《静脉血栓栓塞》.ppt

危重患者的VTE高危因素和发病率 危重患者的VTE预防指南和评估 ICU内的VTE预防方法 几个肺栓塞病例,Covidien | October 4, 2019 | Confidential,2 |,静脉血栓栓塞症(VTE)包括深静脉血栓(DVT)和肺栓塞(PE)。,Definition of Venous Thromboembolism (VTE) 静脉血栓栓塞的定义,Pulmonary Embolism,1Circulation 1996;93:2212; 2N Engl J Med 2004;350:2257 3Lancet 1997;349:759; 4J Gen Intern Med 2000;26:425,Fatal PE,Asymptomatic PE,Symptomatic DVT,Pulmonary Embolism,4 out of 5 patients will not have any symptoms of thrombosis,Asymptomatic DVT,20%,80%,80% ASYMPTOMATICS,Confidential, Tyco Corporation,Covidien | 4/10/2019 | Confidential,4 |,解决,DVT的后果,静脉血栓栓塞-,Covidien | 4/10/2019 | Confidential,Confidential, Tyco Corporation,5 |,血流淤滞,血管壁损伤,凝血功能改变,血液循环流速减慢。血流淤滞同时发生在术中和术后的卧床时间,发生在术侧肢体的操作过程中会扭折血管，如全膝或全髋成型术,静脉血液郁积也会造成静脉扩张和内皮细胞损伤。,术后血液中促凝血酶原激酶和纤维蛋白原水平升高，组织损伤处表面凝结被激活都导致了血液的高凝状态。,为什么会形成DVT？,当没有任何预防措施时，DVT在某些专科中的发生率高于50,但是，仅有25的DVT患者会表现出症状,OMeara et al. Prophylaxis for Venous Thromboembolism in Total Hip Arthroplasty. ORTHOPEDICS.,深静脉血栓流行病学（外科各专业）,临床路径推荐,Risk factors for VTE,Active cancer or cancer treatment Age over 60 years Critical care admission Dehydration Known thrombophilias Obesity (body mass index BMI over 30 kg/m2) One or more significant medical comorbidities (for example: heart disease; metabolic, endocrine or respiratory pathologies; acute infectious diseases; inflammatory conditions) Personal history or first-degree relative with a history of VTE Use of hormone replacement therapy Use of oestrogen-containing contraceptive therapy Varicose veins with phlebitis For women who are pregnant or have given birth within the previous 6 weeks,Regard medical patients as being at increased risk of VTE if they:,have had or are expected to have significantly reduced mobility for 3 days or more or are expected to have ongoing reduced mobility relative to their normal state and have one or more of the risk factors,Regard surgical patients and patients with trauma as being at increased risk of VTE if they meet one of the following criteria:,surgical procedure with a total anaesthetic and surgical time of more than 90 minutes, or 60 minutes if the surgery involves the pelvis or lower limb acute surgical admission with inflammatory or intra-abdominal condition expected significant reduction in mobility one or more of the risk factors,Risk factors for bleeding,Active bleeding Acquired bleeding disorders (such as acute liver failure) Concurrent use of anticoagulants known to increase the risk of bleeding (such as warfarin with international normalised ratio INR higher than 2) Lumbar puncture/epidural/spinal anaesthesia expected within the next 12 hours Lumbar puncture/epidural/spinal anaesthesia within the previous 4 hours Acute stroke Thrombocytopenia (platelets less than 75 x 109/l) Uncontrolled systolic hypertension (230/120 mmHg or higher) Untreated inherited bleeding disorders (such as haemophilia and von Willebrands disease),Pharmacological VTE prophylaxis,For example:General medical patients fondaparinux sodium low molecular weight heparin (LMWH) unfractionated heparin (UFH) (for patients with renal failure). Start pharmacological VTE prophylaxis as soon as possible after risk assessment has been completed. Continue until the patient is no longer at increased risk of VTE,Patients with stroke,Patients with cancer Patients with central venous catheters Patients in palliative care All surgery Cardiac surgery Gastrointestinal, gynaecological, thoracic and urological,物理预防在ICU的优势： ICU患者刚入院时大多具有消化道应激性溃疡出血风险 部分重症患者有凝血功能障碍、肾功能障碍 ICU患者本身情况复杂，用药难以掌握,出血并发症,物理预防：ICU患者不可或缺,18 |,静脉瓣后清除,SCD压力系统提供最佳连续梯度压力模式使股静脉血流速度达到最大 “理想的压力模式为踝部35mmHg，小腿30mmHg，大腿20mmHg。” “ 然而，由于广泛存在的个体差异，这个压力可以稍微增加（例如45，40，30mmHg）。”