靜脈血栓栓塞課件

靜脈血栓栓塞危重患者的VTE高危因素和發(fā)病率危重患者的VTE預(yù)防指南和評(píng)估ICU內(nèi)的VTE預(yù)防方法幾個(gè)肺栓塞病例

Covidien|15January2024|Confidential3|靜脈血栓栓塞癥(VTE)包括深靜脈血栓(DVT)和肺栓塞(PE)。

DefinitionofVenousThromboembolism(VTE)

靜脈血栓栓塞的定義PulmonaryEmbolism1Circulation1996;93:2212;2NEnglJMed2004;350:22573Lancet1997;349:759;4JGenInternMed2000;26:425FatalPEAsymptomaticPESymptomaticDVTPulmonaryEmbolism4outof5patientswillnothaveanysymptomsofthrombosisAsymptomaticDVT20%80%80%ASYMPTOMATICS11050100300-1000Confidential,?TycoCorporation

Covidien|15/01/2024|Confidential5|解決DVT的后果靜脈血栓栓塞--

Covidien|15/01/2024|ConfidentialConfidential,?TycoCorporation6|血流淤滯血管壁損傷凝血功能改變?yōu)槭裁磿?huì)形成DVT？當(dāng)沒(méi)有任何預(yù)防措施時(shí)，DVT在某些專科中的發(fā)生率高于50％但是，僅有25％的DVT患者會(huì)表現(xiàn)出病癥O’Mearaetal.ProphylaxisforVenousThromboembolisminTotalHipArthroplasty.ORTHOPEDICS.深靜脈血栓流行病學(xué)〔外科各專業(yè)〕ICU入住前存在的高危因素ICU期間獲得的高危因素近期手術(shù)中心靜脈導(dǎo)管創(chuàng)傷、燒傷膿毒癥惡性腫瘤和治療因素藥物鎮(zhèn)靜、麻醉膿毒癥機(jī)械通氣制動(dòng)/臥床、中風(fēng)、脊髓損傷肌松治療高齡藥物治療心臟/呼吸衰竭VTE病史懷孕/產(chǎn)后雌性激素高臨床路徑推薦RiskfactorsforVTEActivecancerorcancertreatmentAgeover60yearsCriticalcareadmissionDehydrationKnownthrombophiliasObesity(bodymassindex[BMI]over30kg/m2)Oneormoresignificantmedicalcomorbidities(forexample:heartdisease;metabolic,endocrineorrespiratorypathologies;acuteinfectiousdiseases;inflammatoryconditions)Personalhistoryorfirst-degreerelativewithahistoryofVTEUseofhormonereplacementtherapyUseofoestrogen-containingcontraceptivetherapyVaricoseveinswithphlebitisForwomenwhoarepregnantorhavegivenbirthwithintheprevious6weeksRegardmedicalpatientsasbeingatincreasedriskofVTEifthey:havehadorareexpectedtohavesignificantlyreducedmobilityfor3daysormoreorareexpectedtohaveongoingreducedmobilityrelativetotheirnormalstateandhaveoneormoreoftheriskfactorsRegardsurgicalpatientsandpatientswithtraumaasbeingatincreasedriskofVTEiftheymeetoneofthefollowingcriteria:surgicalprocedurewithatotalanaestheticandsurgicaltimeofmorethan90minutes,or60minutesifthesurgeryinvolvesthepelvisorlowerlimbacutesurgicaladmissionwithinflammatoryorintra-abdominalconditionexpectedsignificantreductioninmobilityoneormoreoftheriskfactorsRiskfactorsforbleedingActivebleedingAcquiredbleedingdisorders(suchasacuteliverfailure)Concurrentuseofanticoagulantsknowntoincreasetheriskofbleeding(suchaswarfarinwithinternationalnormalisedratio[INR]higherthan2)Lumbarpuncture/epidural/spinalanaesthesiaexpectedwithinthenext12hoursLumbarpuncture/epidural/spinalanaesthesiawithintheprevious4hoursAcutestrokeThrombocytopenia(plateletslessthan75x109/l)Uncontrolledsystolichypertension(230/120mmHgorhigher)Untreatedinheritedbleedingdisorders(suchashaemophiliaandvonWillebrand'sdisease)PharmacologicalVTEprophylaxisForexample:Generalmedicalpatientsfondaparinuxsodiumlowmolecularweightheparin(LMWH)unfractionatedheparin(UFH)(forpatientswithrenalfailure).StartpharmacologicalVTEprophylaxisassoonaspossibleafterriskassessmenthasbeencompleted.ContinueuntilthepatientisnolongeratincreasedriskofVTEPatientswithstrokePatientswithcancerPatientswithcentralvenouscathetersPatientsinpalliativecareAllsurgeryCardiacsurgeryGastrointestinal,gynaecological,thoracicandurological物理預(yù)防在ICU的優(yōu)勢(shì)：ICU患者剛?cè)朐簳r(shí)大多具有消化道應(yīng)激性潰瘍出血風(fēng)險(xiǎn)局部重癥患者有凝血功能障礙、腎功能障礙ICU患者本身情況復(fù)雜，用藥難以掌握,出血并發(fā)癥物理預(yù)防：ICU患者不可或缺19|靜脈瓣后去除SCD壓力系統(tǒng)提供最正確連續(xù)梯度壓力模式使股靜脈血流速度到達(dá)最大“理想的壓力模式為踝部35mmHg，小腿30mmHg，大腿20mmHg。〞“然而，由于廣泛存在的個(gè)體差異，這個(gè)壓力可以稍微增加〔例如45，40，30mmHg〕。〞

