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肝素诱导的血小板减少症一例的诊治体会

肝素诱导的血小板减少症（heparin-induced thrombocytopenia，HIT）是一种罕见疾病，以血小板减少和血栓形成为主要特征。HIT可分为Ⅰ型和Ⅱ型。Ⅰ型HIT较常见，不是免疫性反应，很可能与肝素直接激活血小板有关，是一种良性反应。血小板计数多大于100×109/L，极少显著降低，且可自行恢复。Ⅱ型HIT则是免疫介导的综合征，与很多因素有关，各种给药方式都可引发，如静脉或皮下注射，甚至接触极少量肝素等。本文报告1例行冠脉介入手术使用肝素后发生血小板减少，肺泡出血及深静脉血栓形成，改为磺达肝癸钠抗凝后病情好转出院患者的诊治经过，并结合相关文献进行讨论，以提高对这一罕见疾病的认识及处理能力。临床资料 患者男性，61岁。因“持续胸骨后压榨样疼痛8 h”于2010年2月28日入院。患者于入院前8 h无明显诱因下出现持续性胸骨后压榨性疼痛，无心悸、呼吸困难、咳嗽、咯血，无头晕、意识丧失，休息后无法缓解。患者至我院急诊就诊，行心电图检查示急性前壁非ST段抬高性心肌梗死。立即急诊行冠脉造影+内支架植入术，在前降支近段，回旋支，前降支第一对角支处分别植入3枚Firebird球囊支架，术中应用普通肝素8500 U抗凝。患者术中血压、心率稳定，未诉不适。术后给予低分子肝素钙0.4 mL皮下注射1次/12 h抗凝，术后以“冠心病，急性心肌梗死”收入我院心血管内科。既往有高血压病史10余年，最高血压为200/110 mm Hg（1 mm Hg=0.133 kPa），不规律服药，血压控制不佳。无吸烟，饮酒史。入院体检：体温37.3 ℃，脉搏112次/min，呼吸23次/min，血压155/83 mm Hg。神志清，精神萎靡，心率112次/min，律齐，各瓣膜区未闻及明显杂音，两肺叩诊音略浊，右下肺可闻及少许散在湿啰音，各瓣膜区未及病理性杂音。腹部、脊柱、四肢检查无明显异常发现。

Anticoagulation Management in Patients with Heparin-induced Thrombocytopenia Undergoing Extracorporeal　Circulation

Patients with heparin-induced thrombocytopenia have a poor prognosis and high mortality, thus surgical risk under extracorporeal circulation increased. Early diagnosis, safe and effective alternative anticoagulation strategy are crucial for these patients to receive extracorporeal circulation surgery. This review focuses on the pathophysiology, laboratory examination, diagnosis and alternative anticoagulation strategy of extracorporeal circulation for patients with heparin-induced thrombocytopenia.

血小板减少症患者的心瓣膜置换术

目的总结合并血小板减少症的患者接受心瓣膜置换术的治疗经验,并探讨其可行性。方法对28例心脏瓣膜病合并血小板减少症患者施行心瓣膜置换术,入院时血小板为23×109/L～50×109/L(42.00×109/L±7.41×109/L),所有患者均使用膜肺并在预充液中分别加入300×104U～500×104U的抑肽酶。行二尖瓣置换术12例,主动脉瓣置换术8例,双瓣膜置换术8例;转流结束以鱼精蛋白中和肝素后立即输注新鲜血小板13～27U(17.8±3.9U)。结果3例术后12h内因胸腔引流管引流量大而行二次开胸探查,1例术后3d死于心室颤动,其余患者均治愈出院。结论加强术中处理,可以使血小板数维持于20×109/L～50×109/L的心脏瓣膜病合并血小板减少症的患者安全接受心瓣膜置换术。

乙二胺四乙酸依赖的假性血小板减少症一例

原发免疫性血小板减少症研究进展

原发免疫性血小板减少症（ITP）是一种常见的出血性疾病，其发病机制仍不十分清楚。现有治疗方案在ITP的治疗中取得一定的疗效，如糖皮质激素、静脉注射免疫球蛋白以及脾切除等，但仍有较多患者面临复发难治的问题。现将近年ITP发病机制、诊断和治疗等方面的研究进展作一综述。

