摘要
目的：评价单纯应用压力梯度长袜（GCS）或与歇充分装置（IPC）联合应用预防大手术病人后下肢深静脉血性形成（DVT）的效果和安全性，并观察手术前后凝血、纤溶活性的变化。方法：连续入选胸科、泌尿外科、肝胆外科恶生肿瘤根治手术患者240例，分为对照组（C）和三个实验组，即单纯GCS＋IPC全程组：按GCS组选好合适袜子，将合适型号压力腿套（型号与袜子一致）固定在袜子外面，连接IPC，手术切皮前即刻开始应用，持续应用至次日晨，然后每隔2h应用2h，一直应用到患者下床活动：GCS＋IPC术后组：手术结束回病房或ICU即刻开始应用IPC，持续至次日晨，然后每隔2h应用2h，一直应用到患者下床活动。所有患者术后3-8天内行双下肢深静脉血管超声检查，均记录双下肢动静脉血流速度，及血栓发生的部分。15例GCS＋IPC全程组患者和15例对照组患者分别手术前、切皮2h及24h外周采集静脉血测定D-二聚体（D-Dimer、D-D）、纤溶酶原激活剂抗原（PA-Ag）、纤溶酶原激活剂抑制剂（PAI）、血管性血友病因子（vWF）、凝血酶原时间（PT）和活化的部分凝血活酶时间（aPTT）。术前评价血栓栓塞发生的风险。结果：240例入选患者中，于术后3-8天超声检查DVT发生率在GCS＋IPC全程组，GCS＋IPC术后组和单纯GCS组分别为15%（P〈0.05），23.3%（P〈0.05）和30%（P〉0.05），而对照组为48.3%，1例GCS患者近端DVT，其余均为远端DVT。血凝指标：实验组D-D在切皮2h没有明显变化，24小时明显增加，而对照组切皮2h明显高于术前。切皮2小时实验组tPA-Ag明显低于对照组，而vWF明显高于对照组。PAI在手术后两组无明显变化。随着年龄、体重增大和危险因素个数的增加，DVT的发生率增加。结论：GCS＋IPC全程组及GCS＋IPC术后组能有效降低大手术后DVT，预防效果以GCS＋IPC全程组最。单纯应用GCS可能适合中危或中危以下DVT风险的手术患者。GCS＋IPC全程组凝血纤溶指标变化指示IPC可能增加纤溶活性。
Objective： This prospective study was to evaluate the efficacy and safety of graduated compression stocking（GCS）alone or combined with intermittent pneumatic compression（IPC）for preventing deep venous thrombosis（DVT）in patients performing major surgery with malignancy.Changes of hemostatic substrate were observed perioperatively.Methods：Consecutive 240 cases of patients with malignant tumor from department of thoracic surgery,urology and hepatobilliary surgery were allocated into control or one of and three test groups （GCS alone, GCS ＋ full-time IPC and GCS ＋ postoperative IPC）. GCS was taken before surgery and continued postoperatively until recovery to normal mobility.IPC was initiated before surgery in group of GCS＋fult-time IPC and immediately after surgery in group of GCS＋postoperative IPC until next morning, then intermittent 2h use with 2h interval until off-bed mobility. Deep venous ultrasound imaging were performed in all patients 3-8d postoperatively for thrombosis screening and blood velocity determination. Blood was sampled in 15 cases of GCS＋full-time IPC and 15 cases of controls immediately before surgery, 2h after skin incision and 24h after surgery for the determination of plasma D-Dimer （D-D）, tissue-type plasminogen activator antigen （tPA-Ag）, plasminogen activator inhibitor antigen （PAI-Ag）, von Willebrand factor （vWF）, activated partial thromboplastin time （APTT） and prothrombin time （PT）. No thrombo-embolic history were found in all patients. The risk for thromboembolism were assessed before surgery. Results： DVT were found in 9/60 （15%）, 14/60 （23.3%）, 18/60 （30%） in group GCS＋full-time IPC, GCS＋postoperative IPC and GCS alone respectively, compared with 29/60 （48.3%） in control group with no prophylaxis, P〈0.05. Proximal thrombosis was fond in only one case. Hemostatic parameter： D-D increased significantly 24h postoperatively in test group but not in controts, tPA-Ag level was lower in test group compared with controls 2h after surgery, in contrast, vWF was higher in test group, no significant changes were fond for PAl. The higher the age, body weight and risk factor, the more the DVT incidence. Conclusions： In high risk patients with major surgery and malignant tumor, prophylaxis with GCS＋full-time IPC and GCS＋postoperative IPC can prevent DVT effectively. GCS alone may only apply to mild to intermediate risk of patients thrombosis prevention. Hemostatic changes after surgery in group of GCS＋full-time IPC showed that mechanic measures may contribute to decreased thrombosis by increasing fibrinolytic activity.
出处
《麻醉与监护论坛》
2005年第4期210-213,共4页
Forum of Anesthesia and Monitoring
