Хотелось бы обратить внимание коллег-ортопедов на недавний обзор 11 национальных рекомендаций по профилактике тромбоза в ортопедии и травматологии, где дискутируются сходства и различия в зависимости от страны (а также специализации экспертов):
J Thromb Haemost. 2009 Dec 21.
Comparing consensus guidelines on thromboprophylaxis in orthopaedic surgery.
Struijk-Mulder MC, Ettema HB, Verheyen CC, Büller HR.
Eleven guidelines from the following associations were included: The American College of
Chest Physicians (ACCP)[1], the American Academy of Orthopaedic Surgeons (AAOS)[2],
the Cardiovascular Disease Educational and Research Trust (ICS)[3], the National Institute
for Clinical health and Excellence (NICE, United Kingdom)[4], the Scottish Intercollegiate
Guidelines Network (SIGN)[5], Die Arbeitsgemeinschaft der Wissenschaftlichen
Medizinischen Fachgesellschaften (AWMF, Germany)[6], a Sociedade Brasileira de
Angiologia e CirurgiaVascular (SBACV)[7], the South African Society of Thrombosis and
Haemostasis[8], Medical Front International Limited (Japan)[9], the French Society for
Anaesthesiology and Intensive Care (SFAR)[10] and the Australia and New Zealand working
party on the management and prevention of venous thromboembolism [11].
Никакого варфарина в фиксированной дозе нет и в помине...
Гайдлайны спорят о варфарине:
Disagreements between guidelines
Total Hip Arthroplasty and Total Knee Arthroplasty
VKAs are recommended in THA and TKA in 7 out of 11 guidelines. The ICS prefers LMWH
and fondaparinux above VKA in THA, because two large studies showed less efficacy and
higher rates of major bleeding with VKA compared to LMWH [21, 22]. Moreover, warfarin
was identified as a major risk factor for re-admission and fatal bleeding in national registries
[23, 24]. When a high bleeding risk is present in THA, the sole use of mechanical devices for
thromboprophylaxis is recommended by 5 guidelines. In TKA, mechanical devices without
pharmacological prophylaxis are recommended in 5 guidelines, regardless of the bleeding
risk. However, the level of evidence for the sole use of mechanical devices is lower than the
level of evidence for pharmacological prophylaxis...
И аспирине
Aspirin
The main issue leading to conflicting recommendations on the use of aspirin is whether there
is a relationship between asymptomatic DVT detected by venography or CUS and clinically
important VTE (symptomatic DVT and PE). The ACCP, for instance, states that there is a
strong relation between asymptomatic DVT and symptomatic DVT and PE [27]. In contrast,
the AAOS concludes that there is no convincing evidence linking asymptomatic DVT to
clinically relevant symptomatic DVT and PE. The ACCP seems to put a bigger emphasis on
the effective reduction of VTE and the AAOS seems more concerned with bleeding
complications. Both VTE and bleeding risk are, of course, very important considerations
when choosing thromboprophylaxis. The mix of hematologists and orthopedic surgeons of the
specific committees seems an attractive explanation for the different views.
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