Covidien|15/01/2024|ConfidentialConfidential,?TycoCorporation22|Nicolaidesetal.IntermittentSequentialPneumaticCompressionoftheLegsinthePreventionofVenousStasisandPostoperativeDeepVenousThrombosis,Surgery1980:87:69-76大腿小腿踝部壓力mmHgSCD壓力系統(tǒng)在股靜脈血液去除方面，速度明顯優(yōu)于小腿、單一壓力系統(tǒng).“SCD可以在很短的時(shí)間內(nèi)清空靜脈瓣后淤滯的血液，而如果只對(duì)小腿施壓,相應(yīng)的染色物質(zhì)會(huì)停留長(zhǎng)時(shí)間。〞〔小腿、單一壓力系統(tǒng)〕Confidential,?TycoCorporation

Covidien|15/01/2024|ConfidentialMittlemanetal.EffectivenessofLegCompressioninPreventingVenousStasis.TheAmericanJournalofSurgery1982;144:611-613

Covidien|15/01/2024|ConfidentialConfidential,?TycoCorporation25|靜脈再充盈檢測(cè)

Covidien|15/01/2024|ConfidentialConfidential,?TycoCorporation26|血液移動(dòng)總量相同的情況在靜脈曲張的病人中，仰臥位增加71.9%，半臥位增加77.9%，坐姿時(shí)增加55.7%。〞Kakkosetal.Improvedhemodynamiceffectivenessandassociatedclinicalcorrelationsofanewintermittentpneumaticcomporessionsysteminpatientswithchronicvenousinsufficiency.JournalofVascularSurgery,Nov2001;Vol34,No.5,915-922將腿部血液清除達(dá)到最大值

主機(jī)連接管腿套/足套〔45mmHg,40mmHg,30mmHg〕(130mmHg)

Covidien|15/01/2024|ConfidentialConfidential,?TycoCorporation32|J.CapriniMD.

Covidien|15/01/2024|ConfidentialConfidential,?TycoCorporation33|T.E.D.AntiembolismStockingT.E.D.抗血栓壓力帶OtherAntiembolismStocking其它抗血栓壓力帶圓周鑲嵌編織法單向水平伸展確?？寡▔毫У墓潭▓A周編織提供單向伸展確保壓力分布正確定位垂直伸展使尼龍襪滑落UsingtheKendallTEDstockingswhichapplythecorrectpressureprofile,Holford(B.M.J.1976,2969-970)showedthatTEDstockingsreducedtheincidenceofdeepveinthrombosisinsurgicalpatientsfrom49%to23%andconcluded〞…improperdesign,constructionorfitcanbedangerous.〞垂直伸展使尼龍襪滑落7位半臥位自愿者，5個(gè)帶水壓計(jì)的可充氣套觀察血流速度確定理想的壓力分布18，14，8，10，8mmHg相對(duì)與基線，平均股靜脈血流速度增加138.4%

Covidien|15/01/2024|ConfidentialConfidential,?TycoCorporation34|項(xiàng)目實(shí)驗(yàn)組VS對(duì)比組結(jié)果結(jié)論1單物理預(yù)防VS單藥物預(yù)防無(wú)顯著差異物理預(yù)防和藥物預(yù)防一樣有效；但物理預(yù)防的并發(fā)癥更低2聯(lián)合預(yù)防VS藥物預(yù)防有顯著差異物理預(yù)防會(huì)使藥物預(yù)防更加有效3單物理預(yù)防VS聯(lián)合預(yù)防無(wú)顯著差異只使用物理預(yù)防足以有效預(yù)防DVT100+文獻(xiàn)證明SCD和TED的有效性

Covidien|15/01/2024|ConfidentialConfidential,?TycoCorporation36|靜脈血栓物理預(yù)防全方位解決方案AVI動(dòng)靜脈脈沖系統(tǒng)SCD氣動(dòng)歇式壓力裝置TED抗血栓壓力帶Case1：luckypatient，luckydoctorFemale，63yearsRecurrentsyncopeSpO260%~70%HypotensionECG：RBBBD-Dimer：2.386ug/mlCTA：肺動(dòng)脈主干及雙肺動(dòng)脈多發(fā)性栓塞rt-PA50mgDay-2:ECGnormal;有嘔吐表現(xiàn)CT小腦半球少量出血保守治愈

Case2：Bravedoctor第一次尿激酶溶栓150萬(wàn)u一次VD，復(fù)查肺CTA如上圖，機(jī)械通氣氧合改善不滿意，未能脫機(jī)尿激酶二次溶栓4400u/Kg/h