#1
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Ïëàâèêñ è ñïèíàëüíàÿ àíåñòåçèÿ?
Ïîñòóïèëà ïàöèåíòêà ~60 ë. ñ ïåðåëîìîì áåäðà. Äâà èíôàðêòà ìåñÿöà 3 íàçàä. Ìåñÿö íàçàä - ìàììàðî-êîðîíàðíîå øóíòèðîâàíèå, ïîëó÷àåò ïëàâèêñ. Òåðàïåâò â ïàíèêå - âîîáùå íè÷åãî íèççÿ. Ñâîçèëè ê êàðäèîëîãàì - íèêàêèõ ïðîòèâîïîêàçàíèé ê ëþáîé îïåðàöèè. Àíåñòåçèîëîãè ñðàçó õîòÿò îòìåíèòü ïëàâèêñ, à ÷åðåç íåäåëþ äåëàòü ñïèíàëüíóþ. Ïîòîìó êàê ñïðîñèëè ãëàâíîãî àíåñòåçèîëîãà îáëàñòè, à òîò òàê ñêàçàë. Ñàìè íàøè àíåñòåçèîëîãè, ïî-ìîåìó, ïîáàèâàþòñÿ ïðîâåðèòü îáîñíîâàííîñòü ýòîé äèðåêòèâû. Ïîñìîòðåë ëèòåðàòóðó - ïîëíûé ðàçíîáîé, êòî-òî îòìåíÿåò, êòî-òî íåò. Ïðè÷åì êòî íå îòìåíÿåò - ïðîáëåì íåòó, ïèøóò.
Åñòü íà ñåãîäíÿ åñëè íå îêîí÷àòåëüíûé, òî õîòü õîòü êàêîé-òî ñåðüåçíûé ýâèäåíñ íà ýòó òåìó? Ñïàñèáî. |
#2
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Àêòóàëüíûé ýâèäåíñ êàê ðàç è îçâó÷èë ãëàâíûé àíåñòåçèîëîã îáëàñòè. Ñîãëàñíî àêòóàëüíûì ðåêîìåíäàöèÿì ASRA (American Society of Regional Anesthesia), êëîïèäîãðåëü äîëæåí áûòü îòìåíåí çà 7 äíåé äî ïëàíèðóåìîé îïåðàöèè ïîä ðåãèîíàëüíîé àíåñòåçèåé. Ýòî ïîçâîëÿåò çíà÷èòåëüíî ñíèçèòü ðèñê ýïèäóðàëüíîé ãåìàòîìû (è ñíèçèòü ïåðèîïåðàöèîííóþ êðîâîïîòåðþ, êñòàòè òîæå). http://www.asra.com/consensus-statements/2.html
Îäíàêî, ñïðàâåäëèâîñòè ðàäè, ñëåäóåò îòìåòèòü, ÷òî äàæå ó ïàöèåíòîâ, ïîëó÷àþùèõ àíòèòðîìáîöèòàðíûå ïðåïàðàòû è àíòèêîàãóëÿíòû, ðèñê ðàçâèòèÿ ýïèäóðàëüíîé ãåìàòîìû äîñòàòî÷íî íèçîê. Åùå ññûëêè â òåìó: http://bja.oxfordjournals.org/cgi/reprint/99/3/316 http://bja.oxfordjournals.org/cgi/reprint/99/4/594 |
#3
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Öèòàòà:
Öèòàòà:
Öèòàòà:
We conclude that the risk/benefit ratio of preoperative withdrawal of antiplatelet drugs in order to perform a regional or neuraxial blockade is not justified. Ýòî çíà÷èò, ÷òî íå íàäî ðàäè ÑÀ îòìåíÿòü ïëàâèêñ, ëó÷øå ñäåëàòü äðóãîé âèä àíåñòåçèè? Èëè ÷òî íå îòìåíÿéòå ïëàâèêñ è äåëàéòå ñïèíàëüíóþ? Íàñ÷åò ïîâûøåííûõ êðîâîòå÷åíèé - íå ïîäòâåðæäàåòñÿ ýòî íà ïîäîáíûõ îïåðàöèÿõ. [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] This study has demonstrated that patients taking clopidogrel (Plavix) are at no increased risk of bleeding complications or increased transfusional requirement after early hip fracture surgery when compared those taking aspirin or no anticoagulant. Simply taking clopidogrel should not be considered a contraindication for early hip fracture surgery or result in delaying treatment. Âèä àíåñòåçèè åùå áû óêàçàëè, çàðàçû. Ïðèäåòñÿ ñïðîñèòü.  Àíãëèè ñ ýòèì âîïðîñîì òîæå èíòåðåñíî, îäíî íàçâàíèå ñòàòüè ÷åãî ñòîèò: Operative delay for orthopedic patients on clopidogrel (plavix): a complete lack of consensus (2008). Èíòåðåñíî, îíè ÷òî, ýòè ðåêîìåíäàöèè ASRA íå ÷èòàëè? (Ñîìíåâàþñü) Åñëè ÷èòàëè, êàê ó íèõ õâàòàåò äóõó âîïðåêè ýòèì ðåêîìåíäàöèÿì äåéñòâîâàòü? Âèäèìî, êàêèå-òî äðóãèå ðåêîìåíäàöèè ÷èòàþò? Êàêèå? |
#4
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Áîëåå àêòóàëüíûõ ðåêîìåíäàöèé ïî ïðîáëåìå ïîêà íå îïóáëèêîâàíî.
