兒童急性淋巴細(xì)胞白血病臨床路徑(版)

創(chuàng)作時(shí)間：二零二一年六月三十日/r/n創(chuàng)作時(shí)間：二零二一年六月三十日/r/n創(chuàng)作時(shí)間：二零二一年六月三十日/r/n創(chuàng)作時(shí)間：二零二一年六月三十日/r/n兒童急性淋巴細(xì)胞白血病臨床路徑之馬矢奏春創(chuàng)作/r/n創(chuàng)作時(shí)間：二零二一年六月三十日/r/n創(chuàng)作時(shí)間：二零二一年六月三十日/r/n（2017年版）/r/n一、/r/n兒童急性淋巴細(xì)胞白血病（ALL）臨床路徑標(biāo)準(zhǔn)住院流程/r/n(一)/r/n適用對(duì)象./r/n第一診斷為兒童急性淋巴細(xì)胞白血病(ICD-10:C91.0)的標(biāo)危、中危組患者./r/n(二)/r/n診斷依據(jù)./r/n根據(jù)《臨床診療指南－小兒內(nèi)科分冊(cè)》（中華醫(yī)學(xué)會(huì)編著,人民衛(wèi)生出書社）,《諸福棠實(shí)用兒科學(xué)（第七版）》（人民衛(wèi)生出書社）,《血液病診斷及療效標(biāo)準(zhǔn)(第三版)》（張之南、沈悌主編著,科學(xué)出書社）./r/n（一）體檢：可有發(fā)熱、皮膚粘膜蒼白、皮膚出血點(diǎn)及瘀斑、淋湊趣及肝脾腫年夜、胸骨壓痛等./r/n（二）血細(xì)胞計(jì)數(shù)及分類./r/n（三）骨髓檢查：形態(tài)學(xué)（包括組化檢查）./r/n（四）免疫分型./r/n（五）細(xì)胞遺傳學(xué)：核型分析,FISH(需要時(shí))./r/n（六）白血病相關(guān)基因./r/n(三)/r/n危險(xiǎn)度分組標(biāo)準(zhǔn)./r/n（一）標(biāo)危組：必需同時(shí)滿足以下所有條件：1.年齡≥1歲且＜10歲；/r/n2.WBC＜50×10/r/n9/r/n/L；/r/n潑尼松反應(yīng)良好/r/n（/r/n8/r/n天外周血白血病細(xì)胞＜/r/n1/r/n10/r/n9/r/n/L）；/r/n非/r/nT-ALL；/r/n非成熟/r/nB-ALL；/r/n無/r/nt（9;22）/r/n或/r/nBCR/ABL/r/n融合基因；無/r/nt（4;11）/r/nMLL/AF4融合基因；無t（1;19）/r/n或/r/nE2A/PBX1/r/n治療第/r/n15/r/n天骨髓呈/r/nM1(原幼淋細(xì)胞＜5%/r/n)或/r/nM2（/r/n5%-25%）,/r/n33/r/n（二）/r/n4/r/n1/r/n.無/r/nt（9;22）/r/n或/r/nBCR/ABL/r/n潑尼松反應(yīng)良好/r/n（/r/n8/r/n天外周血白血病細(xì)胞＜/r/n1/r/n10/r/n9/r/n/L）；/r/n標(biāo)危誘導(dǎo)緩解治療第/r/n15/r/n天骨髓呈/r/nM3（/r/n25%）/r/n15天骨髓呈M1/M2；/r/n如有條件進(jìn)行微小殘留?。∕RD）/r/n33/r/nMRD＜/r/n10/r/n－2/r/n./r/n同時(shí)至少符合以下條件之一：5.WBC≥50×10/r/n9/r/n/L；/r/n6.年齡≥10歲；/r/n7.T-ALL；/r/n8.t（1;19）/r/n或/r/nE2A/PBX1/r/n9.年齡＜1歲且無MLL基因重排./r/n（三）高危組：必需滿足下列條件之一：/r/n潑尼松反應(yīng)不良（/r/n8/r/n1×10/r/n9/r/n/L）；/r/n2.t（9;22）/r/n或/r/nBCR/ABL/r/n3.t（4;11）/r/n或/r/nMLL/AF4/r/n15天骨髓呈M3；/r/n33/r/n（＞5％）,/r/n呈/r/nM2/M3；/r/nMRD/r/n33/r/nMRD≥10/r/n－2/r/n周/r/nMRD≥10/r/n－3/r/n./r/n(四)/r/n選擇治療方案的依據(jù)./r/n根據(jù)《臨床診療指南－小兒內(nèi)科分冊(cè)》（中華醫(yī)學(xué)會(huì)編著 /r/n人民衛(wèi)生出書社）/r/n,/r/n/r/n《諸福棠實(shí)用兒科學(xué)（第七版）》（人民衛(wèi)生出書社）/r/nVDLP（D）方案：/r/nmg·m/r/n-2/r/n·d/r/n-1/r/n1/r/n4/r/n2mg；或長春地辛（VDS）3mg·m/r/n-2/r/n·d/r/n-1/r/n1/r/n4/r/n4mg；/r/n柔紅霉素（DNR）30mg·m/r/n-2/r/n·d/r/n-1/r/n,每周1次,共2-4次；/r/n左旋門冬酰胺酶/r/nL-as/r/n5000-1000/r/nu/r/n-/r/n-/r/n,/r/n共/r/n6-10/r/n次；或/r/n培門冬酰胺酶/r/nPeg-as/r/n2500/r/n-/r/n-/r/n,/r/n共/r/n2/r/n次；/r/n潑尼松（PDN）45-60mg·m/r/n-2/r/n·d/r/n-1/r/n,d1-28,第29-35天遞加至停.