儿童急性淋巴细胞白血病临床路径(版)

创作时间：二零二一年六月三十日/r/n创作时间：二零二一年六月三十日/r/n创作时间：二零二一年六月三十日/r/n创作时间：二零二一年六月三十日/r/n儿童急性淋巴细胞白血病临床路径之马矢奏春创作/r/n创作时间：二零二一年六月三十日/r/n创作时间：二零二一年六月三十日/r/n（2017年版）/r/n一、/r/n儿童急性淋巴细胞白血病（ALL）临床路径标准住院流程/r/n(一)/r/n适用对象./r/n第一诊断为儿童急性淋巴细胞白血病(ICD-10:C91.0)的标危、中危组患者./r/n(二)/r/n诊断依据./r/n根据《临床诊疗指南－小儿内科分册》（中华医学会编著,人民卫生出书社）,《诸福棠实用儿科学（第七版）》（人民卫生出书社）,《血液病诊断及疗效标准(第三版)》（张之南、沈悌主编著,科学出书社）./r/n（一）体检：可有发热、皮肤粘膜苍白、皮肤出血点及瘀斑、淋凑趣及肝脾肿年夜、胸骨压痛等./r/n（二）血细胞计数及分类./r/n（三）骨髓检查：形态学（包括组化检查）./r/n（四）免疫分型./r/n（五）细胞遗传学：核型分析,FISH(需要时)./r/n（六）白血病相关基因./r/n(三)/r/n危险度分组标准./r/n（一）标危组：必需同时满足以下所有条件：1.年龄≥1岁且＜10岁；/r/n2.WBC＜50×10/r/n9/r/n/L；/r/n泼尼松反应良好/r/n（/r/n8/r/n天外周血白血病细胞＜/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无/r/nt（9;22）/r/n或/r/nBCR/ABL/r/n融合基因；无/r/nt（4;11）/r/nMLL/AF4融合基因；无t（1;19）/r/n或/r/nE2A/PBX1/r/n治疗第/r/n15/r/n天骨髓呈/r/nM1(原幼淋细胞＜5%/r/n)或/r/nM2（/r/n5%-25%）,/r/n33/r/n（二）/r/n4/r/n1/r/n.无/r/nt（9;22）/r/n或/r/nBCR/ABL/r/n泼尼松反应良好/r/n（/r/n8/r/n天外周血白血病细胞＜/r/n1/r/n10/r/n9/r/n/L）；/r/n标危诱导缓解治疗第/r/n15/r/n天骨髓呈/r/nM3（/r/n25%）/r/n15天骨髓呈M1/M2；/r/n如有条件进行微小残留病（MRD）/r/n33/r/nMRD＜/r/n10/r/n－2/r/n./r/n同时至少符合以下条件之一：5.WBC≥50×10/r/n9/r/n/L；/r/n6.年龄≥10岁；/r/n7.T-ALL；/r/n8.t（1;19）/r/n或/r/nE2A/PBX1/r/n9.年龄＜1岁且无MLL基因重排./r/n（三）高危组：必需满足下列条件之一：/r/n泼尼松反应不良（/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选择治疗方案的依据./r/n根据《临床诊疗指南－小儿内科分册》（中华医学会编著 /r/n人民卫生出书社）/r/n,/r/n/r/n《诸福棠实用儿科学（第七版）》（人民卫生出书社）/r/nVDLP（D）方案：/r/nmg·m/r/n-2/r/n·d/r/n-1/r/n1/r/n4/r/n2mg；或长春地辛（VDS）3mg·m/r/n-2/r/n·d/r/n-1/r/n1/r/n4/r/n4mg；/r/n柔红霉素（DNR）30mg·m/r/n-2/r/n·d/r/n-1/r/n,每周1次,共2-4次；/r/n左旋门冬酰胺酶/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培门冬酰胺酶/r/nPeg-as/r/n2500/r/n-/r/n-/r/n,/r/n共/r/n2/r/n次；/r/n泼尼松（PDN）45-60mg·m/r/n-2/r/n·d/r/n-1/r/n,d1-28,第29-35天递加至停.