从重症监护角度思考普通外科围手术期静脉血栓栓塞症防治

普通外科围手术期病人,尤其是重症监护病人存在多种容易导致血栓形成的高危因素,因而较之其他病人,具有更高的静脉血栓栓塞症(VTE)发病风险,在该类人群中切实做好VTE防治工作刻不容缓。准确评估发病风险,是做好VTE的防治工作的关键第一步。目前常用的Caprini模型对于预测围手术期病人的血栓风险具有较高的敏感度,临床上将血浆标记物与该模型相结合,可进一步提高重症监护病人VTE风险的预测价值。重症病人的VTE预防及治疗须强调个体化,综合评价血栓与出血的风险,兼顾有效性及安全性,选择最佳策略和最优剂量,改善病人预后。     

静脉血栓栓塞症抗凝原则及并发症处理

静脉血栓栓塞症（VTE）包括深静脉血栓（DVT）和肺栓塞（PE）,其基础治疗为抗凝。对于VTE风险评估中高危而且没有出血风险的病人推荐进行预防性抗凝。已经发生的VTE在评估低出血风险后更加需要进行长期治疗性抗凝。常见抗凝药物包括普通肝素、低分子肝素、华法林、利伐沙班为代表的直接口服抗凝药、磺达肝癸钠和阿加曲班。不同抗凝药物有各自的适应人群、注意事项和推荐剂量。对于血栓复发风险高的病人建议延长抗凝。     

普外科围手术期抗栓治疗管理进展

目的总结普外科围手术期静脉血栓栓塞症(venous thromboembolism,VTE)发生发展的概况,同时总结围手术期的抗栓治疗策略。方法收集国内外有关抗栓治疗的文献及指南并作综述。结果围手术期VTE很常见。在围手术期合理评估每例患者的情况,采用合理的预防措施,同时规范地使用抗凝、抗血小板药物及止血剂可以减少围手术期VTE事件的发生。结论如何平衡好血栓栓塞与出血之间的平衡是一个富有争议的话题,需要我们学习并加以掌握,制定合理的抗栓策略,降低栓塞并发症,从而更好地为患者服务。     

重视普通外科围手术期静脉血栓栓塞症规范化防治

普通外科围手术期病人是静脉血栓栓塞症(VTE)的高发人群,近年来国内外已经日益重视普通外科围手术期VTE的预防,但是在开展预防的前提下普通外科围手术期VTE仍时有发生,目前国内围手术期的风险评估和预防实施率仍不高,因此有必要重视普通外科围手术期VTE的规范化防治。规范化预防包括采用Caprini评分进行VTE风险评估以及在此基础上结合出血评估采用相应的机械预防和药物预防措施。规范化治疗主要是请血管外科和呼吸科专科医师协助根据指南对深静脉血栓形成(DVT)和肺动脉栓塞(PE)进行及时的诊断和治疗。治疗首选抗凝,其次根据病人病情和危险分层可进行溶栓、腔内治疗。同时植入滤器应严格按照指征。     

湖北省胃肠外科医师围手术期静脉血栓栓塞症预防理念现状分析

目的 分析湖北省胃肠外科医师围手术期静脉血栓栓塞症（VTE）预防理念现状。方法 2020-06-01—2020-06-20华中科技大学同济医学院附属协和医院对湖北省胃肠外科联盟医师进行问卷调查。问卷内容包括基本信息、VTE预防理念、术前VTE预防现状、术后VTE预防现状及抗凝药物使用情况等。结果 收集有效问卷509份,参与医师来自湖北省15个市（州）的112家医院。387名医师表示日常工作中使用VTE风险评分工具,其中55.6%的医师使用Caprini评分,1.6%的医师围手术期全程评估病人VTE风险。397名医师表示术前会对病人行药物预防,其中15.6%的医师对＞50%的病人行药物预防;389名医师表示术后会对病人行药物预防,其中48.8%的医师对＞50%的病人行药物预防。25.1%（128/509）的医师表示术前对病人同时行D-二聚体及下肢多普勒超声血管检查,15.3%（78/509）术后对病人监测D-二聚体及下肢多普勒超声血管检查。16.5%（84/509）的医师表示对VTE高危病人出院后进行足疗程低分子肝素治疗。结论 湖北省胃肠外科医师已具备一定的VTE预防理念,但部分医师在围手术期VTE评估、药物预防及检查方面仍存在诸多不足。     

