發(fā)布時間：2018-06-24 05:08

  本文選題：低分子肝素 + 靜脈血栓��； 參考：《河北醫(yī)科大學(xué)》2015年碩士論文

【摘要】：目的:近年來,隨著我國老齡化進程的發(fā)展,髖部骨折發(fā)生率有逐漸增多的趨勢,由于高齡、創(chuàng)傷、臥床制動等原因?qū)е吕夏昊颊吖钦酆笥兄^高的下肢靜脈血栓發(fā)生率,由于較高的發(fā)生率及嚴(yán)重的臨床后果,對骨科病人深靜脈血栓的預(yù)防就顯得尤為重要了。目前,主要的預(yù)防措施有兩種:機械性預(yù)防和藥物預(yù)防。機械性預(yù)防即采用物理方法促進靜脈血液回流,增加血液流速,減少血液淤積,從而減少血栓的發(fā)生,常用的方法有彈力襪和靜脈泵裝置,其優(yōu)點在于不增加出血風(fēng)險,缺點是在創(chuàng)傷患者中應(yīng)用不便,并且其療效尚未取得一致意見。藥物預(yù)防常用的有阿司匹林、肝素、低分子肝素等。阿司匹林可減少血小板聚集從而降低血栓發(fā)生率,但不被作為常規(guī)用藥。肝素因為需嚴(yán)密觀察患者凝血功能,有出血風(fēng)險、過敏反應(yīng)等并發(fā)癥而應(yīng)用受限。目前應(yīng)用最廣的是低分子肝素(LMWH),低分子肝素鈣是一種新型的抗凝血酶Ⅲ(ATⅢ)依賴性抗血栓形成藥,具有明顯的抗凝血因子X a活性,抗凝血因子Ⅱa或抗凝血酶的活性較低。低分子肝素可抑制體內(nèi)、外血栓和動靜脈血栓的形成,但不影響血小板聚集和纖維蛋白原與血小板的結(jié)合。在發(fā)揮抗栓作用時,出血的可能性較小。低分子肝素能刺激內(nèi)皮細胞釋放組織因子凝血途徑抑制物和纖溶酶原活化物,不被第4因子中和,對血小板功能亦無明顯影響;對血栓溶解有間接協(xié)同作用,可用于治療已形成的深部靜脈血栓。因此,低分子肝素受到廣大骨科醫(yī)師推崇。但是,對于應(yīng)用方法尚未取得一致意見,各有支持者,有學(xué)者認為應(yīng)加大使用量,每日皮下注射兩次,強化預(yù)防效果。并且,研究多集中于術(shù)后抗凝方案,術(shù)前抗凝方案以及對機體失血的影響報道較少。為此,本研究通過前瞻性研究方法,將患者分為兩組:A組采用低分子肝素鈣5000IU皮下注射,每日一次;B組采用低分子肝素鈣5000IU皮下注射,每日兩次,對其預(yù)防效果、手術(shù)失血量及并發(fā)癥的發(fā)生率進行對比,分析其治療效果,為臨床應(yīng)用提供理論依據(jù)。方法:對2014年5月至2015年9月就診于河北省滄州中西醫(yī)結(jié)合醫(yī)院并住院治療的股骨粗隆間骨折患者分為兩組,共65例,納入標(biāo)準(zhǔn):1、同意加入并簽署知情同意書者;2、所有患者均為跌倒所致低能量損傷,無其它部位骨折,無開放性傷口;3、年齡大于60歲;4、入院后即刻行彩色多普勒超聲檢查DVT陰性;5、既往無血栓栓塞性疾病病史。排除標(biāo)準(zhǔn):1、中、重度肝腎功能損害者。2、凝血功能障礙者。3、近期有出血性疾病病史者。4、對低分子肝素成分過敏者。5、有消化道潰瘍者。6、細菌性心內(nèi)膜炎者。7、拒絕參加者。A組患者采用低分子肝素鈣5000IU皮下注射,每日一次;B組患者采用低分子肝素鈣5000IU皮下注射,每日兩次。所有患者均行手術(shù)治療,麻醉方法采用椎管內(nèi)麻醉,于術(shù)前12小時停用低分子肝素鈣,手術(shù)方法均為股骨近端髓內(nèi)釘進行固定,術(shù)后放置引流管,記錄其引流量,術(shù)后12小時繼續(xù)按照術(shù)前抗凝方案預(yù)防DVT,術(shù)后第3天復(fù)查血常規(guī),觀察其血紅蛋白變化。術(shù)后一周進行雙下肢靜脈彩色多普勒超聲檢查,了解有無血栓形成。結(jié)果:所有患者于術(shù)后一周均無癥狀性DVT發(fā)生,其中A組發(fā)生患肢小腿肌間靜脈叢血栓5例,發(fā)生率15.6%,B組發(fā)生患肢小腿肌間靜脈叢血栓3例,發(fā)生率9.1%。兩組DVT發(fā)生率差異無統(tǒng)計學(xué)意義(X2=0.642,P=0.422)。兩組患者術(shù)后3天復(fù)查血常規(guī)顯示血紅蛋白含量較術(shù)前明顯下降,差異具有統(tǒng)計學(xué)意義。但是,兩組間患者血紅蛋白含量變化比較不具有統(tǒng)計學(xué)意義。所有患者均未出現(xiàn)消化道出血、血腫、傷口滲血增加、硬膜外血腫等并發(fā)癥。兩組患者術(shù)后引流量平均分別為(250.8±71.7)、(269.5±60.3)mL,差異無統(tǒng)計學(xué)意義(t=0.166,P=0.835)。結(jié)論:本研究顯示常規(guī)劑量低分子肝素每日一次皮下注射和每日兩次皮下注射并于術(shù)前12小時停用、術(shù)后12小時繼續(xù)應(yīng)用對手術(shù)后失血量影響無明顯差異。對于預(yù)防效果,兩組均無癥狀性DVT發(fā)生,每日兩次皮下注射VTE發(fā)生率略低,但并無統(tǒng)計學(xué)差異,因此,臨床應(yīng)用應(yīng)根據(jù)患者發(fā)生血栓風(fēng)險程度,酌情調(diào)整應(yīng)用頻次。
[Abstract]:Objective: in recent years, with the development of the aging process in China, the incidence of hip fracture is increasing gradually. Due to old age, trauma, bed brake and so on, the elderly patients have higher incidence of lower limb venous thrombosis after fracture. The prevention of deep venous thrombosis in Department of orthopedics is the result of high incidence and severe clinical consequences. It is particularly important. At present, there are two main preventive measures: mechanical prevention and drug prevention. Mechanical prevention is the use of physical methods to promote venous blood flow, increase blood flow rate, reduce blood stasis, and reduce the occurrence of thrombus. The common method is elastic socks and venous pump device, its advantage is that it does not increase bleeding. The risk, the disadvantage is the inconvenience in the trauma patients, and its effect has not been agreed. Drug prevention commonly used aspirin, heparin, low molecular weight heparin, etc.. Aspirin can reduce platelet aggregation and reduce the incidence of thrombus, but not as a routine drug. Risk, allergy and other complications are limited. Low molecular weight heparin (LMWH) is the most widely used, low molecular weight heparin calcium is a new antithrombin III (AT III) dependent antithrombotic drug, with obvious anticoagulant factor X a activity and low activity of anticoagulant factor II A or anticoagulant. Low molecular weight heparin can inhibit the body The formation of external thrombus and arteriovenous thrombosis does not affect platelet aggregation and the binding of fibrinogen to platelets. The possibility of bleeding is smaller when antithrombotic action is played. Low molecular weight heparin stimulates endothelial cells to release tissue factor coagulation pathway inhibitors and plasminogen activator, not neutralized by fourth factors, and the function of platelets There is no obvious effect on the thrombolytic