Macdonald R L, Amidei C, Lin G, Munshi I, Baron J, Weir B K, Brown F, Erickson R K, Hekmatpanah J
Department of Surgery, Pritzker School of Medicine, University of Chicago Medical Center, Illinois 60637, USA.
Neurosurgery. 1999 Aug;45(2):245-51; discussion 251-2. doi: 10.1097/00006123-199908000-00008.
To determine whether perioperative subcutaneous heparin is safe to use for patients undergoing craniotomy and to determine the incidence of venous thromboembolism in patients undergoing craniotomy.
Perioperative prophylaxis with subcutaneous heparin, 5000 U every 12 hours, was begun at induction of anesthesia for craniotomy and continued for 7 days postoperatively or until the patient was ambulating. Entry criteria to the study included patient age over 18 years and no evidence of deep vein thrombosis (DVT) preoperatively as judged by lower limb duplex ultrasound. Patients were excluded if they had duplex evidence of DVT or clinical evidence of pulmonary embolus (PE) preoperatively, had hypersensitivity to heparin or related products, had sustained a penetrating head injury, or refused informed consent. Any patient undergoing craniotomy was eligible, including patients with a ruptured aneurysm or arteriovenous malformation and those with spontaneous intracranial hemorrhage. Patients underwent duplex study 1 week after surgery and 1 month of clinical follow-up. Records were also kept on 68 nonstudy patients who refused consent. All patients were treated with lower limb pneumatic compression devices.
One hundred six patients were treated. No differences were noted between study and nonstudy patients in some individual risk factors for DVT or PE, such as obesity, smoking, paralysis, infection, pregnancy or postpartum state, varicose veins, heart failure, or previous DVT or PE. Significantly more (43 of 106) patients in the study group had a history of risk factors for DVT or PE, particularly malignancy, however, compared with nonstudy patients (20 of 68 patients; chi2, P < 0.01). There were no differences between groups in intraoperative blood loss, transfusion requirements, or postoperative platelet counts. Four clinically significant hemorrhages occurred during surgery in patients receiving heparin. Three resulted from intraoperative aneurysm rupture and one from intraventricular bleeding during resection of an arteriovenous malformation. These events were believed to be related to known complications of these operations, not to heparin. Of the study patients, two developed symptomatic DVT and one developed a nonfatal PE during the 1-month postoperative period. One additional study patient developed DVT below the popliteal veins, which was not treated. Four study patients developed DVT 1 to 2 months after surgery. In nonstudy patients, three developed DVT and two developed PE (one fatal, one nonfatal).
Perioperative heparin may be safe to administer to patients undergoing craniotomy, but a larger study is needed to demonstrate efficacy.
确定围手术期皮下注射肝素用于开颅手术患者是否安全，并确定开颅手术患者静脉血栓栓塞的发生率。
在开颅手术麻醉诱导时开始围手术期皮下注射肝素预防，每12小时注射5000单位，术后持续7天或直至患者能走动。研究的入选标准包括患者年龄超过18岁且术前经下肢双功超声检查无深静脉血栓形成（DVT）证据。如果患者术前有双功超声检查显示DVT或肺栓塞（PE）的临床证据、对肝素或相关产品过敏、有穿透性头部损伤或拒绝知情同意，则被排除。任何接受开颅手术的患者均符合条件，包括患有动脉瘤破裂或动静脉畸形以及自发性颅内出血的患者。患者在术后1周接受双功超声检查并进行1个月的临床随访。还记录了68名拒绝同意的非研究患者的情况。所有患者均接受下肢气动压迫装置治疗。
106例患者接受了治疗。在DVT或PE的一些个体危险因素方面，如肥胖、吸烟、瘫痪、感染、妊娠或产后状态、静脉曲张、心力衰竭或既往DVT或PE，研究组和非研究组患者之间未发现差异。然而，与非研究患者（68例中的20例）相比，研究组中有更多（106例中的43例）患者有DVT或PE的危险因素史，尤其是恶性肿瘤（卡方检验，P<0.01）。两组在术中失血量、输血需求或术后血小板计数方面无差异。接受肝素治疗的患者在手术期间发生了4例具有临床意义的出血。3例是由于术中动脉瘤破裂，1例是在切除动静脉畸形时发生脑室内出血。这些事件被认为与这些手术已知的并发症有关，而非肝素。在研究患者中，2例在术后1个月内发生有症状的DVT，1例发生非致命性PE。另有1例研究患者在腘静脉以下发生DVT，未进行治疗。4例研究患者在术后1至2个月发生DVT。在非研究患者中，3例发生DVT，2例发生PE（1例致命，1例非致命）。
围手术期给予开颅手术患者肝素可能是安全的，但需要更大规模的研究来证明其疗效。
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