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中国循证儿科杂志

中国循证儿科杂志 ›› 2020, Vol. 15 ›› Issue (3): 187-190.

• 论著 • 上一篇    下一篇

存在出血风险患儿行腰椎穿刺术后3天内发生穿刺部位血肿的病例系列报告

张孟婕1,2，刘冰1,2，陈天明1,2，曾跃萍3，徐新4，郑胡镛5，黑明燕6，李牧寒1,2，王壮壮1,2，孙艺1,2，刘钢1,2   

  1. 首都医科大学附属北京儿童医院 北京，100000;1 感染内科，2 儿科重大疾病研究教育部重点实验室，3 病案科，4 信息中心，5 血液肿瘤中心，6 新生儿中心
  • 收稿日期:2019-11-19 修回日期:2020-01-05 出版日期:2020-06-25 发布日期:2020-06-25
  • 通讯作者: 刘钢

Puncture site hematoma occurring within 3 days after lumbar puncture in children at risk of bleeding：A case series report

ZHANG Meng-jie 1,2, LIU Bing1,2, CHEN Tian-ming1,2, ZENG Yue-ping3, XU Xin4, ZHENG Hu-yong5,  HEI Ming-yan6, LI Mu-han1,2, WANG Zhuang-zhuang1,2, SUN Yi1,2, LIU Gang1,2   

  1. Beijing Children's Hospital, Capital Medical University, Beijing 100000, China; 1 Department of Infectious Diseases, 2 Key Laboratory of Major Disease in Children, Ministry of Education, 3 Medical Records Section, 4 Information Center, 5 Blood Tumor Center, 6 Newborn Center
  • Received:2019-11-19 Revised:2020-01-05 Online:2020-06-25 Published:2020-06-25
  • Contact: LIU Gang

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摘要： 目的探讨存在出血风险患儿行腰椎穿刺（腰穿）术是否容易发生穿刺部位血肿。方法回顾性收集首都医科大学附属北京儿童医院（我院）接受过腰穿且存在凝血功能异常（主要指有出血风险）的住院患儿的病历，排除入院至出院时间≤24 h病历，考察有出血风险时行腰穿术后3 d内是否发生穿刺部位血肿。出血风险综合指标包括：①有出血的症状和体征；②腰穿前3 d内接受过抗凝治疗、或输注过PLT或血浆；③PLT、纤维蛋白原（FIB）低于正常值下限，凝血酶原时间（PT）、部分凝血活酶时间（APTT）、抗凝酶Ⅲ（AT-Ⅲ）活性和国际标准化比值（INR）高于上限。符合①或②，合并③为有出血风险。结果2014年1月1日至2019年7月30日我院出院病历病案首页有腰穿记录并排除24 h出院病历，最终232例患儿370例次腰穿记录进入本文分析。232例患儿中，年龄4 h至17岁8个月，中位年龄为3岁。370例次腰穿中，以怀疑各种中枢神经系统感染性疾病（209例次，56.5%）和需要鞘内注射药物（142例次，38.4%）为主，无存在腰穿绝对禁忌证行腰穿病例。存在出血风险综合指标异常的患儿，即使有出血表现/抗凝药物和输注PLT史且实验室6项指标中任意指标指示出血风险［PLT 1~97(53±30)×109·L-1、PT 13~24.8(15.7±3.4) s、APTT 40.4~157.9(60.2±20.2) s、INR 1.21~2.11(1.53±0.34)、FIB 0.68~1.99(1.34±0.40) g·L-1、AT-Ⅲ130~158.6(144.3±11.7)%］，行腰穿后3 d内穿刺部位均未发生血肿。结论有出血表现、腰穿前抗凝或输血治疗、实验室出血指标异常儿童腰穿部位发生血肿风险极低。

Abstract: ObjectiveTo investigate whether children with a risk of bleeding are prone to hematoma at the puncture site during lumbar puncture. MethodsThe medical records of hospitalized children who had undergone lumbar puncture and had abnormal coagulation function (mainly referring to the risk of bleeding) were retrospectively collected from Beijing Children's Hospital of Capital Medical University, and the medical records with hospitalization time ≤24 h were excluded. We investigated whether the hematoma at the puncture site was prone to occur within 3 days after lumbar puncture when there was a risk of bleeding. The indicators of bleeding risk included: a. there were signs or symptoms of bleeding; b. within 3 days before lumbar puncture, anticoagulation treatment, platelet transfusion or plasma transfusion had been used; c. platelet count (PLT) and fibrinogen (FIB) is lower than the lowest limit of normal value, and prothrombin time (PT), partial thromboplastin time (APTT), antithrombin Ⅲ (AT-Ⅲ) activity and international standardized ratio (INR) were above the highest limit. Risk of bleeding was defined as a/b and c. ResultsAccording to the first page of our hospital discharge medical records with lumbar punctures and discharge after 24 hours from January 1st, 2014 to July 30th, 2019, a total of 232 children with 370 lumbar punctures were included. Among the 232 children, the age ranged from 4 hours to 17 years and 8 months, with a median age of 3 years. Among the 370 cases of lumbar puncture, the main indications were suspected various infectious diseases of the central nervous system (209 cases, 56.5%) and the need for intrathecal injection (142 cases, 38.4%). There were no cases with absolute contraindication of lumbar puncture. None of children with abnormal bleeding risk indicators had hematoma at the puncture site within 3 days after lumbar puncture even if they had signs of bleeding / history of anticoagulation drugs and PLT transfusion, and any of the following 6 laboratory indicators of bleeding risk——PLT 1-97(53±30)×109·L-1、PT 13-24.8(15.7±3.4)s、APPT 40.4-157.9(60.2±20.2)s、INR 1.21-2.11(1.53±0.34)、FIB 0.68-1.99(1.34±0.40) g·L-1、AT-Ⅲ 130-158.6(144.3±11.7) %. ConclusionThe bleeding risk at the puncture site was extremely low in children with hemorrhagic manifestations, anticoagulation or blood transfusion therapy before lumbar puncture, and abnormal laboratory bleeding indicators.

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