圍手術(shù)期靜脈血栓栓塞VTE的防治課件

1、圍手術(shù)期靜脈血栓栓塞VTE的防治,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,圍手術(shù)期靜脈血栓栓塞VTE

2、的防治,Deep Venous Thrombosis (DVT,Pulmonary Embolism (PE,圍手術(shù)期靜脈血栓栓塞VTE的防治,VTE-related deaths,200,000 per year in US 1/3 occur following surgery 23-fold for cancer patients,圍手術(shù)期靜脈血栓栓塞VTE的防治,Prophylaxis,VTE,Bleeding,VTE 71% Death 46,Major bleeding 103% Wound hematoma 88,Mismetti P, et al. Meta-analysis

3、of low molecular weight heparin in the prevention of venous thromboembolism in general surgery .Br J Surg . 2001 ; 88 ( 7 ): 913 - 930,圍手術(shù)期靜脈血栓栓塞VTE的防治,Caprini Risk Assessment Model,圍手術(shù)期靜脈血栓栓塞VTE的防治,Caprini風(fēng)險(xiǎn)評分,圍手術(shù)期靜脈血栓栓塞VTE的防治,VTE RiskFor General Surgery,Including GI, Urological, Vascular, Breast,

4、and Thyroid Procedures,圍手術(shù)期靜脈血栓栓塞VTE的防治,Risk Factors for Major Bleeding Complications,General risk factors Active bleeding Previous major bleeding Known, untreated bleeding disorder Severe renal or hepatic failure Thrombocytopenia Acute stroke Uncontrolled systemic hypertension Lumbar puncture, epid

5、ural, or spinal anesthesia within previous 4 h or next 12 h Concomitant use of anticoagulants, antiplatelet therapy, or thrombolytic drugs,圍手術(shù)期靜脈血栓栓塞VTE的防治,Risk Factors for Major Bleeding Complications,Procedure-specific risk factors Abdominal surgery Male sex, preoperative hemoglobin level 13 g/dL,

6、 malignancy, and complex surgery defined as two or more procedures, difficult dissection, or more than one anastamosis Pancreaticoduodenectomy Sepsis, pancreatic leak, sentinel bleed Hepatic resection Number of segments, concomitant extrahepatic organ resection, primary liver malignancy, lower preop

7、erative hemoglobin level, and platelet counts,圍手術(shù)期靜脈血栓栓塞VTE的防治,Risk Factors for Major Bleeding Complications,Procedure-specific risk factors Cardiac surgery Use of aspirin Use of clopidogrel within 3 d before surgery BMI 25 kg/m2, nonelective surgery, placement of five or more grafts, older age Olde

8、r age, renal insufficiency, operation other than CABG, longer bypass time Thoracic surgery Pneumonectomy or extended resection,圍手術(shù)期靜脈血栓栓塞VTE的防治,Risk Factors for Major Bleeding Complications,Procedures in which bleeding complications may have especially severe consequences Craniotomy Spinal surgery S

9、pinal trauma Reconstructive procedures involving free flap,圍手術(shù)期靜脈血栓栓塞VTE的防治,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 the degree of co

10、nfidence 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,圍手術(shù)期靜脈血栓栓塞VTE的防

11、治,Prevention of VTE in General and Abdominal-pelvic Surgical Patients,圍手術(shù)期靜脈血栓栓塞VTE的防治,Perioperative Management ofAntithrombotic Therapy,Vitamin K Antagonist (VKA) : warfarin, acenocoumarol, phenprocoumon, and anisindione Antiplatelet drugs: Acetylsalicylic Acid, clopidogrel, dipyridamole, and nonst

12、eroidal antiinflammatory drug USE or NOT,圍手術(shù)期靜脈血栓栓塞VTE的防治,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

13、require temporary interruption of a VKA before surgery, we recommend: stopping VKAs approximately 5 days before surgery (1C) resuming VKAs approximately 12 to 24 h after surgery (evening of or next morning) (2C,圍手術(shù)期靜脈血栓栓塞VTE的防治,Bridging Anticoagulation,In patients with a mechanical heart valve, atri

14、al fibrillation, or VTE at high risk for thromboembolism, we suggest bridging anticoagulation (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 anticoagulation we suggest stopping LMW

15、H 24 h before surgery (2C) UFH 46 h before surgery (2C,圍手術(shù)期靜脈血栓栓塞VTE的防治,Bridging Anticoagulation,In patients who are 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) . I

16、n 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,圍手術(shù)期靜脈血栓栓塞VTE的防治,Acetylsalicylic Acid (ASA,In patients at moderate to high risk for cardio

17、vascular 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 ASA 7 to 10 days before surgery(2C),圍手術(shù)期靜脈血栓栓塞VTE的防治,Antithro

18、mbotic Therapy for VTE Disease,Initial Treatment Long-term Therapy(initial treatment 3 months) Patients with no cancer VKA (2C) LMWH (2C) Patients with cancer LMWH (2B) VKA (2B) Extended Therapy(beyond 3 months) same as the first 3 months (2C,圍手術(shù)期靜脈血栓栓塞VTE的防治,Clinical Suspicion of Acute VTE,High cli

19、nical 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 clinical suspicion: not tre

20、ating with parenteral anticoagulants while awaiting the results of diagnostic tests, provided test results are expected within 24 h (2C,圍手術(shù)期靜脈血栓栓塞VTE的防治,Initial Treatment of DVT,In patients with acute DVT, we recommend early initiation of VKA (eg, same day as parenteral therapy is started), and cont

21、inuation 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 therapy alone over catheter-directed thrombolysis (CDT) (2C) , systemic thrombol

22、ysis (2C), operative venous thrombectomy(2C), IVC filter(1B,圍手術(shù)期靜脈血栓栓塞VTE的防治,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 anticoagulation (LMWH, fondaparinux, IV UFH, or S

23、C UFH) for a minimum of 5 days and until the INR is 2.0 or above for at least 24 h (1B),圍手術(shù)期靜脈血栓栓塞VTE的防治,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 higher (INR 3.0-5

24、.0) range for all treatment durations (1B),圍手術(shù)期靜脈血栓栓塞VTE的防治,Duration of Anticoagulant Therapy,圍手術(shù)期靜脈血栓栓塞VTE的防治,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

25、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 developing hypotension, we suggest administration of thrombolytic therapy (2C),圍手術(shù)期靜脈血栓栓塞VTE的防治,Catheter-Based Thrombus Removal,In patients with hypotension, we suggest surgical catheter-assisted thrombus removal if they have contra