#61
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#62
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Ýòî ïîíÿòíî. À ìîæåò ëè ïíåâìîêîìïðåññèÿ ðàññìàòðèâàòüñÿ êàê àëüòåðíàòèâíûé ìåòîä ïðîôèëàêòèêè ÒÃÂ, èëè îáÿçàòåëüíî íàäî õîòü àñïèðèí, íî äîáàâèòü? Íàñêîëüêî ýôôåêòèâíåå ïðè ýòîì ñòàíóò ïðîôèëàêòè÷åñêèå ìåðîïðèÿòèÿ? Àñïèðèí âåäü òîæå àãðåññèâíûé ïðåïàðàò, îáëàäàåò óëüöåðîãåííûì äåéñòâèåì, ãåìîððàãè÷åñêèå îñëîæíåíèÿ îïÿòü æå âîçìîæíû.
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#63
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Öèòàòà:
Îäíî äåëî ðåêîìåíäàöèè àññîöèàöèé, ãäå ýòîò ìîìåíò åùå íå óïîìèíàåòñÿ. Äðóãîå äåëî îòäåëüíûå ðàáîòû, ãäå ïðåðûâèñòàÿ ïíåâìîêîìïðåññèÿ (ÏÏÊ) èñïîëüçîâàëàñü êàê ìîíîïðîôèëàêòèêà ó ïàöèåíòîâ ñ âûñîêèì ðèñêîì îñëîæíåíèé ôàðìàêîëîãè÷åñêîé ïðîôèëàêòèêè. Ëè÷íî ÿ íå âèæó ñìûñë äîáàâëÿòü ê íåé àñïèðèí, ïîñêîëüêó åå êàê ðàç è èñïîëüçóþò êîãäà íåò âîçìîæíîñòè ïðèìåíèòü ïîëíîöåííóþ ôàðìïðîôèëàêòèêó. Ýòàê ìîæíî çàäàòüñÿ âîïðîñîì à íå äîáàâèòü ëè òðåíòàë... Âîîáùå â ñòðóêòóðå êîìïëåêñíîé ïðîôèëàêòèêè ïïê â ïåðèîä ëåæàíèÿ ðóòèííî áûëà áû âåðîÿòíî î÷åíü ïîëåçíà, íî ñîáñòâåííî íàøå ó÷ðåæäåíèå ïïê âîîáùå íå ðàñïîëàãàåò. Êàê-òî íå ïîïàëèñü â ðóêó èññëåäîâàíèÿ. Ñâîèõ íåò. À ó âàñ åñòü ÏÏÊ è ÷àñòî áûâàþò ïàöèåíòû ñ ïðîòèâîïîêàçàíèÿìè ê ôîíäàïàðèíóêñó/ÍÌÃ/âàðôàðèíó? |
#64
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Ó ìåíÿ - ðåäêî. Íî ÿ êîíñóëüòèðóþ òðàâìàòîëîãè÷åñêèõ áîëüíûõ. Íàøè òðàâìàòîëîãè ñ áîëüøîé îïàñêîé íàçíà÷àþò ÍÌÃ, è ÷àùå âñåãî íà ìíîãî ïîçæå, ÷åì ñëåäîâàëî áû. Äóìàþ, ïðè òàêèõ óñëîâèÿõ ÏÏÊ áûëà áû óìåñòíîé.
