圍手術(shù)期抗栓治療 microsoft powerpoint

1、抗栓治療患者的圍手術(shù)期處理抗凝治療及血栓預(yù)防第九版抗栓治療的藥物抗凝：華法林、肝素、低分子肝素抗血小板：ASA、氯吡格雷等手術(shù)！血栓？出血？標(biāo)準(zhǔn)的手術(shù)前抗栓方案的制定大手術(shù)前7天討論制定抗凝治療的措施。提供病人：華法林、抗血小板藥物是否繼續(xù)應(yīng)用？低分子肝素應(yīng)用劑量、時(shí)間？INR的檢測？根據(jù)藥品情況、患者血栓或出血風(fēng)險(xiǎn)制定策略。確保注射方法正確。INR檢測:手術(shù)前INR升高病人可應(yīng)用維生素K口服12.5毫克。評估手術(shù)出血風(fēng)險(xiǎn)。評估出血風(fēng)險(xiǎn) 1 抗凝劑劑量：大劑量出血風(fēng)險(xiǎn)大 2 手術(shù)出血多的：尿路手術(shù)、結(jié)腸息肉切成、腸道手術(shù)、起搏器、肝脾腎手術(shù)、心臟顱內(nèi)脊柱手術(shù)。 3 出血風(fēng)險(xiǎn)少的手術(shù)：牙科、皮膚

2、科、白內(nèi)障手術(shù)。 4 病人有出血傾向的手術(shù)前血栓風(fēng)險(xiǎn)評估血栓高風(fēng)險(xiǎn)因素congestive heart failure, hypertension,age 75 years, diabetes mellitus, prior stroke or transient ischemic attack血栓風(fēng)險(xiǎn)與手術(shù)心臟搭橋、換瓣：導(dǎo)致心血管及腦血管事件其他手術(shù)：危險(xiǎn)性各異評估血栓的風(fēng)險(xiǎn)根據(jù)病人及手術(shù)評估血栓風(fēng)險(xiǎn)：1高風(fēng)險(xiǎn) ：血栓風(fēng)險(xiǎn)大于10%2中風(fēng)險(xiǎn) ：10%而大于5%3低風(fēng)險(xiǎn) ：血栓風(fēng)險(xiǎn)5% 橋接抗凝we define bridging anticoagulation as the adminis

3、tration of a short-acting anticoagulant, consisting of subcutaneous (SC) low-molecular-weight heparin(LMWH) or IV unfractionated heparin(UFH), for an 10- to 12-day period during interruption of VKA therapy when the international normalized ratio (INR) is not within a therapeutic range.華法林暫停，應(yīng)用低分子肝素、

4、或肝素過渡橋接抗凝的目的平衡血栓與手術(shù)出血，保證病人平安血栓高風(fēng)險(xiǎn)病人需橋接抗凝治療In patients with a mechanical heart valve,atrial fibrillation, or VTE at high risk for thromboembolism,we suggest bridging anticoagulation instead of no bridging during interruption of VKA therapy (Grade 2C).靜脈血栓、心臟機(jī)械瓣膜、房顫等血栓高風(fēng)險(xiǎn)患者建議橋接抗凝。出血風(fēng)險(xiǎn)高時(shí)傾向于減量或不用decline

5、)。血栓低風(fēng)險(xiǎn)患者不建議橋接抗凝中度風(fēng)險(xiǎn)者根據(jù)病人情況、手術(shù)情況評估后確定是否橋接抗凝。華法林術(shù)前5天停用In patients who require temporary interruptionof a VKA before surgery, we recommend stopping VKAs approximately 5 days before surgery instead of stopping VKAs a shorter time before surgery (Grade 1C) .理論上可減少出血風(fēng)險(xiǎn)。手術(shù)前檢測術(shù)前1天查INRINR高于1.5，維生素K4 1毫克口服華法

6、林手術(shù)后12或24小時(shí)再加用In patients who require temporary interruption of a VKA before surgery, we recommend resuming VKAs approximately 12 to 24 h after surgery (evening of or next morning) and when there is adequate hemostasis instead of later resumption of VKAs (Grade 2C) .適當(dāng)止血，術(shù)后12或24小時(shí)開始應(yīng)用，而不是更晚。華法林 術(shù)后24

7、小時(shí)給予華法林，第1-2天可給予雙倍劑量，4-6天INR到達(dá)2-3之間橋接抗凝的藥物肝素低分子肝素術(shù)前停用肝素及低分子肝素應(yīng)用肝素治療或橋接治療者術(shù)前4-6小時(shí)停用，而不是更短。治療劑量的低分子肝素最后1劑建議術(shù)前24小時(shí)給予，而不是12小時(shí)。橋接抗凝的劑量高劑量: 治療劑量低劑量：預(yù)防劑量中等劑量出血風(fēng)險(xiǎn)高術(shù)后橋接抗凝應(yīng)適當(dāng)延遲，在手術(shù)后48-72小時(shí)，而不是24小時(shí)?？寡“逯委煹膰中g(shù)期處理ASA預(yù)防心血管疾病者小的牙科、皮膚科、白內(nèi)障手術(shù)可繼續(xù)服用ASA對于非心臟手術(shù)：應(yīng)根據(jù)病人心腦血管疾病的風(fēng)險(xiǎn)決定是否停用ASA，對于血栓低風(fēng)險(xiǎn)病人可手術(shù)前710天停用。CABG手術(shù)患者目前正接受ASA治療者可繼續(xù)ASA.雙重抗血小板治療的患者，建議術(shù)前5天停用氯吡格雷、普拉格雷。冠脈支架植入術(shù)后手術(shù)金屬裸支架：建議推遲手術(shù)最少6周藥物洗脫支