Quebbemann Brian, Akhondzadeh Morad, Dallal Ramsey
The N.E.W. Program, Orange County, Newport Beach, CA 92660, USA.
Obes Surg. 2005 Oct;15(9):1221-4. doi: 10.1381/096089205774512528.
The pharmacokinetics of subcutaneous heparin administration in the obese patient are unpredictable. Peak levels are slowly reached and the effects are not rapidly reversible. Low-dose, continuous, intravenous heparin is easily reversed, is more efficacious and is cost-effective.
From November 2000 until July 2005, 822 consecutive patients were administered continuous intravenous unfractionated heparin at 400 U/hr (9,600 U/day) starting in the preoperative holding area and maintained until discharge. All clinically significant events were documented.
634 laparoscopic gastric bypass, 10 revisions and 188 Lap-Band procedures were performed. The mean age was 43+/-11 years (15-74) and mean BMI was 45.2+/-7.1 (30-86). There was only one (0.12%) clinically evident thromboembolic event in the entire cohort (after a gastric bypass). Anti-Xa levels and prothrombin time were followed in a group of 40 patients and were found to be normal in all. Bleeding that required transfusion occurred in 1.3% of patients. In 41 patients (5%), heparin therapy was terminated or temporarily held due to need for extensive adhesiolysis or acute drop in hematocrit, with-or-without other evidence of postoperative bleeding. Average estimated blood loss during surgery was 36 cc (5-500 cc). One patient was inadvertently administered excessive doses of heparin due to a pump error without significant sequelae.
Continuous low-dose intravenous heparin therapy is associated with an extremely low incidence of thromboembolic events and a low risk for perioperative hemorrhage. Intravenous heparin also has the benefits of being inexpensive and rapidly reversible.
肥胖患者皮下注射肝素的药代动力学难以预测。达到峰值水平缓慢，且效果不能迅速逆转。低剂量、持续静脉注射肝素易于逆转，更有效且具有成本效益。
从2000年11月至2005年7月，822例连续患者从术前等待区开始以400 U/小时（9600 U/天）的剂量持续静脉注射普通肝素，并维持至出院。记录所有临床显著事件。
进行了634例腹腔镜胃旁路手术、10例翻修手术和188例胃束带手术。平均年龄为43±11岁（15 - 74岁），平均体重指数为45.2±7.1（30 - 86）。在整个队列中（胃旁路手术后）仅有1例（0.12%）临床明显的血栓栓塞事件。对40例患者进行了抗Xa水平和凝血酶原时间监测，发现均正常。1.3%的患者发生了需要输血的出血情况。在41例患者（5%）中，由于需要广泛粘连松解或血细胞比容急剧下降（无论有无其他术后出血证据），肝素治疗被终止或暂时停用。手术期间平均估计失血量为36毫升（5 - 500毫升）。1例患者因泵故障意外给予过量肝素，但无明显后遗症。
持续低剂量静脉注射肝素治疗与极低的血栓栓塞事件发生率和围手术期出血低风险相关。静脉注射肝素还具有价格低廉且易于逆转的优点。
