重症医学科病人中肝素诱导的血小板减少症(1)
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摘 要 肝素诱导的血小板减少症(HIT)是一种与肝素相关的严重副反应。其中II型HIT是一种免疫介导的常发生在使用普通肝素、但较少发生在使用低分子量肝素病人中的血栓形成并发症，可见于各临床专科，但易被临床医师忽视或漏诊，特别是重症医学科危重病人普遍存在血小板减少现象且通常可由HIT外的其它病症所致，诊断较为困难。应用4T评分表有助于这类病人的确诊与治疗用药的选择。确诊HIT需实验室检查发现存在HIT抗体，而血小板功能检测与抗原检测相结合可提高诊断试验的特异性和敏感度。HIT治疗较棘手，严重者会危及生命，故临床疑诊HIT即应尽早开始替代抗凝治疗，治疗药物可选择直接凝血酶抑制剂和Xa因子抑制剂。
关键词 肝素诱导的血小板减少症 达那肝素 磺达肝素 来匹卢定 阿加曲班
中图分类号：R973.2; R558.2 文献标识码：A 文章编号：1006-1533(2012)07-0012-05
Heparin-induced thrombocytopenia in intensive care patients
Zhang Bin
(ICU, Affiliated Hospital of Nantong University, Nantong, 226001)
Abstract Heparin-induced thrombocytopenia (HIT) is one of the most serious adverse events associated with heparin. HIT type II is an immune-mediated prothrombotic complication, which is more often caused by unfractionated heparin than low-molecular-weight heparin. It can be found in every clinical special department that diagnosis is often missed or ignored by the clinicians. There are a lot of difficulties in the diagnosis of HIT in the ICU as thrombocytopenia is universal in these patients and usually caused by rather conditions than HIT. The 4T’s score may be helpful in establishing the diagnosis and treatment of these patients. The diagnosis of HIT requires HIT antibodies existence found in the laboratory testing. The combination of functional and antigen assays has the highest performance in terms of specificity and sensitivity. The treatment of HIT is difficult, and there is a life-threatening in severe patients. To avoid serious bad consequence of HIT, alternative therapeutic anticoagulation should be initiated as soon as possibly based on high clinical suspicion. For treatment of HIT, the alternative anticoagulants such as the direct thrombin inhibitors and factor Xa inhibitors are approved.
Key Words heparin-induced thrombocytopenia; danaproid; fondaparinux; lepirudin; argatroban
肝素是一种在凝血过程中由肥大细胞和嗜碱粒细胞释放的抗凝物质，在体内、体外均具有很强的抗凝活性，是临床上常用的抗凝剂、尤其是用于血栓栓塞性疾病的防治[1]。肝素诱导的血小板减少症(HIT)是一种肝素诱发、免疫介导的促血栓形成并发症，常见于普通肝素(UFH)、但较少发生在低分子量肝素(LMWH)治疗中或治疗后，是与肝素有关的最严重的副反应。尽管HIT的发生率不高(在UFH治疗者中约为1%～5%)[1]，但可见于各临床专科且易被临床医师忽视、常造成漏诊，治疗亦较棘手，严重者会危及生命。为避免HIT对病人造成严重不良后果，临床医师应给予高度关注 ......
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