《靜脈血栓栓塞》課件

1、靜脈血栓栓塞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)防指南和評估ICU內(nèi)的VTE預(yù)防方法幾個肺栓塞病例危重患者的VTE高危因素和發(fā)病率 Covidien | 16 October 2022 | Confidential3 |靜脈血栓栓塞癥(VTE)包括深靜脈血栓(DVT)和肺栓塞(PE)。 Definition of Venous Thromboembolism (VTE)靜脈血栓栓塞的定義Pulmonary Embolism Covidien | 10 October 2021Circulation 1996;93:2212; 2N Engl J Med 2004;35

2、0:22573Lancet 1997;349:759; 4J Gen Intern Med 2000;26:425Fatal PEAsymptomatic PESymptomatic DVTPulmonary Embolism 4 out of 5 patients will not have any symptoms of thrombosisAsymptomatic DVT20%80%80% ASYMPTOMATICS11050100300- 10001Circulation 1996;93:2212; 2N Confidential, Tyco Corporation Covidien

3、| 16 October 2022 | Confidential5 |解決DVT的后果靜脈血栓栓塞-Confidential, Tyco Corporati Covidien | 16 October 2022 | ConfidentialConfidential, Tyco Corporation6 |血流淤滯血管壁損傷凝血功能改變血液循環(huán)流速減慢。血流淤滯同時發(fā)生在術(shù)中和術(shù)后的臥床時間發(fā)生在術(shù)側(cè)肢體的操作過程中會扭折血管，如全膝或全髖成型術(shù),靜脈血液郁積也會造成靜脈擴張和內(nèi)皮細胞損傷。術(shù)后血液中促凝血酶原激酶和纖維蛋白原水平升高，組織損傷處表面凝結(jié)被激活都導(dǎo)致了血液的高凝狀態(tài)。為什么會形成

4、DVT？ Covidien | 10 October 202當沒有任何預(yù)防措施時，DVT在某些?？浦械陌l(fā)生率高于50但是，僅有25的DVT患者會表現(xiàn)出癥狀OMeara et al. Prophylaxis for Venous Thromboembolism in Total Hip Arthroplasty. ORTHOPEDICS.深靜脈血栓流行病學(xué)（外科各專業(yè)）當沒有任何預(yù)防措施時，DVT在某些專科中的發(fā)生率高于50但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、麻醉膿毒癥機械通氣制動/臥床、中風(fēng)、脊髓損傷肌松治療高齡藥

5、物治療心臟/呼吸 衰竭VTE病史懷孕/產(chǎn)后雌性激素高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)中靜脈血栓栓塞課件臨床路徑推薦臨床路徑推薦Risk factors for VTEActive cancer or cancer treatmentAge over 60 yearsCritical care admissionDehydrationKnown thrombophiliasObesity (body mass index BMI over 30 kg/m2)One or more significant medical comorbidities (for exampl

6、e: heart disease; metabolic, endocrine or respiratory pathologies; acute infectious diseases; inflammatory conditions)Personal history or first-degree relative with a history of VTEUse of hormone replacement therapyUse of oestrogen-containing contraceptive therapyVaricose veins with phlebitisFor wom

7、en who are pregnant or have given birth within the previous 6 weeksRisk factors for VTEActive canRegard medical patients as being at increased risk of VTE if they:have had or are expected to have significantly reduced mobility for 3 days or more orare expected to have ongoing reduced mobility relati

8、ve to their normal state and have one or more of the risk factorsRegard medical patients as beiRegard surgical patients and patients with trauma as being at increased risk of VTE if they meet one of the following criteria:surgical procedure with a total anaesthetic and surgical time of more than 90

9、minutes, or 60 minutes if the surgery involves the pelvis or lower limbacute surgical admission with inflammatory or intra-abdominal conditionexpected significant reduction in mobilityone or more of the risk factorsRegard surgical patients and pRisk factors for bleedingActive bleedingAcquired bleedi

10、ng disorders (such as acute liver failure)Concurrent use of anticoagulants known to increase the risk of bleeding (such as warfarin with international normalised ratio INR higher than 2)Lumbar puncture/epidural/spinal anaesthesia expected within the next 12 hoursLumbar puncture/epidural/spinal anaes

11、thesia within the previous 4 hoursAcute strokeThrombocytopenia (platelets less than 75 x 109/l)Uncontrolled systolic hypertension (230/120 mmHg or higher)Untreated inherited bleeding disorders (such as haemophilia and von Willebrands disease)Risk factors for bleedingActivPharmacological VTE prophyla