Efficacy Evaluation of Argatroban in Treatment of Lower Extremity Deep Vein Thrombosis

目的 比较常规使用肝素和阿加曲班治疗下肢深静脉血栓（DVT）患者的临床疗效。方法 将188例下肢DVT患者按照随机数字表分成阿加曲班组（n=94）和对照组（低分子肝素钙+尿激酶，n=94），比较2组患者治疗前、后双侧肢体周径差和疗效的差异，并在治疗过程中监测凝血指标（PT、APTT及PLT）变化。结果 阿加曲班组治疗10 d后，双侧肢体周径差较治疗前明显减小（Plt;0.05），总有效率（97.87%）优于对照组（89.37%），Plt;0.05。阿加曲班组无血小板减少症（HIT）发生，对照组发生2例HIT； 阿加曲班组PT、APTT和PLT变化均处于正常范围，与对照组比较差异无统计学意义（Pgt;0.05）。结论 阿加曲班治疗下肢DVT安全、有效。

重视血液疾病的临床研究

大剂量地塞米松冲击治疗成人重症免疫性血小板减少症近期疗效观察

目的观察大剂量地塞米松静脉冲击治疗重症免疫性血小板减少症（ITP）的近期疗效及安全性。 方法2010年1月－2013年6月,采用大剂量地塞米松短期（40 mg/d×4 d）静脉冲击治疗80例重症ITP患者，观察血小板计数（BPC）、出血症状的变化及药物不良反应。 结果冲击治疗4 d，出血症状减轻，活动性出血消失，BPC都有升高，完全反应率33.75%，总有效率77.50%。18例延长疗程3 d后，总有效率提高到100.00%，完全反应率47.50%。只有1例出现轻度水钠潴留，无高血压、高血糖、电解质紊乱及严重感染发生。 结论大剂量地塞米松冲击治疗ITP，安全有效、不良反应少。

慢性/复发性原发免疫性血小板减少症合并抗 O 升高二例

Expression and clinical significance of immune cell subsets in elderly patients with primary immune thrombocytopenia

Objective To investigate the expression and clinical significance of T lymphocyte subsets, natural killer (NK) cells and CD19+ B cells in the elderly with primary immune thrombocytopenia (ITP) before and after treatment. Methods The elderly ITP patients diagnosed and treated in the Songjiang Hospital Affiliated to Shanghai Jiaotong University School of Medicine (preparatory stage) between January 2014 and June 2019 were retrospectively selected as the observation group. The healthy elderly in the same period were selected as the control group. According to the treatment, the observation group was divided into effective group and ineffective group. The expression levels of T lymphocyte subsets (CD3+, CD4+, CD8+ and CD4+/CD8+), NK cells and CD19+ B cells were observed and analyzed. Results A total of 75 subjects were included, including 35 in the observation group and 40 in the control group. The total effective rate was 85.71% (30/35). Before treatment, the expression levels of T lymphocyte subsets (CD3+, CD4+ and CD4+/CD8+) in the observation group were lower than those in the control group (P<0.05). There was no significant difference in other indexes between the two groups (P>0.05). After treatment, except for CD8+, the expression levels of T lymphocyte subsets (CD3+, CD4+ and CD4+/CD8+) in the observation group were higher than those before treatment (P<0.05). The expression levels of NK cells and CD19+ B cells were lower than those before treatment (P<0.05). The expression levels of T lymphocyte subsets (CD3+, CD4+ and CD4+/CD8+) in the effective group were higher than those before treatment (P<0.05), while the expression level of CD19+ B cells was lower than that before treatment (P<0.05). There was no significant difference in other indexes before and after treatment (P>0.05). There was no significant difference in the expression levels of T lymphocyte subsets (CD3+, CD4+, CD8+ and CD4+/CD8+), NK cells and CD19+ B cells in the ineffective group before and after treatment (P>0.05). Conclusions T lymphocyte subsets are abnormal in elderly ITP patients. The immune abnormality of T lymphocyte may be one of the reasons for elderly patients with ITP. With the improvement of therapeutic effect, immune cell subsets have also been improved.