Priglinger U, Delle Karth G, Geppert A, Joukhadar C, Graf S, Berger R, Hülsmann M, Spitzauer S, Pabinger I, Heinz G
Department of Cardiology, University of Vienna, Austria.
Crit Care Med. 2003 May;31(5):1405-9. doi: 10.1097/01.CCM.0000059725.60509.A0.
Subcutaneously administered low-molecular-weight heparins are widely used for prevention of venous thromboembolism. The appropriateness of the subcutaneous route in critically ill patients has never been established.
To determine anti-Xa activities in critically ill patients and in noncritically ill patients receiving prophylactic doses of subcutaneous enoxaparin.
Prospective, controlled, open-labeled study.
Tertiary medical-cardiologic-postoperative intensive care unit and a general medical ward at a university hospital.
A total of 16 intensive care unit patients (group 1; age, 61.1 +/- 16 yrs; male/female ratio, 7/9; Acute Physiology and Chronic Health Evaluation II score, 20.9 +/- 7; mechanical ventilation, n = 15; vasopressors, n = 13) and 13 noncritically ill medical patients (group 2; age, 61.7 +/- 9 yrs; male/female ratio, 7/6) were studied. Body mass index (25.7 +/- 5 vs. 24 +/- 6 kg/m2, p = not significant) was comparable and serum creatinine levels (0.83 +/- 0.25 vs. 1.07 +/- 0.3 mg/dL, group 1 vs. 2) were within the normal range in both groups. Patients with impaired renal function, receiving hemofiltration, or requiring therapeutic anticoagulation were not eligible.
None.
Anti-Xa activities were determined at 0, 1, 3, 6, and 12 hrs after a single daily subcutaneous dose of 40 mg enoxaparin on day 1 and at 3 hrs after 40 mg of enoxaparin on days 2-5. Mean anti-Xa levels at 0 to 12 hrs were consistently lower in group 1 compared with group 2 by analysis of variance (p =.001 between groups and over time), as was the area under the curve at 0 to 12 hrs (2.6 +/- 1 vs. 4.2 +/- 1.7 units x mL(-1) x hr(-1), group 1 vs. 2, p =.008). Significant differences in anti-Xa activity were also found on days 2-5 (p =.001). Peak anti-Xa activities at 3 hrs after administration were negatively correlated with the body mass index (r = -.41, p <.03). No correlation was found between the anti-Xa activity at 3 hrs and the dose of norepinephrine (r =.12, p =.7).
Critically ill patients with normal renal function demonstrated significantly lower anti-Xa levels in response to a single daily dose of subcutaneous enoxaparin when compared with medical patients in the normal ward.
皮下注射低分子量肝素广泛用于预防静脉血栓栓塞。但在重症患者中皮下给药途径的适宜性尚未得到证实。
测定接受预防性剂量皮下注射依诺肝素的重症患者和非重症患者的抗Xa活性。
前瞻性、对照、开放标签研究。
大学医院的三级医疗-心脏病学-术后重症监护病房和普通内科病房。
共研究了16例重症监护病房患者（第1组；年龄61.1±16岁；男女比例7/9；急性生理与慢性健康状况评分II为20.9±7；15例接受机械通气；13例使用血管升压药）和13例非重症内科患者（第2组；年龄61.7±9岁；男女比例7/6）。两组的体重指数（25.7±5 vs. 24±6 kg/m²，p无统计学意义）相当，血清肌酐水平（第1组vs.第2组，0.83±0.25 vs. 1.07±0.3 mg/dL）均在正常范围内。肾功能受损、接受血液滤过或需要治疗性抗凝的患者不符合入选标准。
无。
在第1天每日单次皮下注射40 mg依诺肝素后0、1、3、6和12小时以及第2 - 5天注射40 mg依诺肝素后3小时测定抗Xa活性。通过方差分析，第1组0至12小时的平均抗Xa水平始终低于第2组（组间及随时间变化，p = 0.001），0至12小时的曲线下面积也是如此（第1组vs.第2组，2.6±1 vs. 4.2±1.7单位×mL⁻¹×hr⁻¹，p = 0.008）。在第2 - 5天抗Xa活性也存在显著差异（p = 0.001）。给药后3小时的抗Xa活性峰值与体重指数呈负相关（r = -0.41，p < 0.03）。未发现给药后3小时的抗Xa活性与去甲肾上腺素剂量之间存在相关性（r = 0.12，p = 0.7）。
与普通病房的内科患者相比，肾功能正常的重症患者每日单次皮下注射依诺肝素后抗Xa水平显著降低。
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