12、xisFor example:General medical patientsfondaparinux sodiumlow molecular weight heparin (LMWH)unfractionated heparin (UFH) (for patients with renal failure).Start pharmacological VTE prophylaxis as soon as possible after risk assessment has been completed. Continue until the patient is no longer at i

13、ncreased risk of VTEPharmacological VTE prophylaxiPatients with strokePatients with cancerPatients with central venous cathetersPatients in palliative careAll surgeryCardiac surgeryGastrointestinal, gynaecological, thoracic and urologicalPatients with strokePatients w靜脈血栓栓塞課件物理預(yù)防在ICU的優(yōu)勢： ICU患者剛?cè)朐簳r大多

14、具有消化道應(yīng)激性潰瘍出血風(fēng)險 部分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患者不可或缺物理預(yù)防在ICU的優(yōu)勢：物理預(yù)防：ICU患者不可或缺19 |19 |靜脈瓣后清除靜脈瓣后清除靜脈血栓栓塞課件SCD壓力系統(tǒng)提供最佳連續(xù)梯度壓力模式使股靜脈血流速度達到最大“理想的壓力模式為踝部35mmHg，小腿30mmHg，大腿20mmHg?！薄?然而，由于廣泛存在的個體差異，這個壓力可以稍微增加（例如45，40，30mmHg）。” Covidien | 16 October 2022 | ConfidentialConfidential, Tyco

15、 Corporation22 |Nicolaides et al. Intermittent Sequential Pneumatic Compression of the Legs in the Prevention of Venous Stasis and Postoperative Deep Venous Thrombosis, Surgery 1980: 87: 69-76大腿小腿踝部壓力mmHgSCD壓力系統(tǒng)提供最佳連續(xù)梯度壓力模式使股靜脈血流速度達到最SCD壓力系統(tǒng)在股靜脈血液清除方面，速度明顯優(yōu)于小腿、單一壓力系統(tǒng). “SCD 可以在很短的時間內(nèi)清空靜脈瓣后淤滯的血液，而如果只對

16、小腿施壓,相應(yīng)的染色物質(zhì)會停留長時間?！保ㄐ⊥?、單一壓力系統(tǒng)）Confidential, Tyco Corporation Covidien | 16 October 2022 | ConfidentialMittleman et al. Effectiveness of Leg Compression in Preventing Venous Stasis. The American Journal of Surgery 1982; 144:611-613SCD壓力系統(tǒng)在股靜脈血液清除方面，速度明顯優(yōu)于小腿、單一壓靜脈血栓栓塞課件 Covidien | 16 October 2022 | C

17、onfidentialConfidential, Tyco Corporation25 |靜脈再充盈檢測 Covidien | 10 October 202 Covidien | 16 October 2022 | ConfidentialConfidential, Tyco Corporation26 |血液移動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%，坐姿時增加55.7%。”Kakkos et al. Improved hemodynamic effectiveness and associated clinical correlations of a

18、new intermittent pneumatic comporession system in patients with chronic venous insufficiency. Journal of Vascular Surgery, Nov 2001; Vol 34, No. 5, 915-922 Covidien | 10 October 202靜脈血栓栓塞課件將腿部血液清除達到最大值將腿部血液清除達到最大值主機連接管腿套/足套 （45mmHg, 40mmHg,30mmHg） (130mmHg)主機腿部壓力：預(yù)防深靜脈血栓癥和肺部栓塞足部壓力：1.增強血液循環(huán)2.預(yù)防深靜脈血栓癥

19、3.急性水腫4.慢性水腫5.外傷或外科手術(shù)引發(fā)的四肢疼痛6.腿部潰瘍7.靜脈郁積/靜脈功能障礙腿部壓力：腿部壓力：任何有可能防礙充氣壓力帶作用的腿局部情況，例如：（a）皮炎，（b）靜脈結(jié)扎（在手術(shù)后即刻），（c）壞疽，或者（d）剛做完皮膚移植手術(shù)嚴重的動脈硬化癥或其它缺血性血管病腿部大范圍水腫或由充血性心力衰竭引發(fā)的肺部水腫腿部嚴重畸形疑似已出現(xiàn)深靜脈血栓癥足部壓力：增強回流心臟的流速會有害的情況下充血性心力衰竭已出現(xiàn)深靜脈血栓癥、血栓(性)靜脈炎或肺部栓塞對于手足部存在感染或感覺遲鈍情況的患者，使用時必須非常小心腿部壓力：“盡管梯度壓力彈力襪外表看上去很簡單，但是其中的設(shè)計卻很復(fù)雜，對于技術(shù)

