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#16
26.05.2005, 17:46
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Сообщение от kardio-1
Здравствуйте! Гепарин в/в, сколько едениц? отчегоже В\В а не п\к ??? 
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#17
26.05.2005, 18:00
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Цитата:
Кстати, если не ошибаюсь, то, если Вы выбираете схему, подразумевающую первую инъекцию геперина ПОСЛЕ операции, то в дальнейшем гепарин (клексан в нашем госпитале) вводится дважды в сутки, что экономически нежелательно. В общем лучше почитать. Кидайте мыло кому надо, вышлю.
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#18
26.05.2005, 18:22
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Chest. 2003 Dec;124(6 Suppl):386S-392S. Kearon C.
Duration of venous thromboembolism prophylaxis after surgery. [Ссылки доступны только зарегистрированным пользователям ] [Ссылки доступны только зарегистрированным пользователям ] Abstract Venous thromboembolism (VTE) prophylaxis is indicated while in the hospital after major surgery. There is evidence that the prevalence of asymptomatic deep-vein thrombosis, detected by routine venography after major orthopedic surgery, is lower at hospital discharge in patients who have received 10 days rather than 5 days of prophylaxis. This observation supports the current American College of Chest Physicians (ACCP) recommendation for a minimum of 7 to 10 days of prophylaxis after hip and knee replacement, even if patients are discharged from the hospital within 7 days of surgery. As risk of VTE persists for up to 3 months after surgery, patients at high risk for postoperative VTE may benefit from extended prophylaxis (eg, an additional 3 weeks after the first 7 to 10 days). Extended prophylaxis with low-molecular-weight heparin (LMWH) reduces the frequency of postdischarge VTE by approximately two thirds after hip replacement; however, the resultant absolute reduction in the frequency of fatal pulmonary embolism is small (ie, estimated at 1 per 2,500 patients). Indirect evidence suggests that, compared with LMWH, efficacy of extended prophylaxis after hip replacement is greater with fondaparinux, similar with warfarin, and less with aspirin. Extended prophylaxis is expected to be of less benefit after knee than after hip replacement. In keeping with current ACCP recommendations, at a minimum, extended prophylaxis should be used after major orthopedic surgery in patients who have additional risk factors for VTE (eg, previous VTE, cancer). If anticoagulant drug therapy is stopped after 7 to 10 days, an additional month of prophylaxis with aspirin should be considered. Recommended Duration of Prophylaxis After Major Orthopedic Surgery The Sixth ACCP Consensus Conference on Antithrombotic Therapy,6 which was published in January 2001, makes two main recommendations about the duration of anticoagulant prophylaxis after major orthopedic surgery. The first recommendation, which relates to the minimum duration of initial prophylaxis with LMWH or warfarin (target INR, 2.5; range, 2.0 to 3.0) is as follows: "The optimal duration of anticoagulant prophylaxis after total hip or knee replacement surgery is uncertain, although at least 7 to 10 days of prophylaxis is recommended (grade 1A)." The second recommendation, which relates to the use of extended prophylaxis, is as follows: "Extended out-of-hospital LMWH prophylaxis (beyond 7 to 10 days after surgery) may reduce the incidence of clinically important thromboembolic events, and we recommend this approach at least for high-risk patients (grade 2A because of uncertainty regarding cost-effectiveness)." Both of these recommendations still appear to be valid; however, both are open to interpretation. In the remainder of this review, I will suggest approaches to the implementation of these recommendations that reflect my interpretation of current evidence and consider differences among patients and between surgical centers. Method of Initial Prophylaxis In the absence of a contraindication, anticoagulant therapy is the preferred method of initial prophylaxis after hip or knee replacement or surgery for hip fracture; fondaparinux may be added to LMWH and warfarin as appropriate options. Aspirin is not an adequate initial method of prophylaxis. Duration of Initial Prophylaxis Anticoagulant prophylaxis should be used for a minimum of 7 days, and 10 days is expected to be superior. This usually requires that prophylaxis is continued for some days after hospital discharge. A minimum of 10 days rather than 7 days of prophylaxis should be considered if there is a delay (eg, > 24 h) between surgery and when LMWH or fondaparinux therapy is started, or if warfarin is used. Anticoagulant prophylaxis should also be continued while in the hospital, even if hospital discharge is markedly delayed. Method of Extended Prophylaxis Based on indirect comparisons, fondaparinux is expected to be more effective than LMWH but may be associated with more bleeding. LMWH therapy reduces the frequency of symptomatic VTE substantially, without causing an increase of major bleeding. Warfarin is expected to be as effective as LMWH but may cause more bleeding during extended prophylaxis. If the decision has been made not to continue fondaparinux, LMWH, or warfarin therapy beyond 7 to 10 days, switching to aspirin for a month of extended prophylaxis is recommended (unless there is a contraindication). The decision to use extended prophylaxis with fondaparinux, LMWH, warfarin, or aspirin, or not to use any form of extended prophylaxis, is influenced by many factors that are summarized in Table 3 . Currently, our practice is to extend anticoagulant prophylaxis to 4 weeks after hip or knee replacement or hip fracture if patients have a particularly high risk of VTE, as evidenced by a previous VTE or active malignancy (often a pathologic hip fracture), provided they do not have a high risk of bleeding. This selective approach to the use of extended anticoagulant prophylaxis is considered conservative by many; a more liberal approach, including use of such prophylaxis in all major orthopedic patients who are not at high risk for bleeding, is also reasonable. If we do not extend anticoagulant prophylaxis, we routinely recommend aspirin (80 mg/d or 325 mg/d) for a month after completing 7 to 10 days of initial prophylaxis with anticoagulants. We do not use aspirin if there are concerns about aspirin intolerance or if there is a history of GI bleeding. Duration of Extended Prophylaxis The longer that prophylaxis is administered, the more effective it is expected to be. Whereas the decision is usually to stop at 7 to 10 days, or to continue prophylaxis for approximately 4 weeks, these two options should not be applied rigidly. Extended prophylaxis for < 4 weeks is expected to be more effective than stopping at 10 days and may be appropriate for some patients (eg, out-of-hospital prophylaxis is poorly tolerated). Longer than 4 weeks of prophylaxis may be indicated for discharged patients who remain at high risk for VTE (eg, very immobile with additional risk factors). Standardized Approach to Initial and Extended Prophylaxis at Individual Hospitals Decisions about VTE prophylaxis are influenced by, and impact on, a large number of health-care providers, including surgeons, anesthesiologists, anticoagulation services, nurses, community services, family doctors, pharmacists, and hospital administration, as well as patients and their families. While it is important that there is the flexibility to tailor management in individual patients, in order to avoid confusion and ensure that all patients receive appropriate prophylaxis, provision of prophylaxis should be standardized as much as possible within each hospital. This requires close communication and cooperation among all parties. Abbreviations: ACCP = American College of Chest Physicians; DVT = deep vein thrombosis; INR = international normalized ratio; LMWH = low-molecular-weight heparin; PE = pulmonary embolism; VTE = venous thromboembolism
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#19
26.05.2005, 18:35
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Short-Duration Prophylaxis Against Venous Thromboembolism After Total Hip or Knee Replacement
A Meta-analysis of Prospective Studies Investigating Symptomatic Outcomes James D. Douketis, MD, FRCPC; John W. Eikelboom, MBBS, MSc, FRACP; Daniel J. Quinlan, MBBS; Andrew R. Willan, PhD; Mark A. Crowther, MD, MSc, FRCPC Arch Intern Med. 2002;162:1465-1471. [Ссылки доступны только зарегистрированным пользователям ]
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#20
26.05.2005, 18:40
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Chest. 2004 Sep;126(3 Suppl):338S-400S.
Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, Ray JG. [Ссылки доступны только зарегистрированным пользователям ] [Ссылки доступны только зарегистрированным пользователям ] Abstract This article discusses the prevention of venous thromboembolism (VTE) and is part of the Seventh American College of Chest Physicians Conference on Antithrombotic and Thrombolytic Therapy: Evidence-Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients’ values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S–187S). Among the key recommendations in this chapter are the following. We recommend against the use of aspirin alone as thromboprophylaxis for any patient group (Grade 1A). For moderate-risk general surgery patients, we recommend prophylaxis with low-dose unfractionated heparin (LDUH) (5,000 U bid) or low-molecular-weight heparin (LMWH) [ 3,400 U once daily] (both Grade 1A). For higher risk general surgery patients, we recommend thromboprophylaxis with LDUH (5,000 U tid) or LMWH (> 3,400 U daily) [both Grade 1A]. For high-risk general surgery patients with multiple risk factors, we recommend combining pharmacologic methods (LDUH three times daily or LMWH, > 3,400 U daily) with the use of graduated compression stockings and/or intermittent pneumatic compression devices (Grade 1C+). We recommend that thromboprophylaxis be used in all patients undergoing major gynecologic surgery (Grade 1A) or major, open urologic procedures, and we recommend prophylaxis with LDUH two times or three times daily (Grade 1A). For patients undergoing elective total hip or knee arthroplasty, we recommend one of the following three anticoagulant agents: LMWH, fondaparinux, or adjusted-dose vitamin K antagonist (VKA) [international normalized ratio (INR) target, 2.5; range, 2.0 to 3.0] (all Grade 1A). For patients undergoing hip fracture surgery (HFS), we recommend the routine use of fondaparinux (Grade 1A), LMWH (Grade 1C+), VKA (target INR, 2.5; range, 2.0 to 3.0) [Grade 2B], or LDUH (Grade 1B). We recommend that patients undergoing hip or knee arthroplasty, or HFS receive thromboprophylaxis for at least 10 days (Grade 1A). We recommend that all trauma patients with at least one risk factor for VTE receive thromboprophylaxis (Grade 1A). In acutely ill medical patients who have been admitted to the hospital with congestive heart failure or severe respiratory disease, or who are confined to bed and have one or more additional risk factors, we recommend prophylaxis with LDUH (Grade 1A) or LMWH (Grade 1A). We recommend, on admission to the intensive care unit, all patients be assessed for their risk of VTE. Accordingly, most patients should receive thromboprophylaxis (Grade 1A). Summary of Recommendations 1.0 General Recommendations 1.4.3. We recommend that mechanical methods of prophylaxis be used primarily in patients who are at high risk of bleeding (Grade 1C+) or as an adjunct to anticoagulant-based prophylaxis (Grade 2A). We recommend that careful attention be directed toward ensuring the proper use of, and optimal compliance with, the mechanical device (Grade 1C+). 1.4.4. We recommend against the use of aspirin alone as prophylaxis against VTE for any patient group (Grade 1A). 1.4.5.1. For each of the antithrombotic agents, we recommend that clinicians consider the manufacturer’s suggested dosing guidelines (Grade 1C). 1.4.5.2. We recommend consideration of renal impairment when deciding on doses of LMWH, fondaparinux, the direct thrombin inhibitors, and other antithrombotic drugs that are cleared by the kidneys, particularly in elderly patients and those who are at high risk for bleeding (Grade 1C+). 1.5.1. In all patients undergoing neuraxial anesthesia or analgesia, we recommend special caution when using anticoagulant prophylaxis (Grade 1C+). 2.0 General, Vascular, Gynecologic, and Urologic Surgery 2.1 General surgery 2.1.1. In low-risk general surgery patients (Table 5) who are undergoing a minor procedure, are < 40 years of age, and have no additional risk factors, we recommend against the use of specific prophylaxis other than early and persistent mobilization (Grade 1C+). 2.1.2. Moderate-risk general surgery patients are those patients undergoing a nonmajor procedure and are between the ages of 40 and 60 years or have additional risk factors, or those patients who are undergoing major operations and are < 40 years of age with no additional risk factors. We recommend prophylaxis with LDUH, 5,000 U bid, or LMWH, 3,400 U once daily (both Grade 1A). 2.1.3. Higher-risk general surgery patients are those undergoing nonmajor surgery and are > 60 years of age or have additional risk factors, or patients undergoing major surgery who are > 40 years of age or have additional risk factors. We recommend thromboprophylaxis with LDUH, 5,000 U tid, or LMWH, > 3,400 U daily (both Grade 1A). 2.1.4. In high-risk general surgery patients with multiple risk factors, we recommend that pharmacologic methods (ie, LDUH, tid, or LMWH, > 3,400 U daily) be combined with the use of GCS and/or IPC (Grade 1C+). 