围手术期静脉血栓栓塞(VTE)的防治.ppt

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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),Pulmonar

2、y Embolism(PE),VTE-related deaths,200,000 per year in US1/3 occur following surgery23-fold for cancer patients,Prophylaxis?,VTE,Bleeding,VTE 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 i

3、n general surgery.Br J Surg.2001;88(7):913-930.,Caprini Risk Assessment Model,Caprini风险评分,VTE RiskFor General Surgery,Including GI,Urological,Vascular,Breast,and Thyroid Procedures,Risk Factors for Major Bleeding Complications,General risk factorsActive bleedingPrevious major bleedingKnown,untreated

4、 bleeding disorderSevere renal or hepatic failureThrombocytopeniaAcute strokeUncontrolled systemic hypertensionLumbar puncture,epidural,or spinal anesthesia within previous 4 h or next 12 hConcomitant use of anticoagulants,antiplatelet therapy,or thrombolytic drugs,Risk Factors for Major Bleeding Co

5、mplications,Procedure-specific risk factorsAbdominal surgeryMale sex,preoperative hemoglobin level 13 g/dL,malignancy,and complex surgery defined as two or more procedures,difficult dissection,or more than one anastamosisPancreaticoduodenectomySepsis,pancreatic leak,sentinel bleedHepatic resectionNu

6、mber of segments,concomitant extrahepatic organ resection,primary liver malignancy,lower preoperative hemoglobin level,and platelet counts,Risk Factors for Major Bleeding Complications,Procedure-specific risk factorsCardiac surgeryUse of aspirinUse of clopidogrel within 3 d before surgeryBMI 25 kg/m

7、2,nonelective surgery,placement of five or more grafts,older ageOlder age,renal insufficiency,operation other than CABG,longer bypass timeThoracic surgeryPneumonectomy or extended resection,Risk Factors for Major Bleeding Complications,Procedures in which bleeding complications may have especially s

8、evere consequencesCraniotomySpinal surgerySpinal traumaReconstructive procedures involving free flap,Prevention of VTE in General and Abdominal-pelvic Surgical Patients,Recommendations are classified as strong(Grade1)or weak(Grade2),according to the balance between benefits,risks,burden,and cost,and

9、 the degree of confidence in estimates of benefits,risks,and burden.Quality of evidence are classified as high(GradeA),moderate(GradeB),or low(GradeC)according to factors that include the risk of bias,precision of estimates,the consistency of the results,and the directness of the evidence.,Preventio

10、n of VTE in General and Abdominal-pelvic Surgical Patients,Perioperative Management ofAntithrombotic Therapy,Vitamin K Antagonist(VKA):warfarin,acenocoumarol,phenprocoumon,and anisindioneAntiplatelet drugs:Acetylsalicylic Acid,clopidogrel,dipyridamole,and nonsteroidal antiinflammatory drugUSE or NOT

11、?,Vitamin K Antagonist(VKA),In patients undergoing major surgery or procedures,interruption of VKAs,in general,is required to minimize perioperative bleeding,whereas VKA interruption may not be required in minor procedures.In patients who require temporary interruption of a VKA before surgery,we rec

12、ommend:stopping VKAs approximately 5 days before surgery(1C)resuming VKAs approximately 12 to 24 h after surgery(evening of or next morning)(2C),Bridging Anticoagulation,In patients with a mechanical heart valve,atrial fibrillation,or VTE athigh risk for thromboembolism,we suggest bridging anticoagu

13、lation(LMWH or UFH)during interruption of VKA therapy(2C)low risk for thromboembolism,we suggest no-bridging anticoagulation(2C)In patients who are receiving bridging anticoagulationwe suggest stoppingLMWH 24 h before surgery(2C)UFH 46 h before surgery(2C),Bridging Anticoagulation,In patients who ar

14、e receiving bridging anticoagulation with therapeutic-dose SC LMWH and are undergoing high-bleeding-risk surgery,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-bleedin

15、g-risk surgery,we suggest resuming therapeutic-dose LMWH approximately 24 h after surgery.,Acetylsalicylic 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

16、 patients at low risk for cardiovascular events who are receiving ASA therapy,we suggest stopping ASA 7 to 10 days before surgery(2C).,Antithrombotic Therapy for VTE Disease,Initial TreatmentLong-term Therapy(initial treatment 3 months)Patients with no cancerVKA(2C)LMWH(2C)Patients with cancerLMWH(2

17、B)VKA(2B)Extended Therapy(beyond 3 months)same as the first 3 months(2C),Clinical Suspicion of Acute VTE,High clinical suspicion:treatment with parenteral anticoagulants while awaiting the results of diagnostic tests(2C)Intermediate clinical suspicion:treatment with parenteral anticoagulants if the

18、results of diagnostic tests are expected to be delayed for more than 4 h(2C)Low clinical 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 DVT,In patients with acute DVT,we reco

19、mmend 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 a minimum of 5 days and until the INR is 2.0 or above for at least 24 h(1B).early ambulation over initial bed rest(2C)anticoagulant therap

20、y alone over catheter-directed thrombolysis(CDT)(2C),systemic thrombolysis(2C),operative venous thrombectomy(2C),IVC filter(1B),Initial Treatment of Acute PE,In patients with acute PE,we recommend early initiation of VKA(eg,same day as parenteral therapy is started),and continuation of parenteral an

21、ticoagulation(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).,Intensity of Anticoagulant Effect,In 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

22、 higher(INR 3.0-5.0)range for all treatment durations(1B).,Duration of Anticoagulant Therapy,Systemic Thrombolytic Therapy,In patients with hypotension who do not have a high risk of bleeding,we suggest systemically administered thrombolytic therapy over no such therapy(2C).In most patients without

23、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 developing hypotension,we s

24、uggest administration of thrombolytic therapy(2C).,Catheter-Based Thrombus Removal,In patients with hypotension,we suggest surgical catheter-assisted thrombus removal if they have contraindications to thrombolysisfailed thrombolysisshock that is likely to cause death before systemic thrombolysis can

25、 take effect(eg,within hours)(2C),Surgical Embolectomy,In patients with hypotension,we suggest surgical pulmonary Embolectomy if they have contraindications to thrombolysisfailed thrombolysis or catheter-assisted embolectomyshock that is likely to cause death before thrombolysis can take effect(eg,w

26、ithin hours)(2C),Post-thrombotic Syndrome(PTS),In patients with acute symptomatic DVT of the leg,we suggest the use of compression stockings to prevent PTS(2B).In patients with PTS of the leg,we suggest a trial of compression stockings(2C).In patients with severe PTS of the leg that is not adequately relieved by compression stockings,we suggest a trial of an intermittent compression device(2B).,