1、圍術(shù)期大面積肺梗塞Perioperative Massive Pulmonary Embolism (PMPE)從 處理 到 預(yù)防,麻 醉 科 朱斌 黃宇光,Why 麻醉科 ？,Perioperative medicine -describes the consultation, care, or co-management of a patient undergoing surgery that is provided by an anesthesiologist, an internal medicine generalist or hospitalist.,Why 麻醉科 ？,瓶頸科室,

2、平臺科室,麻醉醫(yī)生是手術(shù)室的 “內(nèi)科醫(yī)生”,Confidential Enquiry into Perioperative Deaths (CEPOD) -reported in 1987 Unique to this study was the establishment of “crown privilege” by the government to allow total confidentiality The data or information sent to the Confidential Enquiry into Perioperative Deaths is theref

3、ore protected from subpoena ,Deaths occurring within 30 days after surgery were included in the study. There were 4034 deaths in an estimated 485,850 operations,Why me ？,面臨的問題慘痛的事件,北大醫(yī)院事件與風(fēng)波?!,男性，56歲，11-9因車禍致骨盆、恥骨骨折、多發(fā)肋骨骨折、肩胛骨骨折、腰椎壓縮性骨折。11-17全麻下行骨盆骨折內(nèi)固定術(shù)。術(shù)前PaO2 56,PaCO2 33。入室血壓120/80，HR 102，SpO2 94。

4、全麻順利，手術(shù)開始10min后Bp驟降至65/35， PETCO2 33迅速降至193mmHg，即刻給予升壓藥，Bp繼續(xù)降至3424mmHg，HR 107bpm, ECG示室早、室速，啟動CPR并動員全院力量搶救。搶救時(shí)間1小時(shí)50分鐘后放棄。,男性，30歲，一月前多處刀扎傷失血性休克、多科協(xié)作行急診手術(shù)。手術(shù)全程約12小時(shí)，由于缺乏血液供應(yīng)，術(shù)中較長時(shí)間血壓維持在5070/3040。待輸血后生命體征逐漸好轉(zhuǎn)，術(shù)畢送返ICU?；颊咴贗CU治療兩天后轉(zhuǎn)回泌尿外科病房，因?yàn)椴∏樾g(shù)后一直臥床，術(shù)后第5天突發(fā)呼吸心跳驟停，經(jīng)搶救無效死亡。尸檢證實(shí)為肺栓塞。,面臨的問題沉重的數(shù)據(jù),在美國，肺栓塞每年發(fā)病

5、約63萬70萬例 在美國或歐洲每年約有10-30萬死于PE 臨床死因第三位: 腫瘤、心肌梗死、肺栓塞 79%PE病人有DVT證據(jù)(二者共屬于VTE, 是同一疾病的兩個(gè)不同階段。) 11%PE死于發(fā)病1h以內(nèi)，89%存活至少1h以上； Heart 2008;94;795-802 N Engl J Med 2008;358:1037-52 N Engl J Med 2008;359:2804-13.,國內(nèi)PE死亡人數(shù)？ 全國肺栓塞協(xié)作組40家醫(yī)院19952006年統(tǒng)計(jì)的PE病例數(shù)從90 年 200 余例增加到2006 年的1859 例，增加近十倍（死亡率1015%） 中國介入放射學(xué)2008; 7:

6、276-277 骨科大手術(shù)后DVT發(fā)生率： 41%-60% 2009年中國骨科大手術(shù)靜脈血栓栓塞癥預(yù)防指南,面臨的問題沉痛的教訓(xùn),肺栓塞不應(yīng)被視為少見病、罕見病 不應(yīng)受到公眾和醫(yī)務(wù)人員的冷落與忽視 病因：血栓、心臟病、腫瘤、分娩、多發(fā)骨折,肺栓塞是三高一低： 發(fā)病率高、死亡率高、漏診率高、知曉率低,從DVT到PE,N Engl J Med 2008;358 （March）:1037-52,PMPE,51-71%DVT患者可能發(fā)生PE,DVT高危因素,深靜脈血栓形成的診斷和治療指南（2007）中華醫(yī)學(xué)會外科學(xué)分會血管外科學(xué)組,2009年中國骨科大手術(shù)靜脈血栓栓塞癥預(yù)防指南,DVT診斷的臨床評分,

