肺栓塞治療課件

肺栓塞

（pulmonaryembolism）

繩紫肺栓塞

（pulmonaryembolism）Riskstratification：Clinicalparameters：PESIImagingoftherightventriclebyechocardiographyorcomputed tomographicangiographyLaboratorytestsandbiomarkers肺栓塞

（pulmonaryembolism）Initialriskstratification低危險(xiǎn)肺血栓栓塞癥：BP、RV正常；4%次大塊肺血栓栓塞癥：BP正常，RV功能不全；5%~10%大塊肺血栓栓塞癥：RV功能不全，伴低血壓或心源性休克；30%肺栓塞

（pulmonaryembolism）Variouspredictionrulesbasedonclinicalparametershavebeen showntobehelpfulintheprognosticassessmentofpatientswithacutePE.Ofthose,thepulmonaryembolismseverityindex(PESI，肺栓塞嚴(yán)重指數(shù))isthemostextensivelyvalidatedscoretodate.OwingtothecomplexityoftheoriginalPESI,whichincludes11differentlyweightedvariables,asimplifiedversionknownassPESI（簡(jiǎn)化版肺栓塞嚴(yán)重指數(shù)）hasbeendevelopedandvalidated.肺栓塞

（pulmonaryembolism）肺栓塞

（pulmonaryembolism）TreatmentintheacutephaseChronicthromboembolicpulmonaryhypertension（CTEPH,慢性血栓栓塞性肺高壓）SpecificproblemsPregnancyPulmonaryembolismandcancerNon-thromboticpulmonaryembolismTreatmentintheacutephaseHaemodynamicandrespiratorysupportAnticoagulationThrombolytictreatmentSurgicalembolectomy（血栓切除術(shù)）Percutaneouscatheter-directedtreatment（經(jīng)皮導(dǎo)管介入治療）Venousfilters（靜脈濾器）Earlydischargeandhometreatment1、HaemodynamicandrespiratorysupportAcuteRVfailurewithresultinglowsystemicoutputistheleading causeofdeathinpatientswithhigh-riskPE.Therefore,supportive treatmentisvitalinpatientswithPEandRVfailure.絕對(duì)臥床休息，心電監(jiān)護(hù)，血?dú)夥治?；吸氧、機(jī)械通氣；擴(kuò)容治療會(huì)加重右室擴(kuò)大，減低心排出量，不建議使用，液體負(fù)荷量控制在500ml內(nèi)；嚴(yán)重胸痛者注射嗎啡，休克者禁用；保持大便通暢，必要時(shí)用通便藥或灌腸，防止用力引起栓子脫落；急救：Norepinephrine、dobutamine、dopamine、Epinephrin……1、HaemodynamicandrespiratorysupportNorepinephrine： improveRVfunctionviaadirectpositiveinotropiceffect,whilealsoimprovingRVcoronaryperfusionbyperipheralvascularalpha-receptorstimulationandtheincreaseinsystemicBP.dobutamine、dopamine：

dopaminereceptor：使腎及腸系膜血管擴(kuò)張，腎血流量及腎小球?yàn)V過(guò)率增加，尿量及鈉排泄量增加； β1-R：對(duì)心肌產(chǎn)生正性應(yīng)力作用，使心肌收縮力及心搏量增加，最終使心排血量增加、收縮壓升高，冠脈血流及耗氧改善。Epinephrine： combinesthebeneficialpropertiesofnorepinephrineanddobutamine,withoutthesystemicvasodilatoryeffectsofthelatter.ItmaythereforeexertbeneficialeffectsinpatientswithPEandshock.2、Anticoagulation適應(yīng)癥：

急性肺血栓栓塞癥低危險(xiǎn)組患者，應(yīng)予抗凝治療；

大塊肺血栓栓塞癥患者，應(yīng)先溶栓后抗凝治療；

次大塊肺血栓栓塞癥患者，無(wú)論是否溶栓，都應(yīng)該進(jìn)行抗凝治療。禁忌癥：

活動(dòng)性出血、凝血功能障礙、未予控制的嚴(yán)重高血壓……并發(fā)癥：

出血2、AnticoagulationParenteralanticoagulation： UFH vsLMWH

2、AnticoagulationParenteralanticoagulation：UFH adjusted,basedontheactivatedpartialthromboplastintime(aPTT：正常值的1.5-2.5倍；若血小板降低達(dá)30%以上（或<100×109/L）,停用肝素。）LMWH