新型冠状病毒感染合并静脉血栓栓塞症的临床研究进展——基于当前的循证证据

新型冠状病毒感染容易引起机体内凝血功能紊乱，从而导致新冠感染患者发生静脉血栓栓塞症（VTE）的风险比普通人大大增加。以低分子肝素（LMWH）为主的抗凝治疗为目前血栓防治的首选方法，结合先进、完善的评分体系进行评估并及早进行科学、合理的血栓预防具有重大的临床意义。本文对目前新型冠状病毒感染合并VTE的临床研究进展进行综述，为临床医生诊治该类患者提供相应的决策参考。     

脊柱疾病术后静脉血栓栓塞症的危险因素研究进展

<正>静脉血栓栓塞症(VTE)包括深静脉血栓栓塞症(DVT)和肺动脉血栓栓塞症(PE)。DVT是指深静脉腔内血液的病态凝结,这种血块可留在原位,或移至肺动脉导致PE。DVT和PE是VTE在不同部位和不同阶段的2种临床表现形式。VTE是骨科术后常见的并发症,有较高的致残率及致死率。VTE在脊柱手术后发生率与关节手术相似~([1])。确定围手术期VTE的危险因素将有助于评估患者形成VTE的风险程度。术前进行风险评估和危险分层,筛选     

出凝血功能检测项目在围手术期静脉血栓栓塞症诊治中的价值和意义

出凝血检测在排除诊断静脉血栓栓塞症(VTE)、辅助诊断易栓疾病、评估VTE危险度以及抗栓药物监测等方面有重要价值。临床医师在使用这些指标前,不但需充分考虑病人人群特点和药物影响,还应熟悉血栓试验的主要应用原则,包括:(1)在排除诊断VTE时,应了解本机构内D-二聚体方法的诊断敏感性,确保安全性和有效性。(2)D-二聚体应用于不同人群和诊疗目的时,相应的临界值可能不同。(3)对疑似遗传缺陷病人进行实验室筛查之前,应详细了解病史和家族史。(4)检测狼疮抗凝物、肝素诱导的血小板减少症抗体前,应首先使用相应的风险评估模型或验前概率评分筛选出符合检测指征的病人。     

上海市普通外科病人静脉血栓栓塞症防治管理规范(2020版)

静脉血栓栓塞症(VTE)是指各种病因(如静脉血滞缓、静脉壁血管内膜损伤或血液高凝等)导致血液在静脉系统不正常凝集的一组疾病,包括肺动脉栓塞(PE)和深静脉血栓形成(DVT)。上海市普通外科临床质量控制中心自2018年发布《上海市普通外科住院病人静脉血栓栓塞症防治管理规范》(以下简称2018版《规范》)至今已2年,推动了上海市普通外科围手术期血栓防治工作的推广,同时积累了上海在血栓防治方面的临床数据。截止至2019年9月,上海市二级以上医院已有88%建立VTE防控体系,在病史中包含了VTE风险评估表,并且大部分医院已有电子病案的嵌入或纸质病史的记录;84%的医院有VTE和PE的联合会诊团队;92%医院的普通外科已按照2018版《规范》为住院病人评估VTE风险,74%的科室在病人手术后再次评估VTE风险,38%的科室在出院前会再次为病人评估VTE风险。上海市普通外科在临床实践中防治VTE的理念和实践有了很大进步,但与先进国家和医院的防治实践相比仍有较大差距。     