Öèòàòà:
Öèòàòà:
Guidelines recommend withholding clopidogrel for ≥7 days preoperatively for patients undergoing elective surgery, but no recommendations are currently available for similar patients being treated for a hip fracture. Òàê ÷òî ðåêîìåíäàöèè âñå ÷èòàþò òå æå ñàìûå. Êðîìå òîãî, èññëåäîâàíèå, ñóäÿ ïî âñåìó, âûïîëíåíî íà äîñòàòî÷íî íèçêîì ìåòîäîëîãè÷åñêîì óðîâíå. È öåííîñòü ïîëó÷åííûõ â íåì ðåçóëüòàòîâ íåâåëèêà. Öèòàòà:
Âî âòîðûõ, .. CONCLUSIONS:: The majority of orthopedic surgery residency programs who responded to the survey wait less than 3 days for urgent surgery and do not delay surgery for emergency cases for patients on clopidogrel. At this point we feel that an early intervention that occurs within approximately 2 days, with the acceptance of the possibility of increased blood loss is in the patient's best interest. Based on the reviewed physiology, a perioperative platelet transfusion may be of some benefit as the transfused platelets would be effective in forming a viable plug. Îáðàòèòå âíèìàíèå - íàñêîëüêî äåëèêàòíû â ñâîèõ âûâîäàõ àâòîðû. |
#5
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Âîò, êñòàòè, íàøåë åùå îäíó èíòåðåñíóþ ññûëêó: http://www.thrombosisjournal.com/content/5/1/6
"Clopidogrel in Orthopaedic patients: a review of current practice in Scotland" Â èíòðî, îïÿòü òàêè óêàçûâàåòñÿ .. Current guidelines recommend withholding clopidogrel for 7 days pre-operatively. However these are not based on orthopaedic patients. Ñîãëàñíî îïðîñàì, ñóùåñòâóþùàÿ ïðàêòèêà ïåðèîïåðàöèîííîé îòìåíû êëîïèäîãðåëÿ òàêîâà: Of those, 13.9% did not routinely stop it, and 86.1% stopped it 5–21 days pre-operatively (47.2% at 7 days). |
#6
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Öèòàòà:
Öèòàòà:
Öèòàòà:
È, êàê àâòîðû âûÿâèëè, vast majority of programs 66 (89%) reported no delay to the operating room for patients on clopidogrel. Èíòåðåñíî, â xUSSR òîæå 90% ó÷ðåæäåíèé íå îòêëàäûâàåò íà íåäåëþ hip fracture surgery ó ïàöèåíòîâ íà ïëàâèêñå? È çà ãîäû íåóæåëè íå íàáðàëàñü ñòàòèñòêè, íà ñêîëüêî æå ñïèíàëüíûõ àíåñòåçèé ñëó÷àåòñÿ ýòîò æóïåë, ãåìàòîìà ñïèííàÿ, íà ôîíå ïëàâèêñà, â ÷àñòíîñòè? Ïðî íà ôîíå LMWH âîò ÷òî-òî ïèñàëè, íå ïîìíþ öèôðû òî÷íî, íî øòóê 40 ïî Øòàòàì íàáðàëîñü çà âñå âðåìÿ. Ñ ïëàâèêñîì ðåæå, ÷àùå? |
#7
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Öèòàòà:
Âîò ýòî ñàìîå èíòåðåñíîå è åñòü - íà êàêîì îñíîâàíèè îíè íå îòìåíÿþò? |
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#8
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Öèòàòà:
Perioperative management of trauma patients admitted on clopidogrel (Plavix). A survey of orthopaedic departments across the United Kingdom.(2007) Òîæå èíòåðåñíûå ðåïçóëüòàòû: 41% (56) stop clopidogrel and operate immediately, 11% (15) stop clopidogrel for between 5 and 10 days pre-operatively, 10% (14) stop clopidogrel for 10 days preoperatively, 19% (26) continue clopidogrel and operate immediately, 19% (26) have another protocol. À âåäü â ýòîì òåêñòå ASRA 2002 ãîäà íàïèñàíî, ÷òî äîëæíî áûòü. Ïî÷åìó çàìåòíàÿ ÷àñòü ñîîáùåñòâà äåéñòâóåò èíà÷å? |
#9