或者PDN45-60mg·m/r/n-2/r/n·d/r/n-1/r/n,d1-7,地塞米松（DXM）6-8mg·m/r/n-/r/n2/r/n·d/r/n-1/r/n,d8-28,第29-35天遞加至停./r/nPDN試驗(yàn)d1-7,從足量的25%用起,根據(jù)臨床反應(yīng)逐漸加至足/r/n量,7天內(nèi)累積劑量>210mg·m/r/n-2/r/n·kg/r/n-1/r/n·d/r/n-1/r/n）,以免發(fā)生腫瘤溶解綜合征,d8評(píng)估./r/n1.CAM/r/n環(huán)磷酰胺（CTX）800-1000mg·m/r/n-2/r/n·d/r/n-1/r/n,1次；/r/n阿糖胞苷（Ara-C）75-100mg·m/r/n-2/r/n·d/r/n-1/r/n/r/n7-8/r/n6-巰基嘌呤（6-MP）60-75mg·m/r/n-2/r/n·d/r/n-1/r/n/r/n7-14/r/n中危組患者重復(fù)一次CAM方案.2.mM方案：/r/n年夜劑量甲氨喋呤/r/n,每兩周/r/n1/r/n次,共/r/n次；/r/n四氫葉酸鈣（CF）15mg·m/r/n-2/r/n,/r/n6/r/n1/r/n3-8/r/n血藥濃度給予調(diào)整；/r/n6-MP25mg·m/r/n-2/r/n·d/r/n-1/r/n,不超越56天,根據(jù)WBC調(diào)整劑量./r/n上述方案實(shí)施期間需要進(jìn)行水化、堿化.C.延遲強(qiáng)化治療：/r/nVDLP（D）方案：/r/nmg·m/r/n-2/r/n·d/r/n-1/r/n1/r/n3/r/n2mg；或長春地辛（VDS）3mg·m/r/n-2/r/n·d/r/n-1/r/n1/r/n3/r/n4mg；/r/nDN/r/nR/r/n或阿霉素/r/nAD/r/n25-30m/r/n-/r/n-/r/n,/r/n每周/r/n1/r/n共/r/n1-/r/n3/r/n次；/r/nL-asp/r/n5000-10000u·m/r/n-2/r/n·d/r/n-1/r/n,共/r/n4-8/r/n次；或培門冬酰胺酶/r/nPeg-as/r/n2500/r/n-/r/n-/r/n,/r/n共/r/n1/r/n次；/r/nPDN45-60mg·m/r/n-2/r/n·d/r/n-1/r/n或DXM6-8mg·m/r/n-2/r/n·d/r/n-1/r/n,d1-7,d15-21.2.CAM方案:/r/nCTX800-1000mg·m/r/n-2/r/n·d/r/n-1/r/n,1次；/r/nAra-C75-100mg·m/r/n-2/r/n·d/r/n-1/r/n7-8/r/n6-MP60-75mg·m/r/n-2/r/n·d/r/n-1/r/n7-14/r/n8/r/n（/r/n8/r/n6-MP+MTX/r/n體方案見下）./r/n中危組患者重復(fù)一次上述/r/nVDLP（D）/r/n和/r/nCAM/r/nD.維持治療方案：/r/nMP+MTX方案：/r/n6-MP50mg·m/r/n-2/r/n·d/r/n-1/r/n,繼續(xù)睡前空腹口服；/r/nMTX15-30mg·m/r/n-2/r/n,每周1次,口服或肌注,繼續(xù)至終止治療/r/n（/r/n2.5-3/r/n2-2.5/r/n）./r/n根據(jù)/r/nWBC/r/nVD/r/n（6-MP+MTX/r/n4-8/r/n）：mg·m/r/n-2/r/n·d/r/n-1/r/n,/r/n1/r/nDXM6-8mg·m/r/n-2/r/n·d/r/n-1/r/n,d1-7./r/nE/r/n.中樞神經(jīng)白血?。?r/n/r/nCNSL）/r/n的防治：腰穿及鞘內(nèi)注射至少16-24/r/nMTX/r/n如下：/r/n<12/r/n月/r/n6mg,/r/n月/r/n9mg,/r/n>36/r/n月/r/n<12/r/n月/r/n15mg,/r/n月/r/n25mg,/r/n>36/r/n月/r/n<12/r/n月/r/n2.5mg/r/n,年齡/r/n月/r/n2.5mg/r/n>36/r/n月/r/n5mg./r/nCNSL/r/n<1/r/n1/r/n(五)/r/n根據(jù)患者的疾病狀態(tài)選擇路徑./r/n初治兒童ALL臨床路徑和完全緩解（CR）的兒童ALL臨床路徑（附后）./r/n(六)/r/n參考費(fèi)用標(biāo)準(zhǔn)./r/n（一）標(biāo)危組患者平均全程參考費(fèi)用標(biāo)準(zhǔn)控制在8萬元內(nèi)./r/n（二）中危組患者平均全程參考費(fèi)用標(biāo)準(zhǔn)控制在15萬元內(nèi)./r/n初治兒童ALL臨床路徑/r/n（2017年版）/r/n一、初治兒童ALL臨床路徑標(biāo)準(zhǔn)住院流程/r/n（一）標(biāo)準(zhǔn)住院日為35天內(nèi)./r/n（二）進(jìn)入路徑標(biāo)準(zhǔn)./r/n第一診斷必需符合兒童急性淋巴細(xì)胞白血病（/r/nALL）/r/n碼（ICD10：2)/r/n當(dāng)患者同時(shí)具有其他疾病診斷時(shí),但在住院期間不需要特/r/n（三）明確診斷及入院慣例檢查需3-5天（指工作日）./r/n1.必需的檢查項(xiàng)目：/r/n血慣例、尿慣例、年夜便慣例；/r/n肝腎功能、電解質(zhì)、凝血功能、血型、輸血前檢查；/r/nX/r/n（/r/n臟和腹部、睪丸等）、眼底檢查；/r/n查；/r/n骨髓檢查（形態(tài)學(xué)包括組化）/r/n學(xué)、白血病相關(guān)基因檢測(cè)；/r/n4/r/n內(nèi),鞘內(nèi)注射化療藥物；/r/nMRI/r/nCT/r/n意書、腰穿及鞘內(nèi)注射同意書、化療知情同意書、輸血知情同意書、靜脈插管同意書（有條件時(shí)/r/n（四）化療前準(zhǔn)備./r/n抗菌藥物,可選用頭孢類（或青霉素類）抗炎治療,3天后發(fā)熱不緩解者,可考慮更換為碳青酶烯類和/或糖肽類和/或抗真菌治/r/n療；有明確臟器感染患者應(yīng)根據(jù)感染部位及病原微生物培養(yǎng)結(jié)果選用相應(yīng)抗菌藥物./r/n2.