普通外科围手术期静脉血栓栓塞症防治中血管外科干预原则与策略

静脉血栓栓塞症(VTE)是普通外科围手术期严重的并发症之一,具有发病率高、易漏诊、潜在风险高等特点。围手术期对高危人群进行有效预防措施,降低VTE的发生率,以及针对已经并发VTE病人,采取适当的治疗措施,对于促进病人术后恢复,降低相应并发症发生率,提高病人生活质量具有重要意义。     

Therapy Insight: management of urology patients taking long-term warfarin anticoagulation therapy

Chronic warfarin anticoagulation is commonly used to prevent thromboembolism in patients with atrial fibrillation or venous thromboembolism, and in the management of patients with mechanical heart valves. Interruption of long-term anticoagulation therapy for elective, planned urologic procedures in these patients creates a complex situation in which competing risks of thrombosis and hemorrhage must be managed; when anticoagulation is withheld patients are at risk of thrombosis, and when it is restarted they are at risk of hemorrhage. Patients at a high risk of thrombosis are typically given bridging therapy with heparin to reduce the amount of time without anticoagulation. Outcomes from bridging therapy are influenced by patient characteristics, including the risk of thromboembolism from underlying medical conditions and the risk of perioperative bleeding, and by characteristics of the procedures themselves. The safety and efficacy of different approaches are not well documented. Data regarding periprocedural anticoagulation management of urology patients is limited and principally describes outcomes related to transurethral prostate surgery. Results from these studies indicate that various strategies of anticoagulation interruption and bridging therapy result in low frequencies of thromboembolism, but variable rates of hemorrhage. Patients on anticoagulation therapy who are due to undergo invasive urologic procedures that have a low risk of developing thromboembolism can discontinue warfarin 4-5 days before the procedure, and resume it postprocedure. Bridging therapy to prevent thrombosis is necessary for patients at a higher risk of developing thromboembolism. Future research should develop strategies to maintain low rates of thrombosis but reduce the frequency of postoperative hemorrhage.     

Perioperative management of chronic anticoagulation in orthopaedic surgery

The orthopaedic patient on chronic anticoagulation therapy is at risk of thromboembolism and hemorrhage in the perioperative period. To establish the most effective anticoagulation regimen, patients should be stratified according to the risk of arterial or venous thromboembolism. Timing of surgery, thromboembolic risk, and bleeding risk should be considered when developing an anticoagulation protocol. Retrievable inferior vena cava filters may be a viable alternative to bridging therapy in patients at high risk of venous thromboembolism and/or bleeding.     

Current clinical concepts in perioperative anticoagulation

Management of patients with significant risks for thromboembolism in the perioperative period requires consideration of both risks of thromboembolism and risks of anticoagulant therapy. Patients who are receiving warfarin therapy because of recent venous thromboembolism, nonvalvular atrial fibrillation, and mechanical heart valves are at increased risk during the interval when the warfarin is discontinued and when the international normalized ratio is at a subtherapeutic level. In patients with an acute venous thromboembolic event within the past month, the use of intravenous heparin appears to be justified both preoperatively and postoperatively. If the venous thromboembolic event was within the past 2 to 3 months, use of intravenous heparin appears justified in the postoperative period. More than 3 months after an acute episode of venous thrombophlebitis, the relatively low risk of recurrence does not appear to justify the risks of complications from intravenous heparin. Patients with increased risks of arterial embolism, specifically those with nonvalvular atrial fibrillation and mechanical heart valves, are generally not at sufficient risk of arterial embolism to justify use of intravenous heparin during the perioperative subtherapeutic international normalized ratio interval when warfarin is withheld. A potential increased risk of recurrent arterial embolism when the preceding event was within a month suggests that elective surgery should be deferred beyond a month whenever possible in such patients. The use of fixed-dose, subcutaneous low molecular weight heparin has been observed to have advantages over use of unfractionated intravenous heparin both in terms of safety and efficiency. Further refinements in management of patients with significant risks of thromboembolism may occur with increased experience with low molecular weight heparin.     

