婦人科手術患者におけるより合理的な肺血栓塞栓症予防法の確立を目指した臨床的検討(<特集>第57回シンポジウム: 肺塞栓-その予防と治療-)

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Purposes The aims of this study were to clarify the problem of our prophylactic methods for postoperative pulmonary thromboembolism (PTE) and to propose the measures to prevent this complication more efficiently. The present prophylactic method in our department was the combination of intermittent pneumatic compression during and after operation, and anticoagulation after operation. Methods We estimated several markers for coagulation and fibrinolysis in blood samples obtained from the patients who underwent operation for gynecological diseases in our department to estimate the presence or absence of hypercoagulability, which is one of three major factors responsible for the formation of venous thrombi associated with postoperative PTE. Blood samples were obtained once preoperatively and 8 times postoperatively for each patients. The markers examined were TAT (thrombin-antithrombin complex), SFMC (Soluble fibrin monomer complex), D-dimer, AT III (antithrombin III), Protein C, and Protein S. Two coagulation markers, TAT and SFMC correlate with the generation of thrombin and fibrin respectively, both of which are key factors of coagulation system. AT III, Protein C, and Protein S are natural coagulation inhibitors and the deficiency of them is known to be associated with the increased risk of venous thromboembolism. Results We obtained blood samples from 88 patients under informed consent. Two patients developed PTE with the onset at postoperative day 1. Including these 2 cases, postoperative PTE developed in 5 cases during this study. All the cases were under prophylaxis for postoperative PTE, and, then, these PTE cases suggest the weak points of our prophylactic method. In the 2 cases complicated with postoperative PTE, the levels of TAT and SFMC were high immediately after operation and, then, decreased, suggesting that the causative venous thrombi for the PTE were probably formed during operation. To examine whether we can diagnose such cases by the postoperative estimation of the markers, we compared the level of TAT, SFMC, and D-dimer in the 2 cases with postoperative PTE with that of other 86 cases without PTE. The marker levels at 0 hour or 6 hours after operation of the 2 cases with PTE were in higher range, compared with the cases without PTE, though some cases without PTE showed the similar high level with the cases with PTE. Thus, the estimations of coagulation markers seemed to be useful as screening for cases with DVT developed during operation. The estimation of AT III, and Protein C pathways, revealed the transient decrease of them after operation. 58% of cases decreased in either of the two pathways and 29% of cases, in both pathways. The multivariate study revealed that the decrease of the coagulation inhibitors were correlated with the blood loss during operation, operation time and operation size. The deficiency of these pathways seemed to reach abnormal levels during operation, and thus, the decrease of these coagulation inhibitors possibly was associated with the formation of DVT during operation. Conclusions We should cope enough with the generation of DVT with the onset during operation. In our department, we try to begin anticoagulation during operation for patients with very high risk of this complication. The postoperative estimation of coagulation markers may be helpful for the screening of DVT formed during operation. The decrease of natural coagulation inhibitors during operation may be associated with the DVT formation during operation.
社団法人日本産科婦人科学会の論文
2005-09-01

婦人科手術患者におけるより合理的な肺血栓塞栓症予防法の確立を目指した臨床的検討(<特集>第57回シンポジウム: 肺塞栓-その予防と治療-)

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