對(duì)Hb﹤80g/L,PLT﹤20×10/r/n9/r/n/L或有活動(dòng)性出血的患者,分別輸濃縮紅細(xì)胞、單采或多采血小板,若存在彌散性血管內(nèi)凝血（DIC）傾向則當(dāng)PLT﹤50×10/r/n9/r/n/L即應(yīng)輸注單采或多采血小板,并使用肝素等其他DIC治療藥物.有心功能不全者可放寬輸血指征./r/n﹤/r/n/L,/r/n輸/r/n（五）化療開始于診斷第1-5天./r/n（六）/r/n化療方案./r/nVDLP（D）方案：/r/nmg·m/r/n-2/r/n·d/r/n-1/r/n1/r/n4/r/n2mg；或長春地辛（VDS）3mg·m/r/n-2/r/n·d/r/n-1/r/n1/r/n4/r/n4mg；/r/n柔紅霉素（DNR）30mg·m/r/n-2/r/n·d/r/n-1/r/n,每周1次,共2-4次；/r/n左旋門冬酰胺酶/r/nL-as/r/n5000-1000/r/nu/r/n-/r/n-/r/n,/r/n共/r/n6-10/r/n次；或/r/n培門冬酰胺酶/r/nPeg-as/r/n2500/r/n-/r/n-/r/n,/r/n共/r/n2/r/n次；/r/n潑尼松（PDN）45-60mg·m/r/n-2/r/n·d/r/n-1/r/n,/r/nd1-28,/r/n29-35/r/nPDN/r/n/r/n45-60mg·m/r/n-2/r/n·d/r/n-1/r/n,/r/nd1-7,地塞米松（DXM）6-8mg·m/r/n-/r/n2/r/n·d/r/n-1/r/n,d8-28,第29-35天遞加至停./r/nPDN/r/nd1-7/r/n25%用起,根據(jù)臨床反應(yīng)逐漸加至足/r/n量,/r/n7/r/n天內(nèi)累積劑量/r/n>210mg·m/r/n-2/r/n·kg/r/n-1/r/n·d/r/n-1/r/n）,/r/n以免發(fā)生腫瘤溶解/r/n綜合征,第8天評(píng)估./r/n（七）化療后必需復(fù)查的檢查項(xiàng)目./r/n1.血慣例、尿慣例、年夜便慣例./r/n8/r/n15/r/n33/r/n病變檢測(cè)./r/n（八）化療中及化療后治療./r/n1.感染防治：/r/n發(fā)熱患者建議立即進(jìn)行病原微生物培養(yǎng)并使用抗菌藥物,/r/n可選用頭孢類（或青霉素類）/r/n抗炎治療,/r/n3/r/n//r/n或糖肽類和/r/n//r/n或抗真菌治療；有明確臟器感染的患者,應(yīng)根據(jù)感染部位及病原微生物培養(yǎng)結(jié)果選用相應(yīng)抗菌藥物./r/n臟器功能損傷的相應(yīng)防治：止吐、保肝、水化、堿化、防/r/n治尿酸腎?。▌e嘌呤醇）、抑酸劑等./r/n成份輸血:適用于/r/nHb﹤80g/L,/r/n/r/nPLT﹤20×10/r/n9/r/n/L或有活動(dòng)性出血的患者,分別輸濃縮紅細(xì)胞、單采或多采血小板,若存在DIC/r/n傾向則/r/nPLT﹤50×10/r/n9/r/n/L/r/nDIC/r/n造血生長因子:化療后中性粒細(xì)胞絕對(duì)值（/r/nANC）≤×10/r/n9/r/n/L,/r/n可使用粒細(xì)胞集落安慰因子（G-CSF）5μg·Kg/r/n-1/r/n·d/r/n-1/r/n./r/n（九）出院標(biāo)準(zhǔn)./r/n./r/n2.沒有需要住院處置的并發(fā)癥和(或)合并癥./r/n（十）變異及原因分析./r/n治療前、中、后有感染、貧血、出血及其他合并癥者,需/r/n二、初治兒童/r/nALL/r/n適用對(duì)象：/r/n第一診斷為/r/n初治兒童急性淋巴細(xì)胞白血?。↖CD-10：2）擬行誘導(dǎo)化療/r/n患者姓名：性別：年齡：門診號(hào)：住院號(hào)：/r/n住院日期：年月日 出院日期：年月日 標(biāo)準(zhǔn)住院日/r/n35/r/n天內(nèi)/r/n時(shí)間/r/n時(shí)間/r/n1/r/n2/r/n詢問病史及體格檢查/r/n完成病歷書寫/r/n主 /r/n□/r/n/r/n開化驗(yàn)單/r/n上級(jí)醫(yī)師查房與化療前評(píng)估/r/n要 /r/n□/r/n/r/n根據(jù)血象及凝血功能決定是否成份/r/n診 /r/n血/r/n療 /r/n□/r/n/r/n向家屬告病重或病危并簽署病重或病/r/n工 /r/n危通知書/r/n作 /r/n□/r/n/r/n患者家屬簽署骨穿同意書、腰穿同意/r/n書、輸血知情同意書、靜脈插管同意書（條件允許時(shí)）/r/n長期醫(yī)囑：/r/n兒科血液病護(hù)理慣例/r/n飲食/r/n抗菌藥物（需要時(shí)）/r/n補(bǔ)液治療（水化、堿化）/r/n其他醫(yī)囑/r/n重 /r/n臨時(shí)醫(yī)囑：/r/n血慣例、尿慣例、年夜便慣例/r/n要 □/r/n/r/n肝腎功、電解質(zhì)、凝血功能、血型/r/n輸血前檢查/r/n醫(yī) □/r/n/r/n胸部/r/n/r/nX/r/n/r/n線平片、心電圖/r/nB/r/n/r/n超（多/r/n位）/r/n囑 □/r/n/r/n頭顱、頸胸部/r/n/r/nMRI/r/n/r/n或/r/n/r/nCT/r/n、脊柱側(cè)/r/n片、腦電圖、血?dú)夥治觯ㄐ枰獣r(shí)）/r/n靜脈插管術(shù)（條件允許時(shí)）/r/n病原微生物培養(yǎng)（需要時(shí)）/r/n輸血醫(yī)囑（需要時(shí)）/r/n耳鼻喉、眼底檢查/r/n其他醫(yī)囑/r/n主要□介紹病房環(huán)境、設(shè)施和設(shè)備護(hù)理□入院護(hù)理評(píng)估/r/n工作/r/n