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天递加至停./r/nPDN试验d1-7,从足量的25%用起,根据临床反应逐渐加至足/r/n量,7天内累积剂量>210mg·m/r/n-2/r/n·kg/r/n-1/r/n·d/r/n-1/r/n）,以免发生肿瘤溶解综合征,d8评估./r/n1.CAM/r/n环磷酰胺（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-巯基嘌呤（6-MP）60-75mg·m/r/n-2/r/n·d/r/n-1/r/n/r/n7-14/r/n中危组患者重复一次CAM方案.2.mM方案：/r/n年夜剂量甲氨喋呤/r/n,每两周/r/n1/r/n次,共/r/n次；/r/n四氢叶酸钙（CF）15mg·m/r/n-2/r/n,/r/n6/r/n1/r/n3-8/r/n血药浓度给予调整；/r/n6-MP25mg·m/r/n-2/r/n·d/r/n-1/r/n,不超越56天,根据WBC调整剂量./r/n上述方案实施期间需要进行水化、碱化.C.延迟强化治疗：/r/nVDLP（D）方案：/r/nmg·m/r/n-2/r/n·d/r/n-1/r/n1/r/n3/r/n2mg；或长春地辛（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；或培门冬酰胺酶/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体方案见下）./r/n中危组患者重复一次上述/r/nVDLP（D）/r/n和/r/nCAM/r/nD.维持治疗方案：/r/nMP+MTX方案：/r/n6-MP50mg·m/r/n-2/r/n·d/r/n-1/r/n,继续睡前空腹口服；/r/nMTX15-30mg·m/r/n-2/r/n,每周1次,口服或肌注,继续至终止治疗/r/n（/r/n2.5-3/r/n2-2.5/r/n）./r/n根据/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.中枢神经白血病（/r/n/r/nCNSL）/r/n的防治：腰穿及鞘内注射至少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,年龄/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根据患者的疾病状态选择路径./r/n初治儿童ALL临床路径和完全缓解（CR）的儿童ALL临床路径（附后）./r/n(六)/r/n参考费用标准./r/n（一）标危组患者平均全程参考费用标准控制在8万元内./r/n（二）中危组患者平均全程参考费用标准控制在15万元内./r/n初治儿童ALL临床路径/r/n（2017年版）/r/n一、初治儿童ALL临床路径标准住院流程/r/n（一）标准住院日为35天内./r/n（二）进入路径标准./r/n第一诊断必需符合儿童急性淋巴细胞白血病（/r/nALL）/r/n码（ICD10：2)/r/n当患者同时具有其他疾病诊断时,但在住院期间不需要特/r/n（三）明确诊断及入院惯例检查需3-5天（指工作日）./r/n1.必需的检查项目：/r/n血惯例、尿惯例、年夜便惯例；/r/n肝肾功能、电解质、凝血功能、血型、输血前检查；/r/nX/r/n（/r/n脏和腹部、睾丸等）、眼底检查；/r/n查；/r/n骨髓检查（形态学包括组化）/r/n学、白血病相关基因检测；/r/n4/r/n内,鞘内注射化疗药物；/r/nMRI/r/nCT/r/n意书、腰穿及鞘内注射同意书、化疗知情同意书、输血知情同意书、静脉插管同意书（有条件时/r/n（四）化疗前准备./r/n抗菌药物,可选用头孢类（或青霉素类）抗炎治疗,3天后发热不缓解者,可考虑更换为碳青酶烯类和/或糖肽类和/或抗真菌治/r/n疗；有明确脏器感染患者应根据感染部位及病原微生物培养结果选用相应抗菌药物./r/n2.对Hb﹤80g/L,PLT﹤20×10/r/n9/r/n/L或有活动性出血的患者,分别输浓缩红细胞、单采或多采血小板,若存在弥散性血管内凝血（DIC）倾向则当PLT﹤50×10/r/n9/r/n/L即应输注单采或多采血小板,并使用肝素等其他DIC治疗药物.