围手术期静脉血栓栓塞(VTE)的防治.ppt

PreventionandTreatmentofPerioperativeVenousThromboembolism VTE GordonH Guyatt etal AntithromboticTherapyandPreventionofThrombosis 9thed AmericanCollegeofChestPhysiciansEvidence BasedClinicalPracticeGuidelines CHEST2012 141 2 Suppl 7S 47S DeepVenousThrombosis DVT PulmonaryEmbolism PE VTE relateddeaths 200 000peryearinUS1 3occurfollowingsurgery2 3 foldforcancerpatients Prophylaxis VTE Bleeding VTE 71 Death 46 Majorbleeding 103 Woundhematoma 88 MismettiP etal Meta analysisoflowmolecularweightheparininthepreventionofvenousthromboembolismingeneralsurgery BrJSurg 2001 88 7 913 930 CapriniRiskAssessmentModel Caprini风险评分 VTERiskForGeneralSurgery IncludingGI Urological Vascular Breast andThyroidProcedures RiskFactorsforMajorBleedingComplications GeneralriskfactorsActivebleedingPreviousmajorbleedingKnown untreatedbleedingdisorderSevererenalorhepaticfailureThrombocytopeniaAcutestrokeUncontrolledsystemichypertensionLumbarpuncture epidural orspinalanesthesiawithinprevious4hornext12hConcomitantuseofanticoagulants antiplatelettherapy orthrombolyticdrugs RiskFactorsforMajorBleedingComplications Procedure specificriskfactorsAbdominalsurgeryMalesex preoperativehemoglobinlevel 13g dL malignancy andcomplexsurgerydefinedastwoormoreprocedures difficultdissection ormorethanoneanastamosisPancreaticoduodenectomySepsis pancreaticleak sentinelbleedHepaticresectionNumberofsegments concomitantextrahepaticorganresection primarylivermalignancy lowerpreoperativehemoglobinlevel andplateletcounts RiskFactorsforMajorBleedingComplications Procedure specificriskfactorsCardiacsurgeryUseofaspirinUseofclopidogrelwithin3dbeforesurgeryBMI 25kg m2 nonelectivesurgery placementoffiveormoregrafts olderageOlderage renalinsufficiency operationotherthanCABG longerbypasstimeThoracicsurgeryPneumonectomyorextendedresection RiskFactorsforMajorBleedingComplications ProceduresinwhichbleedingcomplicationsmayhaveespeciallysevereconsequencesCraniotomySpinalsurgerySpinaltraumaReconstructiveproceduresinvolvingfreeflap PreventionofVTEinGeneralandAbdominal pelvicSurgicalPatients Recommendationsareclassifiedasstrong Grade1 orweak Grade2 accordingtothebalancebetweenbenefits risks burden andcost andthedegreeofconfidenceinestimatesofbenefits risks andburden Qualityofevidenceareclassifiedashigh GradeA moderate GradeB orlow GradeC accordingtofactorsthatincludetheriskofbias precisionofestimates theconsistencyoftheresults andthedirectnessoftheevidence PreventionofVTEinGeneralandAbdominal pelvicSurgicalPatients PerioperativeManagementofAntithromboticTherapy VitaminKAntagonist VKA warfarin acenocoumarol phenprocoumon andanisindioneAntiplateletdrugs AcetylsalicylicAcid clopidogrel dipyridamole andnonsteroidalantiinflammatorydrugUSEorNOT VitaminKAntagonist VKA Inpatientsundergoingmajorsurgeryorprocedures interruptionofVKAs ingeneral isrequiredtominimizeperioperativebleeding whereasVKAinterruptionmaynotberequiredinminorprocedures InpatientswhorequiretemporaryinterruptionofaVKAbeforesurgery werecommend stoppingVKAsapproximately5daysbeforesurgery 1C resumingVKAsapproximately12to24haftersurgery eveningofornextmorning 2C BridgingAnticoagulation Inpatientswithamechanicalheartvalve atrialfibrillation orVTEathighriskforthromboembolism wesuggestbridginganticoagulation LMWHorUFH duringinterruptionofVKAtherapy 2C