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#65
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Êîëëåãè! Õî÷ó ïîäåëèòüñÿ îáíîâëåííîé âåðñèåé ãàéäà AAOS
[Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Äëÿ òåõ, êîìó òðóäíî ïðî÷èòàòü ôóëëòåêñò - [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Öèòàòà:
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#66
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"Ñàìûì àâòîðèòåòíûì ãàéäëàéíîì, íà êîòîðûé îðèåíòèðóþòñÿ, èëè, êàê ìèíèìóì, ïðèíèìàþò âî âíèìàíèå, ÿâëÿåòñÿ ãàéäëàéí ACCP.  2012 ãîäó áûëà îïóáëèêîâàíà äåâÿòàÿ ðåäàêöèÿ ýòîãî ìàñøòàáíîãî äîêóìåíòà [15], è, ñðàçó ïîñëå ïîÿâëåíèÿ â ïå÷àòè, äåâÿòûé ãàéäëàéí ïîðîäèë áóðíûå äèñêóññèè. Äåëî â òîì, ÷òî â îòëè÷èå îò ïðåäûäóùèõ âåðñèé ãàéäëàéíîâ ACCP, ðåêîìåíäàöèè êîòîðûõ áûëè äîñòàòî÷íî îæèäàåìûìè, äåâÿòîå èçäàíèå âûãëÿäèò ïðàêòè÷åñêè ðåâîëþöèîííûì – ìíîãèå ðåêîìåíäàöèè èçìåíèëè ñâîþ ñèëó, ñàì äîêóìåíò ïðèîáðåë íîâóþ ñòðóêòóðó, à â íåêîòîðûõ ðàçäåëàõ, è, â ÷àñòíîñòè, â îðòîïåäèè, ïîÿâèëèñü ðåêîìåíäàöèè, êîòîðûå ïðÿìî ïðîòèâîðå÷àò ðåêîìåíäàöèÿì âîñüìîãî èçäàíèÿ.
Íàïðèìåð, íàèáîëåå ÿðêîå îòëè÷èå êàñàåòñÿ ïðèìåíåíèÿ àñïèðèíà. Âîñüìîå èçäàíèå ãàéäëàéíà ACCP â îáùèõ ðåêîìåíäàöèÿõ ñîäåðæèò ñëåäóþùóþ ôðàçó: ìû íå ðåêîìåíäóåì èñïîëüçîâàòü àñïèðèí êàê ñðåäñòâî ìîíîïðîôèëàêòèêè äëÿ ëþáûõ ïàöèåíòîâ (ñòåïåíü ðåêîìåíäàöèè 1A).  ðàçäåëå ÷àñòíûõ ðåêîìåíäàöèé ýêñïåðòû òàêæå íå ðåêîìåíäóþò èñïîëüçîâàòü àñïèðèí êàê ñðåäñòâî ìîíîïðîôèëàêòèêè ïðè ýíäîïðîòåçèðîâàíèè òàçîáåäðåííîãî (ñòåïåíü ðåêîìåíäàöèè 1A), êîëåííîãî (ñòåïåíü ðåêîìåíäàöèè 1A) ñóñòàâîâ è ïðè îïåðàöèÿõ ïî ïîâîäó ïåðåëîìîâ ïðîêñèìàëüíîãî îòäåëà áåäðåííîé êîñòè (ñòåïåíü ðåêîìåíäàöèè 1A). Îäíàêî â äåâÿòîì èçäàíèè ãàéäëàéíà ACCP ïîÿâèëàñü ïðàêòè÷åñêè ïðÿìî ïðîòèâîïîëîæíàÿ ðåêîìåíäàöèÿ: «Ó ïàöèåíòîâ, êîòîðûì âûïîëíÿåòñÿ ýíäîïðîòåçèðîâàíèå êîëåííîãî èëè òàçîáåäðåííîãî ñóñòàâîâ, â ñðàâíåíèè ñ îòñóòñòâèåì ïðîôèëàêòèêè ìû ðåêîìåíäóåì èñïîëüçîâàòü îäèí èç ñëåäóþùèõ ïðåïàðàòîâ â òå÷åíèå ìèíèìóì 10-14 äíåé: íèçêîìîëåêóëÿðíûå ãåïàðèíû, ôîíäàïàðèíóêñ, àïèêñàáàí, äàáèãàòðàí, ðèâàðîêñàáàí, íèçêèå äîçû íåôðàêöèîíèðîâàííîãî ãåïàðèíà, àíòàãîíèñòû âèòàìèíà Ê â ïîäîáðàííîé äîçå, àñïèðèí (âñå ñòåïåíü 1B)». Èòàê, ìû ñòàëè ñâèäåòåëÿìè óäèâèòåëüíîãî èçìåíåíèÿ ðåêîìåíäàöèé îò çàïðåùåíèÿ èñïîëüçîâàíèÿ àñïèðèíà ñî ñòåïåíüþ 1A äî åãî ðàçðåøåíèÿ, ïðè÷åì ñî ñòåïåíüþ 1Â. Ìîæåò áûòü, ñ ìîìåíòà âûõîäà â ñâåò âîñüìîé ðåäàêöèè ãàéäëàéíà ACCP â 2008 ãîäó