有心功能不全者可放宽输血指征./r/n﹤/r/n/L,/r/n输/r/n（五）化疗开始于诊断第1-5天./r/n（六）/r/n化疗方案./r/nVDLP（D）方案：/r/nmg·m/r/n-2/r/n·d/r/n-1/r/n1/r/n4/r/n2mg；或长春地辛（VDS）3mg·m/r/n-2/r/n·d/r/n-1/r/n1/r/n4/r/n4mg；/r/n柔红霉素（DNR）30mg·m/r/n-2/r/n·d/r/n-1/r/n,每周1次,共2-4次；/r/n左旋门冬酰胺酶/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培门冬酰胺酶/r/nPeg-as/r/n2500/r/n-/r/n-/r/n,/r/n共/r/n2/r/n次；/r/n泼尼松（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天递加至停./r/nPDN/r/nd1-7/r/n25%用起,根据临床反应逐渐加至足/r/n量,/r/n7/r/n天内累积剂量/r/n>210mg·m/r/n-2/r/n·kg/r/n-1/r/n·d/r/n-1/r/n）,/r/n以免发生肿瘤溶解/r/n综合征,第8天评估./r/n（七）化疗后必需复查的检查项目./r/n1.血惯例、尿惯例、年夜便惯例./r/n8/r/n15/r/n33/r/n病变检测./r/n（八）化疗中及化疗后治疗./r/n1.感染防治：/r/n发热患者建议立即进行病原微生物培养并使用抗菌药物,/r/n可选用头孢类（或青霉素类）/r/n抗炎治疗,/r/n3/r/n//r/n或糖肽类和/r/n//r/n或抗真菌治疗；有明确脏器感染的患者,应根据感染部位及病原微生物培养结果选用相应抗菌药物./r/n脏器功能损伤的相应防治：止吐、保肝、水化、碱化、防/r/n治尿酸肾病（别嘌呤醇）、抑酸剂等./r/n成份输血:适用于/r/nHb﹤80g/L,/r/n/r/nPLT﹤20×10/r/n9/r/n/L或有活动性出血的患者,分别输浓缩红细胞、单采或多采血小板,若存在DIC/r/n倾向则/r/nPLT﹤50×10/r/n9/r/n/L/r/nDIC/r/n造血生长因子:化疗后中性粒细胞绝对值（/r/nANC）≤×10/r/n9/r/n/L,/r/n可使用粒细胞集落安慰因子（G-CSF）5μg·Kg/r/n-1/r/n·d/r/n-1/r/n./r/n（九）出院标准./r/n./r/n2.没有需要住院处置的并发症和(或)合并症./r/n（十）变异及原因分析./r/n治疗前、中、后有感染、贫血、出血及其他合并症者,需/r/n二、初治儿童/r/nALL/r/n适用对象：/r/n第一诊断为/r/n初治儿童急性淋巴细胞白血病（ICD-10：2）拟行诱导化疗/r/n患者姓名：性别：年龄：门诊号：住院号：/r/n住院日期：年月日 出院日期：年月日 标准住院日/r/n35/r/n天内/r/n时间/r/n时间/r/n1/r/n2/r/n询问病史及体格检查/r/n完成病历书写/r/n主 /r/n□/r/n/r/n开化验单/r/n上级医师查房与化疗前评估/r/n要 /r/n□/r/n/r/n根据血象及凝血功能决定是否成份/r/n诊 /r/n血/r/n疗 /r/n□/r/n/r/n向家属告病重或病危并签署病重或病/r/n工 /r/n危通知书/r/n作 /r/n□/r/n/r/n患者家属签署骨穿同意书、腰穿同意/r/n书、输血知情同意书、静脉插管同意书（条件允许时）/r/n长期医嘱：/r/n儿科血液病护理惯例/r/n饮食/r/n抗菌药物（需要时）/r/n补液治疗（水化、碱化）/r/n其他医嘱/r/n重 /r/n临时医嘱：/r/n血惯例、尿惯例、年夜便惯例/r/n要 □/r/n/r/n肝肾功、电解质、凝血功能、血型/r/n输血前检查/r/n医 □/r/n/r/n胸部/r/n/r/nX/r/n/r/n线平片、心电图/r/nB/r/n/r/n超（多/r/n位）/r/n嘱 □/r/n/r/n头颅、颈胸部/r/n/r/nMRI/r/n/r/n或/r/n/r/nCT/r/n、脊柱侧/r/n片、脑电图、血气分析（需要时）/r/n静脉插管术（条件允许时）/r/n病原微生物培养（需要时）/r/n输血医嘱（需要时）/r/n耳鼻喉、眼底检查/r/n其他医嘱/r/n主要□介绍病房环境、设施和设备护理□入院护理评估/r/n工作/r/n