20、細節(jié)的關(guān)注可以得到有效的預(yù)防方法?！?Covidien | 16 October 2022 | ConfidentialConfidential, Tyco Corporation32 |J.Caprini MD. “盡管梯度壓力彈力襪外表看上去很簡單，但是其中的設(shè)計卻很復(fù)雜 Covidien | 16 October 2022 | ConfidentialConfidential, Tyco Corporation33 |T.E.D. Antiembolism StockingT.E.D. 抗血栓壓力帶Other Antiembolism Stocking其它抗血栓壓力帶圓周鑲嵌編織法單向水

21、平伸展確保抗血栓 壓力帶的固定圓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Using the Kendall TED stockings which apply the correct pressure profile, Holford (B.M.J. 1976,2 969-970) showed that TED stockings reduced the incidence of deep vein thrombosis in surgical patients from 49% to 23% and concluded”improper design, construct

22、ion or fit can be dangerous.”垂直伸展使尼龍襪滑落 Covidien | 10 October 2027位半臥位自愿者，5個帶水壓計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相對與基線，平均股靜脈血流速度增加138.4% Covidien | 16 October 2022 | ConfidentialConfidential, Tyco Corporation34 | Covidien | 10 October 202項目實驗組 VS 對比組結(jié)果結(jié)論1單物理預(yù)防VS單藥物預(yù)防無顯著差異物理預(yù)防和藥物預(yù)防一樣有效；但物理預(yù)防的并發(fā)癥更

23、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)防無顯著差異只使用物理預(yù)防足以有效預(yù)防DVT100+文獻證明SCD和TED的有效性項目實驗組 VS 對比組結(jié)果結(jié)論1單物理預(yù)防VS單藥物預(yù)防無Woolson et al. Journal of Bone & Joint Surgery 1991 (全髖關(guān)節(jié)置換術(shù)病人)“我們相信在術(shù)中和術(shù)后使用間歇式充氣壓力裝置（無抗凝劑），是有效，安全和便利的?！?Covidien | 16 October 2022 | ConfidentialConfidential, Tyco Corporation36 |Woo

24、lson et al. Journal of Bone亞洲人群髖關(guān)節(jié)手術(shù)后采用非藥物預(yù)防后無癥狀的深靜脈血栓的自然過程術(shù)后沒有患者發(fā)展致命有癥狀的肺栓塞，或近端深靜脈血栓。但是9個患者（5%）發(fā)展成遠端深靜脈血栓，沒有術(shù)前相關(guān)危險因子。這9位患者術(shù)后緊密隨訪未用抗凝劑治療，6個月后所有的血栓消失未發(fā)展成肺栓塞或血栓性靜脈炎亞洲人群髖關(guān)節(jié)手術(shù)后采用非藥物預(yù)防后無癥狀的深靜脈血栓的自然靜脈血栓物理預(yù)防全方位解決方案AVI 動靜脈脈沖系統(tǒng)SCD氣動歇式壓力裝置TED抗血栓壓力帶靜脈血栓物理預(yù)防全方位解決方案AVI 動靜脈脈沖系統(tǒng)SCD氣Case 1：lucky patient，lucky docto

25、rFemale，63yearsRecurrent syncopeSpO2 60%70%HypotensionECG：RBBBD-Dimer：2.386ug/mlCTA：肺動脈主干及雙肺動脈多發(fā)性栓塞Case 1：lucky patient，lucky docrt-PA 50mg Day-2:ECG normal;有嘔吐表現(xiàn)CT小腦半球少量出血保守治愈 rt-PA 50mg Case 2： Brave doctorCase 2： Brave doctor第一次尿激酶溶栓 150萬u一次VD，復(fù)查肺CTA如上圖，機械通氣氧合改善不滿意，未能脫機尿激酶 二次溶栓4400u/Kg/h,共十二小時緩解，氧合改善，出院回當?shù)蒯t(yī)院復(fù)查CTA肺動脈血栓消失第一次尿激酶溶栓 150萬u一次VD，復(fù)查肺CTA如上圖，機Case 3 Lo