围手术期静脉血栓栓塞(VTE)的防治

1、Prevention and Treatment of Perioperative Venous Thromboembolism (VTE)Gordon H. Guyatt, et al. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. CHEST 2012; 141(2)(Suppl):7S47S.Deep Venous Thrombosis(DVT)Pul

2、monary Embolism(PE)VTE-related deaths200,000 per year in US1/3 occur following surgery23-fold for cancer patientsProphylaxis?VTEBleedingVTE 71%Death 46%Major bleeding 103%Wound hematoma 88%Mismetti P, et al. Meta-analysis of low molecular weight heparin in the prevention of venous thromboembolism in

3、 general surgery .Br J Surg . 2001 ; 88 ( 7 ): 913 - 930 .Caprini Risk Assessment Model1 PointAge 41-60 ySepsis (25 kg/Swollen legsAbnormal pulmonary functionAcute myocardial infarctionSerious lung disease, including pneumonia ( 1 mo)Congestive heart failure ( 1 mo)Pregnancy or postpartumHistory of

4、inflammatory bowel diseaseHistory of unexplained or recurrent spontaneous abortionOral contraceptives or hormone replacementMedical patient at bed rest3 PointsAge 75 yLupus anticoagulantHistory of VTEAnticardiolipinAntibodiesFamily history of VTEElevated serumHomocysteine Factor V LeidenHeparin-indu

5、cedthrombocytopeniaProthrombin 20210AOther congenital oracquired thrombophilia5 PointsStroke ( 1 mo)Elective arthroplastyHip, pelvis, or leg fractureAcute spinal cord injury ( 72 h)Major open surgery ( 45 min)Laparoscopic surgery ( 45 min)Immobilizing plaster castCentral venous accessCaprini风险评分危险因素

6、危险因素 得分：得分：1分分年龄41-60岁败血症（1个月内）小手术静脉曲张BMI25 kg/肺功能异常下肢水肿急性心肌梗塞严重肺部疾病，包括肺炎（1个月内）充血性心力衰竭（1个月内）妊娠期或产后肠炎病史不能解释或二次自然流产病史口服避孕药或激素替代治疗需要卧床休息的患者危险因素危险因素 得分：得分：3分分年龄75岁狼疮抗凝物阳性VTE病史抗心磷脂抗体阳性VTE家族史血清同型半胱氨酸升高因子V Leiden 阳性肝素诱导的血小板减少症凝血酶原20210A阳性其他先天性或获得性血栓症危险因素危险因素 得分：得分：5分分脑卒中（1个月内）髋关节、骨盆或下肢骨折择期关节置换术急性脊柱损伤（1个月内）

7、危险因素危险因素 得分：得分：2分分年龄61-74岁恶性肿瘤关节镜手术卧床（72h）开放式手术（45min）石膏固定腹腔镜手术（45min）中央静脉通路VTE Risk For General SurgeryIncluding GI, Urological, Vascular, Breast, and Thyroid Procedures VTE Risk Caprini ScoreObserved Risk of Symptomatic VTE, %Very low00Low1-20.7Moderate3-41.0High 51.9Risk Factors for Major Bleedin

8、g ComplicationsGeneral risk factorsActive bleedingPrevious major bleedingKnown, untreated bleeding disorderSevere renal or hepatic failureThrombocytopeniaAcute strokeUncontrolled systemic hypertensionLumbar puncture, epidural, or spinal anesthesia within previous 4 h or next 12 hConcomitant use of a

9、nticoagulants, antiplatelet therapy, or thrombolytic drugsRisk Factors for Major Bleeding ComplicationsProcedure-specific risk factorsAbdominal surgeryMale sex, preoperative hemoglobin level 25 kg/m2, nonelective surgery, placement of five or more grafts, older ageOlder age, renal insufficiency, ope

10、ration other than CABG, longer bypass timeThoracic surgeryPneumonectomy or extended resectionRisk Factors for Major Bleeding ComplicationsProcedures in which bleeding complications may have especially severe consequencesCraniotomySpinal surgerySpinal traumaReconstructive procedures involving free fl

11、apPrevention of VTE in General and Abdominal-pelvic Surgical PatientsRiskProphylaxis for normal paitientsProphylaxis for patients at high risk for major bleeding complications very low riskno specific pharmaclogic (1B) or mechanical (2C) prophylaxis be used other than early ambulationlow riskmechani

12、cal prophylaxis, preferably with intermittent pneumatic compression (IPC) (2C)moderate risklow-molecular-weight heparin(LMWH) (2B), low-dose unfractionated heparin(LDUH) (2B),or mechanical prophylaxis, preferably with IPC (2C)mechanical prophylaxis, preferably with IPC (2C)Recommendations are classi

13、fied as strong (Grade 1) or weak (Grade 2), according to the balance between benefits, risks, burden, and cost, and the degree of confidence in estimates of benefits, risks, and burden.Quality of evidence are classified as high (Grade A), moderate (Grade B), or low (Grade C) according to factors tha

14、t include the risk of bias, precision of estimates, the consistency of the results, and the directness of the evidence.Prevention of VTE in General and Abdominal-pelvic Surgical PatientsRiskProphylaxis for normal paitientsProphylaxis for patients at high risk for major bleeding complications high ri