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Öèòàòà:
Òî åñòü òî, ÷òî åñòü 2002 ã., â êà÷åñòâå guideline äëÿ ýòîãî êîíòåêñòà óæå íå êîòèðóåòñÿ, íàäî ïîíèìàòü. |
#10
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Öèòàòà:
Àìåðèêàíöû (òå, êîòîðûõ ÿ öèòèðîâàë âûøå) ïèøóò, ÷òî ðåêîìåíäàöèè ASRA íå ó÷èòûâàþò ñïåöèôèêè îðòîïåäè÷åñêèõ îïåðàöèé è óêàçûâàþò, ÷òî áðàòü â ïðèíöèïå ìîæíî è ðàíüøå, íî ïðèêðûâàòüñÿ, â ñëó÷àå ïîâûøåííîé êðîâîòî÷èâîñòè, òðîìáîìàññîé. Åùå îäèí àðãóìåíò ïðîòèâ - ðåêîìåíäàöèè ïðîèçâîäèòåëÿ (åäèíñòâåííûé, èìåþùèé èç âûøåïåðå÷èñëåííîãî þðèäè÷åñêóþ ñèëó äëÿ íàñ). Òàê âîò, ïðîèçâîäèòåëü òàêæå ðåêîìåíäóåò îòìåíÿòü ïëàâèêñ çà 7 äíåé äî ïëàíîâîé îïåðàöèè. Ðåçþìèðóÿ, ïî ìîåìó ñêðîìíîìó ìíåíèþ, â íàñòîÿùåå âðåìÿ îäíîçíà÷íîéé ïîçèöèè ïî ýòîìó âîïðîñó íåò. Äîêàçàòåëüñòâ çà è ïðîòèâ íåäîñòàòî÷íî. Òåîðåòè÷åñêè ìîæíî âçÿòü è ðàíüøå, ÷åì ñïóñòÿ 7 äíåé ïîñëå îòìåíû ïëàâèêñà, íî íóæíû óáåäèòåëüíûå îáîñíîâàíèÿ äëÿ ýòîãî. Æåëàòåëüíî îáîñíîâàòü âñå ïîäðîáíî â èñòîðèè áîëåçíåé. |
#11
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Öèòàòà:
J Orthop Surg (Hong Kong). 2007 Dec;15(3):270-2. Anti-platelet agents and surgical delay in elderly patients with hip fractures. Harty JA, McKenna P, Moloney D, D'Souza L, Masterson E. Department of Orthopaedic Surgery, Midwestern Regional Hospital, Dooradoyle, Limerick, Ireland. [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] PURPOSE: To assess the risk of surgical delay in elderly hip fracture patients on anti-platelet agents. METHODS: Records of 180 patients aged over 65 years with either an intertrochanteric or femoral neck fracture were reviewed. The clopidogrel group included 10 patients on clopidogrel alone and 11 others on clopidogrel and aspirin, whereas the control group included 69 on aspirin alone and the remaining 90 not on any anti-coagulants. The 2 groups were compared with regard to time to surgery, preoperative American Society of Anesthesiologists (ASA) score, pre- and post-operative haemoglobin levels, in-patient complication rates, duration of hospital stay, and 30-day mortality. RESULTS: In the clopidogrel and control groups respectively, the mean times to surgery were 7.2 and 2.1 days (p=0.03, t-test), the mean preoperative ASA scores were 3.35 and 2.8 (p=0.29, t-test), the mean preoperative haemoglobin levels were 119 and 115 g/l (p=0.5, t-test), the mean postoperative haemoglobin levels were 98 and 96 g/l (p=0.68, t-test), the mean durations of hospital stay were 7.4 and 3.1 days (p=0.02, t-test). The 30-day mortalities were 6/21 (29%) and 6/159 (4%) [p=0.0003, Fisher's exact test]. CONCLUSION: Surgical delay in elderly patients on anti-platelet agents with hip fracture was associated with higher mortality. Despite the risk of increased blood loss, we suggest early surgery be carried out by an experienced surgeon to expedite the operating time. Pooled platelets should be given intravenously one to 2 hours preoperatively. |
#12
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Î÷åíü èíòåðåñíîå èññëåäîâàíèå, ñïàñèáî. Íî íå ñîâñåì àäàïòèðóåìî ê íàøèì óñëîâèÿì, õîòÿ áû âîò ïî ýòîé ïðè÷èíå ..