effect of thrombolysis, which can be used in the treatment of deep venous thrombosis that has been formed. Therefore, low molecular weight heparin is respected by the doctors in the Department of orthopedics. However, there is no agreement on the application methods, each has its supporters, and some scholars believe that the dosage should be increased two times a day to strengthen the preventive effect. In addition, the study focused on postoperative anticoagulant regimens, and there were few reports on preoperative anticoagulant schemes and the effect on blood loss in the body. To this end, the patients were divided into two groups by prospective study methods: group A was subcutaneously injected with low molecular heparin calcium 5000IU daily, and group B was subcutaneously injected with low molecular weight heparin calcium 5000IU every day. The effects of prevention, blood loss and complications were compared, and the therapeutic effect was analyzed. Methods: two groups were divided into two groups of 65 cases of intertrochanteric fracture of femur, which were treated in Cangzhou and Western Medicine Hospital of Hebei province from May 2014 to September 2015, and were included in the standard: 1, agreed to join and sign. 2, all patients were low energy damage caused by fall, no other parts of fracture, no open wound, 3, age greater than 60 years old; 4, DVT negative after admission, 5, history of thrombotic thromboembolic disease. 1, moderate, severe liver and kidney dysfunction,.2,.3,.3 .4, a person with a history of hemorrhagic disease, was allergic to low molecular weight heparin (.5),.6 of peptic ulcers, and.7 for bacterial endocarditis. The patients in group.A were refused subcutaneous injection of low molecular weight heparin calcium 5000IU daily, and the B group was subcutaneously injected with low molecular heparin calcium 5000IU two times a day. All patients were treated with surgical treatment. Treatment, anesthesia was used in spinal canal anesthesia and low molecular weight heparin calcium was stopped 12 hours before operation. The operation method was fixed for proximal femoral nail. Drainage tube was placed after operation to record its flow rate. After 12 hours of operation, DVT was prevented by preoperative anticoagulant scheme. Blood routine was reviewed on third days after operation, and the hemoglobin changes were observed. One week after operation, the changes of hemoglobin were observed. Two lower extremities venous color Doppler ultrasound examination was carried out to understand the formation of thrombus. Results: all patients had no symptomatic DVT in one week after operation, among which group A had 5 cases of limb intermuscular venous plexus thrombosis, the incidence rate was 15.6%, group B had 3 cases of limb intermuscular venous plexus thrombosis, and there was no difference in the incidence of DVT in group 9.1%. two. Significance (X2=0.642, P=0.422). Two groups of patients after 3 days reexamination of blood routine showed that the hemoglobin content was significantly lower than before the operation, the difference was statistically significant. However, the hemoglobin content changes in the two groups were not statistically significant. All patients had no gastrointestinal bleeding, hematoma, increased osmotic bleeding, epidural hematoma, and so on. Complications. The average flow rate of the two groups was (250.8 + 71.7) and (269.5 + 60.3) mL respectively. The difference was not statistically significant (t=0.166, P=0.835). Conclusion: This study showed that the routine dose of low molecular weight heparin was subcutaneous injection once a day and two subcutaneous injections daily and stopped for 12 hours before the operation. The blood loss after operation was continued 12 hours after the operation. There was no significant difference in the effect. For the prevention effect, the two groups were asymptomatic DVT, and the incidence of two subcutaneous injection of subcutaneous injection was slightly lower, but there was no statistical difference. Therefore, the clinical application should be based on the degree of thrombus risk and adjust the frequency of application.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2015
【分類號】：R687.3

