新鲜冰冻血浆后稳定.1例术后第5天出现上消化道出血,予暂停抗凝,应用生长抑素及质子泵抑制剂,出血迅速控制.1例术后第3天黄疸加重,予护肝、退黄治疗后缓解.围手术期显性出血(686±141.8) ml.无围手术期死亡,无肝衰竭、肝性脑病、肝肾综合征发生.围手术期及后续随访均未发生DVT.结论肝硬化患者凝血功能异常存在DVT风险,须个体化维持出血/凝血平衡,增加THA围手术期的安全性.
목적 탐토간경화환자인공전관관절치환(total hip arthroplasty,THA)위수술기심정맥혈전(deep veinthrombosis, DVT)적풍험,평개개체화항응치료적안전성화가행성.방법 2009년1월지2014년12월위수술기접수개체화항응치료합병간경화적25례THA환자진행전첨성연구,남17례,녀8례;년령평균위(57.9±9.2)세;고골두결혈성배사18례、골관절염7례,균위단측.위수술기응용저분자간소.수궤선택2008년1월지2008년12월행THA적비간경화환자30례적상관동태지표작위삼조,감측간공능화응혈지표.대출혈량대혹소화도출혈병례잠완항응,괄당보충응혈매원복합물、신선빙동혈장,유지출혈/응혈평형.결과 소유환자수술균순리완성병획수방,수방시간(34±15.7)개월.술전Harris평분(32.4±10.2)분,말차수방위(82.9±6.1)분,차이유통계학의의.위수술기급수방기간균무탈위、가체주위골절급가체주위감염발생.개체화항응치료보지위수술기환자출혈/응혈평형,응혈지표동태곡선미명현편리삼조곡선.1례술후48 h하지기간혈종형성,여잠정항응,보충응혈매원복합물、신선빙동혈장후은정.1례술후제5천출현상소화도출혈,여잠정항응,응용생장억소급질자빙억제제,출혈신속공제.1례술후제3천황달가중,여호간、퇴황치료후완해.위수술기현성출혈(686±141.8) ml.무위수술기사망,무간쇠갈、간성뇌병、간신종합정발생.위수술기급후속수방균미발생DVT.결론 간경화환자응혈공능이상존재DVT풍험,수개체화유지출혈/응혈평형,증가THA위수술기적안전성.
Objective To investigate the perioperative risk of deep vein thrombosis (DVT) in patients with hepatic cirrhosis that underwent total hip arthroplasty (THA), and to evaluate the safety and feasibility of individualized anti-coagulation treatment.Methods There were 25 patients complicating hepatic cirrhosis that underwent THA (from Jan.to Dec.2014), including 17 males and 8 females, aged 57.9t9.2 years.The primary causes of THA were avascular necrosis of the femoral head (eighteen cases) and osteoarthritis of the hip (seven cases).Low molecular weight heparin (LMWH) was applied for anti-coagulation treatment.Parameters of hepatic function and coagulation function of THA cases (randomized thirty cases, from Jan.2008 to Dec.2008) without hepatic cirrhosis were used as reference for monitoring.For the cases of massive blood loss or upper gastrointestinal hemorrhage, a LMWH administration pause and an administration of fresh frozen plasma and clotting factors were performed in order to maintain a hemorrage/coagulation balance.The clinical outcome of the hip joint was evaluated and complications were treated.A subsequent follow-up was also carried out after perioperative period.Results All cases received successful surgeries and followed up.The follow-up duration was 34± 15.7 months.The preoperative Harris hip score was 32.4± 10.2 points, while the most recent follow-up score was 82.9±6.1 points, which was statistically significant.Dislocation, periprosthetic fracture and periprosthetic infection were absent.All cases received individualized anti-coagulation treatments during peripoerative period.A hemorrage/coagulation balance was achieved.The dynamic parameter curves did not present excessive deviation from reference.One case encountered intermuscular hematoma of the lower limbs 48 hours postoperatively, which was solved by a LMWH pause and administration of fresh frozen plasma and clotting factors.One case suffered upper gastrointestinal hemorrhage five days postoperatively, which was controlled by a LMWH pause and the administration of somatostatin and proton pump inhibitor.Jaundic got worse in one case three days postoperatively but got relieved after treatment.Overt blood loss was 686t141.8 ml.Perioperative death, hepatic failure, hepatic encephalopath, hepatorenal syndrome were absent.No DVT was observed.Conclusion There are risks of DVT in patients of hepatic cirrhosis.Individualized anti-coagulation treatment is needed during perioperative period of THA.