2.1.5. In general surgery patients with a high risk of bleeding, we recommend the use of mechanical prophylaxis with properly fitted GCS or IPC, at least initially until the bleeding risk decreases (Grade 1A). 2.1.6. In selected high-risk general surgery patients, including those who have undergone major cancer surgery, we suggest post-hospital discharge prophylaxis with LMWH (Grade 2A). 2.2 Vascular surgery 2.2.1. In patients undergoing vascular surgery who do not have additional thromboembolic risk factors, we suggest that clinicians not routinely use thromboprophylaxis (Grade 2B). 2.2.2. For patients undergoing major vascular surgical procedures who have additional thromboembolic risk factors, we recommend prophylaxis with LDUH or LMWH (Grade 1C+). 2.3 Gynecologic surgery 2.3.1. For gynecologic surgery patients undergoing brief procedures of 30 min for benign disease, we recommend against the use of specific prophylaxis other than early and persistent mobilization (Grade 1C+). 2.3.2. For patients undergoing laparoscopic gynecologic procedures, in whom additional VTE risk factors are present, we recommend the use of thromboprophylaxis with one or more of the following: LDUH, LMWH, IPC, or GCS (all Grade 1C). 2.3.3. We recommend that thromboprophylaxis be used in all major gynecologic surgery patients (Grade 1A). 2.3.4. For patients undergoing major gynecologic surgery for benign disease, without additional risk factors, we recommend LDUH, 5,000 U bid (Grade 1A). Alternatives include once-daily prophylaxis with LMWH, 3,400 U/d (Grade 1C+), or IPC started just before surgery and used continuously while the patient is not ambulating.(Grade 1B). 2.3.5. For patients undergoing extensive surgery for malignancy, and for patients with additional VTE risk factors, we recommend routine prophylaxis with LDUH, 5,000 U tid (Grade 1A), or higher doses of LMWH (ie, > 3,400 U/d) [Grade 1A]. Alternative considerations include IPC alone continued until hospital discharge (Grade 1A), or a combination of LDUH or LMWH plus mechanical prophylaxis with GCS or IPC (all Grade 1C). 2.3.6. For patients undergoing major gynecologic procedures, we suggest that prophylaxis continue until discharge from the hospital (Grade 1C). For patients who are at particularly high risk, including those who have undergone cancer surgery and who are > 60 years of age or have previously experienced a VTE, we suggest continuing prophylaxis for 2 to 4 weeks after hospital discharge (Grade 2C). 2.4 Urologic surgery 2.4.1. In patients undergoing transurethral or other low-risk urologic procedures, we recommend against the use of specific prophylaxis other than early and persistent mobilization (Grade 1C+). 2.4.2. For patients undergoing major, open urologic procedures, we recommend routine prophylaxis with LDUH twice daily or three times daily (Grade 1A). Acceptable alternatives include prophylaxis with IPC and/or GCS (Grade 1B) or LMWH (Grade 1C+). 2.4.3. For urologic surgery patients who are actively bleeding or are at very high risk for bleeding, we recommend the use of mechanical prophylaxis with GCS and/or IPC at least until the bleeding risk decreases (Grade 1C+). 2.4.4. For patients with multiple risk factors, we recommend combining GCS and/or IPC with LDUH or LMWH (Grade 1C+). 2.5 Laparoscopic surgery 2.5.1. We recommend against routine thromboprophylaxis in these patients, other than aggressive mobilization (Grade 1A). 2.5.2. For patients undergoing laparoscopic procedures and who have additional thromboembolic risk factors, we recommend the use of thromboprophylaxis with one or more of the following: LDUH, LMWH, IPC, or GCS (Grade 1C+).
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#21
26.05.2005, 18:40
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3.0 Orthopedic Surgery
3.1 Elective hip arthroplasty 3.1.1. For patients undergoing elective THR, we recommend the routine use of one of the following three anticoagulants: (1) LMWH (at a usual high-risk dose, started 12 h before surgery or 12 to 24 h after surgery, or 4 to 6 h after surgery at half the usual high-risk dose and then increasing to the usual high-risk dose the following day); (2) fondaparinux, (2.5 mg started 6 to 8 h after surgery) or (3) adjusted-dose VKA started preoperatively or the evening after surgery (INR target, 2.5; INR range, 2.0 to 3.0) [all Grade 1A]. Underlying values and preferences. We have not recommended the use of fondaparinux over LMWH and VKA, or the use of LMWH over VKA, because we place a relatively low value on the prevention of venographic thrombosis and a relatively high value on minimizing bleeding complications. 3.1.2. We recommend against the use of aspirin, dextran, LDUH, GCS, IPC, or VFP as the only method of thromboprophylaxis in these patients (Grade 1A). 