病例报告：重型再生障碍性贫血伴极重度血小板减少症患者输注血小板后紧急超声引导下双腔PICC置管

文献信息

中文摘要

背景： 拟接受异基因造血细胞移植（HCT）的重型再生障碍性贫血（SAA）患者需要可靠的中心静脉通路，然而相关操作证据基础来源于血小板计数约为10-50 × 10⁹/L的患者，并未涵盖骨髓衰竭所致的极重度血小板减少症。
病例描述： 一名56岁女性SAA患者，伴中性粒细胞减少、真菌性上颌窦炎、散在瘀斑，无活动性自发性出血，需要在预处理前紧急建立多腔静脉通路。其入院时血小板计数为1 × 10⁹/L，在输注1个单位200 mL单采血小板后约14小时测得的计数为2 × 10⁹/L，持续性增量不佳。由于该样本的采集时间不在任何标准化输血后时间间隔内，无法计算校正计数增量，也无法确定血小板输注无效；在操作时间窗内无法进行HLA和HPA抗体检测。
干预与结局： 经多学科评估后，给予第二个200 mL单采血小板输注，随后立即在超声引导下经右侧贵要静脉置入5-Fr双腔耐高压注射型PICC。置管紧接输血后进行，中间无间隔，因此最后记录的计数2 × 10⁹/L早于第二个单位输注，且未重新测量静脉穿刺时的数值。根据保存的操作图像测量，导管与静脉比值约为32%。首次穿刺即成功建立通路，导管尖端确认位于上腔静脉下三分之一处。世界卫生组织1级穿刺点渗血经压迫10分钟后停止。在63个导管日期间及3个月随访时，未记录到2级或以上出血、输血反应、导管闭塞、移位、导管相关血流感染或临床明显的导管相关血栓形成。未进行常规血栓筛查超声。
结论： 本报告记录了当移植无法推迟时，如何应用一条协调的风险控制路径，该路径结合必要性评估、血小板支持、可压迫的穿刺部位、首次即成功的超声引导置管以及针对特定时间间隔的监测，并明确了未来前瞻性研究应采集的测量指标。单例病例无法确立在极低血小板计数下置入PICC的安全性，也无法界定血小板阈值，尤其是因为置管时的血小板计数未重新测量。

英文摘要

BACKGROUND: Patients with severe aplastic anemia (SAA) proceeding to allogeneic hematopoietic cell transplantation (HCT) require reliable central venous access, yet the procedural evidence base was generated at platelet counts of roughly 10-50 × 109/L and does not extend to the extreme thrombocytopenia of marrow failure.
CASE DESCRIPTION: A 56-year-old woman with SAA, neutropenia, fungal maxillary sinusitis, scattered ecchymoses, and no active spontaneous bleeding required urgent multi-lumen access before conditioning. Her admission platelet count was 1 × 109/L, and after one 200-mL apheresis platelet transfusion the count measured approximately 14 h later was 2 × 109/L, a poor sustained increment. Because that sample fell outside any standardized post-transfusion interval, a corrected count increment could not be calculated and refractoriness could not be established; HLA and HPA antibody testing was not available within the procedural window.
INTERVENTION AND OUTCOMES: After multidisciplinary review, a second 200-mL apheresis platelet transfusion was given and a 5-Fr dual-lumen power-injectable PICC was inserted immediately afterward through the right basilic vein under ultrasound guidance. Insertion followed the transfusion without an interval, so the last recorded count of 2 × 109/L precedes the second unit and the value at venipuncture was not remeasured. The catheter-to-vein ratio, measured from the stored procedural images, was approximately 32%. Access was achieved on the first puncture and the tip confirmed in the lower third of the superior vena cava. World Health Organization grade 1 puncture-site oozing stopped after 10 min of compression. No bleeding of grade 2 or higher, transfusion reaction, occlusion, migration, catheter-related bloodstream infection, or clinically evident catheter-related thrombosis was documented over 63 catheter-days or at 3-month follow-up. Routine thrombosis-screening ultrasound was not performed.
CONCLUSION: This report documents how a coordinated risk-control pathway combining necessity assessment, platelet support, a compressible access site, first-pass ultrasound-guided insertion, and interval-specific surveillance was applied when transplantation could not be deferred, and it specifies the measurements that future prospective series should capture. A single case cannot establish the safety of PICC placement at extremely low platelet counts or define a platelet threshold, particularly because the count at the time of insertion was not remeasured.