Estepp Jeremie H, Smeltzer Matthew P, Kang Guolian, Howard Scott C, Reiss Ulrike M
*Department of Hematology †Department of Pathology §Department of Biostatistics, St. Jude Children's Research Hospital ‡Division of Epidemiology, Biostatistics, and Environmental Health, The University of Memphis School of Public Health ¶University of Tennessee Health Science Center, Memphis, Memphis, TN.
J Pediatr Hematol Oncol. 2017 Nov;39(8):596-601. doi: 10.1097/MPH.0000000000000988.
Children with acute lymphoblastic leukemia or lymphoma (ALL) undergo multiple lumbar punctures (LPs) and frequently require low-molecular-weight heparin (LMWH) for thromboembolic complications. We evaluated if withholding LMWH 24 hours before and after LPs prevented bleeding complications. Children (n=133) with ALL from who were: (1) treated at St. Jude Children's Research Hospital, (2) received LMWH (2×/day of ~1 mg/kg) between January 2004 until December 2012, and (3) underwent a LP were analyzed. Spinal hematoma was defined as a clinical suspicion leading to diagnostic imaging. Traumatic LP was defined as ≥10 red blood cells per microliter of cerebrospinal fluid. In 1708 LPs, no hematomas occurred. For each child treated with LMWH, the probability of experiencing a spinal hematoma during the entire ALL treatment course was 0% (95% confidence interval [CI], 0.0%-2.7%), and in each LP, assuming no intrapatient correlation, the probability of spinal hematoma was 0% (95% CI, 0.0%-0.2%). Traumatic LPs were more common when performed when children were not receiving LMWH therapy (odds ratio [OR], 1.5; 95% CI, 1.1-2.2) which may be explained by clinician optimization of known risk factors for traumatic cerebrospinal fluid before the procedures. Withholding LMWH for 24 hours before and after LPs in children being treated for ALL is safe.
患有急性淋巴细胞白血病或淋巴瘤（ALL）的儿童要接受多次腰椎穿刺（LP），并且经常需要使用低分子量肝素（LMWH）来预防血栓栓塞并发症。我们评估了在腰椎穿刺前后24小时停用低分子量肝素是否能预防出血并发症。对来自圣裘德儿童研究医院接受治疗的133例ALL儿童进行了分析，这些儿童：（1）于2004年1月至2012年12月期间接受LMWH治疗（每天2次，每次约1 mg/kg），（2）接受过腰椎穿刺。脊髓血肿定义为经诊断性影像学检查临床怀疑的情况。创伤性腰椎穿刺定义为每微升脑脊液中红细胞≥10个。在1708次腰椎穿刺中，未发生血肿。对于每例接受LMWH治疗的儿童，在整个ALL治疗过程中发生脊髓血肿的概率为0%（95%置信区间[CI]，0.0%-2.7%），并且在每次腰椎穿刺中，假设患者内无相关性，发生脊髓血肿的概率为0%（95%CI，0.0%-0.2%）。当儿童未接受LMWH治疗时进行腰椎穿刺，创伤性腰椎穿刺更常见（优势比[OR]，1.5；95%CI，1.1-2.2），这可能是因为临床医生在操作前优化了已知的创伤性脑脊液危险因素。在接受ALL治疗的儿童中，在腰椎穿刺前后24小时停用LMWH是安全的。
