2018 年第 12 期 第 13 卷

急性白血病化疗后弥漫性肺泡出血患者临床特点及重症支持治疗的经验总结

Clinical features and therapeutic experiences of diffuse alveolar hemorrhage secondary to chemotherapy in patients with acute leukemia

作者：周刚安友仲朱凤雪沈佳伟

英文作者：

单位：100044北京大学人民医院重症医学科

英文单位：

关键词：急性白血病；弥漫性肺泡出血；白细胞溶解；机械通气支持

英文关键词：

• 摘要：

• 【摘要】目的    初步分析急性白血病患者化疗后弥漫性肺泡出血(DAH)的临床特点并总结此严重并发症重症支持治疗的要点。方法    收集2014年5月至2016年2月北京大学人民医院重症医学科收治的19例因白血病化疗后出现DAH而转入重症医学科的患者的临床资料，总结发病规律、临床特点及治疗转归。结果    患者化疗后出现首发症状后病情进展迅速，死亡率高［68.4%(13/19）］。患者入院时至入重症监护病房（ICU）时，白细胞计数及血红蛋白下降明显［6.82（2.12,22.08）×109/L比28.18（5.63,74.22）×109/L、（63±14）g/L比（79±19）g/L］，差异均有统计学意义（均P＜0.05）。患者入ICU时动脉血氧分压、改良氧和指数、脉搏血氧饱和度提示严重呼吸衰竭，经积极监护支持治疗后有明显改善［（145±33）mmHg（1 mmHg=0.133 kPa）比（70±19）mmHg、（250±81）比（110±35）、（98.6±1.2）比（90.0±6.2）］，差异均有统计学意义（均P＜0.05），同时经ICU积极治疗，患者凝血指标（凝血酶原时间、活化部分凝血活酶时间、D-二聚体）较入ICU时明显改善［（17±3）s比（20±5）s、39.3（34.9,49.6）s比49.9（36.8,64.2）s、2 400(1 450,7 900)μg/L比 4 400（1 550,20 000）μg/L］，差异均有统计学意义（均P＜0.05）。结论    急性白血病化疗后出现DAH是临床上急危重症，由多种机制参与其中，其中白细胞溶解是机制之一，需临床医师提高警惕，做到早识别、早治疗，各种形式的氧疗（面罩吸氧、无创呼吸机、有创机械通气）及积极对症治疗（纠正凝血、贫血等）是挽救患者生命的主要治疗方式。

• 【Abstract】Objective    To analyze the clinical features and supportive treatments of diffuse alveolar hemorrhage（DAH） after chemotherapy in patients with acute leukemia. Methods    Clinical data of 19 cases of DAH after acute leukemia chemotherapy admitted to intensive care unit（ICU） of Peking University People′s Hospital from May 2014 to February 2016 were reviewed. Onset regularities, clinical characteristics, treatments and outcomes were analyzed. Results    DAH progressed rapidly after the occurrence of inital symptoms with a high mortality［68.4%(13/19）］. At the admission of ICU, leucocyte count and hemoglobin level significantly decreased compared to the basic levels［6.82（2.12,22.08）×109/L vs 28.18（5.63,74.22）×109/L; （63±14）g/L vs （79±19）g/L］（P＜0.05）. All patients had severe respiratory failure; arterial partial pressure of oxygen, modified oxygenation index and pulse oxygen saturation after support therapy in ICU were significantly improved compared to those at admission［（145±33）mmHg vs （70±19）mmHg, （250±81） vs （110±35）, （98.6±1.2） vs （90.0±6.2）］（P＜0.05）. Prothrombin time, activated partial thromboplastin time and D-dimer level after therapy were significantly improved compared to those at admission ［（17±3）s vs （20±5）s; 39.3（34.9,49.6）s vs 49.9（36.8,64.2）s; 2 400(1 450,7 900)μg/L vs 4 400（1 550,20 000）μg/L］（P＜0.05）. Conclusions    DAH is a life-threatening complication after chemotherapy for acute leukemia, caused by many mechanisms including chemotherapy-induced leukocytolysis. Early identification and treatment of DAH is critical. Oxygen therapies（mask oxygen inhalation and mechanical ventilation） and supportive treatments（correcting coagulation and anemia） are the primary managements for life saving.