不同剂量低分子肝素预防老年髋部骨折围手术期深静脉血栓及隐性失血的随机对照研究

A Randomized Controlled Trial of Different Doses of Low-Molecular-Weight Heparin for the Prevention of Perioperative Deep Vein Thrombosis and Hidden Blood Loss in Elderly Patients with Hip Fractures

摘要: 目的：探讨半剂量(2500 IU)与全剂量(5000 IU)低分子肝素钠联合基础及物理抗栓，在预防老年髋部骨折围手术期深静脉血栓(DVT)中的有效性与安全性，重点评估其对术后隐性失血(HBL)及早期康复的影响。方法：前瞻性纳入2023年6月~2025年6月宿州市立医院骨科收治的218例老年单侧闭合性髋部骨折择期手术患者。随机分为半量组(109例)和全量组(109例)。两组均接受标准基础与物理抗栓。在此基础上，半量组围术期给予低分子肝素钠2500 IU皮下注射(1次/d)，全量组给予5000 IU (1次/d)，均持续至术后14 d。对比两组术后14 d下肢DVT与肺栓塞(PE)发生率；采用Gross方程与Nadler公式测算总失血量及HBL；监测术后红细胞压积(Hct)、显性出血量(VBL)及凝血功能指标(PT, APTT, D-Dimer, FIB)。结果：两组基线资料具有可比性(P > 0.05)。术后14 d，半量组与全量组的DVT发生率分别为6.42%和5.50%，差异无统计学意义(P = 0.772)；两组术后30 d内均无症状性PE发生。半量组术后3 d的Hct水平显著优于全量组，总隐性失血量显著低于全量组(285.4 ± 68.2 mL vs 412.6 ± 92.5 mL, P < 0.001)，切口活动性渗血率及异体红细胞输注率(9.17% vs 22.02%)均显著降低(P < 0.05)。术后3 d及7 d时，全量组的PT与APTT延长幅度显著高于半量组(P < 0.001)。此外，半量组平均住院日更短，住院总费用显著降低(P < 0.05)。结论：老年髋部骨折患者围术期采用半剂量低分子肝素的抗凝防栓效能与全剂量等效，且能更温和地调控内源性凝血瀑布，显著减少术后隐性失血，降低贫血及输血风险，有利于促进患者早期康复，具有较高的卫生经济学价值。

Abstract: Objective: To investigate the efficacy and safety of half-dose (2500 IU) versus full-dose (5000 IU) low-molecular-weight heparin (LMWH) combined with basic and physical thromboprophylaxis in the prevention of perioperative deep vein thrombosis (DVT) in elderly patients with hip fractures, with a focus on its impact on postoperative hidden blood loss (HBL) and early rehabilitation. Methods: A total of 218 elderly patients with unilateral closed hip fractures who underwent elective surgery in the Department of Orthopedics, Suzhou Municipal Hospital between June 2023 and June 2025 were prospectively enrolled and randomly divided into a half-dose group (n = 109) and a full-dose group (n = 109). Both groups received standard basic and physical thromboprophylaxis. On this basis, the half-dose group received subcutaneous injections of LMWH at 2500 IU once daily, while the full-dose group received 5000 IU once daily, both continuing until postoperative day 14. The incidences of lower extremity DVT and pulmonary embolism (PE) were compared between the two groups at postoperative day 14. Total blood loss and HBL were calculated using the Gross equation and Nadler formula. Postoperative hematocrit (Hct), visible blood loss (VBL), and coagulation parameters (PT, APTT, D-Dimer, FIB) were monitored. Results: Baseline characteristics between the two groups were comparable (P > 0.05). At postoperative day 14, the incidences of DVT in the half-dose group and full-dose group were 6.42% and 5.50%, respectively, showing no statistically significant difference (P = 0.772). No symptomatic PE occurred within 30 days postoperatively in either group. On postoperative day 3, the Hct level in the half-dose group was significantly superior to that in the full-dose group, and total HBL was significantly lower (285.4 ± 68.2 mL vs. 412.6 ± 92.5 mL, P < 0.001). Furthermore, the rate of active incision bleeding and allogeneic red blood cell transfusion rate (9.17% vs. 22.02%) were significantly decreased in the half-dose group (P < 0.05). At postoperative days 3 and 7, the prolongation of PT and APTT in the full-dose group was significantly higher than that in the half-dose group (P < 0.001). Additionally, the half-dose group had a shorter average hospital stay and significantly lower total hospitalization costs (P < 0.05). Conclusion: Perioperative thromboprophylaxis with half-dose LMWH in elderly patients with hip fractures demonstrates equivalent anticoagulant efficacy to full-dose LMWH. Moreover, it regulates the endogenous coagulation cascade more mildly, significantly reduces postoperative hidden blood loss, lowers the risks of anemia and blood transfusion, facilitates early patient rehabilitation, and offers high health economic value.