围手术期静脉血栓栓塞(VTE)的防治-课件.ppt

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.1ppt课件Deep Venous Thrombosis(DVT)Pulmo

2、nary Embolism(PE)2ppt课件VTE-related deaths200,000 per year in US1/3 occur following surgery23-fold for cancer patients3ppt课件Prophylaxis?VTEBleedingVTE 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 thromboemb

3、olism in general surgery.Br J Surg.2001;88(7):913-930.4ppt课件Caprini Risk Assessment Model5ppt课件Caprini风险评分6ppt课件VTE Risk For General SurgeryIncluding GI,Urological,Vascular,Breast,and Thyroid Procedures7ppt课件Risk Factors for Major Bleeding ComplicationsGeneral risk factorsActive bleedingPrevious maj

4、or bleedingKnown,untreated 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 drugs8ppt课件Ris

5、k Factors for Major Bleeding ComplicationsProcedure-specific risk factorsAbdominal surgeryMale sex,preoperative hemoglobin level 25 kg/m2,nonelective surgery,placement of five or more grafts,older ageOlder age,renal insufficiency,operation other than CABG,longer bypass timeThoracic surgeryPneumonect

6、omy or extended resection10ppt课件Risk Factors for Major Bleeding ComplicationsProcedures in which bleeding complications may have especially severe consequencesCraniotomySpinal surgerySpinal traumaReconstructive procedures involving free flap11ppt课件Prevention of VTE in General and Abdominal-pelvic Su

7、rgical PatientsRecommendations are classified as strong(Grade 1)or weak(Grade 2),according to the balance between benefits,risks,burden,and cost,and the degree of confidence in estimates of benefits,risks,and burden.Quality of evidence are classified as high(Grade A),moderate(Grade B),or low(Grade C

8、)according to factors that include the risk of bias,precision of estimates,the consistency of the results,and the directness of the evidence.12ppt课件Prevention of VTE in General and Abdominal-pelvic Surgical Patients13ppt课件Perioperative Management ofAntithrombotic TherapyVitamin K Antagonist(VKA):war

9、farin,acenocoumarol,phenprocoumon,and anisindioneAntiplatelet drugs:Acetylsalicylic Acid,clopidogrel,dipyridamole,and nonsteroidal antiinflammatory drugUSE or NOT?14ppt课件Vitamin K Antagonist(VKA)In patients undergoing major surgery or procedures,interruption of VKAs,in general,is required to minimiz

10、e perioperative bleeding,whereas VKA interruption may not be required in minor procedures.In patients who 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 m

11、orning)(2C)15ppt课件Bridging AnticoagulationIn patients with a mechanical heart valve,atrial fibrillation,or VTE athigh 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)

12、In patients who are receiving bridging anticoagulationwe suggest stoppingLMWH 24 h before surgery(2C)UFH 46 h before surgery(2C)16ppt课件Bridging AnticoagulationIn patients who are receiving bridging anticoagulation with therapeutic-dose SC LMWH and are undergoing high-bleeding-risk surgery,we suggest

13、 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-bleeding-risk surgery,we suggest resuming therapeutic-dose LMWH approximately 24 h after surgery.17ppt课件Acetylsalicylic Acid(ASA)I

14、n 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 patients at low risk for cardiovascular events who are receiving ASA therapy,we suggest stopping ASA 7 to 10 days bef

15、ore surgery(2C).18ppt课件Antithrombotic Therapy for VTE DiseaseInitial TreatmentLong-term Therapy(initial treatment 3 months)Patients with no cancerVKA(2C)LMWH(2C)Patients with cancerLMWH(2B)VKA(2B)Extended Therapy(beyond 3 months)same as the first 3 months(2C)19ppt课件Clinical Suspicion of Acute VTEHig

16、h clinical 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 treat

17、ing with parenteral anticoagulants while awaiting the results of diagnostic tests,provided test results are expected within 24 h(2C)20ppt课件Initial Treatment of DVTIn patients with acute DVT,we recommend early initiation of VKA(eg,same day as parenteral therapy is started),and continuation of parente

18、ral 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 thrombolysis(2C),operative venous thrombe

19、ctomy(2C),IVC filter(1B)21ppt课件Initial Treatment of Acute PEIn 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 SC UFH)for a minimum of 5 days and until the INR is 2.0

20、or above for at least 24 h(1B).22ppt课件Intensity of Anticoagulant EffectIn 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 3.0-5.0)range for all treatment durations(1B).23ppt课件Duration of Anticoagulant Th

21、erapy24ppt课件Systemic Thrombolytic TherapyIn 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 hypotension,we recommend against systemically administered thrombolytic therapy(1C

22、).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).25ppt课件Catheter-Based Thrombus R

23、emovalIn 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 take effect(eg,within hours)(2C)26ppt课件Surgical EmbolectomyIn patients with

24、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,within hours)(2C)27ppt课件Post-thrombotic Syndrome(PTS)In patients with acu

25、te 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).28ppt课件