3.2 Elective knee arthroplasty 3.2.1. For patients undergoing elective TKA, we recommend routine thromboprophylaxis using LMWH (at the usual high-risk dose), fondaparinux, or adjusted-dose VKA (target INR, 2.5; INR range, 2.0 to 3.0) [all Grade 1A]. Underlying values and preferences. We have not recommended fondaparinux over LMWH and VKA, or LMWH over VKA, because we place a relatively low value on the prevention of venographic thrombosis and a relatively high value on minimizing bleeding complications. 3.2.2. The optimal use of IPC is an alternative option to anticoagulant prophylaxis (Grade 1B). 3.2.3. We recommend against the use of any of the following as sole methods of thromboprophylaxis: aspirin (Grade 1A); LDUH (Grade 1A); or VFP (Grade 1B). 3.3 Knee arthroscopy 3.3.1. We suggest clinicians do not use routine thromboprophylaxis in these patients, other than early mobilization (Grade 2B). 3.3.2. For patients undergoing arthroscopic knee surgery who are at a higher than usual risk, based on preexisting VTE risk factors or following a prolonged or complicated procedure, we suggest thromboprophylaxis with LMWH (Grade 2B). 3.4 Hip fracture surgery 3.4.1. For patients undergoing HFS, we recommend the routine use of fondaparinux (Grade 1A), LMWH at the usual high-risk dose (Grade 1C+), adjusted-dose VKA (target INR, 2.5; INR range, 2.0 to 3.0) [Grade 2B], or LDUH (Grade 1B). 3.4.2. We recommend against the use of aspirin alone (Grade 1A). 3.4.3. If surgery will likely be delayed, we recommend that prophylaxis with either LDUH or LMWH be initiated during the time between hospital admission and surgery (Grade 1C+). 3.4.4. We recommend mechanical prophylaxis if anticoagulant prophylaxis is contraindicated because of a high risk of bleeding (Grade 1C+). 3.5 Other prophylaxis issues in major orthopedic surgery 3.5.1. For major orthopedic surgical procedures, we recommend that a decision about the timing of the initiation of pharmacologic prophylaxis be based on the efficacy-to-bleeding tradeoffs for that particular agent (Grade 1A). For LMWH, there are only small differences between starting preoperatively or postoperatively, and both options are acceptable (Grade 1A). 3.5.2. We recommend against the routine use of DUS screening at the time of hospital discharge in asymptomatic patients following major orthopedic surgery (Grade 1A). 3.5.3.1. We recommend that patients undergoing THR, TKA, or HFS receive thromboprophylaxis with LMWH (using a high-risk dose), fondaparinux (2.5 mg daily), or a VKA (target INR, 2.5; INR range, 2.0 to 3.0) for at least 10 days (Grade 1A). 3.5.3.2. We recommend that patients undergoing THR or HFS be given extended prophylaxis for up to 28 to 35 days after surgery (Grade 1A). The recommended options for THR include LMWH (Grade 1A), a VKA (Grade 1A), or fondaparinux (Grade 1C+). The recommended options following HFS are fondaparinux (Grade 1A), LMWH (Grade 1C+), or a VKA (Grade 1C+). 3.6 Elective spine surgery 3.6.1. For spinal surgery patients with no additional risk factors, we recommend against the routine use of any thromboprophylaxis modality, apart from early and persistent mobilization (Grade 1C). 3.6.2. We recommend that some form of prophylaxis be used in patients undergoing spinal surgery who exhibit additional risk factors such as advanced age, known malignancy, presence of a neurologic deficit, previous VTE, or an anterior surgical approach (Grade 1B). 3.6.3. For patients with additional risk factors, we recommend any of the following prophylaxis options: postoperative LDUH alone (Grade 1C+); postoperative LMWH alone (Grade 1B); or perioperative IPC alone (Grade 1B). Other considerations include perioperative GCS alone (Grade 2B), or perioperative IPC combined with GCS (Grade 2C). In patients with multiple risk factors for VTE, we recommend combining LDUH or LMWH with GCS and/or IPC (Grade 1C+). 3.7 Isolated lower extremity injuries We suggest that clinicians not use thromboprophylaxis routinely in patients with isolated lower extremity injuries (Grade 2A). 4.0 Neurosurgery 4.0.1. We recommend that thromboprophylaxis be routinely used in patients undergoing major neurosurgery (Grade 1A). 4.0.2. We recommend the use of IPC with or without GCS in patients undergoing intracranial neurosurgery (Grade 1A). 4.0.3. Acceptable alternatives to the above options are prophylaxis with LDUH (Grade 2B) or postoperative LMWH (Grade 2A). 4.0.4. We suggest the combination of mechanical prophylaxis (ie, GCS and/or IPC) and pharmacologic prophylaxis (ie, LDUH or LMWH) in high-risk neurosurgery patients (Grade 2B).