15、skpharmacologic prophylaxis with LMWH (1B) or LDUH (1B), mechanical prophylaxis with elastic stockings (ES) or IPC should be added to pharmacologic prophylaxis (2C)mechanical prophylaxis, preferably with IPC, until the risk of bleeding diminishes and pharmacologic prophylaxis may be initiated (2C)hi

16、gh riskcancer extended-duration pharmacologic prophylaxis (4 weeks) with LMWH (1B)high riskLMWH and UH contraindicatedlow-dose aspirin (2C), fondaparinux (璜达肝癸钠) (2C),or mechanical prophylaxis, preferably with IPC (2C)Perioperative Management ofAntithrombotic TherapylVitamin K Antagonist (VKA) : war

17、farin, acenocoumarol, phenprocoumon, and anisindionelAntiplatelet drugs: Acetylsalicylic Acid, clopidogrel, dipyridamole, and nonsteroidal antiinflammatory drugUSE or NOT?Vitamin K Antagonist (VKA) In patients undergoing major surgery or procedures, interruption of VKAs, in general, is required to m

18、inimize perioperative bleeding, whereas VKA interruption may not be required in minor procedures.In patients who require temporary interruption of a VKA before surgery, we recommend: lstopping VKAs approximately 5 days before surgery (1C)lresuming VKAs approximately 12 to 24 h after surgery (evening

19、 of or next morning) (2C)Bridging AnticoagulationIn patients with a mechanical heart valve, atrial fibrillation, or VTE atlhigh risk for thromboembolism, we suggest bridging anticoagulation (LMWH or UFH) during interruption of VKA therapy (2C)llow risk for thromboembolism, we suggest no-bridging ant

20、icoagulation (2C)In patients who are receiving bridging anticoagulationwe suggest stoppinglLMWH 24 h before surgery (2C)lUFH 46 h before surgery (2C)Bridging AnticoagulationIn patients who are receiving bridging anticoagulation with therapeutic-dose SC LMWH and are undergoing high-bleeding-risk surg

21、ery, we suggest resuming therapeutic-dose LMWH 4872 h after surgery (2C) . In patients who are receiving bridging anticoagulation with therapeutic-dose SC LMWH and are undergoing non-high-bleeding-risk surgery, we suggest resuming therapeutic-dose LMWH approximately 24 h after surgery.Acetylsalicyli

22、c Acid (ASA)In patients at moderate to high risk for cardiovascular events who are receiving ASA therapy and require noncardiac surgery, we suggest continuing ASA around the time of surgery (2C) . In patients at low risk for cardiovascular events who are receiving ASA therapy, we suggest stopping AS

23、A 7 to 10 days before surgery(2C) .Antithrombotic Therapy for VTE DiseaseInitial TreatmentLong-term Therapy(initial treatment 3 months)Patients with no cancerlVKA (2C) lLMWH (2C) Patients with cancerlLMWH (2B) lVKA (2B) Extended Therapy(beyond 3 months) same as the first 3 months (2C)Clinical Suspic

24、ion of Acute VTEHigh clinical suspicion: treatment with parenteral anticoagulants while awaiting the results of diagnostic tests (2C)Intermediate clinical suspicion: treatment with parenteral anticoagulants if the results of diagnostic tests are expected to be delayed for more than 4 h (2C)Low clini

25、cal suspicion: not treating with parenteral anticoagulants while awaiting the results of diagnostic tests, provided test results are expected within 24 h (2C)Initial Treatment of DVTIn patients with acute DVT, we recommend learly initiation of VKA (eg, same day as parenteral therapy is started), and

26、 continuation of parenteral anticoagulation (LMWH, fondaparinux, IV UFH, or SC UFH) for a minimum of 5 days and until the INR is 2.0 or above for at least 24 h (1B) .learly ambulation over initial bed rest (2C) lanticoagulant therapy alone over catheter-directed thrombolysis (CDT) (2C) , systemic th

27、rombolysis (2C), operative venous thrombectomy(2C), IVC filter(1B) Initial Treatment of Acute PEIn patients with acute PE, we recommend early initiation of VKA (eg, same day as parenteral therapy is started), and continuation of parenteral anticoagulation (LMWH, fondaparinux, IV UFH, or SC UFH) for

28、a minimum of 5 days and until the INR is 2.0 or above for at least 24 h (1B) .Intensity of Anticoagulant EffectIn patients with VTE who are treated with VKA, we recommend a therapeutic INR range of 2.0 to 3.0 (target INR of 2.5) over a lower (INR , 2) or higher (INR 3.0-5.0) range for all treatment

29、durations (1B) .Duration of Anticoagulant TherapySituationDurationPE or proximal DVT of the leg provoked by surgery or by a nonsurgicaltransient risk factor3 months(1B)PE or DVT of the leg andactive cancerextended therapy(1B/2B)unprovoked PE or DVT ofthe legfirst VTE, proximal, low or moderate bleed

30、ing riskextended therapy(2B)first VTE, proximal, high bleeding risk3 months(1B)first VTE, distal3 months(2B/1B)second VTE, low or moderate bleeding riskextended therapy(1B/2B)second VTE, high bleeding risk3 months(2B)Systemic Thrombolytic TherapyIn patients with hypotension who do not have a high ri

31、sk of bleeding, we suggest systemically administered thrombolytic therapy over no such therapy (2C) . In most patients without hypotension, we recommend against systemically administered thrombolytic therapy (1C) .In selected patients without hypotension and with a low risk of bleeding whose initial clinical presentation or clinical course after starting anticoagulant therapy suggests a high risk of