A. Idiopathic thrombocytopenic purpura clinical pathway standard hospitalization process
(A) Applicable objects.
The first diagnosis of idiopathic thrombocytopenic purpura (ITP) (ICD-10: D69.3)
(B) Diagnosis basis.
According to the Diagnostic and Efficacy Criteria for Hematological Diseases (edited by Zhang Zhinan and Shen Ti, Science Press, 2008, 3rd edition) and the American Society of Hematology Guidelines on ITP (Blood, 1996, 88(1):3-40), Clinical Diagnostic and Treatment Guidelines – Hematology Subvolume (edited by Chinese Medical Association, People’s Health Press)
1. Medical history.
2. Decreased platelet count on multiple tests (including blood smear).
3. The spleen is not large or mildly enlarged.
4. Increased or normal megakaryocyte count with maturation disorders on bone marrow examination.
5. Exclude other causes of thrombocytopenia.
(C) The basis for selecting the treatment plan.
According to “Deng Jiadong Clinical Hematology” (edited by Deng Jiadong, Shanghai Science and Technology Press, 2001, first edition) and “American Society of Hematology Guidelines on ITP” (Blood, 1996, 88(1):3-40), “Clinical Diagnosis and Treatment Guide-Hematology Subvolume” (edited by Chinese Medical Association, People’s Health Press)
1. Glucocorticoids as first choice treatment: can be given in regular doses or short courses of high doses.
2. Emergency treatment: for severe and extensive bleeding; suspected or definite intracranial bleeding; those who need emergency surgery or delivery.
(1) Intravenous infusion of gammaglobulin.
(2) Transfusion of platelets.
(d) The standard hospitalization day of clinical pathway is within 14 days.
(E) The criteria for entering the pathway.
1. The first diagnosis must be in accordance with ICD-10: D69.3 Idiopathic thrombocytopenic purpura disease code.
2. Blood test indicators meet the indications for needing hospitalization: platelet count <20×109/L, or with bleeding manifestations or bleeding risk (e.g. hypertension, peptic ulcer, etc.).
3. Patients can enter the pathway when they also have other disease diagnoses but do not require special treatment during hospitalization and do not affect the implementation of the clinical pathway process for the first diagnosis.
(f) Definite diagnosis and routine examination for hospital admission takes 2-3 days (meaning working days).
1. Required examination items.
(1) Routine blood, routine urine, routine stool + occult blood;
(2) Liver and kidney function, electrolytes, coagulation function, pre-transfusion test, blood sedimentation, blood smear, blood group, autoimmune system disease screening;
(3) Chest X-ray, electrocardiogram, abdominal ultrasound;
2. Fever or suspected infection: pathogenic microbial culture, imaging;
(3) Bone marrow morphology examination.
(vii) Treatment starts on day 1 of diagnosis.
(viii) Treatment selection.
1. Glucocorticoids as the first choice of treatment: observe the side effects of corticosteroids and treat them symptomatically; prevent and control the damage of organ function, including acid suppression and calcium supplementation, etc.
(1) Conventional dose (prednisone 1mg・Kg-1・d-1).
(2) Short course of high dose administration (methylprednisolone 1.0g・d-1×3d, or dexamethasone 40mg・d-1×4d).
2. Emergency treatment: for severe and extensive bleeding; suspected or definite intracranial hemorrhage; those who need emergency surgery or delivery.
(1) Intravenous infusion of gammaglobulin: 0.4g・Kg-1・d-1×5d or 1.0g・Kg-1・d-1×2d.
(2) Platelet transfusion.
(ix) Discharge criteria.
Platelets >20×109/L without platelet transfusion and lasting for more than 3 days.
(J) Variation and cause analysis.
Platelets persistently below 20×109/L for >2 weeks after treatment are withdrawn from the pathway.