體重決定給藥劑量,不需測(cè)APTT和調(diào)整劑量。 periodicmeasurementofanti-factorXaactivity(anti-Xalevels)maybeconsideredduringpregnancy.Fondaparinux

aselectivefactorXainhibitoradministeredoncedailybysubcutaneousinjectionatweight-adjusteddoses,withouttheneedformonitoring.2、AnticoagulationParenteralanticoagulation：2、AnticoagulationVitaminKantagonists:Oralanticoagulantsshouldbeinitiatedassoonaspossible,andpreferablyonthesamedayastheparenteralanticoagulant.VKAs:Including:warfarin,acenocoumarol,phenprocoumon,phenindioneandflunidionethe‘goldstandard’inoralanticoagulationformorethan50yearsandremainthepredominantanticoagulantsprescribedforPE.AnticoagulationwithUFH,LMWH,orfondaparinuxshouldbecontinuedforatleast5daysanduntiltheinternationalnormalizedratio(INR)hasbeen2.0–3.0fortwoconsecutivedays2、AnticoagulationVitaminKantagonists: Warfarin: 間接作用的香豆素類口服抗凝藥;通過(guò)抑制肝臟環(huán)氧化還原酶，使無(wú)活性的氧化型維生素K（VK）無(wú)法還原為有活性的還原型VK，阻止VK的循環(huán)應(yīng)用，干擾VK依賴性凝血因子II、VII、IX、X的羧化，使這些凝血因子無(wú)法活化，僅停留在前體階段，而達(dá)到抗凝的目的;對(duì)已經(jīng)合成的上述因子并無(wú)直接對(duì)抗作用，必須等待這些因子在體內(nèi)相對(duì)消耗后，才能發(fā)揮抗凝效應(yīng)，所以本藥起效慢，停藥后藥效持續(xù)時(shí)間長(zhǎng)（直到VK依賴行因子恢復(fù)到一定濃度后，抗凝作用才消失）Warfarin2、AnticoagulationNeworalanticoagulants（NOACs）:Including:Dabigatran、Rivaroxaban、Apixaban、Edoxaban（rivaroxaban,dabigatranandapixabanareapprovedfortreatmentofVTEintheEUin2014;edoxabaniscurrentlyapprovedfortreatmentofVTEintheFDAin2015）theresultsofthetrialsusingNOACsinthetreatmentofVTEindicatethattheseagentsarenon-inferior(intermsofefficacy)andpossiblysafer(particularlyintermsofmajorbleeding)thanthestandardheparin/VKAregimen.Atpresent,NOACscanbeviewedasanalternative tostandardtreatment.3、ThrombolytictreatmentObjective:ThrombolytictreatmentofacutePErestorespulmonaryperfusionmorerapidlythananticoagulationwithUFHalone;Theearlyresolutionofpulmonaryobstructionleadstoapromptreductioninpulmonaryarterypressureandresistance;improvementinRVfunction.3、Thrombolytictreatment