7、深靜脈血栓形成的診斷和治療指南（2007年版） 中華醫(yī)學(xué)會外科學(xué)分會血管外科學(xué)組,DVT診斷流程,深靜脈血栓形成的診斷和治療指南（2007年版） 中華醫(yī)學(xué)會外科學(xué)分會血管外科學(xué)組,PE診斷流程-1,N Engl J Med 2008;359（12）:2804-13,無 低血壓 和 休克,PE診斷流程-2,N Engl J Med 2008;359（12）:2804-13,有 低血壓 和 休克,緊 急！,PE診斷流程-3 Perioperative Massive-PE,PE中高危病人（評分2） 氣管插管病人PETCO2突然劇降 循環(huán)突然崩潰 需要立即CPR CPR成功者才可能有機(jī)會確診,2/3

8、病人在出現(xiàn)循環(huán)崩潰后1小時(shí)內(nèi)死于PMPE 由于情況緊急,要求利用一切可能的手段快速有效地糾正病人MAP!,臨床鑒別診斷,PE風(fēng)險(xiǎn)分級及處理,N Engl J Med 2008;359（12）:2804-13,PE預(yù)防與處理,如前所述，強(qiáng)調(diào)PMPE的處理不如強(qiáng)調(diào)術(shù)前加強(qiáng)對DVT和PE高危病人的篩查 PMPE可能只有緊急的外科取栓和ECMO才可能有機(jī)會成功救治病人。,PE預(yù)防,強(qiáng)調(diào)DVT的術(shù)前篩查 梯度加壓彈力襪 強(qiáng)調(diào)術(shù)后早期活動 強(qiáng)調(diào)DVT和PE高風(fēng)險(xiǎn)病人圍術(shù)期的抗凝治療 DVT明確的病人術(shù)前應(yīng)有血管科會診，以決定血栓的處理及是否需要在術(shù)前植入下腔靜脈濾器,PUMCH 深靜脈血栓/肺栓塞（DVT

9、/PE）風(fēng)險(xiǎn)預(yù)警及預(yù)防流程草案 - 適應(yīng)癥,Assessment of risk and prophylaxis for deep vein thrombosis and pulmonary embolism in medically ill patients during their early days of hospital stay at a tertiary care center in a developing country. Vascular Health and Risk Management. 4 August 2009,PUMCH 深靜脈血栓/肺栓塞（DVT/PE）風(fēng)險(xiǎn)預(yù)

10、警及預(yù)防流程草案 - 禁忌癥,如存在上述問題，請相關(guān)專業(yè)科室會診（呼吸 or 血液 or 血管）,As noted earlier, about half of those who develop DVT/PE have two things in common. First, they have one or more identifiable risk factors for the disease. Second, they experience some sort of triggering event, such as hospitalization, trauma, surgery

11、, or a prolonged period of immobilization. The other half of those who get the disease have “unprovoked DVT/PE”that is, the reasons for the events are unknown. The search was conducted at on June 27, 2006, and more than 100 guidelines related to PE and DVT were found. The initial s

12、earch on the term “pulmonary embolism” produced 111 guidelines. While searching on the term “deep vein thrombosis” 88 guidelines were produced The National Quality Forum (NQF) now recommends that all hospitalized patients be evaluated upon admission and regularly thereafter, and that those found to

13、be at risk be given prophylaxis for VTE,A call to action is a science-based document to stimulate action nationwide to solve a major public health problem. Over the years, the Surgeon General has issued several calls to action. The first and most important document was the Report on Smoking and Heal

14、th issued in 1964.2 This warning about the health risks of cigarettes was issued by the Surgeon General at a time when smoking was common and fashionable. It caught the attention of the general public and set the groundwork for the subsequent 40 years of research and awareness that resulted in the lowest smoking rates in history. Now, 44 years later, the alarm has been sounded on ano