/r/n上級(jí)醫(yī)師查房/r/n完成入院檢查/r/n測(cè)（有條件時(shí)）/r/n血/r/n控制感染等對(duì)癥支持治療/r/n完成需要的相關(guān)科室會(huì)診/r/n完成上級(jí)醫(yī)師查房記錄等病歷書寫/r/n長期醫(yī)囑/r/n：/r/n患者既往基礎(chǔ)用藥/r/n防治尿酸腎病（別嘌呤醇）/r/n抗菌藥物（需要時(shí)）/r/n補(bǔ)液治療（水化、堿化）/r/n臨時(shí)醫(yī)囑：/r/n骨穿/r/n骨髓形態(tài)學(xué)、免疫分型、細(xì)胞遺傳學(xué)、和預(yù)后相關(guān)基因突變檢測(cè)（/r/n件時(shí)）/r/n血慣例/r/n輸血醫(yī)囑（需要時(shí)）/r/n其他醫(yī)囑/r/n□宣教（血液病知識(shí)）/r/n病情□無□有,原因：/r/n變異/r/n1./r/n記錄/r/n護(hù)士/r/n簽名/r/n時(shí)間/r/n

/r/n□無□有,原因：/r/n1./r/n2./r/n住院第3-5天/r/n主要 /r/n□根據(jù)初步骨髓結(jié)果制定治療方案□化療/r/n診療 /r/n□患者家屬簽署化療知情同意書□重要臟器呵護(hù)/r/n工作 /r/n□住院醫(yī)師完成病程記錄□止吐/r/n□上級(jí)醫(yī)師查房/r/n長期醫(yī)囑：/r/n□化療醫(yī)囑(以下方案選一)/r/n□VDLP:mg·m/r/n-2/r/n·d/r/n-1/r/n,QW,共4次,每次最年夜絕對(duì)量不超越2mg；/r/n（或VDS3mg·m/r/n-2/r/n·d/r/n-1/r/n,QW,共4次,每次最年夜絕對(duì)量不超越/r/n4mg）/r/n