lowriskforthromboembolism wesuggestno bridginganticoagulation 2C InpatientswhoarereceivingbridginganticoagulationwesuggeststoppingLMWH24hbeforesurgery 2C UFH4 6hbeforesurgery 2C BridgingAnticoagulation Inpatientswhoarereceivingbridginganticoagulationwiththerapeutic doseSCLMWHandareundergoinghigh bleeding risksurgery wesuggestresumingtherapeutic doseLMWH48 72haftersurgery 2C Inpatientswhoarereceivingbridginganticoagulationwiththerapeutic doseSCLMWHandareundergoingnon high bleeding risksurgery wesuggestresumingtherapeutic doseLMWHapproximately24haftersurgery AcetylsalicylicAcid ASA InpatientsatmoderatetohighriskforcardiovasculareventswhoarereceivingASAtherapyandrequirenoncardiacsurgery wesuggestcontinuingASAaroundthetimeofsurgery 2C InpatientsatlowriskforcardiovasculareventswhoarereceivingASAtherapy wesuggeststoppingASA7to10daysbeforesurgery 2C AntithromboticTherapyforVTEDisease InitialTreatmentLong termTherapy initialtreatment 3months PatientswithnocancerVKA 2C LMWH 2C PatientswithcancerLMWH 2B VKA 2B ExtendedTherapy beyond3months sameasthefirst3months 2C ClinicalSuspicionofAcuteVTE Highclinicalsuspicion treatmentwithparenteralanticoagulantswhileawaitingtheresultsofdiagnostictests 2C Intermediateclinicalsuspicion treatmentwithparenteralanticoagulantsiftheresultsofdiagnostictestsareexpectedtobedelayedformorethan4h 2C Lowclinicalsuspicion nottreatingwithparenteralanticoagulantswhileawaitingtheresultsofdiagnostictests providedtestresultsareexpectedwithin24h 2C 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 InitialTreatmentofAcutePE InpatientswithacutePE werecommendearlyinitiationofVKA eg samedayasparenteraltherapyisstarted andcontinuationofparenteralanticoagulation LMWH fondaparinux IVUFH orSCUFH foraminimumof5daysanduntiltheINRis2 0oraboveforatleast24h 1B IntensityofAnticoagulantEffect InpatientswithVTEwhoaretreatedwithVKA werecommendatherapeuticINRrangeof2 0to3 0 targetINRof2 5 overalower INR 2 orhigher INR3 0 5 0 rangeforalltreatmentdurations 1B DurationofAnticoagulantTherapy SystemicThrombolyticTherapy Inpatientswithhypotensionwhodonothaveahighriskofbleeding wesuggestsystemicallyadministeredthrombolytictherapyovernosuchtherapy 2C Inmostpatientswithouthypotension werecommendagainstsystemicallyadministeredthrombolytictherapy 1C Inselectedpatientswithouthypotensionandwithalowriskofbleedingwhoseinitialclinicalpresentationorclinicalcourseafterstartinganticoagulanttherapysuggestsahighriskofdevelopinghypotension wesuggestadministrationofthrombolytictherapy 2C Catheter BasedThrombusRemoval Inpatientswithhypotension wesuggestsurgicalcatheter assistedthrombusremovaliftheyhavecontraindicationstothrombolysisfailedthrombolysisshockthatislikelytocausedeathbeforesystemicthrombolysiscantakeeffect eg withinhours 2C SurgicalEmbolectomy Inpatientswithhypotension wesuggestsurgicalpulmonaryEmbolectomyiftheyhavecontraindicationstothrombolysisfailedthrombolysisorcatheter assistedembolectomyshockthatislikelytocausedeathbeforethrombolysiscantakeeffect eg withinhours 2C Post thromboticSyndrome PTS InpatientswithacutesymptomaticDVToftheleg wesuggesttheuseofcompressionstockingstopreventPTS 2B InpatientswithPTSoftheleg wesuggestatrialofcompressionstockings 2C InpatientswithseverePTSofthelegthatisnotadequatelyrelievedbycompressionstockings wesuggestatrialofanintermittentcompressiondevice 2B