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特发性血小板减少性紫癜以眼科症状为首诊一例

腹腔镜脾切除术治疗特发性血小板减少性紫癜的护理

【摘要】 目的 〖JP2〗总结腹腔镜脾切除术治疗特发性血小板减少性紫癜患者围手术期的护理。 方法 2005年11月-2008年6月，对40例行腹腔镜脾切除术治疗特发性血小板减少性紫癜患者，在术前、术后予以精心护理，并针对患者个体及各种征状，采取积极有效的护理措施，防止各种并发症发生。 结果 38例患者顺利康复出院；1例术后出血，经积极治疗后治愈出院；1例发生左下肢深静脉血栓，经抗凝溶栓治疗后好转出院。 结论 有效的围手术期护理能降低腹腔镜脾切除术后并发症的发生，减轻患者的痛苦，促进患者早期康复。

肝素诱导的血小板减少症一例的诊治体会

肝素诱导的血小板减少症（heparin-induced thrombocytopenia，HIT）是一种罕见疾病，以血小板减少和血栓形成为主要特征。HIT可分为Ⅰ型和Ⅱ型。Ⅰ型HIT较常见，不是免疫性反应，很可能与肝素直接激活血小板有关，是一种良性反应。血小板计数多大于100×109/L，极少显著降低，且可自行恢复。Ⅱ型HIT则是免疫介导的综合征，与很多因素有关，各种给药方式都可引发，如静脉或皮下注射，甚至接触极少量肝素等。本文报告1例行冠脉介入手术使用肝素后发生血小板减少，肺泡出血及深静脉血栓形成，改为磺达肝癸钠抗凝后病情好转出院患者的诊治经过，并结合相关文献进行讨论，以提高对这一罕见疾病的认识及处理能力。临床资料 患者男性，61岁。因“持续胸骨后压榨样疼痛8 h”于2010年2月28日入院。患者于入院前8 h无明显诱因下出现持续性胸骨后压榨性疼痛，无心悸、呼吸困难、咳嗽、咯血，无头晕、意识丧失，休息后无法缓解。患者至我院急诊就诊，行心电图检查示急性前壁非ST段抬高性心肌梗死。立即急诊行冠脉造影+内支架植入术，在前降支近段，回旋支，前降支第一对角支处分别植入3枚Firebird球囊支架，术中应用普通肝素8500 U抗凝。患者术中血压、心率稳定，未诉不适。术后给予低分子肝素钙0.4 mL皮下注射1次/12 h抗凝，术后以“冠心病，急性心肌梗死”收入我院心血管内科。既往有高血压病史10余年，最高血压为200/110 mm Hg（1 mm Hg=0.133 kPa），不规律服药，血压控制不佳。无吸烟，饮酒史。入院体检：体温37.3 ℃，脉搏112次/min，呼吸23次/min，血压155/83 mm Hg。神志清，精神萎靡，心率112次/min，律齐，各瓣膜区未闻及明显杂音，两肺叩诊音略浊，右下肺可闻及少许散在湿啰音，各瓣膜区未及病理性杂音。腹部、脊柱、四肢检查无明显异常发现。

Correlation between thrombocytopenia and short-term prognosis of patients with in-hospital cardiac arrest after spontaneous circulation recovery