/r/nDNR30/r/n/r/n

/r/n,QW,共2-4次；/r/nL-asp5000-10000u·m/r/n-2/r/n·d/r/n-1/r/n,共6-10次；/r/n（或Peg-asp2500u·m/r/n-2/r/n·d/r/n-1/r/n,共2次）/r/nPDN45-60mg·m/r/n-2/r/n·d/r/n-1/r/n,d1-28,第29-35天遞加至停./r/n（PDN試驗(yàn)d1-7,d8評(píng)估）./r/n□/r/nVDLD:VCR1.5mg/r/n·m/r/n-2/r/n·d/r/n-1/r/n,/r/nQW,/r/n共/r/n4/r/n次,每次最年夜絕對(duì)量不超越2mg；/r/n重 /r/n4mg）/r/n

/r/n（或VDS3mg·m/r/n-2/r/n·d/r/n-1/r/n,QW,共4次,每次最年夜絕對(duì)量不超越/r/nDNR30mg·m/r/n-2/r/n·d/r/n-1/r/n,QW,共2-4次；/r/n要 /r/nL-asp5000-10000/r/n/r/n

/r/n,共6-10次；/r/n醫(yī) /r/n（或/r/nPeg-asp/r/n/r/n2500u·m/r/n-2/r/n·d/r/n-1/r/n/r/n,/r/n/r/n共/r/n2/r/n次）/r/nPDN45-60mg·m/r/n-2/r/n·d/r/n-1/r/n,d1-7；/r/n囑 /r/nDXM/r/n/r/n6-8mg·m/r/n-2/r/n·d/r/n-1/r/n,/r/n/r/nd8-28,/r/n第/r/n29-35/r/n天遞加至/r/n./r/n（PDN試驗(yàn)d1-7,d8評(píng)估）./r/n止吐、抗感染等對(duì)癥支持治療醫(yī)囑□補(bǔ)液治療（水化、堿化）/r/n重要臟器功能呵護(hù)：防治尿酸腎病 □復(fù)方磺胺異噁唑/r/n（別嘌呤醇）、保肝、抑酸等 □其他醫(yī)/r/n臨時(shí)醫(yī)囑：/r/n輸血醫(yī)囑（需要時(shí)）/r/n心電監(jiān)護(hù)（需要時(shí)）/r/n復(fù)查肝腎功、電解質(zhì)/r/n隔日復(fù)查血慣例（需要時(shí)可每天復(fù)查）/r/n血培養(yǎng)（高熱時(shí)）/r/n呈現(xiàn)感染時(shí),需屢次重復(fù)各種體液或分泌物病原學(xué)檢查及相關(guān)影像學(xué)檢查/r/n靜脈插管護(hù)理、換藥/r/n腰穿,鞘內(nèi)注射（具體劑量見住院流程）/r/n腦脊液慣例、生化和細(xì)胞形態(tài)學(xué)檢查/r/n其他醫(yī)囑/r/n主要□觀察患者病情變動(dòng)護(hù)理□心理與生活護(hù)理/r/n工作□化療期間囑患者多飲水病情□無□有,原因：/r/n變異1./r/n記錄/r/n護(hù)士/r/n簽名/r/n時(shí)間 住院第/r/n6-34/r/n天 出院日/r/n住院醫(yī)師完成病歷書寫/r/n主 /r/n□/r/n/r/n復(fù)查血慣例/r/n注意觀察體溫、血壓、體重等/r/n,/r/n/r/n防/r/n要 /r/n并發(fā)癥/r/n診 /r/n□/r/n/r/n成份輸血、抗感染等支持治療（需要/r/n療 /r/n時(shí)）/r/n工 /r/n□/r/n/r/n造血生長因子（需要時(shí)/r/n作 /r/n□/r/n/r/n骨髓檢查/r/n腰穿,鞘內(nèi)注射/r/n長期醫(yī)囑：/r/n潔凈飲食/r/n抗感染等支持治療（需要時(shí)）/r/n其他醫(yī)囑/r/n臨時(shí)醫(yī)囑：/r/n血慣例、尿慣例、年夜便慣例/r/n重 /r/n□/r/n/r/n肝腎功、電解質(zhì)、凝血功能/r/n輸血醫(yī)囑（需要時(shí)）/r/n要 /r/n□/r/n/r/n第/r/n8/r/n天查外周血涂片中幼稚細(xì)胞計(jì)數(shù)/r/n15/r/n33/r/n醫(yī) /r/n□/r/n/r/n腰/r/n穿/r/n,/r/n/r/n鞘內(nèi)注射（具體劑量見住院/r/n程）/r/n囑 /r/n□/r/n/r/n腦脊液慣例、生化和細(xì)胞形態(tài)學(xué)檢查/r/n復(fù)查治療前有白血病細(xì)胞浸潤改變的/r/n各項(xiàng)檢查/r/n

