静脉血栓栓塞-ppt课件

静脉血栓栓塞危重患者的VTE高危因素和发病率危重患者的VTE预防指南和评估ICU内的VTE预防方法几个肺栓塞病例Covidien|August26,2020|Confidential3|静脉血栓栓塞症(VTE)包括深静脉血栓(DVT)和肺栓塞(PE)。DefinitionofVenousThromboembolism(VTE)静脉血栓栓塞的定义PulmonaryEmbolism1Circulation2019;93:2212;2NEnglJMed2019;350:22573Lancet2019;349:759;4JGenInternMed2000;26:425FatalPEAsymptomaticPESymptomaticDVTPulmonaryEmbolism4outof5patientswillnothaveanysymptomsofthrombosisAsymptomaticDVT20%80%80%ASYMPTOMATICS11050100300-1000Confidential,©TycoCorporationCovidien|26/08/2020|Confidential5|解决DVT的后果静脉血栓栓塞--Covidien|26/08/2020|ConfidentialConfidential,©TycoCorporation6|血流淤滞血管壁损伤凝血功能改变血液循环流速减慢。血流淤滞同时发生在术中和术后的卧床时间发生在术侧肢体的操作过程中会扭折血管，如全膝或全髋成型术,静脉血液郁积也会造成静脉扩张和内皮细胞损伤。术后血液中促凝血酶原激酶和纤维蛋白原水平升高，组织损伤处表面凝结被激活都导致了血液的高凝状态。为什么会形成DVT？当没有任何预防措施时，DVT在某些专科中的发生率高于50％但是，仅有25％的DVT患者会表现出症状O’Mearaetal.ProphylaxisforVenousThromboembolisminTotalHipArthroplasty.ORTHOPEDICS.深静脉血栓流行病学（外科各专业）ICU入住前存在的高危因素ICU期间获得的高危因素•近期手术•中心静脉导管•创伤、烧伤•脓毒症•恶性肿瘤和治疗因素•药物镇静、麻醉•脓毒症•机械通气•制动/卧床、中风、脊髓损伤•肌松治疗•高龄•药物治疗•心脏/呼吸衰竭•VTE病史•怀孕/产后•雌性激素高临床路径推荐RiskfactorsforVTEActivecancerorcancertreatmentAgeover60yearsCriticalcareadmissionDehydrationKnownthrombophiliasObesity(bodymassindex[BMI]over30kg/m2)Oneormoresignificantmedicalcomorbidities(forexample:heartdisease;metabolic,endocrineorrespiratorypathologies;acuteinfectiousdiseases;inflammatoryconditions)Personalhistoryorfirst-degreerelativewithahistoryofVTEUseofhormonereplacementtherapyUseofoestrogen-containingcontraceptivetherapyVaricoseveinswithphlebitisForwomenwhoarepregnantorhavegivenbirthwithintheprevious6weeksRegardmedicalpatientsasbeingatincreasedriskofVTEifthey:havehadorareexpectedtohavesignificantlyreducedmobilityfor3daysormoreorareexpectedtohaveongoingreducedmobilityrelativetotheirnormalstateandhaveoneormoreoftheriskfactorsRegardsurgicalpatientsandpatientswithtraumaasbeingatincreasedriskofVTEiftheymeetoneofthefollowingcriteria:surgicalprocedurewithatotalanaestheticandsurgicaltimeofmorethan90minutes,or60minutesifthesurgeryinvolvesthepelvisorlowerlimbacutesurgicaladmissionwithinflammatoryorintra-abdominalconditionexpectedsignificantreductioninmobilityoneormoreoftheriskfactorsRiskfactorsforbleedingActivebleedingAcquiredbleedingdisorders(suchasacuteliverfailure)Concurrentuseofanticoagulantsknowntoincreasetheriskofbleeding(suchaswarfarinwithinternationalnormalisedratio[INR]higherthan2)Lumbarpuncture/epidural/spinalanaesthesiaexpectedwithinthenext12hoursLumbarpuncture/epidural/spinalanaesthesiawithintheprevious4hoursAcutestrokeThrombocytopenia(plateletslessthan75x109/l)Uncontrolledsystolichypertension(230/120mmHgorhigher)Untreatedinheritedbleedingdisorders(suchashaemophiliaandvonWillebrand'sdisease)PharmacologicalVTEprophylaxisForexample:Generalmedicalpatientsfondaparinuxsodiumlowmolecularweightheparin(LMWH)unfractionatedheparin(UFH)(forpatientswithrenalfailure).StartpharmacologicalVTEprophylaxisassoonaspossibleafterriskassessmenthasbeencompleted.ContinueuntilthepatientisnolongeratincreasedriskofVTEPatientswithstrokePatientswithcancerPatientswithcentralvenouscathetersPatientsinpalliativecareAllsurgeryCardiacsurgeryGastrointestinal,gynaecological,thoracicandurological物理预防在ICU的优势：•ICU患者刚入院时大多具有消化道应激性溃疡出血风险•部分重症患者有凝血功能障碍、肾功能障碍•ICU患者本身情况复杂，用药难以掌握,出血并发症物理预防：ICU患者不可或缺19|静脉瓣后清除SCD压力系统提供最佳连续梯度压力模式使股静脉血流速度达到最大◦“理想的压力模式为踝部35mmHg，小腿30mmHg，大腿20mmHg。”◦“然而，由于广泛存在的个体差异，这个压力可以稍微增加（例如45，40，30mmHg）。”Covidien|26/08/2020|ConfidentialConfidential,©TycoCorporation22|Nicolaidesetal.IntermittentSequentialPneumaticCompressionoftheLegsinthePreventionofVenousStasisandPostoperativeDeepVenousThrombosis,Surgery1980:87:69-76大腿小腿踝部压力mmHgSCD压力系统在股静脉血液清除方面，速度明显优于小腿、单一压力系统.◦“SCD可以在很短的时间内清空静脉瓣后淤滞的血液，而如果只对小腿施压,相应的染色物质会停留长时间。”（小腿、单一压力系统）Confidential,©TycoCorporationCovidien|26/08/2020|ConfidentialMittlemanetal.EffectivenessofLegCompressioninPreventingVenousStasis.TheAmericanJournalofSurgery1982;144:611-613Covidien|26/08/2020|ConfidentialConfidential,©TycoCorporation25|静脉再充盈检测Covidien|26/08/2020|ConfidentialConfidential,©TycoCorporation26|血液移动总量━相同的情况在静脉曲张的病人中，仰卧位增加71.9%，半卧位增加77.9%，坐姿时增加55.7%。”Kakkosetal.Improvedhemodynamiceffectivenessandassociatedclinicalcorrelationsofanewintermittentpneumaticcomporessionsysteminpatientswithchronicvenousinsufficiency.JournalofVascularSurgery,Nov2019;Vol34,No.5,915-922将腿部血液清除达到最大值主机连接管腿套/足套（45mmHg,40mmHg,30mmHg）(130mmHg)腿部压力：◦预防深静脉血栓症和肺部栓塞足部压力：◦1.增强血液循环◦2.预防深静脉血栓症◦3.急性水肿◦4.慢性水肿◦5.外伤或外科手术引发的四肢疼痛◦6.腿部溃疡◦7.静脉郁积/静脉功能障碍腿部压力：◦任何有可能防碍充气压力带作用的腿局部情况，例如：（a）皮炎，（b）静脉结扎（在手术后即刻），（c）坏疽，或者（d）刚做完皮肤移植手术◦严重的动脉硬化症或其它缺血性血管病◦腿部大范围水肿或由充血性心力衰竭引发的肺部水肿◦腿部严重畸形◦疑似已出现深静脉血栓症足部压力：增强回流心脏的流速会有害的情况下◦充血性心力衰竭◦已出现深静脉血栓症、血栓(性)静脉炎或肺部栓塞◦对于手足部存在感染或感觉迟钝情况的患者，使用时必须非常小心“尽管梯度压力弹力袜外表看上去很简单，但是其中的设计却很复杂，对于技术细节的关注可以得到有效的预防方法。”Covidien|26/08/2020|ConfidentialConfidential,©TycoCorporation32|J.CapriniMD.Covidien|26/08/2020|ConfidentialConfidential,©TycoCorporation33|T.E.D.AntiembolismStockingT.E.D.抗血栓压力带OtherAntiembolismStocking其它抗血栓压力带•圆周镶嵌编织法•单向水平伸展确保抗血栓压力带的固定•圆周编织提供单向伸展确保压力分布正确定位•垂直伸展使尼龙袜滑落UsingtheKendallTEDstoc