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#22
26.05.2005, 18:41
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5.0 Trauma, Spinal Cord Injury, Burns
5.1 Trauma 5.1.1. We recommend that all trauma patients with at least one risk factor for VTE receive thromboprophylaxis, if possible (Grade 1A). 5.1.2. In the absence of a major contraindication, we recommend that clinicians use LMWH prophylaxis starting as soon as it is considered safe to do so (Grade 1A). 5.1.3. We recommend that mechanical prophylaxis with IPC, or possibly with GCS alone, be used if LMWH prophylaxis is delayed or if it is currently contraindicated due to active bleeding or a high risk for hemorrhage (Grade 1B). 5.1.4. We recommend DUS screening in patients who are at high risk for VTE (eg, the presence of a SCI, lower extremity or pelvic fracture, major head injury, or an indwelling femoral venous line), and who have received suboptimal prophylaxis or no prophylaxis (Grade 1C). 5.1.5. We recommend against the use of IVCFs as primary prophylaxis in trauma patients (Grade 1C). 5.1.6. We recommend the continuation of thromboprophylaxis until hospital discharge, including the period of inpatient rehabilitation (Grade 1C+). We suggest continuing prophylaxis after hospital discharge with LMWH or a VKA (target INR, 2.5; INR range, 2.0 to 3.0) in patients with major impaired mobility (Grade 2C). 5.2 Acute SCI 5.2.1. We recommend that thromboprophylaxis be provided for all patients with acute SCIs (Grade 1A). 5.2.2. We recommend against the use of LDUH, GCS, or IPC as single prophylaxis modalities (Grade 1A). 5.2.3. In patients with acute SCI, we recommend prophylaxis with LMWH, to be commenced once primary hemostasis is evident (Grade 1B). We suggest the combined use of IPC and either LDUH (Grade 2B) or LWMH (Grade 2C) as alternatives to LMWH. 5.2.4. We recommend the use of IPC and/or GCS when anticoagulant prophylaxis is contraindicated early after injury (Grade 1C+). 5.2.5. We recommend against the use of an IVCF as primary prophylaxis against PE (Grade 1C). 5.2.6. During the rehabilitation phase following acute SCI, we recommend the continuation of LMWH prophylaxis or conversion to an oral VKA (INR target, 2.5; INR range, 2.0 to 3.0) [Grade 1C]. 5.3 Burns 5.3.1. We recommend that burn patients with additional risk factors for VTE, including one or more of the following: advanced age, morbid obesity, extensive or lower extremity burns, concomitant lower extremity trauma, use of a femoral venous catheter, and/or prolonged immobility, receive thromboprophylaxis, if possible (Grade 1C+). 5.3.2. If there are no contraindications, we recommend the use of either LDUH or LMWH, starting as soon as it is considered safe to do so (Grade 1C+). 6.0 Medical conditions 6.0.1. In acutely ill medical patients who have been admitted to the hospital with congestive heart failure or severe respiratory disease, or who are confined to bed and have one or more additional risk factors, including active cancer, previous VTE, sepsis, acute neurologic disease, or inflammatory bowel disease, we recommend prophylaxis with LDUH (Grade 1A) or LMWH (Grade 1A). 6.0.2. In medical patients with risk factors for VTE, and in whom there is a contraindication to anticoagulant prophylaxis, we recommend the use of mechanical prophylaxis with GCS or IPC (Grade 1C+). 7.0 Cancer patients 7.0.1. We recommend that cancer patients undergoing surgical procedures receive prophylaxis that is appropriate for their current risk state (Grade 1A). Refer to the recommendations in the relevant surgical subsections. 7.0.2. We recommend that hospitalized cancer patients who are bedridden with an acute medical illness receive prophylaxis that is appropriate for their current risk state (Grade 1A). Refer to the recommendations in the section dealing with medical patients. 7.0.3. We suggest that clinicians not routinely use prophylaxis to try to prevent thrombosis related to long-term indwelling CVCs in cancer patients (Grade 2B). Specifically, we suggest that clinicians not use LMWH (Grade 2B), and we recommend against the use of fixed-dose warfarin (Grade 1B) for this indication.
