Лечение больных с гепарин-индуцированной тромбоцитопенией

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Тип ГИТ i не требует специфической терапии. При типе ГИТ ii необходима немедленная отмена гепарина и антикоагулянтная терапия рекомбинантным гирудином или данапароидом или фондапарином.

Рекомендации американской коллегии торакальных врачей по терапии ГИТ:

Ø использовать один из следующих антикоагулянтов: фондапаринукс натрия (уровень доказательств – 1), данапароид натрия (уровень доказательств - I), лепирудин (уровень доказательств - I), аргатробан (уровень доказательств - I);

Ø антикоагулянты необходимо применять до восстановления количества тромбоцитов, так как при ГИТ имеется высокий риск тромбоза (уровень доказательств - II);

Ø низкомолекулярные гепарины противопоказаны при ГИТ (уровень доказательств - I);

Ø у пациентов с ГИТ не должен использоваться один варфарин (без прямых антикоагулянтов) из-за риска возникновения варфарин-индуцированного некроза кожи (уровень доказательств - I);

Ø не рекомендуется трансфузия тромбоцитов с профилактической целью (уровень доказательств - II).

Лечение больных с неllp –синдромом

Медикаментозная коррекция неllp –синдрома – профилактическое введение гепарина в послеродовом периоде (уровень доказательств - III).

Лечение больных с тромботической тромбоцитопенической пурпурой

Основа лечения – плазмообмен (уровень доказательств – II). Проводится в объеме 1 объема циркулирующей крови ежедневно до тех пор, пока не будет нормализован уровень лдг. Если после прекращения терапии количество тромбоцитов снова начинает снижаться, а уровень лдг повышается – плазмообмен возобновляется. Трансфузия тромбоцитов больным с ттп противопоказана (может быть применена только по жизненным показаниям) (уровень доказательств – II). У пациентов с ттп используется также внутривенная глюкокортикоидная терапия (уровень доказательств – II). Основные принципы лечения больных с ТТП суммированы в таблице 4.4.

Таблица 4.4. Принципы лечения больных с ТТП

Лечение больных с гемолитико-уремическим синдромом

Основа лечения – плазмообмен; трансфузия тромбоцитов может быть применена только по жизненным показаниям (уровень доказательств - III).

Профилактика и лечение больных с гемодилюционной тромбоцитопенией

Профилактика заключается в адекватном возмещении потерь тромбоцитов при кровопотере (уровень доказательств –II): 4-5 доз тромбоконцентрата на 1 л переливаемой эритроцитарной массы (1 доза примерно 50 мл).

С лечебной целью, трансфузия тромбоцитов в сочетании с коррекцией дефицита плазменных факторов свертывания показана пациентам с кровотечениями при количестве тромбоцитов менее 50 тыс/мкл или менее 100 тыс/мкл при наличии диффузного капиллярного кровотечения (уровень доказательств – I).

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