D-二聚体动态监测对预测神经脊柱修复术后下肢深静脉血栓形成的意义
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摘要
背景:神经脊柱术后深静脉血栓的发生是临床神经外科及骨科手术常见的术后并发症,多与静脉内膜的损伤,血流的瘀滞以及凝血因子的激活作用相关。早期进行预测可有效避免深静脉血栓的发生对患者疾病预后的不良影响。D-二聚体在深静脉血栓预测中的应用具有极高的灵敏度以及特异度,是深静脉血栓的敏感预测指标。目的:探讨神经脊柱修复术后D-二聚体的血浆质量浓度与深静脉血栓发生的关系。方法:回顾性分析新疆医科大学第一附属医院神经外科2014年4月至2015年8月收治的神经脊柱手术患者83例,根据术后血浆D-二聚体的质量浓度分为2组,其中D-二聚体阳性组48例,D-二聚体阴性组35例。分别监测2组患者术前及术后1,3,5,9,14 d的D-二聚体血浆质量浓度,分析D-二聚体质量浓度与深静脉血栓发生的关系。结果与结论:12组患者术前D-二聚体的质量浓度比较差异无显著性意义(P>0.05);D-二聚体阳性组术后1,3,5,9,14 d的D-二聚体质量浓度均显著高于D-二聚体阴性组(P<0.05);2术后2组患者中D-二聚体呈阳性且浓度持续性增高的共有28例,经双下肢深静脉彩色多普勒超声检查后,D-二聚体阳性组出现深静脉血栓的患者有7例,肺栓塞的患者有4例;D-二聚体阴性组患者未出现深静脉血栓及肺栓塞;3结果提示,神经脊柱修复术后D-二聚体血浆浓度阳性提示有深静脉血栓发生的可能,若D-二聚体质量浓度持续增高,应高度警惕深静脉血栓的发生。
BACKGROUND:Deep vein thrombosis is a common postoperative complication after spinal surgery in clinical department of neurosurgery and department of orthopedics.Deep vein thrombosis is mostly related to vein intima injury,stasis and activation of blood coagulation factor.Early effective prediction can effectively avoid the adverse effects on the prognosis of patients with deep vein thrombosis.D-dimer used in the prediction of deep venous thrombosis has high sensitivity and specificity,and can be used as a sensitive predictor for deep vein thrombosis.OBJECTIVE:To explore the relationship between plasma D-dimer mass concentration and deep vein thrombosis after spinal surgery.METHODS:A total of 83 patients treated with spinal surgery collected from Department of Neurosurgery,First Affiliated Hospital of Xinjiang Medical University from April 2014 to August 2015 were retrospectively analyzed.They were divided into two groups according to postoperative plasma D-dimer mass concentration:D-dimer positive group(n=48) and D-dimer negative group(n=35).We monitored D-dimer mass concentration in both groups preoperatively and postoperatively 1,3,5,9 and 14 days,and analyzed the relationship between D-dimer mass concentration and deep vein thrombosis.RESULTS AND CONCLUSION:(1) No significant difference in D-dimer mass concentration was determined between the two groups(P > 0.05).D-dimer mass concentration was significantly higher in the D-dimer positive group than in the D-dimer negative group 1,3,5,9,and 14 days postoperatively(P < 0.05).(2) After operation,plasma D-dimer of 28 cases was positive,with persistent increasing.Double lower limb deep vein color Doppler ultrasound demonstrated that seven patients experienced deep vein thrombosis and four patients suffered from pulmonary embolism in D-dimer positive group.There was no deep vein thrombosis and pulmonary embolism in the D-dimer negative group.(3) These results indicate that positive D-dimer concentration of patients after spinal surgery suggests the possibility of deep vein thrombosis.If the concentration of D-dimer is persistently high,we should highly alert to the occurrence of deep vein thrombosis.
