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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.,1,t课件,Prevention and Treatme
2、nt of Pe,Deep Venous Thrombosis(DVT),Pulmonary Embolism(PE),2,t课件,Deep Venous ThrombosisPulmonar,VTE-related deaths,200,000 per year in US1/3 occur following surgery23-fold for cancer patients,3,t课件,VTE-related deaths200,000 per,Prophylaxis?,VTE,Bleeding,VTE 71%Death 46%,Major bleeding 103%Wound hem
3、atoma 88%,Mismetti P, et al. Meta-analysis of low molecular weight heparin in the prevention of venous thromboembolism in general surgery .Br J Surg . 2001 ; 88 ( 7 ): 913 - 930 .,4,t课件,Prophylaxis?VTEBleedingVTE 71,Caprini Risk Assessment Model,5,t课件,Caprini Risk Assessment Model5,Caprini风险评分,6,t课件
4、,Caprini风险评分6ppt课件,VTE RiskFor General Surgery,Including GI, Urological, Vascular, Breast, and Thyroid Procedures,7,t课件,VTE RiskFor General Surgery7p,Risk Factors for Major Bleeding Complications,General risk factorsActive bleedingPrevious major bleedingKnown, untreated bleeding disorderSevere renal
5、 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 drugs,8,t课件,Risk Factors for Major Bleedi,Risk Factors for Major B
6、leeding Complications,Procedure-specific risk factorsAbdominal surgeryMale sex, preoperative hemoglobin level 13 g/dL, malignancy, and complex surgery defined as two or more procedures, difficult dissection, or more than one anastamosisPancreaticoduodenectomySepsis, pancreatic leak, sentinel bleedHe
7、patic resectionNumber of segments, concomitant extrahepatic organ resection, primary liver malignancy, lower preoperative hemoglobin level, and platelet counts,9,t课件,Risk Factors for Major Bleedi,Risk Factors for Major Bleeding Complications,Procedure-specific risk factorsCardiac surgeryUse of aspir
8、inUse of clopidogrel within 3 d before surgeryBMI 25 kg/m2, nonelective surgery, placement of five or more grafts, older ageOlder age, renal insufficiency, operation other than CABG, longer bypass timeThoracic surgeryPneumonectomy or extended resection,10,t课件,Risk Factors for Major Bleedi,Risk Facto
9、rs for Major Bleeding Complications,Procedures in which bleeding complications may have especially severe consequencesCraniotomySpinal surgerySpinal traumaReconstructive procedures involving free flap,11,t课件,Risk Factors for Major Bleedi,Prevention of VTE in General and Abdominal-pelvic Surgical Pat
10、ients,Recommendations are classified as strong (Grade1) or weak (Grade2), 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 (GradeA), moderate (GradeB), or low (Grade
11、C) according to factors that include the risk of bias, precision of estimates, the consistency of the results, and the directness of the evidence.,12,t课件,Prevention of VTE in General a,Prevention of VTE in General and Abdominal-pelvic Surgical Patients,13,t课件,Prevention of VTE in General a,Periopera
12、tive Management ofAntithrombotic Therapy,Vitamin K Antagonist (VKA) : warfarin, acenocoumarol, phenprocoumon, and anisindioneAntiplatelet drugs: Acetylsalicylic Acid, clopidogrel, dipyridamole, and nonsteroidal antiinflammatory drugUSE or NOT?,14,t课件,Perioperative Management ofAn,Vitamin K Antagonis
13、t (VKA),In patients undergoing major surgery or procedures, interruption of VKAs, in general, is required to minimize 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: stoppin
14、g VKAs approximately 5 days before surgery (1C)resuming VKAs approximately 12 to 24 h after surgery (evening of or next morning) (2C),15,t课件,Vitamin K Antagonist (VKA) In,Bridging Anticoagulation,In patients with a mechanical heart valve, atrial fibrillation, or VTE athigh risk for thromboembolism,
15、we suggest bridging anticoagulation (LMWH or UFH) during interruption of VKA therapy (2C)low risk for thromboembolism, we suggest no-bridging anticoagulation (2C)In patients who are receiving bridging anticoagulationwe suggest stoppingLMWH 24 h before surgery (2C)UFH 46 h before surgery (2C),16,t课件,
16、Bridging AnticoagulationIn pat,Bridging Anticoagulation,In patients who are receiving bridging anticoagulation with therapeutic-dose SC LMWH and are undergoing high-bleeding-risk surgery, we suggest resuming therapeutic-dose LMWH 4872 h after surgery (2C) . In patients who are receiving bridging ant
17、icoagulation with therapeutic-dose SC LMWH and are undergoing non-high-bleeding-risk surgery, we suggest resuming therapeutic-dose LMWH approximately 24 h after surgery.,17,t课件,Bridging AnticoagulationIn pat,Acetylsalicylic Acid (ASA),In patients at moderate to high risk for cardiovascular events wh
18、o 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 before surgery(2C) .,18,t课件,Acetylsalicylic Acid (ASA)In p,Ant
19、ithrombotic Therapy for VTE Disease,Initial 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),19,t课件,Antithrombotic Therapy for VTE,Clinical Suspicio
20、n of Acute VTE,High 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 clinic
21、al suspicion: not treating with parenteral anticoagulants while awaiting the results of diagnostic tests, provided test results are expected within 24 h (2C),20,t课件,Clinical Suspicion of Acute VT,Initial Treatment of DVT,In patients with acute DVT, we recommend early initiation of VKA (eg, same day
22、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 or above for at least 24 h (1B) .early ambulation over initial bed rest (2C) anticoagulant therapy alone over catheter-directed t
23、hrombolysis (CDT) (2C) , systemic thrombolysis (2C), operative venous thrombectomy(2C), IVC filter(1B),21,t课件,Initial Treatment of DVTIn pat,Initial Treatment of Acute PE,In patients with acute PE, we recommend early initiation of VKA (eg, same day as parenteral therapy is started), and continuation
24、 of parenteral 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) .,22,t课件,Initial Treatment of Acute PEI,Intensity of Anticoagulant Effect,In patients with VTE who are treated with VKA, we recommend a therapeutic
25、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) .,23,t课件,Intensity of Anticoagulant Eff,Duration of Anticoagulant Therapy,24,t课件,Duration of Anticoagulant Ther,Systemic Thrombolytic Therapy,In patients with hypotension
26、 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) .In selected patients without hypotension and with a low risk
27、 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) .,25,t课件,Systemic Thrombolytic TherapyI,Catheter-Based Thrombus Removal,In patients with hyp
28、otension, 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),26,t课件,Catheter-Based Thrombus Remova,Surgical Embolectomy,In pat
29、ients with 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),27,t课件,Surgical EmbolectomyIn patient,Pos
30、t-thrombotic Syndrome(PTS),In patients with acute 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) .,28,t课件,Post-thrombotic Syndrome(PTS)I,