mechanism：使用藥物直接或間接的將纖溶酶原轉(zhuǎn)化為纖溶酶，迅速破壞纖維蛋白，溶解血栓；同時(shí)可通過(guò)清除和滅活凝血因子Ⅱ，Ⅴ和Ⅷ，阻礙凝血過(guò)程，發(fā)揮抗凝效應(yīng)。Indication：溶栓的適應(yīng)癥：大塊肺血栓栓塞癥，其特征為右心功能不全，伴低血壓或心源性休克（體循環(huán)動(dòng)脈收縮壓＜90mmHg,或較基礎(chǔ)值下降幅度≥40mmHg）。3、Thrombolytictreatmentapprovedregimens：3、Thrombolytictreatment attention:Thegreatestbenefitisobservedwhentreatmentisinitiatedwithin48hoursofsymptomonset,butthrombolysiscanstillbeusefulinpatientswhohavehadsymptomsfor6–14days.（溶栓時(shí)間窗）Unfractionatedheparininfusionshouldbestoppedduringadministrationofstreptokinaseorurokinase;itcanbecontinuedduringrtPAinfusion.Giventhebleedingrisksassociatedwiththrombolysisandthepossibilitythatitmaybecomenecessarytoimmediatelydiscontinueorreversetheanticoagulanteffectofheparin,itappearsreasonabletocontinueanticoagulationwithUFHfor severalhoursaftertheendofthrombolytictreatmentbeforeswitchingtoLMWHorfondaparinux.溶栓結(jié)束后復(fù)查APTTorPT/2-4h,待APTT或PT恢復(fù)至對(duì)照值的2倍以內(nèi)時(shí)，即應(yīng)開(kāi)始肝素抗凝治療。溶栓的并發(fā)癥：出血、發(fā)熱、過(guò)敏反應(yīng)、低血壓、惡心、嘔吐。鏈霉素具有抗原性，用藥前需肌注苯海拉明/地塞米松；6m內(nèi)不宜再次使用。4、Surgicalembolectomy（血栓切除術(shù)） Indication：high-riskPE,andalsoforselectedpatientswithintermediate-high-riskPE,particularlyifthrombolysisiscontraindicatedorhasfailed.

method：平仰臥位，正中切口開(kāi)胸，打開(kāi)心包，肝素化，主動(dòng)脈、腔靜脈插管建立體外循環(huán)。降溫至30℃，阻斷上、下腔靜脈和升主動(dòng)脈，主動(dòng)脈根部灌注冷血停跳液，行心臟停跳手術(shù)，取栓應(yīng)在心臟停跳后進(jìn)行,切開(kāi)肺動(dòng)脈主干及左右肺動(dòng)脈,根據(jù)血栓生長(zhǎng)位置決定是否延長(zhǎng)切口,使用膽囊取石鉗盡可能完整將整條血栓取出/Fogarty球囊導(dǎo)管取栓。取栓后,在二級(jí)/三級(jí)肺動(dòng)脈分支開(kāi)口見(jiàn)鮮紅的血液流出,說(shuō)明血栓已取干凈。取栓后用0.01%肝素反復(fù)沖洗。如下腔靜脈系統(tǒng)仍有血栓,應(yīng)安置血栓過(guò)濾器，避免血栓再次脫落。5、Percutaneouscatheter-directedtreatment（經(jīng)皮導(dǎo)管介入治療） objective：theremovalofobstructingthrombifromthemainpulmonaryarteriestofacilitateRVrecoveryandimprovesymptomsandsurvival.