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#23
26.05.2005, 18:42
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8.0 Critical care
8.1. We recommend that, on admission to a critical care unit, all patients be assessed for their risk of VTE. Accordingly, most patients should receive thromboprophylaxis (Grade 1A). 8.2. For patients who are at high risk for bleeding, we recommend mechanical prophylaxis with GCS and/or IPC until the bleeding risk decreases (Grade 1C+). 8.3. For ICU patients who are at moderate risk for VTE (eg, medically ill or postoperative patients), we recommend using LDUH or LMWH prophylaxis (Grade 1A). 8.4. For patients who are at higher risk, such as that following major trauma or orthopedic surgery, we recommend LMWH prophylaxis (Grade 1A). 9.0 Long distance travel 9.1. We recommend the following general measures for long-distance travelers (ie, flights of > 6 h duration): avoidance of constrictive clothing around the lower extremities or waist; avoidance of dehydration; and frequent calf muscle stretching (Grade 1C). 9.2. For long-distance travelers with additional risk factors for VTE, we recommend the general strategies listed above. If active prophylaxis is considered, because of the perceived increased risk of venous thrombosis, we suggest the use of properly fitted, below-knee GCS providing 15 to 30 mm Hg of pressure at the ankle (Grade 2B), or a single prophylactic dose of LMWH injected prior to departure (Grade 2B). 9.3. We recommend against the use of aspirin for VTE prevention associated with travel (Grade 1B). Abbreviations: CI = confidence interval; DUS = Doppler ultrasonography; CVC = central venous catheter; DVT = deep-vein thrombosis; FUT = fibrinogen uptake test; GCS = graduated compression stockings; HFS = hip fracture surgery; HIT = heparin-induced thrombocytopenia; INR = international normalized ratio; IPC = intermittent pneumatic compression; IVCF = inferior vena cava filter; LDUH = low-dose unfractionated heparin; LMWH = low-molecular-weight heparin; NNH = number needed to harm; NNT = number needed to treat; OR = odds ratio; PE = pulmonary embolism; RRR = relative risk reduction; SC = subcutaneous; SCI = spinal cord injury; THR = total hip replacement; TKA = total knee arthroplasty; VFP = venous foot pump; VKA = vitamin K antagonist; VTE = venous thromboembolism
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#24
26.05.2005, 20:58
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Цитата:
И я не согласен, что бы вместо НМГ вводился обычный гепарин, или при рекомендации: "НМГ после операции" следовал вопрос "гепарин в вену сколько?", но это реальность и наша действительность, если пациент не сможет купить НМГ или это не предусмотрено клиникой/страховкой или еще чем, то гепарин лучше, чем ничего - правда его за рубежом кололи в до-НМГ эру по специфич. протоколу - для поддержания АЧТВ на уровне 1,2-1,4 от верхней границы нормы: только названия работ Adjusted versus fixed-dose subcutaneous heparin in the prevention of deep-vein thrombosis after total hip replacement. N Engl J Med. 1983 Oct 20;309(16):954-8 Randomized study of adjusted versus fixed low dose heparin prophylaxis of deep vein thrombosis in hip surgery. Br J Surg. 1989 Sep;76(9):933-5. Prevention of deep vein thrombosis after hip replacement: randomised comparison between unfractionated heparin and low molecular weight heparin. BMJ. 1991 Sep 7;303(6802):543-8. А последний 7-ой консенсус по антитромботич. терапии уже мне знаком с момента появления, да и Валентин Александрович любезно предоставил прямые ссылки на оригинал. Единственно, что не нашел в новой редакции, но есть в предыдущем 6-ом консенсусе (CHest 2001) дозирование пр-тов для различного вида тромбопрофилактики: Heparin 5,000 U SC, given q8–12h starting 1–2 h before operation Heparin SC, given q8h starting at approximately 3,500 U SC and adjusted by± 500 U SC per dose, to maintain a midinterval aPTT at high normal values General surgery, moderate risk: Dalteparin, 2,500 U SC 1–2 h before surgery and once daily postop Enoxaparin, 20 mg SC, 1–2 h before surgery and once daily postop Nadroparin, 2,850 U SC 2–4 h before surgery and once daily postop Tinzaparin, 3,500 U SC 2 h before surgery and once daily postop General surgery, high risk: Dalteparin, 5,000 U SC 8–12 h before surgery and once daily postop Danaparoid, 750 U SC 1–4 h before surgery and q12h postop Enoxaparin, 40 mg SC, 1–2 h preop and once daily postop Enoxaparin, 30 mg SC, q12h starting 8–12 h postop Orthopedic surgery Dalteparin, 5,000 U SC 8–12 h preop and once daily starting 12–24 h postop Dalteparin, 2,500 U SC 6–8 h postop; then 5,000 U SC once daily Danaparoid, 750 U SC 1–4 h preop and q12h postop Enoxaparin, 30 mg SC q12h starting 12–24 h postop Enoxaparin, 40 mg SC once daily starting 10–12 h preop Nadroparin, 38 U/kg SC 12 h preop, 12 h postop, and once daily on postop days 1, 2, and 3; then increase to 57 U/kg SC once daily Tinzaparin, 75 U/kg SC once daily starting 12–24 h postop Tinzaparin, 4,500 U SC 12 h preop and once daily postop Major trauma Enoxaparin, 30 mg SC q12h starting 12–36 h postinjury if hemostatically stable Acute spinal cord injury Enoxaparin, 30 mg SC q12h Medical conditions Dalteparin, 2,500 U SC once daily Danaparoid, 750 U SC q12h Enoxaparin, 40 mg SC once daily Nadroparin, 2,850 U SC once daily Perioperative warfarin: Start daily dose with approximately 5–10 mg the day of or the day after surgery; adjust the dose for a target INR of 2.5 (range 2–3) По последнему вопросу - разница между амер. и евр. подходами дозирования НМГ - похоже оба одинаковы, но можно начинать иньекции и после операции (по крайней мере тогда наши хирирги Вас поймут, а так будут жаловаться, что, дескать, предопер. гепарин усилит интраопер. кровоточивость) и 1 раз в сутки, но нужно начинать в период от 6 до 9 ч (12 ч иногда пишут).
