围手术期静脉血栓栓塞(VTE)的防治ppt课件.ppt

PreventionandTreatmentofPerioperativeVenousThromboembolism(VTE),GordonH.Guyatt,etal.AntithromboticTherapyandPreventionofThrombosis,9thed:AmericanCollegeofChestPhysiciansEvidence-BasedClinicalPracticeGuidelines.CHEST2012;141(2)(Suppl):7S47S.,1,DeepVenousThrombosis(DVT),PulmonaryEmbolism(PE),2,VTE-relateddeaths,200,000peryearinUS1/3occurfollowingsurgery23-foldforcancerpatients,3,Prophylaxis?,VTE,Bleeding,VTE71%Death46%,Majorbleeding103%Woundhematoma88%,MismettiP,etal.Meta-analysisoflowmolecularweightheparininthepreventionofvenousthromboembolismingeneralsurgery.BrJSurg.2001;88(7):913-930.,4,CapriniRiskAssessmentModel,5,Caprini风险评分,6,VTERiskForGeneralSurgery,IncludingGI,Urological,Vascular,Breast,andThyroidProcedures,7,RiskFactorsforMajorBleedingComplications,GeneralriskfactorsActivebleedingPreviousmajorbleedingKnown,untreatedbleedingdisorderSevererenalorhepaticfailureThrombocytopeniaAcutestrokeUncontrolledsystemichypertensionLumbarpuncture,epidural,orspinalanesthesiawithinprevious4hornext12hConcomitantuseofanticoagulants,antiplatelettherapy,orthrombolyticdrugs,8,RiskFactorsforMajorBleedingComplications,Procedure-specificriskfactorsAbdominalsurgeryMalesex,preoperativehemoglobinlevel25kg/m2,nonelectivesurgery,placementoffiveormoregrafts,olderageOlderage,renalinsufficiency,operationotherthanCABG,longerbypasstimeThoracicsurgeryPneumonectomyorextendedresection,10,RiskFactorsforMajorBleedingComplications,ProceduresinwhichbleedingcomplicationsmayhaveespeciallysevereconsequencesCraniotomySpinalsurgerySpinaltraumaReconstructiveproceduresinvolvingfreeflap,11,PreventionofVTEinGeneralandAbdominal-pelvicSurgicalPatients,Recommendationsareclassifiedasstrong(Grade1)orweak(Grade2),accordingtothebalancebetweenbenefits,risks,burden,andcost,andthedegreeofconfidenceinestimatesofbenefits,risks,andburden.Qualityofevidenceareclassifiedashigh(GradeA),moderate(GradeB),orlow(GradeC)accordingtofactorsthatincludetheriskofbias,precisionofestimates,theconsistencyoftheresults,andthedirectnessoftheevidence.,12,PreventionofVTEinGeneralandAbdominal-pelvicSurgicalPatients,13,PerioperativeManagementofAntithromboticTherapy,VitaminKAntagonist(VKA):warfarin,acenocoumarol,phenprocoumon,andanisindioneAntiplateletdrugs:AcetylsalicylicAcid,clopidogrel,dipyridamole,andnonsteroidalantiinflammatorydrugUSEorNOT?,14,VitaminKAntagonist(VKA),Inpatientsundergoingmajorsurgeryorprocedures,interruptionofVKAs,ingeneral,isrequiredtominimizeperioperativebleeding,whereasVKAinterruptionmaynotberequiredinminorprocedures.InpatientswhorequiretemporaryinterruptionofaVKAbeforesurgery,werecommend:stoppingVKAsapproximately5daysbeforesurgery(1C)resumingVKAsapproximately12to24haftersurgery(eveningofornextmorning)(2C),15,BridgingAnticoagulation,Inpatientswithamechanicalheartvalve,atrialfibrillation,orVTEathighriskforthromboembolism,wesuggestbridginganticoagulation(LMWHorUFH)duringinterruptionofVKAtherapy(2C)lowriskforthromboembolism,wesuggestno-bridginganticoagulation(2C)InpatientswhoarereceivingbridginganticoagulationwesuggeststoppingLMWH24hbeforesurgery(2C)UFH46hbeforesurgery(2C),16,BridgingAnticoagulation,Inpatientswhoarereceivingbridginganticoagulationwiththerapeutic-doseSCLMWHandareundergoinghigh-bleeding-risksurgery,wesuggestresumingtherapeutic-doseLMWH4872haftersurgery(2C).Inpatientswhoarereceivingbridginganticoagulationwiththerapeutic-doseSCLMWHandareundergoingnon-high-bleeding-risksurgery,wesuggestresumingtherapeutic-doseLMWHapproximately24haftersurgery.,17,AcetylsalicylicAcid(ASA),InpatientsatmoderatetohighriskforcardiovasculareventswhoarereceivingASAtherapyandrequirenoncardiacsurgery,wesuggestcontinuingASAaroundthetimeofsurgery(2C).InpatientsatlowriskforcardiovasculareventswhoarereceivingASAtherapy,wesuggeststoppingASA7to10daysbeforesurgery(2C).,18,AntithromboticTherapyforVTEDisease,InitialTreatmentLong-termTherapy(initialtreatment3months)PatientswithnocancerVKA(2C)LMWH(2C)PatientswithcancerLMWH(2B)VKA(2B)ExtendedTherapy(beyond3months)sameasthefirst3months(2C),19,ClinicalSuspicionofAcuteVTE,Highclinicalsuspicion:treatmentwithparenteralanticoagulantswhileawaitingtheresultsofdiagnostictests(2C)Intermediateclinicalsuspicion:treatmentwithparenteralanticoagulantsiftheresultsofdiagnostictestsareexpectedtobedelayedformorethan4h(2C)Lowclinicalsuspicion:nottreatingwithparenteralanticoagulantswhileawaitingtheresultsofdiagnostictests,providedtestresultsareexpectedwithin24h(2C),20,InitialTreatmentofDVT,InpatientswithacuteDVT,werecommendearlyinitiationofVKA(eg,samedayasparenteraltherapyisstarted),andcontinuationofparenteralanticoagulation(LMWH,fondaparinux,IVUFH,orSCUFH)foraminimumof5daysanduntiltheINRis2.0oraboveforatleast24h(1B).earlyambulationoverinitialbedrest(2C)anticoagulanttherapyaloneovercatheter-directedthrombolysis(CDT)(2C),systemicthrombolysis(2C),operativevenousthrombectomy(2C),IVCfilter(1B),21,InitialTreatmentofAcutePE,InpatientswithacutePE,werecommendearlyinitiationofVKA(eg,samedayasparenteraltherapyisstarted),andcontinuationofparenteralanticoagulation(LMWH,fondaparinux,IVUFH,orSCUFH)foraminimumof5daysanduntiltheINRis2.0oraboveforatleast24h(1B).,22,IntensityofAnticoagulantEffect,InpatientswithVTEwhoaretreatedwithVKA,werecommendatherapeuticINRrangeof2.0to3.0(targetINRof2.5)overalower(INR,2)orhigher(INR3.0-5.0)rangeforalltreatmentdurations(1B).,23,DurationofAnticoagulantTherapy,24,SystemicThrombolyticTherapy,Inpatientswithhypotensionwhodonothaveahighriskofbleeding,wesuggestsystemicallyadministeredthrombolytictherapyovernosuchtherapy(2C).Inmostpatientswithouthypotension,werecommendagainstsystemicallyadministeredthrombolytictherapy(1C).Inselectedpatientswithouthypotensionandwithalowriskofbleedingwhoseinitialclinicalpresentationorclinicalcourseafterstartinganticoagulanttherapysuggestsahighriskofdevelopinghypotension,wesuggestadministrationofthrombolytictherapy(2C).,25,Catheter-BasedThrombusRemoval,Inpatientswithhypotension,wesuggestsurgicalcatheter-assistedthrombusremovaliftheyhavecontraindicationstothrombolysisfailedthrombolysisshockthatislik