摘要
目的 探讨肾挫裂伤合并急性肺栓塞的抗凝药物治疗决策,提升对该类疾病的治疗水平.方法 回顾性分析四川大学华西医院收治的1例肾挫裂伤合并急性肺栓塞患者的临床资料并进行相关文献复习,以"肺栓塞"及"出血"为检索词检索中国期刊网全文数据库、万方数据库及维普数据库,以"Pulmonary embolism"AND"Hemorrhage"为检索词检索 PubMed、Ovid Medline 及 Embase 数据库,检索时间为1983年1月1日-2023年12月31日.结果 患者为21岁男性,主诉为"右肾挫伤5天,呼吸困难1天".腹部CT提示:右肾边缘不清,肾周见片团状混杂稍高密度影,增强后右肾内见多发强化降低区,多系右肾挫裂伤;腹部超声:右肾周查见范围约10.6 cm × 2.8 cm的低回声区.CT肺动脉造影示肺动脉干分叉处、双肺上叶及下叶肺动脉分支见充盈缺损.血气分析(面罩给氧10 L/min,氧合指数120):pH 7.456,PCO2 24.9 mm Hg,PO273.2 mm Hg.肌红蛋白79.21 ng/ml,肌钙蛋白T 58.7ng/L,BNP 2062 ng/L.考虑诊断肾挫裂伤合并肺栓塞,先后经普通肝素(首剂予以肝素负荷剂量80IU/kg静脉注射,其后以12-18 IU/kg/h持续静脉泵入)抗凝11天、序贯以低分子肝素0.8mlq12h抗凝14天,辅以抗感染、吸氧等对症治疗后,患者呼吸困难逐渐缓解,复查血气分析氧合改善,调整抗凝药物为口服利伐沙班20 mg qd抗凝6个月,后复查CTPA肺栓完全吸收,停用抗凝药物,期间,抗凝治疗2个月后复查腹部CT提示右肾周片状低密度影范围缩小,密度稍增高,肾周出血明显吸收,保肾成功.经上述数据库检索,共检出26篇文献报道30例患者明确诊断为高危出血合并急性肺栓塞,其中死亡3例,好转27例.结论 肾挫裂伤的患者发生急性肺栓塞,在严密监测下,小剂量肝素抗凝安全,有效.高危出血患者合并急性肺栓塞是临床上非常棘手的问题,在权衡出血性疾病与肺栓塞引起不良预后的风险之后,需要在抗凝与出血之间摸索平衡点,在参考相关指南的前提下,执行个体化治疗方案,有助于改善预后.
Abstract
Objective To investigate the anticoagulant drug treatment decision for patients with renal contusion and acute pulmonary embolism,and to enhance the level of treatment for this disease.Methods A retrospective analysis of the clinical data of a patient with renal contusion and acute pulmonary embolism treated at the West China Hospital of Sichuan University,along with a relevant literature review.Databases including PubMed,Ovid Medline,Embase,VIP,Wanfang and Chinese National Knowledge infrastructure were searched using the keywords as"Pulmonary embolism"AND"Hemorrhage"from January 1983 to December 2023.Result The patient was a 21-year-old male who presented with right kidney contusion for 5 days and dyspnea for 1 day.The abdominal CT scan revealed a ruptured right kidney accompanied by hemorrhage and hematoma in the surrounding tissue.Abdomen ultrasound:a low echogenic area measuring approximately 10.6 cmx2.8 cm is noted around the right kidney.The CT pulmonary angiography(CTPA)demonstrated filling defects at the bifurcation of the pulmonary trunk,as well as within the upper and lower lobes of both lungs and their respective branches.The blood gas analysis of patient indicated(face mask oxygen therapy at 10 L/min,oxygenation index of 120):pH 7.456,PCO2 24.9 mm Hg,PO2 73.2 mm Hg.His myocardial markers were Myoglobin:79.21 ng/ml,Troponin T:58.7 ng/L,BNP:2062 ng/L.The patient was diagnosed with renal contusion and pulmonary embolism,and was treated with subcutaneous heparin(initial dose is given as an 80 IU/kg intravenous bolus,followed by a continuous infusion of 12-18 IU/kg/h)and low-molecular-weight heparin at a dose of 0.8 ml every 12 hours one after another for anticoagulation,along with symptomatic treatment.Following the intervention,the patient's respiratory distress showed significant improvement,and subsequent arterial blood gas analysis indicated enhanced oxygenation.Then,the anticoagulant medication was adjusted to oral rivaroxaban anticoagulation for 6 months,follow-up CTPA scan revealed complete resolution of the pulmonary embolism and the abdominal CT scan indicated a reduction in the extent of patchy low-density shadows surrounding the right kidney,leading to the discontinuation of anticoagulation therapy.After searching the above-mentioned databases,total of 26 articles were identified that reported on 30 patients diagnosed with high-risk bleeding and acute pulmonary embolism;among these,3 patients succumbed while 27 exhibited clinical improvement.Conclusions Patients with renal contusion and acute pulmonary embolism can be safely and effectively treated with low-dose heparin anticoagulation under close monitoring.High-risk bleeding patients with acute pulmonary embolism present a significant challenge in clinical practice.After weighing the risks of bleeding disorders and the adverse outcomes of pulmonary embolism,it is necessary to find the optimal balance between anticoagulation and bleeding.Consequently,the formulation of personalized treatment strategies in accordance with established guidelines can enhance patient outcomes.
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