/r/n上級(jí)醫(yī)師查房,進(jìn)行化療/r/n（/r/n評(píng)估,確定有無并發(fā)癥情況,明/r/n確是否出院/r/n書等/r/n向患者交代出院后的注意事項(xiàng),如：/r/n返院復(fù)診的時(shí)間、地址,發(fā)生緊急情況時(shí)的處置等/r/n出院醫(yī)囑：/r/n出院帶藥/r/n按期門診隨訪/r/n監(jiān)測(cè)血慣例、肝腎功、電解質(zhì)等/r/nG-CSF/r/n/r/n5μg/r/n/r/nKg/r/n-1/r/nd/r/n/r/n-1/r/n（需要時(shí)）/r/n影像學(xué)檢查（需要）/r/n病原微生物培養(yǎng)（需要時(shí)）/r/n血培養(yǎng)（高熱時(shí)）/r/n靜脈插管維護(hù)、換藥/r/n其他醫(yī)囑/r/n工作/r/n觀察患者情況/r/n心理與生活護(hù)理/r/n化療期間囑患者多飲水/r/n□指導(dǎo)患者規(guī)畫出院手續(xù)/r/n病情/r/n□無□有,原因：/r/n□無□有,原因：/r/n變異/r/n1./r/n1./r/n記錄/r/n2./r/n2./r/n護(hù)士簽名/r/n醫(yī)師簽名/r/n完全緩解的兒童ALL臨床路徑/r/n（2017年版）/r/n一、完全緩解的ALL臨床路徑標(biāo)準(zhǔn)住院流程/r/n（一）臨床路徑標(biāo)準(zhǔn)住院日為21天內(nèi)./r/n（二）進(jìn)入路徑標(biāo)準(zhǔn)./r/n第一診斷必需符合兒童急性淋巴細(xì)胞白血病/r/n碼（ICD10：2)/r/n經(jīng)誘導(dǎo)化療達(dá)完全緩解/r/n當(dāng)患者同時(shí)具有其他疾病診斷時(shí),但在住院期間不需要特/r/n（三）/r/n2/r/n（指工作日/r/n1.必需的檢查項(xiàng)目：/r/n血慣例、尿慣例、年夜便慣例；/r/n肝腎功能、電解質(zhì)、凝血功能、血型、輸血前檢查；/r/n胸部/r/nX/r/nB/r/n像學(xué)檢查；/r/n骨髓涂片或/r/n/及活檢（需要時(shí)）/r/n、微小殘留病變檢測(cè)(有/r/n條件時(shí))；/r/n書、腰穿及鞘內(nèi)注射同意書、輸血知情同意書、靜脈插管知情同意書./r/n（四）治療開始于入院第3天內(nèi)./r/n（五）治療方案./r/n1.緩解后鞏固治療/r/nCAM/r/n環(huán)磷酰胺（CTX）800-1000mg·m/r/n-2/r/n·d/r/n-1/r/n,1次；/r/n阿糖胞苷（Ara-C）75-100mg·m/r/n-2/r/n·d/r/n-1/r/n7-8/r/n6-巰基嘌呤（6-MP）60-75mg·m/r/n-2/r/n·d/r/n-1/r/n7-14/r/nCAM/r/nmM/r/n年夜劑量甲氨喋呤/r/n,每兩周/r/n1/r/n次,共/r/n次；/r/n四氫葉酸鈣（CF）15mg·m/r/n-2/r/n,/r/n6/r/n1/r/n3-8/r/n6-MP25mg·m/r/n-2/r/n·d/r/n-1/r/n56/r/n天,根據(jù)/r/nWBC/r/nVDLP（D）方案：/r/nmg·m/r/n-2/r/n·d/r/n-1/r/n1/r/n3/r/n2mg；（/r/nVDS3mg·m/r/n-2/r/n·d/r/n-1/r/n,/r/nQW,/r/n3/r/n4mg）/r/nDN/r/nR/r/n或阿霉素/r/nAD/r/n25-30m/r/n,/r/n每周/r/n1/r/n共/r/n1-/r/n3/r/n次；/r/nL-asp/r/n/r/n5000-10000u/r/n·/r/nm/r/n-2/r/n·/r/nd/r/n-1/r/n,共/r/n4-8/r/n（/r/nPeg-asp2500u·m/r/n-2/r/n·d/r/n-1/r/n1/r/n）/r/nPDN/r/n/r/n45-60/r/n/r/ng/r/n-/r/n-/r/n1/r/n或/r/nDXM/r/n/r/n6-8m/r/n-/r/n-/r/n,/r/n/r/nd1-7,/r/n/r/nd15-21./r/nCAM/r/nCTX800-1000mg·m/r/n-2/r/n·d/r/n-1/r/n,1次；/r/nAra-C75-100mg·m/r/n-2/r/n·d/r/n-1/r/n7-8/r/n6-MP60-75mg·m/r/n-2/r/n·d/r/n-1/r/n7-14/r/n8/r/n（/r/n8/r/n6-MP+MTX/r/n體方案見下）./r/n中危組患者重復(fù)一次上述/r/nVDLP（D）/r/n和/r/nCAM/r/n（1）6-MP+MTX方案：/r/n6-MP50mg·m/r/n-2/r/n·d/r/n-1/r/n,繼續(xù)睡前空腹口服；/r/nMTX15-30mg·m/r/n-2/r/n,每周1次,口服或肌注,繼續(xù)至終止治療/r/n（/r/n2.5-3/r/n2-2.5/r/n）./r/n根據(jù)/r/nWBC/r/n（2）VD方案（6-MP+MTX方案期間每4-8周拔出）：/r/nmg·m/r/n-2/r/n·d/r/n-1/r/n,1次,每次最年夜絕對(duì)量不超越2mg；（或VDS3mg·m/r/n-2/r/n·d/r/n-1/r/n,1次,每次最年夜絕對(duì)量不超越4mg）/r/nDXM6-8mg·m/r/n-2/r/n·d/r/n-1/r/n,d1-7./r/n4/r/n.中樞神經(jīng)白血?。?r/n/r/nCNSL）/r/n的防治：腰穿及鞘內(nèi)注射至少16-24/r/nMTX/r/n如下：/r/n<12/r/n6mg,/r/n12-36/r/n9mg,/r/n>36/r/n<12/r/n15mg,/r/n月/r/n25mg,/r/n>36/r/n月/r/n<12/r/n2.5mg,/r/n2.5mg,/r/n>36/r/n月/r/n5mg./r/nCNSL/r/n<1/r/n1/r/n（六）治療后恢復(fù)期復(fù)查的檢查項(xiàng)目./r/n1.血慣例、肝腎功能、電解質(zhì)./r/n./r/n骨髓檢查（需要時(shí)/r/n微小殘留病變檢測(cè)（需要時(shí)/r/n（七）化療中及化療后治療./r/n1.感染防治：/r/n給予復(fù)方磺胺異噁唑預(yù)防卡氏肺胞子蟲肺炎；/r/n發(fā)熱患者建議立即進(jìn)行病原微生物培養(yǎng)并使用抗菌藥物,/r/n可選用頭孢類（或青霉素類）/r/n抗炎治療,/r/n3/r/n//r/n或糖肽類和/r/n//r/n或抗真菌治療；有明確臟器感染患者應(yīng)根據(jù)感染部位及病原微生物培養(yǎng)結(jié)果選用相應(yīng)抗菌藥物；/r/n成份輸血:適用于/r/nHb﹤80g/L,PLT﹤20×10/r/n9/r/n/L/r/n出血的患者,分別輸濃縮紅細(xì)胞、單采或多采血小板.有心功能不/r/n造血生長因子:化療后中性粒細(xì)胞絕對(duì)值（/r/nANC）≤×10/r/n9/r/n/L,/r/n可使用G-CSF5μg·Kg/r/n-1/r/n·d/r/n-1/r/n./r/n（八）出院標(biāo)準(zhǔn)./r/n./r/n2.沒有需要住院處置的并發(fā)癥和/或合并癥./r/n（九）有無變異及原因分析./r/n療中、后有感染、貧血、出血及其他合并癥者,進(jìn)行相關(guān)的診斷和治療,可能延長住院時(shí)間并致費(fèi)用增加./r/n若治療過程中呈現(xiàn)/r/nCNSL,/r/n//r/n二、完全緩解的兒童/r/nALL/r/n適用對(duì)象：/r/n第一診斷為/r/n兒童急性淋巴胞白血病達(dá)CR者（ICD-10：2）擬行緩解后續(xù)化療/r/n患者姓名：性別：年齡： 門診號(hào)：住院號(hào)：/r/n住院日期： 年/r/n/r/n月/r/n/r/n日 出院日期： 年/r/n/r/n月/r/n/r/n日 標(biāo)/r/n住院日/r/n/r/n21/r/n/r/n天內(nèi)/r/n時(shí)間 住院第/r/n1/r/n天/r/n詢問病史及體格檢查/r/n完成病歷書/r/n主 /r/n□/r/n/r/n開化驗(yàn)單/r/n要 /r/n□/r/n/r/n上級(jí)醫(yī)師查房與化療前評(píng)估/r/n診 /r/n□/r/n/r/n患者家/r/n屬/r/n簽署輸血同意書/r/n、/r/n骨/r/n穿/r/n同/r/n療 /r/n書、腰穿同意書、靜脈插管同意書/r/n工/r/n作/r/n