BACKGROUND:Deep vein thrombosis is a common postoperative complication after spinal surgery in clinical department of neurosurgery and department of orthopedics.Deep vein thrombosis is mostly related to vein intima injury,stasis and activation of blood coagulation factor.Early effective prediction can effectively avoid the adverse effects on the prognosis of patients with deep vein thrombosis.D-dimer used in the prediction of deep venous thrombosis has high sensitivity and specificity,and can be used as a sensitive predictor for deep vein thrombosis.OBJECTIVE:To explore the relationship between plasma D-dimer mass concentration and deep vein thrombosis after spinal surgery.METHODS:A total of 83 patients treated with spinal surgery collected from Department of Neurosurgery,First Affiliated Hospital of Xinjiang Medical University from April 2014 to August 2015 were retrospectively analyzed.They were divided into two groups according to postoperative plasma D-dimer mass concentration:D-dimer positive group(n=48) and D-dimer negative group(n=35).We monitored D-dimer mass concentration in both groups preoperatively and postoperatively 1,3,5,9 and 14 days,and analyzed the relationship between D-dimer mass concentration and deep vein thrombosis.RESULTS AND CONCLUSION:(1) No significant difference in D-dimer mass concentration was determined between the two groups(P > 0.05).D-dimer mass concentration was significantly higher in the D-dimer positive group than in the D-dimer negative group 1,3,5,9,and 14 days postoperatively(P < 0.05).(2) After operation,plasma D-dimer of 28 cases was positive,with persistent increasing.Double lower limb deep vein color Doppler ultrasound demonstrated that seven patients experienced deep vein thrombosis and four patients suffered from pulmonary embolism in D-dimer positive group.There was no deep vein thrombosis and pulmonary embolism in the D-dimer negative group.(3) These results indicate that positive D-dimer concentration of patients after spinal surgery suggests the possibility of deep vein thrombosis.If the concentration of D-dimer is persistently high,we should highly alert to the occurrence of deep vein thrombosis.
引文
[1]倪伟.骨科手术后深静脉血栓形成的预防研究及护理[J].中国社区医师,2015,31(19):127-128.
[2]姜延海.脊柱术后应用抗凝药物预防深静脉血栓安全性的相关研究[D].青岛大学,2014.
[3]中华医学会放射学分会介入学组.下肢深静脉血栓形成介入治疗规范的专家共识[J].中华放射学杂志,2011,45(3):293-296.
[4]潘颐聪.D-二聚体的监侧对评估急性期下下肢静脉血栓的疗效及预后的作用[D].广西医科大学,2013.
[5]司文腾,张华果,孙宜保,等.脊柱术后血浆D-二聚体浓度变化与深静脉血栓的关系研究[J].中国骨伤,2014,27(5):405-408.
[6]Schouten HJ,Geersing GJ,Koek HL,et al.Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism:systematic review and meta-analysis.BMJ.2013;346:f2492.
[7]赵玉芬,段小凯.D-二聚体定量检测在外科患者手术后病情监测中的应用[J].河南外科学杂志,2013,19(6):50-54.
[8]山慈明,尹慧珍,杜书明,等.围手术期深静脉血栓形成的物理预防研究进展[J].中华护理杂志,2014,49(3):349-354.
[9]刘华磊,王淑霞.下肢动静脉血栓30例超声诊断分析[J].河南外科学杂志,2015,21(3):130-131.
[10]陶方,季红莉,李中侠,等.高龄住院患者下肢深静脉血栓形成的临床分析及护理[J].河北医药,2015,37(15):2385-2387.
[11]欧永强.D-二聚体、同型半胱氨酸、超敏C反应蛋白对深静脉血栓性疾病早期诊断及预后的价值[J].中国老年学杂志,2012,11(32):2290-2293.
[12]沈毓,王龙,陈彬.深静脉血栓形成的实验室检查现状与进展[J].诊断学理论与实践,2011,10(2):172-174.
[13]李仁科,李学婷,王少华.麻醉对全髋关节置换术患者D-二聚体及深静脉血栓发生率的影响[J].医药论坛杂志,2012,33(11):115-118.
[14]王占鳌.静脉血栓栓塞症的临床预测模型构建研究[D].宁夏医科大学,2012
[15]邓长华.血浆D-二聚体对脊柱结核患者术后早期深静脉血栓形成的诊断价值[J].中国实验诊断学,2015,19(3):471-473.
[16]Kearon C,Ginsberg JS,Douketis J.Management of suspected deep vein thrombosis in outpatients by using clinical assessment and D-dimer testing.Ann Intern Med.2001;135(2):296-304.
[17]Anderson DR,Kovacs MJ,Kovacs G.Combined use of clinical assessment and D-dimer to improve the management of patients presenting to emergency department with suspected deep vein thrombosis(the EDITED Study).J Thromb Haemost.2003;1(4):645-651.
[18]Elf JL,Strandberg K,Nilsson C.Clinical probability assessment and D-dimer determination inpatients with suspected deep vein thrombosis,a prospective multicenter management study.Thromb Res.2009;123(4):612-616.
[19]葛闽霞,周兰芳,李爱强.血浆C反应蛋白及D-二聚体检测在脊柱手术中的应用[J].中医正骨,2012,24(6):66-68.
[20]张立涛,张静梅,梁俊生,等.老年人骨折后早期下肢深静脉血栓形成情况分析[J].中国骨质疏松杂志,2013,19(1):43-45,82.
[21]宫瑜,于红.周期性充气加压预防髋部骨折老年患者术后下肢深静脉血栓的效果[J].中华现代护理杂志,2013,19(22):2715-2718.
[22]Luxembourg B,Schwonberg J,Hecking C,et al.Performance of five D-dimer assays for the exclusion of symptomatic distal legvein thrombosis.Thromb Haemost.2012;107:369-378.
[23]王国杰,张灼锦.血浆D-二聚体检测对下肢深静脉血栓的早期诊断价值[J].实用医学杂志,2012,28(14):2368-2370.
[24]腾飞,何新华,杨杰,等.Wells评分联合D-dimer在急性肺栓塞诊断的临床预测价值[J].中华急诊医学杂志,2015,24(40):422-425.
[25]Penaloza A,Roy PM,Kline J,et al.Performance of age-adjusted D-dimer cut-off to rule out pulmonary embolism.J Thromb Haemost.2012;10(7):1291-1296.
[26]Righini M,Van Es J,Den Exter PL,et al.Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism:the ADJUST-PE study.JAMA.2014;311(11):1117-1124.
[27]Schouten HJ,Geersing GJ,Koek HL,et al.Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism:systematic review and meta-analysis.BMJ.2013;346:f2492.
[28]Lippi G,Favaloro EJ,Cervellin G.A review of the value of D-dimer testing for prediction of recurrent venous thromboembolism with increasingage.Semin Thromb Hemost.2014;40(6):634-639.
[29]Woller SC,Stevens SM,Adams DM,et al.Assessment of the safety and efficiency of using an age-adjusted D-dimer threshold to exclude suspected pulmonary embolism.Chest.2014;146(6):1444-1451.
[30]Mullier F,Vanpee D,Jamart J,et al.Comparison of five D-dimer reagents and application of an age-adjusted cut-off for the diagnosis of venous thromboembolism in emergency department.Blood Coagul Fibrinolysis.2014;25(4):309-315.
[31]余美琴,李俊来,曹晓林,等.老年下肢深静脉血栓患者D-二聚体的临界值研究[J].中华老年心脑血管病杂志,2013,15(1):32-34.
[32]陈霞,张晟.血浆D-二聚体浓度筛查辅助超声联合检测髋部骨折患者下肢深静脉血栓的价值[J].广东医学,2011,32(23):3080-3082.
[33]亓明,白云清.D-二聚体监测对老年长期卧床患者下肢深静脉血栓形成的早期诊断价值[J].中国老年学杂志,2013,33(17):4244-4245.
[34]欧永强.D-二聚体、同型半胱氨酸、超敏C反应蛋白对深静脉血栓性疾病早期诊断及预后的价值[J].中国老年学杂志,2012,32(11):2290-2291.
[35]张辉良,梁俊生,张洪斌,等.利伐沙班与华法林治疗老年髋部骨折术前并存下肢深静脉血栓比较研究[J].长春中医药大学学报,2013,29(2):323-324.
[36]侯伟,熊小明,万趸.骨盆骨折内固定术中应用普通肝素对术后下肢深静脉血栓发生率的影响[J].四川医学,2015,36(7):996-999.
[37]沈明荃,谢增如.复合骨折后下肢深静脉血栓形成Wells评分与D-二聚体及纤维蛋白降解产物的预测[J].中国组织工程研究,2014,18(38):6136-6140.
[38]张纪媛,郭丹青,何惠.下肢深静脉血栓患者外周血血小板p-选择素、D二聚体及超敏C反应蛋白的表达及临床意义[J].中国医药导报,2014,11(20):34-36.
[39]殷明春.D-二聚体在老年下肢深静脉血栓预测中的临界值探讨[J].中国医药导刊,2014,11(2):313-314.
[40]陆燕,蔡攀,汤明荣,等.高龄髋部骨折患者围术期D-二聚体的测定及临床意义[J].国际检验医学杂志,2015,36(1):25-26.
[2]姜延海.脊柱术后应用抗凝药物预防深静脉血栓安全性的相关研究[D].青岛大学,2014.
[3]中华医学会放射学分会介入学组.下肢深静脉血栓形成介入治疗规范的专家共识[J].中华放射学杂志,2011,45(3):293-296.
[4]潘颐聪.D-二聚体的监侧对评估急性期下下肢静脉血栓的疗效及预后的作用[D].广西医科大学,2013.
[5]司文腾,张华果,孙宜保,等.脊柱术后血浆D-二聚体浓度变化与深静脉血栓的关系研究[J].中国骨伤,2014,27(5):405-408.
[6]Schouten HJ,Geersing GJ,Koek HL,et al.Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism:systematic review and meta-analysis.BMJ.2013;346:f2492.
[7]赵玉芬,段小凯.D-二聚体定量检测在外科患者手术后病情监测中的应用[J].河南外科学杂志,2013,19(6):50-54.
[8]山慈明,尹慧珍,杜书明,等.围手术期深静脉血栓形成的物理预防研究进展[J].中华护理杂志,2014,49(3):349-354.
[9]刘华磊,王淑霞.下肢动静脉血栓30例超声诊断分析[J].河南外科学杂志,2015,21(3):130-131.
[10]陶方,季红莉,李中侠,等.高龄住院患者下肢深静脉血栓形成的临床分析及护理[J].河北医药,2015,37(15):2385-2387.
[11]欧永强.D-二聚体、同型半胱氨酸、超敏C反应蛋白对深静脉血栓性疾病早期诊断及预后的价值[J].中国老年学杂志,2012,11(32):2290-2293.
[12]沈毓,王龙,陈彬.深静脉血栓形成的实验室检查现状与进展[J].诊断学理论与实践,2011,10(2):172-174.
[13]李仁科,李学婷,王少华.麻醉对全髋关节置换术患者D-二聚体及深静脉血栓发生率的影响[J].医药论坛杂志,2012,33(11):115-118.
[14]王占鳌.静脉血栓栓塞症的临床预测模型构建研究[D].宁夏医科大学,2012
[15]邓长华.血浆D-二聚体对脊柱结核患者术后早期深静脉血栓形成的诊断价值[J].中国实验诊断学,2015,19(3):471-473.
[16]Kearon C,Ginsberg JS,Douketis J.Management of suspected deep vein thrombosis in outpatients by using clinical assessment and D-dimer testing.Ann Intern Med.2001;135(2):296-304.
[17]Anderson DR,Kovacs MJ,Kovacs G.Combined use of clinical assessment and D-dimer to improve the management of patients presenting to emergency department with suspected deep vein thrombosis(the EDITED Study).J Thromb Haemost.2003;1(4):645-651.
[18]Elf JL,Strandberg K,Nilsson C.Clinical probability assessment and D-dimer determination inpatients with suspected deep vein thrombosis,a prospective multicenter management study.Thromb Res.2009;123(4):612-616.
[19]葛闽霞,周兰芳,李爱强.血浆C反应蛋白及D-二聚体检测在脊柱手术中的应用[J].中医正骨,2012,24(6):66-68.
[20]张立涛,张静梅,梁俊生,等.老年人骨折后早期下肢深静脉血栓形成情况分析[J].中国骨质疏松杂志,2013,19(1):43-45,82.
[21]宫瑜,于红.周期性充气加压预防髋部骨折老年患者术后下肢深静脉血栓的效果[J].中华现代护理杂志,2013,19(22):2715-2718.
[22]Luxembourg B,Schwonberg J,Hecking C,et al.Performance of five D-dimer assays for the exclusion of symptomatic distal legvein thrombosis.Thromb Haemost.2012;107:369-378.
[23]王国杰,张灼锦.血浆D-二聚体检测对下肢深静脉血栓的早期诊断价值[J].实用医学杂志,2012,28(14):2368-2370.
[24]腾飞,何新华,杨杰,等.Wells评分联合D-dimer在急性肺栓塞诊断的临床预测价值[J].中华急诊医学杂志,2015,24(40):422-425.
[25]Penaloza A,Roy PM,Kline J,et al.Performance of age-adjusted D-dimer cut-off to rule out pulmonary embolism.J Thromb Haemost.2012;10(7):1291-1296.
[26]Righini M,Van Es J,Den Exter PL,et al.Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism:the ADJUST-PE study.JAMA.2014;311(11):1117-1124.
[27]Schouten HJ,Geersing GJ,Koek HL,et al.Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism:systematic review and meta-analysis.BMJ.2013;346:f2492.
[28]Lippi G,Favaloro EJ,Cervellin G.A review of the value of D-dimer testing for prediction of recurrent venous thromboembolism with increasingage.Semin Thromb Hemost.2014;40(6):634-639.
[29]Woller SC,Stevens SM,Adams DM,et al.Assessment of the safety and efficiency of using an age-adjusted D-dimer threshold to exclude suspected pulmonary embolism.Chest.2014;146(6):1444-1451.
[30]Mullier F,Vanpee D,Jamart J,et al.Comparison of five D-dimer reagents and application of an age-adjusted cut-off for the diagnosis of venous thromboembolism in emergency department.Blood Coagul Fibrinolysis.2014;25(4):309-315.
[31]余美琴,李俊来,曹晓林,等.老年下肢深静脉血栓患者D-二聚体的临界值研究[J].中华老年心脑血管病杂志,2013,15(1):32-34.
[32]陈霞,张晟.血浆D-二聚体浓度筛查辅助超声联合检测髋部骨折患者下肢深静脉血栓的价值[J].广东医学,2011,32(23):3080-3082.
[33]亓明,白云清.D-二聚体监测对老年长期卧床患者下肢深静脉血栓形成的早期诊断价值[J].中国老年学杂志,2013,33(17):4244-4245.
[34]欧永强.D-二聚体、同型半胱氨酸、超敏C反应蛋白对深静脉血栓性疾病早期诊断及预后的价值[J].中国老年学杂志,2012,32(11):2290-2291.
[35]张辉良,梁俊生,张洪斌,等.利伐沙班与华法林治疗老年髋部骨折术前并存下肢深静脉血栓比较研究[J].长春中医药大学学报,2013,29(2):323-324.
[36]侯伟,熊小明,万趸.骨盆骨折内固定术中应用普通肝素对术后下肢深静脉血栓发生率的影响[J].四川医学,2015,36(7):996-999.
[37]沈明荃,谢增如.复合骨折后下肢深静脉血栓形成Wells评分与D-二聚体及纤维蛋白降解产物的预测[J].中国组织工程研究,2014,18(38):6136-6140.
[38]张纪媛,郭丹青,何惠.下肢深静脉血栓患者外周血血小板p-选择素、D二聚体及超敏C反应蛋白的表达及临床意义[J].中国医药导报,2014,11(20):34-36.
[39]殷明春.D-二聚体在老年下肢深静脉血栓预测中的临界值探讨[J].中国医药导刊,2014,11(2):313-314.
[40]陆燕,蔡攀,汤明荣,等.高龄髋部骨折患者围术期D-二聚体的测定及临床意义[J].国际检验医学杂志,2015,36(1):25-26.