Åñëè âû ãîòîâû ðóòèííî èñïîëüçüçîâàòü òðîìáîìàññó äëÿ ýòîé êàòåãîðèè ïàöèåíòîâ (ó÷èòûâàÿ ñâÿçàííûé ñ ýòèì äîïîëíèòåëüíûé ðèñê è äîïîëíèòåëüíûå õëîïîòû), òî äà, âîçìîæíî åñòü ñìûñë áîëåå ðàííåãî âûïîëíåíèÿ îïåðàöèè. |
#13
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Ìåíÿ âîîäóøåâëÿåò ôðàçà èç ðàñêðèòèêîâàííîãî Âàìè ñîîáùåíèÿ: This study has demonstrated that patients taking clopidogrel (Plavix) are at no increased risk of bleeding complications or increased transfusional requirement after early hip fracture surgery when compared those taking aspirin or no anticoagulant.
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#14
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Öèòàòà:
Êñòàòè, ÿ çàáûë óïîìÿíóòü, ÷òî ó ïàöèåíòîâ, âûñîêî çàâèñèìûõ îò òåðàïèè àíòèêîàãóëÿíòàìè íåêîòîðûå àâòîðû ðåêîìåíäóþò çàáëàãîâðåìåííî îòìåíÿòü àíòèòðîìáîöèòàðíûå ïðåïàðàòû è ïðèêðûâàòüñÿ âñå ýòî âðåìÿ íèçêîìîëåêóëÿðíûìè ãåïàðèíàìè. |
#15
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Ñîâåðøåííî íåïîíÿòíî, ÷åì ðóêîâîäñòâîâàëèñü àâòîðû, íàñòàèâàÿ íà ïðèìåíåíèè èìåííî ïóëèðîâàííûõ òðîìáîöèòîâ (ò.å. òåðàïåâòè÷åñêàÿ äîçà òðîìáîìàññû ñîáèðàåòñÿ - ïóëèðóåòñÿ - ýòî óñòîÿâøèéñÿ òåðìèí äëÿ ýòîé òåõíîëîãèè - ïðè öåíòðèôóãèðîâàíèè íåñêîëüêèõ äîíîðîâ (îò 4 äî 9). À ÷åì õóæå òðîìáîìàññà, çàãîòîâëåííàÿ íà ñåïàðàòîðàõ (ïî ìíå - òàê ëó÷øå)?
Ïëþñ, íåîáõîäèìî íåñëàáîå èññëåäîâàíèå òðåáóåìûõ äîç òðîìáîìàññû... Ïðè÷åì ðåêîìåíäîâàííûé ìîíèòîðèíã òðîìáîýëàñòîãðàôîì ñ àäåíîçèíîì è àäðåíàëèíîì íóæíî åùå óñïåòü îñóùåñòâèòü è îöåíèòü â êîðîòêèé ïðîìåæóòîê ìåæäó òðàíñôóçèåé òðîìáîìàññû è àíåñòåçèåé (1-2 ÷àñà, à â ñëó÷àå íåóäà÷è - îòêëàäûâàòü àíåñòåçèþ/îïåðàöèþ?). |