Prediction of thromboembolism following total hip replacement.

Obesity, edema in the legs before surgery, a history of deep venous thrombosis, varicose veins, and a diagnosis of osteoarthrosis were associated with an increased risk for postoperative thromboembolism. Selective administration of anticoagulants to high risk but not to low risk patients should result in a reduction in total mortality following surgery. It is therefore suggested that when deciding whether prophylactic anticoagulants should be administered to a patient, consideration should be given to that patient's likelihood of developing fatal pulmonary embolism if the anticoagulant is not given, compared to the potential reduction in his risk for fatal pulmonary embolism and the increase in risk for fatal bleeding complications if the anticoagulant is used.     

Management of surgical patients receiving anticoagulation and antiplatelet agents

Background:

Temporary interruption of long‐term anticoagulation and antiplatelet therapy during surgical procedures exposes patients to thrombotic risk. Continuation of these agents, however, is associated with an increased risk of bleeding. Managing anticoagulation can be a particular challenge in the emergency setting.

Methods:

A literature review of published articles sourced using the keywords heparin, warfarin, perioperative, antiplatelet, aspirin and surgery was undertaken. A management plan for all likely situations was developed.

Results and conclusion:

Based on an individual assessment of risk factors for arterial or venous thromboembolism and the risk of perioperative bleeding, it is possible to form an anticoagulant and antiplatelet management plan likely to achieve a low incidence of bleeding and thrombosis. A multidisciplinary approach is desirable. Copyright © 2008 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Venous Thromboembolism After Surgery for Benign Prostatic Hyperplasia

A systematic review has been performed on venous thromboembolism after surgery for benign prostatic hyperplasia. The risk of deep vein thrombosis is two to four times higher after open surgery than after transurethral resection. The risk after the newer transurethral methods (laser, radiofrequency, heat) is not known. Specific studies on thromboprophylaxis are few and have limited numbers of patients. Nonetheless, thromboprophylaxis (heparin) reduces the frequency of postoperative deep vein thrombosis after open surgery. Studies on patients undergoing transurethral resection are lacking. Antifibrinolytic treatment to diminish bleeding does not seem to increase the risk of thrombosis.     

Randomized,pilot study of intermittent pneumatic compression devices plus dalteparin versus intermittent pneumatic compression devices plus heparin for prevention of venous thromboembolism in patients undergoing craniotomy

BACKGROUND: Unfractionated heparin and the low molecular weight heparin, dalteparin, are used for prophylaxis against venous thromboembolism in patients undergoing craniotomy. These drugs were compared in a randomized, prospective pilot study comparing intermittent pneumatic compression devices plus dalteparin to intermittent pneumatic compression devices plus heparin. METHODS: One hundred patients undergoing craniotomy were randomly allocated to receive perioperative prophylaxis with subcutaneous (SC heparin, 5000 units every 12 hours, or dalteparin, 2,500 units once a day, begun at induction of anesthesia and continued for 7 days or until the patient was ambulating. Entry criteria were age over 18 years, no deep vein thrombosis (DVT) preoperatively as judged by lower limb duplex ultrasound and no clinical evidence of pulmonary embolism preoperatively. Patients with hypersensitivity to heparin, penetrating head injury or who refused informed consent were excluded. Patients underwent a duplex study 1 week after surgery and 1 month clinical follow-up. All patients were treated with lower limb intermittent pneumatic compression devices. RESULTS: There were no differences between groups in age, gender, and risk factors for venous thromboembolism. There were no differences between groups in intraoperative blood loss, transfusion requirements or postoperative platelet counts. Two patients receiving dalteparin developed DVT (one symptomatic and one asymptomatic). No patient treated with heparin developed DVT and no patient in either group developed pulmonary embolism. There were two hemorrhages that did not require repeat craniotomy in patients receiving dalteparin and one that did require surgical evacuation in a patient treated with heparin. Drug was stopped in two patients treated with dalteparin because of thrombocytopenia. None of these differences were statistically significant. CONCLUSION: There was no significant difference in postoperative hemorrhage, venous thromboembolism or thrombocytopenia between heparin and dalteparin. The results suggest that, given the small sample size of this trial, both drugs appear to be safe and the incidence of venous thromboembolism by postoperative screening duplex ultrasound appears to be low when these agents are used in combination with intermittent pneumatic compression devices.     