【相似文獻】

相關(guān)期刊論文 前10條

1 劉萍,段金傳;低分子肝素治療老年不穩(wěn)定型心絞痛的療效與安全性[J];臨床薈萃;2001年05期

2 陸紅斌 ,吳慧霞 ,梁曉慧;低分子肝素治療慢性肺源性心臟病療效觀察[J];人民軍醫(yī);2001年11期

3 徐艷;腹壁注射低分子肝素的應(yīng)用體會[J];首都醫(yī)藥;2001年04期

4 陳樹根,方元,胡宏德;低分子肝素致大咯血1例[J];華西醫(yī)學(xué);2002年01期

5 魏琰,王紅燕,付廣印,侯翠霞;低分子肝素治療短暫性腦缺血發(fā)作20例臨床觀察[J];實用心腦肺血管病雜志;2002年01期

6 趙賀玲 ,郭鑌榮 ,牛光清;低分子肝素治療顱內(nèi)靜脈竇血栓形成療效觀察[J];人民軍醫(yī);2003年01期

7 蔣蘇虹,王虹;低分子肝素誘發(fā)的血小板減少癥2例報告[J];心肺血管病雜志;2004年01期

8 茆華武,丁立東;低分子肝素治療頻發(fā)的短暫性腦缺血發(fā)作35例效果觀察[J];南通醫(yī)學(xué)院學(xué)報;2004年02期

9 齊永樂;低分子肝素治療慢性肺心病急性加重期100例[J];現(xiàn)代醫(yī)藥衛(wèi)生;2004年20期

10 董國賓,張增;低分子肝素治療慢性肺心病60例療效觀察[J];山東醫(yī)藥;2005年10期

相關(guān)會議論文 前10條

1 尹林;;低分子肝素與肝素鈉治療深靜脈血栓性靜脈炎的比較[A];2003年全國危重病急救醫(yī)學(xué)學(xué)術(shù)會議論文集[C];2003年

2 尹林;;低分子肝素與肝素鈉治療深靜脈血栓性靜脈炎的比較[A];2004年全國危重病急救醫(yī)學(xué)學(xué)術(shù)會議論文集[C];2004年

3 易興陽;張順開;潘繼豹;潘光強;胡永啟;陳步滿;林瑞聲;余昌明;;第四部分 低分子肝素對進展性缺血性腦卒中預(yù)防作用的探討[A];醫(yī)學(xué)科研成果與應(yīng)用[C];2011年

4 李穎穎;李京;王悅;范慧紅;;低分子肝素研究進展[A];2012年中國藥學(xué)大會暨第十二屆中國藥師周論文集[C];2012年

5 ;低分子肝素致出血1例及文獻分析[A];2010年臨床藥學(xué)學(xué)術(shù)年會暨第六屆臨床藥師論壇論文集[C];2010年

6 高雷;王超;張平;張平;;低分子肝素在兒科中的應(yīng)用[A];第二十屆全國兒科藥學(xué)學(xué)術(shù)會議暨首屆全國兒科中青年藥師論文報告會論文集[C];2009年