/r/n住院第2天/r/n上級(jí)醫(yī)師查房/r/n完成入院檢查/r/n骨穿（/r/n變檢測(cè)）/r/n根據(jù)血象決定是否成份輸血/r/n完成需要的相關(guān)科室會(huì)診/r/n完成上級(jí)醫(yī)師查房記錄等病歷書寫/r/n確定化療方案和日期/r/n重要醫(yī)囑/r/n長期醫(yī)囑：/r/n兒科血液病護(hù)理慣例/r/n飲食：◎普食◎其他/r/n抗菌藥物（需要時(shí)）/r/n臨時(shí)醫(yī)囑：/r/n血慣例、尿慣例、年夜便慣例/r/n輸血前檢查/r/nX/r/nB/r/n頭顱、頸胸部/r/nMRI/r/n或/r/nCT/r/n腦電圖、血?dú)夥治?、超聲心?dòng)（視患者情況而定）/r/n項(xiàng)檢查/r/n靜脈插管術(shù)（有條件時(shí)）/r/n病原微生物培養(yǎng)（需要時(shí)）/r/n輸血醫(yī)囑（需要時(shí)）/r/n其他醫(yī)囑/r/n長期醫(yī)囑/r/n：/r/n患者既往基礎(chǔ)用藥/r/n抗菌藥物（需要時(shí)）/r/n其他醫(yī)囑/r/n臨時(shí)醫(yī)囑：/r/n骨穿（需要時(shí)）/r/n骨髓形態(tài)學(xué)、微小殘留病檢測(cè)（/r/n件并需要時(shí)）/r/n腰穿,鞘內(nèi)注射/r/n（/r/n程）/r/n腦脊液慣例、生化、細(xì)胞形態(tài)/r/n輸血醫(yī)囑（需要時(shí)）/r/n其他醫(yī)囑/r/n主要/r/n介紹病房環(huán)境、設(shè)施和設(shè)備/r/n入院護(hù)理評(píng)估/r/n□宣教（血液病知識(shí)）/r/n病情/r/n1./r/n2./r/n□有,/r/n原因：/r/n□無□有,原因：/r/n1./r/n2./r/n時(shí)間/r/n主 □患者家屬簽署化療知情同意書□化/r/n

