Гепарин-индуцированная тромбоцитопения у пациентов с венозными тромбоэмболическими осложнениями клинические наблюдения и обзор литературы

Выраженная тромбоцитопения значимо (в разы и десятки раз) повышает госпитальную летальность, особенно пациентов общехирургического, сосудистого, ортопедического и травматологического профилей в сравнении с кардиохирургически- ми больными и – в меньшей степени – интервенционными кардиологическими пациентами. Гепарин-индуцированная тромбоцитопения является иммуноопосредованным осложнением и парадоксально сопровождается частыми тромбозами. Риск тромбоза варьирует от 30–50% при умеренной и до 90% – при выраженной тромбоцитопении. Венозные тромбозы при этом преобладают над артериальными, особенно распространены тромбозы глубоких вен нижних конечностей и тромбоэмболии легочной артерии. Нередки инсульты, острый инфаркт миокарда, тромбоз мезентериальных сосудов, позвоночной артерии, центральных катетеров и т. д. Задержка с диагностикой и отменой гепаринов, введение тромбовзвеси, неназначение альтернативных антикоагулянтов ухудшают прогноз и повышают летальность. В настоящее время для оценки вероятности развития гепарин-индуцированной тромбоцитопении у конкретного больного используется балльная шкала 4 Т. Она содержит неточности и предусматривает подсчет баллов по 4 критериям и 3 степеням, что затрудняет ее использование. В начале 2014 г. на основании анализа литературы и собственного опыта нами было разработано упрощенное правило экспресс-диагностики этого состояния. В обзоре описываются патофизиология, эпидемиология, диагностика и аспекты современного лечения этого грозного осложнения, которое можно эффективно профилактировать и успешно лечить. Приводятся клинические примеры, подтвержденные иммунотестом. В следующем сообщении будет приведен 3-летний анализ распространенности, причин и динамики осложнений этого состояния в многопрофильном стационаре, а также результаты внедрения оригинального правила.

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