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目的探讨动脉导管未闭(patent ductus arteriosus,PDA)介入封堵术后严重血小板减少的原因。方法收集重庆医科大学附属儿童医院2006年1月至2016年11月PDA介入封堵术后发生严重血小板减少的病例,分析严重血小板减少发生的高危因素、诊治措施及预后。结果共收集介入封堵PDA患儿848例,其中发生严重血小板减少11例,发生率为1.29%。11例患儿年龄(1.4±0.5)岁,包括男性3例,女性8例。降主动脉造影测PDA直径为(7.9±3.0)mm,选择封堵器前伞直径8~18(11.6±2.5)mm,术后1 d复查心脏超声发现7例患儿有不同程度残余分流。患儿术前血小板为(261.0±74.9)×10~9/L,术后血小板最低下降至(23.4±9.3)×10~9/L。8例发生于术后第1~3天,2例发生于术后第4天,1例发生于术后第6天;8例出现皮肤出血点,3例合并鼻衄,1例合并溶血,6例合并中度贫血(Hb:71~86 g/L),所有病例无重要脏器出血。8例术后1~3 d出现发热,1例合并穿刺处巨大血肿。除1例21-三体综合征患儿合并室间隔缺损封堵术后出现顽固性血小板减少和溶血,内科治疗3周无效转外科手术后血小板恢复外,其余经止血、输注血小板、激素、丙种球蛋白等内科治疗后,9例于术后2周内血小板恢复正常,1例于术后第8周恢复正常。结论 PDA介入封堵术后严重血小板减少的发生可能与PDA直径较大、封堵器直径较大、残余分流、术后感染、穿刺处血肿有关,经正规内科保守治疗,预后良好。
Objective To investigate the causes of severe thrombocytopenia after patent ductus arteriosus (PDA) closure. Methods A case of severe thrombocytopenia after PDA interventional closure in children’s hospital of Chongqing Medical University from January 2006 to November 2016 was collected to analyze the risk factors, diagnosis and treatment measures and prognosis of severe thrombocytopenia. Results A total of 848 cases of PDA were collected and involved in the occlusion of PDA, in which 11 cases had severe thrombocytopenia, the incidence rate was 1.29%. Eleven patients (1.4 ± 0.5) years of age, including 3 males and 8 females. The PDA diameter of the descending aorta was (7.9 ± 3.0) mm and the diameter of the anterior umbrella of the occluder was 8-18 (11.6 ± 2.5) mm. Seven days after the echocardiographic examination, 7 children had residual shunt with different degrees. Preoperative platelets in children with (261.0 ± 74.9) × 10 ~ 9 / L, postoperative platelet decreased to (23.4 ± 9.3) × 10 ~ 9 / L. 8 cases occurred on the 1st to 3rd days postoperatively, 2 cases occurred on the 4th day postoperatively, 1 case occurred on the 6th day postoperatively. Bleeding points were found in 8 cases, nasal mucosa in 3 cases, hemolysis in 1 case, 6 cases with moderate anemia (Hb: 71 ~ 86 g / L), all cases without significant organ bleeding. In 8 cases, 1 to 3 days after operation, fever occurred and 1 case had massive hematoma at the puncture site. In addition to a case of trisomy 21 cases with ventricular septal defect occlusion of patients with stubborn thrombocytopenia and hemolysis, medical treatment 3 weeks invalid after surgery to restore platelets, the rest of the hemostasis, transfusion of platelets, hormones, 9 cases of normal blood platelets returned to normal within 2 weeks after surgery and 1 case returned to normal after 8 weeks of surgery. Conclusion The incidence of severe thrombocytopenia after PDA closure may be related to the larger diameter of PDA, the larger diameter of occluder, residual shunt, postoperative infection and hematoma at puncture site. The conservative treatment with formal internal medicine has a good prognosis.