7 張治云;凌沛學(xué);王鳳山;張?zhí)烀?;低分子肝素臨床應(yīng)用的研究進展[A];山東省藥學(xué)會第一屆學(xué)術(shù)年會論文集（下）[C];2005年

8 鄭福鴻;尹永杰;;低分子肝素的臨床應(yīng)用進展[A];《中華急診醫(yī)學(xué)雜志》第七屆組稿會論文匯編[C];2008年

9 何梅;唐堯;;非ST段抬高性心肌梗死合并血液透析患者使用低分子肝素致出血1例[A];2010年臨床藥學(xué)學(xué)術(shù)年會暨第六屆臨床藥師論壇論文集[C];2010年

10 張治云;凌沛學(xué);王鳳山;張?zhí)烀?;低分子肝素臨床應(yīng)用的研究進展[A];山東省藥學(xué)會2006年生化與生物技術(shù)藥物學(xué)術(shù)研討會論文集[C];2006年

相關(guān)重要報紙文章 前9條

1 翔實;低分子肝素——綜合性效優(yōu)勢備受臨床青睞[N];中國醫(yī)藥報;2007年

2 證券時報記者 許韻紅;圍繞低分子肝素及注射劑兩大重心發(fā)展[N];證券時報;2012年

3 北京安貞醫(yī)院心內(nèi)科教授 陳韻岱邋羅剛;心梗 請選低分子肝素抗凝[N];健康報;2007年

4 濟南市第一人民醫(yī)院神經(jīng)外科主任醫(yī)師 王有國;妊娠期腦血栓：低分子肝素抗凝更安全[N];醫(yī)藥經(jīng)濟報;2011年

5 知陶;療效相當(dāng) 成本減六成[N];醫(yī)藥經(jīng)濟報;2003年

6 靖九江;延長低分子肝素用藥時間可有效預(yù)防靜脈血栓性疾病[N];中國醫(yī)藥報;2007年

7 記者　　李良;上實聯(lián)合控股組建天普海藥[N];中國證券報;2005年

8 本報記者 朱國旺;對ACS的抗凝治療亟待規(guī)范化[N];中國醫(yī)藥報;2009年

9 陶春祥;ACS的藥物治療[N];中國醫(yī)藥報;2004年

相關(guān)博士學(xué)位論文 前2條

1 黃河;創(chuàng)傷性股靜脈血栓基因表達變化及低分子肝素干預(yù)研究[D];昆明醫(yī)學(xué)院;2007年

2 李丹丹;前列腺素E1及低分子肝素對大鼠腎缺血再灌注損傷的免疫調(diào)節(jié)作用及機制研究[D];第二軍醫(yī)大學(xué);2008年

相關(guān)碩士學(xué)位論文 前10條

1 梁曦;低分子肝素作用于非小細胞肺癌患者凝血功能及臨床療效的研究[D];山東大學(xué);2015年

2 羅倩;低分子肝素對急性腦梗死后全身炎癥反應(yīng)綜合征治療作用的研究[D];四川醫(yī)科大學(xué);2015年

3 張楠;低分子肝素對人肺腺癌細胞株A549增殖及血管內(nèi)皮生長因子、轉(zhuǎn)化生長因子β_1表達的影響[D];四川醫(yī)科大學(xué);2015年

4 王元;主動脈內(nèi)球囊反搏術(shù)中使用比伐蘆定及低分子肝素抗凝對血小板減少癥的影響[D];南方醫(yī)科大學(xué);2015年

5 劉陽;不同頻次應(yīng)用低分子肝素預(yù)防髖部骨折靜脈血栓的臨床對比研究[D];河北醫(yī)科大學(xué);2015年

6 于淼;低分子肝素誘導(dǎo)的血小板減少癥發(fā)病率及相關(guān)因素分析[D];河北醫(yī)科大學(xué);2010年

7 王鑫鈺;肝素及低分子肝素質(zhì)量控制相關(guān)對照品及標(biāo)準(zhǔn)試劑的研究[D];中國食品藥品檢定研究院;2015年

8 顏鵬;低分子肝素應(yīng)用時間對預(yù)防骨科手術(shù)靜脈血栓栓塞的影響[D];山西醫(yī)科大學(xué);2010年

9 李雷剛;天然低分子肝素制備及其硫酸化修飾條件的研究[D];黑龍江八一農(nóng)墾大學(xué);2009年

10 趙宏磊;冠狀動脈旁路移植術(shù)后早期應(yīng)用低分子肝素的臨床意義[D];山東大學(xué);2012年

，

本文編號：2060158