/r/n上级医师查房/r/n完成入院检查/r/n测（有条件时）/r/n血/r/n控制感染等对症支持治疗/r/n完成需要的相关科室会诊/r/n完成上级医师查房记录等病历书写/r/n长期医嘱/r/n：/r/n患者既往基础用药/r/n防治尿酸肾病（别嘌呤醇）/r/n抗菌药物（需要时）/r/n补液治疗（水化、碱化）/r/n临时医嘱：/r/n骨穿/r/n骨髓形态学、免疫分型、细胞遗传学、和预后相关基因突变检测（/r/n件时）/r/n血惯例/r/n输血医嘱（需要时）/r/n其他医嘱/r/n□宣教（血液病知识）/r/n病情□无□有,原因：/r/n变异/r/n1./r/n记录/r/n护士/r/n签名/r/n时间/r/n

/r/n□无□有,原因：/r/n1./r/n2./r/n住院第3-5天/r/n主要 /r/n□根据初步骨髓结果制定治疗方案□化疗/r/n诊疗 /r/n□患者家属签署化疗知情同意书□重要脏器呵护/r/n工作 /r/n□住院医师完成病程记录□止吐/r/n□上级医师查房/r/n长期医嘱：/r/n□化疗医嘱(以下方案选一)/r/n□VDLP:mg·m/r/n-2/r/n·d/r/n-1/r/n,QW,共4次,每次最年夜绝对量不超越2mg；/r/n（或VDS3mg·m/r/n-2/r/n·d/r/n-1/r/n,QW,共4次,每次最年夜绝对量不超越/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天递加至停./r/n（PDN试验d1-7,d8评估）./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,每次最年夜绝对量不超越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,每次最年夜绝对量不超越/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医 /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嘱 /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天递加至/r/n./r/n（PDN试验d1-7,d8评估）./r/n止吐、抗感染等对症支持治疗医嘱□补液治疗（水化、碱化）/r/n重要脏器功能呵护：防治尿酸肾病 □复方磺胺异噁唑/r/n（别嘌呤醇）、保肝、抑酸等 □其他医/r/n临时医嘱：/r/n输血医嘱（需要时）/r/n心电监护（需要时）/r/n复查肝肾功、电解质/r/n隔日复查血惯例（需要时可每天复查）/r/n血培养（高热时）/r/n呈现感染时,需屡次重复各种体液或分泌物病原学检查及相关影像学检查/r/n静脉插管护理、换药/r/n腰穿,鞘内注射（具体剂量见住院流程）/r/n脑脊液惯例、生化和细胞形态学检查/r/n其他医嘱/r/n主要□观察患者病情变动护理□心理与生活护理/r/n工作□化疗期间嘱患者多饮水病情□无□有,原因：/r/n变异1./r/n记录/r/n护士/r/n签名/r/n时间 住院第/r/n6-34/r/n天 出院日/r/n住院医师完成病历书写/r/n主 /r/n□/r/n/r/n复查血惯例/r/n注意观察体温、血压、体重等/r/n,/r/n/r/n防/r/n要 /r/n并发症/r/n诊 /r/n□/r/n/r/n成份输血、抗感染等支持治疗（需要/r/n疗 /r/n时）/r/n工 /r/n□/r/n/r/n造血生长因子（需要时/r/n作 /r/n□/r/n/r/n骨髓检查/r/n腰穿,鞘内注射/r/n长期医嘱：/r/n洁净饮食/r/n抗感染等支持治疗（需要时）/r/n其他医嘱/r/n临时医嘱：/r/n血惯例、尿惯例、年夜便惯例/r/n重 /r/n□/r/n/r/n肝肾功、电解质、凝血功能/r/n输血医嘱（需要时）/r/n要 /r/n□/r/n/r/n第/r/n8/r/n天查外周血涂片中幼稚细胞计数/r/n15/r/n33/r/n医 /r/n□/r/n/r/n腰/r/n穿/r/n,/r/n/r/n鞘内注射（具体剂量见住院/r/n程）/r/n嘱 /r/n□/r/n/r/n脑脊液惯例、生化和细胞形态学检查/r/n复查治疗前有白血病细胞浸润改变的/r/n各项检查/r/n

/r/n上级医师查房,进行化疗/r/n（/r/n评估,确定有无并发症情况,明/r/n确是否出院/r/n书等/r/n向患者交代出院后的注意事项,如：/r/n返院复诊的时间、地址,发生紧急情况时的处置等/r/n出院医嘱：/r/n出院带药/r/n按期门诊随访/r/n监测血惯例、肝肾功、电解质等/r/nG-CSF/r/n/r/n5μg/r/n/r/nKg/r/n-1/r/nd/r/n/r/n-1/r/n（需要时）/r/n影像学检查（需要）/r/n病原微生物培养（需要时）/r/n血培养（高热时）/r/n静脉插管维护、换药/r/n其他医嘱/r/n工作/r/n观察患者情况/r/n心理与生活护理/r/n化疗期间嘱患者多饮水/r/n□指导患者规画出院手续/r/n病情/r/n□无□有,原因：/r/n□无□有,原因：/r/n变异/r/n1./r/n1./r/n记录/r/n2./r/n2./r/n护士签名/r/n医师签名/r/n完全缓解的儿童ALL临床路径/r/n（2017年版）/r/n一、完全缓解的ALL临床路径标准住院流程/r/n（一）临床路径标准住院日为21天内./r/n（二）进入路径标准./r/n第一诊断必需符合儿童急性淋巴细胞白血病/r/n码（ICD10：2)/r/n经诱导化疗达完全缓解/r/n当患者同时具有其他疾病诊断时,但在住院期间不需要特/r/n（三）/r/n2/r/n（指工作日/r/n1.必需的检查项目：/r/n血惯例、尿惯例、年夜便惯例；/r/n肝肾功能、电解质、凝血功能、血型、输血前检查；/r/n胸部/r/nX/r/nB/r/n像学检查；/r/n骨髓涂片或/r/n/及活检（需要时）/r/n、微小残留病变检测(有/r/n条件时)；/r/n书、腰穿及鞘内注射同意书、输血知情同意书、静脉插管知情同意书./r/n（四）治疗开始于入院第3天内./r/n（五）治疗方案./r/n1.缓解后巩固治疗/r/nCAM/r/n环磷酰胺（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-巯基嘌呤（6-MP）60-75mg·m/r/n-2/r/n·d/r/n-1/r/n7-14/r/nCAM/r/nmM/r/n年夜剂量甲氨喋呤/r/n,每两周/r/n1/r/n次,共/r/n次；/r/n四氢叶酸钙（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,根据/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体方案见下）./r/n中危组患者重复一次上述/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,继续睡前空腹口服；/r/nMTX15-30mg·m/r/n-2/r/n,每周1次,口服或肌注,继续至终止治疗/r/n（/r/n2.5-3/r/n2-2.5/r/n）./r/n根据/r/nWBC/r/n（2）VD方案（6-MP+MTX方案期间每4-8周拔出）：/r/nmg·m/r/n-2/r/n·d/r/n-1/r/n,1次,每次最年夜绝对量不超越2mg；（或VDS3mg·m/r/n-2/r/n·d/r/n-1/r/n,1次,每次最年夜绝对量不超越4mg）/r/nDXM6-8mg·m/r/n-2/r/n·d/r/n-1/r/n,d1-7./r/n4/r/n.