《静脉血栓栓塞》课件

1、静脉血栓栓塞静脉血栓栓塞危重患者的VTE高危因素和发病率危重患者的VTE预防指南和评估ICU内的VTE预防方法几个肺栓塞病例危重患者的VTE高危因素和发病率 Covidien | 16 October 2022 | Confidential3 |静脉血栓栓塞症(VTE)包括深静脉血栓(DVT)和肺栓塞(PE)。 Definition of Venous Thromboembolism (VTE)静脉血栓栓塞的定义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 |解决DVT的后果静脉血栓栓塞-Confidential, Tyco Corporati Covidien | 16 October 2022 | ConfidentialConfidential, Tyco Corporation6 |血流淤滞血管壁损伤凝血功能改变血液循环流速减慢。血流淤滞同时发生在术中和术后的卧床时间发生在术侧肢体的操作过程中会扭折血管，如全膝或全髋成型术,静脉血液郁积也会造成静脉扩张和内皮细胞损伤。术后血液中促凝血酶原激酶和纤维蛋白原水平升高，组织损伤处表面凝结被激活都导致了血液的高凝状态。为什么会形成

4、DVT？ Covidien | 10 October 202当没有任何预防措施时，DVT在某些专科中的发生率高于50但是，仅有25的DVT患者会表现出症状OMeara et al. Prophylaxis for Venous Thromboembolism in Total Hip Arthroplasty. ORTHOPEDICS.深静脉血栓流行病学（外科各专业）当没有任何预防措施时，DVT在某些专科中的发生率高于50但ICU入住前存在的高危因素ICU期间获得的高危因素近期手术中心静脉导管创伤、烧伤脓毒症恶性肿瘤和治疗因素药物镇静、麻醉脓毒症机械通气制动/卧床、中风、脊髓损伤肌松治疗高龄药

5、物治疗心脏/呼吸 衰竭VTE病史怀孕/产后雌性激素高ICU入住前存在的高危因素ICU期间获得的高危因素近期手术中静脉血栓栓塞课件临床路径推荐临床路径推荐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静脉血栓栓塞课件物理预防在ICU的优势： ICU患者刚入院时大多

14、具有消化道应激性溃疡出血风险 部分重症患者有凝血功能障碍、肾功能障碍 ICU患者本身情况复杂，用药难以掌握,出血并发症物理预防：ICU患者不可或缺物理预防在ICU的优势：物理预防：ICU患者不可或缺19 |19 |静脉瓣后清除静脉瓣后清除静脉血栓栓塞课件SCD压力系统提供最佳连续梯度压力模式使股静脉血流速度达到最大“理想的压力模式为踝部35mmHg，小腿30mmHg，大腿20mmHg。”“ 然而，由于广泛存在的个体差异，这个压力可以稍微增加（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大腿小腿踝部压力mmHgSCD压力系统提供最佳连续梯度压力模式使股静脉血流速度达到最SCD压力系统在股静脉血液清除方面，速度明显优于小腿、单一压力系统. “SCD 可以在很短的时间内清空静脉瓣后淤滞的血液，而如果只对

16、小腿施压,相应的染色物质会停留长时间。”（小腿、单一压力系统）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压力系统在股静脉血液清除方面，速度明显优于小腿、单一压静脉血栓栓塞课件 Covidien | 16 October 2022 | C

17、onfidentialConfidential, Tyco Corporation25 |静脉再充盈检测 Covidien | 10 October 202 Covidien | 16 October 2022 | ConfidentialConfidential, Tyco Corporation26 |血液移动总量相同的情况在静脉曲张的病人中，仰卧位增加71.9%，半卧位增加77.9%，坐姿时增加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静脉血栓栓塞课件将腿部血液清除达到最大值将腿部血液清除达到最大值主机连接管腿套/足套 （45mmHg, 40mmHg,30mmHg） (130mmHg)主机腿部压力：预防深静脉血栓症和肺部栓塞足部压力：1.增强血液循环2.预防深静脉血栓症

19、3.急性水肿4.慢性水肿5.外伤或外科手术引发的四肢疼痛6.腿部溃疡7.静脉郁积/静脉功能障碍腿部压力：腿部压力：任何有可能防碍充气压力带作用的腿局部情况，例如：（a）皮炎，（b）静脉结扎（在手术后即刻），（c）坏疽，或者（d）刚做完皮肤移植手术严重的动脉硬化症或其它缺血性血管病腿部大范围水肿或由充血性心力衰竭引发的肺部水肿腿部严重畸形疑似已出现深静脉血栓症足部压力：增强回流心脏的流速会有害的情况下充血性心力衰竭已出现深静脉血栓症、血栓(性)静脉炎或肺部栓塞对于手足部存在感染或感觉迟钝情况的患者，使用时必须非常小心腿部压力：“尽管梯度压力弹力袜外表看上去很简单，但是其中的设计却很复杂，对于技术

20、细节的关注可以得到有效的预防方法。” Covidien | 16 October 2022 | ConfidentialConfidential, Tyco Corporation32 |J.Caprini MD. “尽管梯度压力弹力袜外表看上去很简单，但是其中的设计却很复杂 Covidien | 16 October 2022 | ConfidentialConfidential, Tyco Corporation33 |T.E.D. Antiembolism StockingT.E.D. 抗血栓压力带Other Antiembolism Stocking其它抗血栓压力带圆周镶嵌编织法单向水

21、平伸展确保抗血栓 压力带的固定圆周编织提供单向伸展确保压力分布正确定位垂直伸展使尼龙袜滑落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.”垂直伸展使尼龙袜滑落 Covidien | 10 October 2027位半卧位自愿者，5个带水压计的可充气套观察血流速度 确定理想的压力分布18，14，8，10，8mmHg相对与基线，平均股静脉血流速度增加138.4% Covidien | 16 October 2022 | ConfidentialConfidential, Tyco Corporation34 | Covidien | 10 October 202项目实验组 VS 对比组结果结论1单物理预防VS单药物预防无显著差异物理预防和药物预防一样有效；但物理预防的并发症更

23、低2联合预防 VS 药物预防有显著差异物理预防会使药物预防更加有效3单物理预防 VS 联合预防无显著差异只使用物理预防足以有效预防DVT100+文献证明SCD和TED的有效性项目实验组 VS 对比组结果结论1单物理预防VS单药物预防无Woolson et al. Journal of Bone & Joint Surgery 1991 (全髋关节置换术病人)“我们相信在术中和术后使用间歇式充气压力装置（无抗凝剂），是有效，安全和便利的。” Covidien | 16 October 2022 | ConfidentialConfidential, Tyco Corporation36 |Woo

24、lson et al. Journal of Bone亚洲人群髋关节手术后采用非药物预防后无症状的深静脉血栓的自然过程术后没有患者发展致命有症状的肺栓塞，或近端深静脉血栓。但是9个患者（5%）发展成远端深静脉血栓，没有术前相关危险因子。这9位患者术后紧密随访未用抗凝剂治疗，6个月后所有的血栓消失未发展成肺栓塞或血栓性静脉炎亚洲人群髋关节手术后采用非药物预防后无症状的深静脉血栓的自然静脉血栓物理预防全方位解决方案AVI 动静脉脉冲系统SCD气动歇式压力装置TED抗血栓压力带静脉血栓物理预防全方位解决方案AVI 动静脉脉冲系统SCD气Case 1：lucky patient，lucky docto

25、rFemale，63yearsRecurrent syncopeSpO2 60%70%HypotensionECG：RBBBD-Dimer：2.386ug/mlCTA：肺动脉主干及双肺动脉多发性栓塞Case 1：lucky patient，lucky docrt-PA 50mg Day-2:ECG normal;有呕吐表现CT小脑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 150万u一次VD，复查肺CTA如上图，机械通气氧合改善不满意，未能脱机尿激酶 二次溶栓4400u/Kg/h,共十二小时缓解，氧合改善，出院回当地医院复查CTA肺动脉血栓消失第一次尿激酶溶栓 150万u一次VD，复查肺CTA如上图，机Case 3 Lo