Deep venous thrombosis prophylaxis in body contouring: 105 consecutive patients

ABSTRACT: Body contouring has a higher rate of thromboembolism than traditional plastic surgery procedures. Although risk stratification protocols exist, few offer specific therapeutic guidelines for deep venous thrombosis prevention. This single surgeon series classifies 105 consecutive patients into low, moderate, high, and highest risk groups. The respective thromboembolism prevention treatment included pneumatic compression devices alone, postoperative low-dose unfractionated heparin (LDUH), preoperative and 2 doses of postoperative LDUH, and preoperative and postoperative LDUH/low-dose molecular weight heparin for 7 days. Complications included 1 reoperation for bleeding. There were no clinically detected deep venous thromboses. In conclusion, this treatment algorithm for thromboembolism prevention results in a low rate of bleeding and thrombosis. Further studies are warranted to determine optimal timing and duration of chemoprophylaxis in plastic surgery patients.     

Complications of subcutaneous low-dose heparin therapy in neurosurgical patients

BACKGROUND Venous thromboembolism is a major cause of postoperative morbidity and mortality in neurosurgery. The use of low-dose unfractionated heparin therapy perioperatively for prophylaxis against deep vein thromboses and pulmonary embolism has been well demonstrated in many other surgical specialties but is less commonly used in neurosurgery because of fears of devastating postoperative hematomas.

METHODS The safety of such therapy has been analyzed in 950 patients undergoing an inpatient neurosurgical procedure. 872 patients (152 cranial procedures) completed treatment with 5000 U sodium heparin subcutaneously twice a day, commencing before surgery and continuing till patients were ambulatory.

RESULTS There were three minor hemorrhagic complications—two superficial wound hematomas (one requiring treatment) and one gastrointestinal hemorrhage—identified. Three clinically significant major complications developed, two epidural hematomas after spinal surgery requiring evacuation and one intraventricular hemorrhage after brain biopsy.

CONCLUSION This report, along with an analysis of previously published reports of low-dose perioperative heparin therapy in neurosurgical patients, suggests that such therapy is unlikely to be associated with increased morbidity. Given the known efficacy of low-dose heparin in reducing venous thromboembolism in other surgical patients, such therapy may reduce mortality and morbidity from thromboembolic complications in neurosurgical patients with minimal risk.     

Risk of intracranial hemorrhage in glioma patients receiving anticoagulant therapy for venous thromboembolism

To determine the risk of intracranial hemorrhage in patients with malignant gliomas who are treated with anticoagulant drugs for late postoperative venous thromboembolism, the authors retrospectively reviewed the computerized data base of all patients with primary brain tumors seen at the University of California, San Francisco, over a 9-year period. Of 915 patients 18 years of age or older who had a pathological diagnosis of malignant glioma and an initial Karnofsky performance scale score of 60% or higher, 36 (4%) developed venous thromboembolism 6 to 246 weeks postoperatively and 22 were treated with anticoagulant drugs. Anticoagulant therapy usually consisted of intravenous heparin for 7 to 10 days, followed for at least 3 to 6 months by either subcutaneous heparin (5000 to 8000 U twice daily) or oral warfarin. All patients were closely monitored to ensure control of hypertension, compliance with therapy, maintenance of prothrombin time within the therapeutic range, and early recognition of adverse side effects. No patient had an intracranial hemorrhage. Thus, anticoagulant agents can be safely administered after intracranial operations for malignant gliomas without increased risk of morbidity or mortality if the patients are carefully monitored according to established guidelines.