method：Forpatientswithabsolutecontraindicationstothrombolysis,：thrombusfragmentationwithpigtailorballooncatheter（碎栓）rheolyticthrombectomywithhydrodynamiccatheterdevices（切除）suctionthrombectomywithaspirationcatheters（抽吸）rotationalthrombectomy（旋磨）Patientswithoutabsolutecontraindicationstothrombolysis：catheter-directedthrombolysisorpharmacomechanicalthrombolysisarepreferredapproaches.6、Venousfilters（靜脈濾器）indication：patientswithacutePEwhohaveabsolutecontraindicationstoanticoagulantdrugs；patientswithobjectivelyconfirmedrecurrentPEdespiteadequateanticoagulationtreatment.Observationalstudiessuggest： insertionofavenousfiltermightreducePE-relatedmortalityratesintheacutephase,benefitpossiblycomingatthecostofanincreasedriskofrecurrenceofVTE.Complications:earlycomplications—insertionsitethrombosis(10%);pericardialtamponade.Latecomplications—DVT（20%）（不推薦PE患者常規(guī)使用Venousfilters）6、Venousfilters（靜脈濾器）7、EarlydischargeandhometreatmentTherapeuticstrategiesDurationofanticoagulation病例一患者李某某，男，48歲，自由職業(yè)者。主訴：咳嗽、胸悶20余天，加重8天?，F(xiàn)病史：患者20天前無(wú)明顯誘因出現(xiàn)咳嗽頻繁，伴活動(dòng)后憋氣、氣短，活動(dòng)耐力較前下降，無(wú)胸痛，無(wú)發(fā)熱、寒戰(zhàn)，就診于當(dāng)?shù)蒯t(yī)院給予“甘草片、羅紅霉素”治療。8天前爬8樓后出現(xiàn)一過(guò)性頭暈黑朦，心悸，無(wú)暈厥，蹲下后緩解。就診于菏澤市牡丹人民醫(yī)院，行肺動(dòng)脈CTA掃描，診斷為“肺栓塞”，給予“阿司匹林、氯吡格雷、低分子肝素5000Ubid”治療4天，仍有憋悶氣短，較前略輕，遂來(lái)我院急診科行血?dú)夥治鯬O267mmHg（吸氧3L/分）,PCO234mmHg，心電圖示中度ST壓低，T波異常，為求進(jìn)一步治療收入我院?；颊咦园l(fā)病以來(lái)，飲食、睡眠可，大小便正常，體重?zé)o明顯變化。病例16個(gè)月前因車禍頭部損傷，腰椎輕微骨折，入院臥床半月，后恢復(fù)良好出院。發(fā)現(xiàn)低血壓20余年，血壓最低可達(dá)85/40mmHg,未診療。發(fā)現(xiàn)心率過(guò)緩20余年。既往史：（-）個(gè)人史：吸煙史30余年，20支/天。體格檢查：T36.8℃，P106次/分，R20次/分，BP88/61mmHg

雙側(cè)呼吸度對(duì)等，未及胸膜摩擦音，雙肺呼吸音清，未聞及明顯啰音。輔助檢查2015-7-26（住院當(dāng)天）CTA：雙側(cè)肺動(dòng)脈及其分支可見(jiàn)充盈缺損。（菏澤市牡丹人民醫(yī)院）2013-7-26血?dú)夥治鯬O267mmHg（吸氧3L/分）,PCO234mmHg2015-7-26心電圖：ST壓低，T波異常。（山東大學(xué)齊魯醫(yī)院）輔助檢查2015-7-27WBC

11.09×10^9／LPT-INR

1.25(0.8-1.2)DD-I2.38(0-0.5ug/ml)BNP4308pg/mlALT113U/LGGT183U/LAST43U/L2015-7-28PT-INR

1.26DD-I1.15CA-12536.72(0-35)NSE23.70(0-20)心臟彩超：LVEF0.77，右心擴(kuò)大，三尖瓣返流（重度），肺動(dòng)脈高壓（重度，肺動(dòng)脈收縮壓90mmHg），心包積液（微量），右室收縮功能減低。初步診斷肺血栓栓塞癥I型呼吸衰竭PESIIV:108危險(xiǎn)分層休克or低血壓？高危診療計(jì)劃內(nèi)科常規(guī)護(hù)理特級(jí)護(hù)理重癥監(jiān)護(hù)病危氧氣吸入心電血壓血氧飽和度監(jiān)護(hù)絕對(duì)臥床低分子肝素5000Uihq12h心電圖血?dú)夥治鲋委煼桨?-27患者胸部強(qiáng)化CT可見(jiàn)雙肺上下動(dòng)脈均可見(jiàn)栓子，肺栓塞診斷成立，栓子面積較大，BNP明顯升高，提示右心功能不全。繼續(xù)齊征皮下注射，加用華法林3mgpoqd。7-28患者持續(xù)低血壓，屬高危組，加之患者經(jīng)抗凝治療后喘憋癥狀改善不明顯，考慮有溶栓治療指征，無(wú)絕對(duì)溶栓禁忌，將溶栓的必要性及相關(guān)風(fēng)險(xiǎn)向患者家屬詳細(xì)講明，家屬表示知情理解并同意溶栓治療。暫停華法林，暫停齊征。是否處于溶栓治療窗尚不能確定，全科專家組病例討論同意患者當(dāng)前有溶栓指征，無(wú)溶栓禁忌，抗凝治療效果不佳，行尿激酶120萬(wàn)單位溶栓治療。溶栓過(guò)程生理鹽水+