ïîÿâèëèñü íîâûå èññëåäîâàíèÿ, äîêàçûâàþùèå ýôôåêòèâíîñòü àñïèðèíà? Íåò, êðóïíûõ ðàíäîìèçèðîâàííûõ èññëåäîâàíèé äî ìîìåíòà ïóáëèêàöèè äåâÿòîãî èçäàíèÿ ãàéäëàéíà ACCP íå âûõîäèëî. Òîãäà ïî÷åìó òàê ðàäèêàëüíî èçìåíèëàñü ðåêîìåíäàöèÿ ACCP ïî àñïèðèíó? Äëÿ òîãî ÷òîáû ïîíÿòü ýòó êîëëèçèþ, ïðèäåòñÿ ðàçîáðàòüñÿ â ìåòîäîëîãèè ðåêîìåíäàöèé ACCP." Ñòàòüÿ íà ýòó òåìó ðàçìåùåíà çäåñü - [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] |
#67
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 îòíîøåíèè ìåõàíè÷åñêîé ïðîôèëàêòèêè. Ñîâåðøåííî ñ Âàìè ñîãëàñåí, ÷òî ïðè áîëåå âûñîêîé êîìïðåññèè ïðîêñèìàëüíûõ ñåãìåíòîâ âåí èëè íåïðàâèëüíîé ôèêñàöèè áèíòû íå óñêîðÿþò êðîâîòîê, à óñèëèâàþò âåíîçíûé çàñòîé, ñîîòâåòñòâåííî, ïîâûøàÿ ðèñê òðîìáîçîâ (ôëåáîòðîìáîçîâ). Íî äóìàþ, ÷òî è ïðèìåíåíèå ýëàñòè÷åñêèõ êîìïðåññèîííûõ ãîëüôîâ è ÷óëîê âðÿä ëè îïðàâäàíî, òàê êàê è çäåñü ñòåïåíü êîìïðåññèè (â òî, ÷òî ïèøóò ïðîèçâîäèòåëè – êàê-òî íå âåðèòñÿ) êîíòðîëèðîâàòü ñëîæíî. Äà è «ïðàâèëüíî» ïîäîáðàòü äîñòàòî÷íî ñîìíèòåëüíî. Íà Çàïàäå âñå øèðå ïðèìåíÿþò ïíåâìàòè÷åñêèå óñòðîéñòâà, ãäå ñòåïåíü êîìïðåññèè îïðåäåëÿåòñÿ ìàíîìåòðîì è ïîääåðæèâàåòñÿ àâòîìàòè÷åñêè. Ìíå êàæåòñÿ âàæíåå ìàêñèìàëüíàÿ àêòèâèçàöèÿ áîëüíîãî, ÷àñòûé ìàññàæ íèæíèõ êîíå÷íîñòåé è ñèñòåìàòè÷åñêèå óïðàæíåíèÿ ËÔÊ.
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#68
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#69
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ïî òåìå â íåäàâíåé ïóáëèêàöèè:
Recent changes to both the ACCP and AAOS guidelines are in agreement for those who choose to use aspirin for chemoprophylaxis of VTE. Current surgical care improvement project measures do not include aspirin as an appropriate sole option for the prevention of VTE, but in patients undergoing elective TKA or who have a contraindication to pharmacologic prophylaxis and undergo a THA or HFS, aspirin in conjunction with compression devices as part of a multimodal approach would meet these measures. Data do not support the hypothesis that aspirin is less likely to cause adverse bleeding events than more potent anticoagulants... --- Ann Pharmacother. 2013 Jan 16. Aspirin for the Prophylaxis of Venous Thromboembolic Events in Orthopedic Surgery Patients: A Comparison of the AAOS and ACCP Guidelines with Review of the Evidence (January). Stewart DW, Freshour JE. East Tennessee State University, Johnson City, TN
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |