70岁以上与60岁以下骨水泥型人工股骨头置换术患者围手术期凝血功能变化的比较研究

目的：研究70岁以上高龄患者骨水泥型人工股骨头置换术围手术期凝血功能的变化.方法：回顾性分析我院2005年1月-2010年12月行骨水泥型人工股骨头置换术患者80例.根据年龄分为高龄组（≥70岁,37例）和非高龄组（＜60岁,43例）,比较两组患者术前、手术当天、术后第3天及第7天凝血酶原时间（PT）、部分凝血活酶时间（APTT）、凝血酶时间（TT）、凝血酶原活动度（PTA）、国际标准化比值（INR）、纤维蛋白原（FIB）、D-二聚体（DD）、抗凝血酶Ⅲ（ATⅢ）、血小板（PLT）水平.结果：与术前相比,两组患者术后当天FIB、DD显著升高（P＜0.05）,ATⅢ降低（P＜0.05）,提示两组均处于高凝状态,且纤溶亢进,此时段TT延长（P＜0.05）、PT延长（P＜0.01）,血小板明显降低,提示存在出血风险.术后第3天,两组TT、PT显著延长（P＜ 0.01）,非高龄组FIB、DD较手术当天明显下降,且恢复至术前水平,PLT恢复显著,高龄组DD降至术前水平,而FIB仍处于较高水平,PLT恢复不显著.非高龄组ATⅢ恢复至术前水平,高龄组ATⅢ恢复较慢,提示高龄组术后第3天有明显的出血倾向,且高凝状态依然持续.术后第7天,除高龄组FIB仍未恢复外,其余指标基本恢复至术前水平,提示凝血与纤溶系统趋于平衡;组间比较,术后当天FIB、INR升高幅度大于非高龄组（P＜0.05）;术后第3天,两组间INR、FIB、DD和PLT变化幅度有统计学差异.结论：骨水泥型人工股骨头置换术对70岁以上高龄患者凝血功能有显著影响,术后高凝状态,纤溶亢进,存在出血倾向,且高凝状态持续时间明显长于60岁以下患者,凝血功能恢复速度慢于60岁以下患者,提示高龄患者围手术期应更加谨慎使用抗凝药物并适当补充凝血因子.

Comparison on perioperative blood coagulation features after cemented artificial femoral head replacement in patients aged 70 years or older compared with those younger than 60 years

Objective：To compare the change in blood coagulation function after cemented artificial femoral head replacement in elderly patients （≥70 years） with those in younger patients （〈60 years）. Methods： Clinical data of 80 cases with cemented artificial femoral head replacement were retrospectively analyzed. The patients were divided into two groups based on the age： elderly group and younger group. Several parameters were analyzed preoperatively, on day of operation, and 3 and 7 days after the operation, including the number of platelet（PLT）, prothrombin time（PT）, activated partial thromboplastin time （APTT）, prothrombin activity（PTA）, fibrinogen （FIB）, international normalized ratio （INR） and thrombin time（TT）, D-dimer（DD）, antithrombin III （AT III ）. Results： Compared with the values recorded before operation, the FIB and DD of both groups were elevated （P〈 0.05）, while AT III was lowered （P〈0.05） in postoperative day, suggesting hypercoagulability with hyperfibrinolysis state, and at the same time TT and PT were prolonged significantly（P〈0.05）, and platelets decreased, suggesting that there was risk of bleeding. Three days after operation, TT, PT of both groups were significantly prolonged （P〈0.01）. The FIB, DD in younger group decreased significantly, and PLT recovered;DD in the elderly group returned to the preoperative level, but FIB was still on a high level, and recovery of PLT was not significant. AT III in non-elderly group returned to the preoperative level, while that of elderly group recovered slowly, suggesting that the elderly group was still in hypercoagulability state, with existence of bleeding tendency. Seven days after surgery, except the persistence of FIB in elderly group, other parameters recovered to the preoperative level, indicating there was a balance between coagulation and fibrinolytic system. When two groups were compared, DD of elderly group was higher than the younger group, and PLT was lower in preoperative day. On first postoperative day, FIB and INR in elderly group increased more than non-elderly group （P〈0.05）. Three days after the operation, there was significance in the values of FIB, INR, DD and PLT between two groups. Conehlsion： The operation of cemented artificial femoral head replacement in elderly patients aged over 70 years can affect the blood coagulation significantly, and duration of hypercoagulable state is significantly longer than that of patients below 60 years of old, and it recovers more slowly, which suggest that the elderly patients should be given coagulation factors appropriately with restriction in the use of anticoagulant drugs.