/r/n住院第3天/r/n要/r/n/r/n□上級(jí)醫(yī)師查/r/n,/r/n/r/n制定化療方案 □重要臟器呵/r/n診/r/n/r/n□住院醫(yī)師完成病程記錄□止吐/r/n療工作/r/n長期醫(yī)囑：/r/n□VDLP:□CAM:/r/nVCR1.5mg·m/r/n-2/r/n·d/r/n-1/r/n,QW,共3次；/r/n（或VDS3mg·m/r/n-2/r/n·d/r/n-1/r/n,QW,共3/r/n次） CTX800-1000mg·m/r/n-2/r/n·d/r/n-1/r/n,/r/n1/r/n次；/r/n7-8/r/n

/r/nDNR或ADR25-30mg·m/r/n-2/r/n·d/r/n-1/r/n,QW,共1-3/r/n/r/n次； Ara-C75-100mg·m/r/n-2/r/n·d/r/n-1/r/n,/r/n/r/n共/r/n14/r/n

/r/nL-asp5000-10000/r/n/r/n

/r/n,共4-8/r/n次； 6-MP60-75/r/n/r/n

/r/n,共7-/r/n（或Peg-asp2500u·m/r/n-2/r/n·d/r/n-1/r/n,共1次）/r/nPDN45-60/r/n/r/n□VDLD:/r/n

/r/n,d1-7,d15-21./r/n重 /r/nVCR/r/n/r/n1.5/r/n/r/nmg·m/r/n-2/r/n·d/r/n-1/r/n,/r/n/r/nQW,/r/n共/r/n3/r/n次；/r/n（或VDS3mg·m/r/n-2/r/n·d/r/n-1/r/n,QW,共3次）/r/n要 /r/nDNR/r/n或/r/nADR/r/n/r/n25-30/r/n/r/nmg·m/r/n-2/r/n·d/r/n-1/r/n,/r/n/r/nQW,/r/n共/r/n1-3/r/n次；/r/nL-asp5000-10000u·m/r/n-2/r/n·d/r/n-1/r/n,共4-8次；/r/n醫(yī) /r/n（或/r/nPeg-asp/r/n