中枢神经白血病（/r/n/r/nCNSL）/r/n的防治：腰穿及鞘内注射至少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）治疗后恢复期复查的检查项目./r/n1.血惯例、肝肾功能、电解质./r/n./r/n骨髓检查（需要时/r/n微小残留病变检测（需要时/r/n（七）化疗中及化疗后治疗./r/n1.感染防治：/r/n给予复方磺胺异噁唑预防卡氏肺胞子虫肺炎；/r/n发热患者建议立即进行病原微生物培养并使用抗菌药物,/r/n可选用头孢类（或青霉素类）/r/n抗炎治疗,/r/n3/r/n//r/n或糖肽类和/r/n//r/n或抗真菌治疗；有明确脏器感染患者应根据感染部位及病原微生物培养结果选用相应抗菌药物；/r/n成份输血:适用于/r/nHb﹤80g/L,PLT﹤20×10/r/n9/r/n/L/r/n出血的患者,分别输浓缩红细胞、单采或多采血小板.有心功能不/r/n造血生长因子:化疗后中性粒细胞绝对值（/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）出院标准./r/n./r/n2.没有需要住院处置的并发症和/或合并症./r/n（九）有无变异及原因分析./r/n疗中、后有感染、贫血、出血及其他合并症者,进行相关的诊断和治疗,可能延长住院时间并致费用增加./r/n若治疗过程中呈现/r/nCNSL,/r/n//r/n二、完全缓解的儿童/r/nALL/r/n适用对象：/r/n第一诊断为/r/n儿童急性淋巴胞白血病达CR者（ICD-10：2）拟行缓解后续化疗/r/n患者姓名：性别：年龄： 门诊号：住院号：/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 标/r/n住院日/r/n/r/n21/r/n/r/n天内/r/n时间 住院第/r/n1/r/n天/r/n询问病史及体格检查/r/n完成病历书/r/n主 /r/n□/r/n/r/n开化验单/r/n要 /r/n□/r/n/r/n上级医师查房与化疗前评估/r/n诊 /r/n□/r/n/r/n患者家/r/n属/r/n签署输血同意书/r/n、/r/n骨/r/n穿/r/n同/r/n疗 /r/n书、腰穿同意书、静脉插管同意书/r/n工/r/n作/r/n

/r/n住院第2天/r/n上级医师查房/r/n完成入院检查/r/n骨穿（/r/n变检测）/r/n根据血象决定是否成份输血/r/n完成需要的相关科室会诊/r/n完成上级医师查房记录等病历书写/r/n确定化疗方案和日期/r/n重要医嘱/r/n长期医嘱：/r/n儿科血液病护理惯例/r/n饮食：◎普食◎其他/r/n抗菌药物（需要时）/r/n临时医嘱：/r/n血惯例、尿惯例、年夜便惯例/r/n输血前检查/r/nX/r/nB/r/n头颅、颈胸部/r/nMRI/r/n或/r/nCT/r/n脑电图、血气分析、超声心动（视患者情况而定）/r/n项检查/r/n静脉插管术（有条件时）/r/n病原微生物培养（需要时）/r/n输血医嘱（需要时）/r/n其他医嘱/r/n长期医嘱/r/n：/r/n患者既往基础用药/r/n抗菌药物（需要时）/r/n其他医嘱/r/n临时医嘱：/r/n骨穿（需要时）/r/n骨髓形态学、微小残留病检测（/r/n件并需要时）/r/n腰穿,鞘内注射/r/n（/r/n程）/r/n脑脊液惯例、生化、细胞形态/r/n输血医嘱（需要时）/r/n其他医嘱/r/n主要/r/n介绍病房环境、设施和设备/r/n入院护理评估/r/n□宣教（血液病知识）/r/n病情/r/n1./r/n2./r/n□有,/r/n原因：/r/n□无□有,原因：/r/n1./r/n2./r/n时间/r/n主 □患者家属签署化疗知情同意书□化/r/n

/r/n住院第3天/r/n要/r/n/r/n□上级医师查/r/n,/r/n/r/n制定化疗方案 □重要脏器呵/r/n诊/r/n/r/n□住院医师完成病程记录□止吐/r/n疗工作/r/n长期医嘱：/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医 /r/n（或/r/nPeg-asp/r/n