,Covidien | 4/10/2019 | Confidential,Confidential, Tyco Corporation,21 |,Nicolaides et al. Intermittent Sequential Pneumatic Compression of the Legs in the Prevention of Venous Stasis and Postoperative Deep Venous Thrombosis, Surgery 1980: 87: 69-76,大腿 小腿 踝部,压力 mmHg,SCD压力系统在股静脉血液清除方面，速度明显优于小腿、单一压力系统. “SCD 可以在很短的时间内清空静脉瓣后淤滞的血液，而如果只对小腿施压,相应的染色物质会停留长时间。”（小腿、单一压力系统）,Confidential, Tyco Corporation,Covidien | 4/10/2019 | Confidential,Mittleman et al. Effectiveness of Leg Compression in Preventing Venous Stasis. The American Journal of Surgery 1982; 144:611-613,Covidien | 4/10/2019 | Confidential,Confidential, Tyco Corporation,24 |,静脉再充盈检测,Covidien | 4/10/2019 | Confidential,Confidential, Tyco Corporation,25 |,血液移动总量,相同的情况在静脉曲张的病人中，仰卧位增加71.9%，半卧位增加77.9%，坐姿时增加55.7%。”,Kakkos et al. Improved hemodynamic effectiveness and associated clinical correlations of a new intermittent pneumatic comporession system in patients with chronic venous insufficiency. Journal of Vascular Surgery, Nov 2001; Vol 34, No. 5, 915-922,主机 连接管 腿套/足套 （45mmHg, 40mmHg,30mmHg） (130mmHg),腿部压力： 预防深静脉血栓症和肺部栓塞 足部压力： 1. 增强血液循环 2. 预防深静脉血栓症 3. 急性水肿 4. 慢性水肿 5. 外伤或外科手术引发的四肢疼痛 6. 腿部溃疡 7. 静脉郁积/静脉功能障碍,腿部压力： 任何有可能防碍充气压力带作用的腿局部情况，例如：（a）皮炎，（b）静脉结扎（在手术后即刻），（c）坏疽，或者（d）刚做完皮肤移植手术 严重的动脉硬化症或其它缺血性血管病 腿部大范围水肿或由充血性心力衰竭引发的肺部水肿 腿部严重畸形 疑似已出现深静脉血栓症 足部压力： 增强回流心脏的流速会有害的情况下 充血性心力衰竭 已出现深静脉血栓症、血栓(性)静脉炎或肺部栓塞 对于手足部存在感染或感觉迟钝情况的患者，使用时必须非常小心,“尽管梯度压力弹力袜外表看上去很简单，但是其中的设计却很复杂，对于技术细节的关注可以得到有效的预防方法。”,Covidien | 4/10/2019 | Confidential,Confidential, Tyco Corporation,31 |,J.Caprini MD.,Covidien | 4/10/2019 | Confidential,Confidential, Tyco Corporation,32 |,T.E.D. Antiembolism Stocking T.E.D. 抗血栓压力带,Other Antiembolism Stocking 其它抗血栓压力带,圆周镶嵌编织法 单向水平伸展确保抗血栓 压力带的固定,圆周编织提供单向伸展确保压力分布正确定位,垂直伸展使尼龙袜滑落,Using the Kendall TED stockings which apply the correct pressure profile, Holford (B.M.J. 1976,2 969-970) showed that TED stockings reduced the incidence of deep vein thrombosis in surgical patients from 49% to 23% and concluded”improper design, construction or fit can be dangerous.”,垂直伸展使尼龙袜滑落,7位半卧位自愿者，5个带水压计的可充气套观察血流速度 确定理想的压力分布18，14，8，10，8mmHg 相对与基线，平均股静脉血流速度增加138.4%,Covidien | 4/10/2019 | Confidential,Confidential, Tyco Corporation,33 |,100+文献证明SCD和TED的有效性,Woolson et al. Journal of Bone & Joint Surgery 1991 (全髋关节置换术病人) “我们相信在术中和术后使用间歇式充气压力装置（无抗凝剂），是有效，安全和便利的。”,Covidien | 4/10/2019 | Confidential,Confidential, Tyco Corporation,35 |,亚洲人群髋关节手术后采用非药物预防后无症状的深静脉血栓的自然过程,术后没有患者发展致命有症状的肺栓塞，或近端深静脉血栓。但是9个患者（5%）发展成远端深静脉血栓，没有术前相关危险因子。这9位患者术后紧密随访未用抗凝剂治疗，6个月后所有的血栓消失未发展成肺栓塞或血栓性静脉炎,静脉血栓物理预防全方位解决方案,AVI 动静脉脉冲系统,SCD气动歇式压力装置,TED抗血栓压力带,Case 1：lucky patient，lucky doctor,Female，63years Recurrent syncope SpO2 60%70% Hypotension ECG：RBBB D-Dimer：2.386ug/ml CTA：肺动脉主干及双肺动脉多发性栓塞,rt-PA 50mg Day-2: ECG normal;有呕吐表现 CT小脑半球少量出血 保守治愈,Case 2： Brave doctor,第一次尿激酶溶栓 150万u一次VD，复查肺CTA如上图，机械通气氧合改善不满意，未能脱机 尿激酶 二次溶栓 4400u/Kg/h,共十二小时 缓解，氧合改善，出院回当地医院复查CTA肺动脉血栓