中国骨科大手术静脉血栓栓塞症【精品-ppt】

中国骨科大手术静脉血栓栓塞症预防指南中华医学会骨科学分会北京协和医院骨科邱贵兴深静脉血栓形成肺栓塞静脉血栓栓塞症VENOUSTHROMBOEMBOLISM，VTE深静脉血栓形成DEEPVENOUSTHROMBOSIS，DVT肺血栓栓塞症PULMONARYTHROMBOEMBOLISM，PTEUVTEDVTPTEUDVT与PTE同一疾病在不同阶段不同部位的表现一个需要整体理解的概念骨科大手术后VTE发生率较高术式DVTPE总发生率近端发生率总发生率致命性THR4257183609280120TKR418552215100117髋骨骨折466023303110375参考文献静脉血栓栓塞（VTE，VENOUSTHROMBOEMBOLISM）的预防，第8版ACCP指南CHEST2008133381453该人群处于VTE极高危状态国外常规血栓预防20余年亚洲骨科大手术后DVT发病率U02070303亚洲19个中心407例患者THR175例（430）TKR136例（334）髋部骨折手术96例（236）其中278例（776）静脉造影U入选中心中国北京协和北大人民上海六院中国台湾韩国马来西亚菲律宾印尼泰国U结果120例患者（432）发生DVTAIDA研究国内U邱贵兴等报道THA及TKA术后DVT发生率LMWH预防组1188/68未预防组30816/52两组发生率的差异有统计学意义P005U余楠生等报道髋关节置换术后DVT发生率20683/402膝关节置换术后DVT发生率582109/187骨科大手术患者（包括髋、膝置换，髋部骨折手术）均为VTE极高危人群流行病学调查证实亚洲骨科大手术患者具有很高的DVT发生率骨科大手术患者必需常规预防DVT骨科大手术患者VTE的危险分度危险度判断指标低度危险手术时间4540岁无危险因素高度危险手术时间30增加出血风险易受药物及食物影响药物预防注意事项U注意药物使用说明、注意事项和副作用U肝肾功能损害者LMWH和磺达肝癸钠不适于严重肾损害者椎管内操作的前后短时间内避免用抗凝药物U区域阻滞麻醉/镇痛（腰丛）注意用药停药及拔管时间区域阻滞麻醉/镇痛的注意事项U阿司匹林术前5天停用U华法林避免硬膜外麻醉或末次给药48HR后拔管ULMWH末次给药18HR后拔管U肝素末次给药812HR后拔管U磺达肝癸钠硬膜外麻醉/镇痛前不建议用药物预防禁忌证U近期活动性出血及凝血障碍U骨筋膜室综合征U严重头颅外伤或急性脊髓损伤U血小板低于20109/LU肝素诱发血小板减少症（HIT）禁用肝素和LMWHU孕妇禁用华法林绝绝对对禁禁忌忌证证药物预防禁忌证U既往颅内出血U既往胃肠道出血U急性颅内损害/肿物U血小板低于100109/LU类风湿视网膜病患者抗凝可能眼内出血相相对对禁禁忌忌证证骨科大手术DVT具体预防方案U人工全髋关节置换术（THR）人工全膝关节置换术（TKR）U髋部周围骨折手术基本预防物理预防药物预防THR及TKR后的药物预防ULMWH术前12HR内不再使用术后1224HR（硬膜外管拔除后24HR）常规剂量或术后46HR给予常规剂量一半次日恢复常规剂量U华法林术前或术后当晚开始应用监测INR202530U磺达肝癸钠L25MG皮下注射L术后624HR（硬膜外管拔除后24H）开始U利伐沙班L10MG口服1次/日L术后610H开始（硬膜外管拔除后610开始）XA因子抑制剂THR及TKR后的药物预防U不建议单独应用低剂量普通肝素阿司匹林右旋糖酐U不建议常规预防性置入下腔静脉过滤器预防PTEU高出血风险患者建议物理预防风险下降后采用药物联合预防注意事项髋部周围骨折术后的药物预防伤后12小时内手术者U术后1224HR（硬膜外腔导管拔除后24HR）皮下常规剂量LMWH或术后46HR给予常规剂量一半次日常规剂量U磺达肝癸钠25MG术后624HR皮下注射U术前或术后当晚用华法林者需监测INR2025调整药物剂量髋部周围骨折术后的药物预防延迟手术者U入院即开始综合预防U术前12小时停用LMWHU术前不建议用磺达肝癸钠（半衰期长）U若术前已用药物抗凝尽量避免硬膜外麻醉U术后用法同12小时内手术者U利伐沙班暂无适应证髋部周围骨折术后的药物预防高出血风险患者推荐单独采取物理预防风险下降后建议药物联合预防注意事项预防VTE的开始时间和时限U骨科大手术围手术期VTE高发期术后24HR内可持续3个月U权衡预防和出血的利弊决定开始用药时间UTHR比TKR所需的抗凝时限更长U推荐药物预防最少10天可延长至1135天关于指南的几点说明U各种预防前参阅药物及医疗器械生产商提供的产品说明书UVTE高危患者综合预防高出血风险者慎用药物预防关于指南的几点说明U不建议单独采用阿司匹林预防VTEU严密观察药物副作用，如出现严重出血倾向及时检查、会诊及处理U药物联用会增加出血的可能性故不推荐联合用药谢谢谢谢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