Objective To investigate the relationship between thrombocytopenia after the restoration of spontaneous circulation and short-term prognosis of patients with in-hospital cardiac arrest. Methods The demographic data, post-resuscitation vital signs, post-resuscitation laboratory tests, and the 28-day mortality rate of patients who experienced in-hospital cardiac arrest at the Emergency Department of West China Hospital, Sichuan University between January 1st, 2016 and December 31st, 2016 were retrospectively analyzed. Logistic regression was used to analyze the correlation between thrombocytopenia after the return of spontaneous circulation and the 28-day mortality rate in these cardiac arrest patients. Results Among the 285 patients included, compared with the normal platelet group (n=130), the thrombocytopenia group (n=155) showed statistically significant differences in red blood cell count, hematocrit, white blood cell count, prothrombin time, activated partial thromboplastin time, and international normalized ratio (P<0.05). The 28-day mortality rate was higher in the thrombocytopenia group than that in the normal platelet group (84.5% vs. 71.5%, P=0.008). Multiple logistic regression analysis indicated that thrombocytopenia [odds ratio =2.260, 95% confidence interval (1.153, 4.429), P=0.018] and cardiopulmonary resuscitation duration [odds ratio=1.117, 95% confidence interval (1.060, 1.177), P<0.001] were independent risk factors for 28-day mortality in patients with in-hospital cardiac arrest. Conclusion Thrombocytopenia after restoration of spontaneous circulation is associated with poor short-term prognosis in patients with in-hospital cardiac arrest.

Clinical Observation of Splenectomy on Chronic Idiopathic Thrombocytopenic Purpura

ObjectiveTo study the results of splenectomy in patients with idiopathic thrombocytopenic purpura. MethodsSeven patients who failed to respond to conservative management were treated with splenectomy and followed up for 6 months to 8 years (1990～1999).ResultsThe presplenectomy patients had symptoms of bleeding and their platelet count on average was 32×109/L. The 3th,7th day and 1th,2th, 6th month after splenectomy, the average platelet count was 191×109/L,354×109/L,317×109/L,200×109/L and 151×109/L respectively. Their platelet recovered to normal during a week in 7 cases (≥100×109/L); In 6 patients the platelet count was normal in the 6th month after splenectomy, the success rate was 6/7, the rate of remission was 1/6. The platelet count after splenectomy was significantly higher than that before splenectomy.ConclusionThere are no correlation between the course of disease before splenectomy and the results of splenectomy. Splenectomy is safe and effective in the treatment of idiopathic thrombocytopenic purpura.

Expression and clinical significance of immune cell subsets in elderly patients with primary immune thrombocytopenia

Objective To investigate the expression and clinical significance of T lymphocyte subsets, natural killer (NK) cells and CD19+ B cells in the elderly with primary immune thrombocytopenia (ITP) before and after treatment. Methods The elderly ITP patients diagnosed and treated in the Songjiang Hospital Affiliated to Shanghai Jiaotong University School of Medicine (preparatory stage) between January 2014 and June 2019 were retrospectively selected as the observation group. The healthy elderly in the same period were selected as the control group. According to the treatment, the observation group was divided into effective group and ineffective group. The expression levels of T lymphocyte subsets (CD3+, CD4+, CD8+ and CD4+/CD8+), NK cells and CD19+ B cells were observed and analyzed. Results A total of 75 subjects were included, including 35 in the observation group and 40 in the control group. The total effective rate was 85.71% (30/35). Before treatment, the expression levels of T lymphocyte subsets (CD3+, CD4+ and CD4+/CD8+) in the observation group were lower than those in the control group (P<0.05). There was no significant difference in other indexes between the two groups (P>0.05). After treatment, except for CD8+, the expression levels of T lymphocyte subsets (CD3+, CD4+ and CD4+/CD8+) in the observation group were higher than those before treatment (P<0.05). The expression levels of NK cells and CD19+ B cells were lower than those before treatment (P<0.05). The expression levels of T lymphocyte subsets (CD3+, CD4+ and CD4+/CD8+) in the effective group were higher than those before treatment (P<0.05), while the expression level of CD19+ B cells was lower than that before treatment (P<0.05). There was no significant difference in other indexes before and after treatment (P>0.05). There was no significant difference in the expression levels of T lymphocyte subsets (CD3+, CD4+, CD8+ and CD4+/CD8+), NK cells and CD19+ B cells in the ineffective group before and after treatment (P>0.05). Conclusions T lymphocyte subsets are abnormal in elderly ITP patients. The immune abnormality of T lymphocyte may be one of the reasons for elderly patients with ITP. With the improvement of therapeutic effect, immune cell subsets have also been improved.