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#25
26.05.2005, 21:26
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Класс! Вот это оперативность! Пока я досматривал " Умножающий печаль" по ОРТ, тут такое происходит.
Действительно, это был декабрьский номер "Chest" за 2003 год, я позже это вспомнил. Насчёт схемы, предусматривающей первую инъекцию гепарина после операции - уточню ещё, мы её не применяем, поэтому неуверенно себя чувствую в этой части вопроса. Но в любом случае, так приятно видеть, что тема интересна не тебе одному:-)
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#26
26.05.2005, 21:43
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Цитата:
CHEST Volume 126/Number 3/ Supplement/September, 2004 The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence-Based Guidelines Chest 2004 Sep; 126 (Suppl) : 163S-696S. По 2-м режимам - вот они: Enoxaparin, 30 mg SC каждые 12h starting 12–24 h послеопер. (америк. режим) Enoxaparin, 40 mg SC once daily starting 10–12 h преоперац. (европ. режим) но недавние уточнения от Раскоба и Хирша полагают, что ...6 h appears to be the threshold for early postoperative administration; initiation 12 to 24 h postoperatively may be less effective than initiation at 6 h...
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#27
26.05.2005, 22:11
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Вот-вот! Их-то я и качнул и их предлагал в своём посте. Я же помню, что где-то прочитал про 2-кратное введение клексана при первой инъекции в послеоперационном периоде.
А что касается снижения кровоточивости при этой операции, то я где-то писал уже об этом. Данные взял из нескольких мест, в основном из Европейского журнала хирургии костей и суставов. Там всё предельно просто, но это ветка по кардиологии, поэтому закругляюсь:-)
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#28
27.05.2005, 05:57
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Скромное мнение анестезиолога
Экстрасистолия -самая маленькая из проблем больного.Что я хочу услышать от своих терапевтических коллег это наибольную полную информацию о больном.Т.е какая хроническая патология в наличии и как качественно больной компенсирован перед плановым вмешательством.
Мин набор исследований( помимо сбора анамнеза и осмотра): 1- гемеглобин, гематокрит. тромбоциты 2- Натрий,калий,Бикарбонат, хлориды, азот мочевины,креатинин,глюкоза ( американская "семерка") 3-Экг,Эхо- стресс ЭХО, если положительная консультация кардиолога и возможно ангиограмма 4- Рентген,спирометрия без и с бронходилататором или 6 -мин "walking test" 5-показатели свертываемости 6-почему нельзя Холтер сделать в стационаре? 7-Вместо Панангина- бананы и апельсиновый сок Я "respectfully"" не соглашусь со спиналкой. Подождем Эхо. Если у больного есть аортальный стеноз с градиентом 30-40 мм, после спиналки неприятно поднимать давление с пола. Кроме того, если уровень спинальной анестезии будет выше ожидаемого и вы заблокируете дополнительные дыхательные мышцы-больного может придется интубировать на боку.Больной должен быть на кардиоселективных Бета-блокерах.Я небольшой сторонник амиодарона. Но это мое личное мнение Р.С. Простите за тупость, а что-такое тромбо-асс?? Это какой-то дорогой аналог аспирина??
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#29
27.05.2005, 13:18
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Цитата:
Какие показатели свертываемости Вы обычно применяете перед операцией? Согласно Раппапорту (и это мнение цитируется в текущ. клин. руководствах), даже при больших операциях без наличия клин. анамнеза о кровоточивости достаточно APTT, тк скрининговые тесты не достат. чувствительные для пограничных гемостат. дефектов и число ложноположит. результатов порой превышает число истинных. Rapaport SI. Preoperative hemostatic evaluation: which tests, if any? Blood. 1983 Feb;61(2):229-31. ТромбоАСС - 100 мг оболочечный аспирин от Lannacher Heilmittel, Австрия, - для тех, кому тяжело (в лом) разделить 325 мг таблетки на 4 части. Цена небольшая - в пределах 1 УЕ (30 tab.). Существует и др. дозировка 50 мг (на мой взгляд, более безопасная), но как-то реже используется в клин. практике.
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#30
27.05.2005, 15:50
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Цитата:
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Линейный вид