Laparoscopic Splenectomy for Idiopathic Thrombocytopenic Purpura in 20 Cases

目的　探讨腹腔镜下脾切除术（LS）治疗特发性血小板减少性紫癜(ITP)的临床效果。方法　我院2003年1月至2008年8月期间行LS治疗ITP患者20例，将术前与术后1、2、7、14、30、90及180 d的血小板计数进行比较。结果　20例ITP患者均顺利完成LS，平均手术时间为156 min，术中出血平均50 ml，平均住院时间为9 d。完全停用药物14例； 4例患者术后需继续服用激素治疗，但激素用量较前明显减少； 无效2例。总有效率为90%。术后1、2、7、14、30、90及180 d的血小板数量分别为(251.6±91.4)×109/L、(312.6±90.1)×109/L、(343.2±103.7)×109/L、(300.0±98.2)×109/L、(175.6±42.6)×109/L、(151.8±42.1)×109/L及(207.0±53.4)×109/L,分别与术前〔(38.3±19.4)×109/L〕比较，经t检验，差异均有统计学意义（P＜0.001）。结论　LS治疗ITP是可行和安全的，手术效果满意。

狼疮肾炎伴血栓性血小板减少性紫癜一例

Status and clinical significance of thrombocytopenia after cardiac surgery in adults

ObjectiveTo observe the status of thrombocytopenia in adult patients after cardiac surgery, and to explore its mechanism and clinical significance.MethodsRetrospective analysis of 240 patients after cardiac surgery in the 2nd ward of surgical intensive care unit (ICU) of Fuwai Hospital from May to June 2020 was conducted, including 137 males and 103 females with a mean age of 56.0±12.0 years. According to postoperative platelet status, the patients were divided into a thrombocytopenia group and a non-thrombocytopenia group. The clinical baseline data, preoperative platelet count, postoperative minimum platelet count, volume of drainage, transfusion of blood products, mechanical ventilator time, ICU stay, hospital stay and complications were compared between the two groups.ResultsThe mean preoperative platelet count was 199×109/L±55×109/L and the mean postoperative platelet nadir was 109×109/L±37×109/L, with a mean reduction rate of 44.1%±15.8%. The platelet count of 235 (97.9%) patients after operation was lower than that before operation. Among them, 98 (40.8%) patients had platelet count<100×109/L, 46 (19.2%)<75×109/L and 8 (3.3%)<50×109/L. Results of multivariable logistic analysis showed that cardiopulmonary bypass time>120 min (OR=2.576, 95%CI 1.313-5.053, P<0.05) was an independent risk factor for postoperative thrombocytopenia. Mechanical ventilator time (25.5±16.8 h vs. 17.3±8.5 h, P<0.05), ICU stay (85.2±54.7 h vs. 60.0±33.9 h, P<0.05) and hospital stay (15.8±6.2 d vs. 14.2±3.9 d, P<0.05) were longer in the thrombocytopenia group (<100×109/L) compared with the non-thrombocytopenia group (>100×109/L). More drainage volume [685 (510, 930) mL vs. 560 (440, 790) mL, P<0.05] and complications occurred in the thrombocytopenia group. In multivariable analysis, thrombocytopenia was significantly inversely associated with prolonged ICU stay (OR=2.993, 95%CI 1.622-5.524, P<0.05).ConclusionThrombocytopenia occurs commonly after adult cardiac surgery, and the incidence in different types of surgery varies. Postoperative thrombocytopenia is related to the prolonged recovery. Extracorporeal circulation may be a contributing factor to thrombocytopenia, and further studies investigating mechanism and strategies to reduce postoperative thrombocytopenia are needed.

慢性/复发性原发免疫性血小板减少症合并抗 O 升高二例