1、Prevention and Treatment of Perioperative Venous Thromboembolism (VTE),Gordon H. Guyatt, et al. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. CHEST 2012; 141(2)(Suppl):7S47S.,Deep Venous Thrombosis (DVT)

2、,Pulmonary Embolism (PE),VTE-related deaths,200,000 per year in US 1/3 occur following surgery 23-fold for cancer patients,Prophylaxis?,VTE,Bleeding,VTE 71% Death 46%,Major bleeding 103% Wound hematoma 88%,Mismetti P, et al. Meta-analysis of low molecular weight heparin in the prevention of venous t

3、hromboembolism in general surgery .Br J Surg . 2001 ; 88 ( 7 ): 913 - 930 .,Caprini Risk Assessment Model,Caprini風(fēng)險(xiǎn)評(píng)分,VTE RiskFor General Surgery,Including GI, Urological, Vascular, Breast, and Thyroid Procedures,Risk Factors for Major Bleeding Complications,General risk factors Active bleeding Prev

4、ious major bleeding Known, untreated bleeding disorder Severe renal or hepatic failure Thrombocytopenia Acute stroke Uncontrolled systemic hypertension Lumbar puncture, epidural, or spinal anesthesia within previous 4 h or next 12 h Concomitant use of anticoagulants, antiplatelet therapy, or thrombo

5、lytic drugs,Risk Factors for Major Bleeding Complications,Procedure-specific risk factors Abdominal surgery Male sex, preoperative hemoglobin level 13 g/dL, malignancy, and complex surgery defined as two or more procedures, difficult dissection, or more than one anastamosis Pancreaticoduodenectomy S

6、epsis, pancreatic leak, sentinel bleed Hepatic resection Number of segments, concomitant extrahepatic organ resection, primary liver malignancy, lower preoperative hemoglobin level, and platelet counts,Risk Factors for Major Bleeding Complications,Procedure-specific risk factors Cardiac surgery Use

7、of aspirin Use of clopidogrel within 3 d before surgery BMI 25 kg/m2, nonelective surgery, placement of five or more grafts, older age Older age, renal insufficiency, operation other than CABG, longer bypass time Thoracic surgery Pneumonectomy or extended resection,Risk Factors for Major Bleeding Co

8、mplications,Procedures in which bleeding complications may have especially severe consequences Craniotomy Spinal surgery Spinal trauma Reconstructive procedures involving free flap,Prevention of VTE in General and Abdominal-pelvic Surgical Patients,Recommendations are classified as strong (Grade1) o

9、r weak (Grade2), according to the balance between benefits, risks, burden, and cost, and the degree of confidence in estimates of benefits, risks, and burden. Quality of evidence are classified as high (GradeA), moderate (GradeB), or low (GradeC) according to factors that include the risk of bias, p

10、recision of estimates, the consistency of the results, and the directness of the evidence.,Prevention of VTE in General and Abdominal-pelvic Surgical Patients,Perioperative Management ofAntithrombotic Therapy,Vitamin K Antagonist (VKA) : warfarin, acenocoumarol, phenprocoumon, and anisindione Antipl

11、atelet drugs: Acetylsalicylic Acid, clopidogrel, dipyridamole, and nonsteroidal antiinflammatory drug USE or NOT?,Vitamin K Antagonist (VKA),In patients undergoing major surgery or procedures, interruption of VKAs, in general, is required to minimize perioperative bleeding, whereas VKA interruption

12、may not be required in minor procedures. In patients who require temporary interruption of a VKA before surgery, we recommend: stopping VKAs approximately 5 days before surgery (1C) resuming VKAs approximately 12 to 24 h after surgery (evening of or next morning) (2C),Bridging Anticoagulation,In pat

13、ients with a mechanical heart valve, atrial fibrillation, or VTE at high risk for thromboembolism, we suggest bridging anticoagulation (LMWH or UFH) during interruption of VKA therapy (2C) low risk for thromboembolism, we suggest no-bridging anticoagulation (2C) In patients who are receiving bridgin

14、g anticoagulation we suggest stopping LMWH 24 h before surgery (2C) UFH 46 h before surgery (2C),Bridging Anticoagulation,In patients who are receiving bridging anticoagulation with therapeutic-dose SC LMWH and are undergoing high-bleeding-risk surgery, we suggest resuming therapeutic-dose LMWH 4872

15、 h after surgery (2C) . In patients who are receiving bridging anticoagulation with therapeutic-dose SC LMWH and are undergoing non-high-bleeding-risk surgery, we suggest resuming therapeutic-dose LMWH approximately 24 h after surgery.,Acetylsalicylic Acid (ASA),In patients at moderate to high risk

16、for cardiovascular events who are receiving ASA therapy and require noncardiac surgery, we suggest continuing ASA around the time of surgery (2C) . In patients at low risk for cardiovascular events who are receiving ASA therapy, we suggest stopping ASA 7 to 10 days before surgery(2C) .,Antithromboti

17、c Therapy for VTE Disease,Initial Treatment Long-term Therapy(initial treatment 3 months) Patients with no cancer VKA (2C) LMWH (2C) Patients with cancer LMWH (2B) VKA (2B) Extended Therapy(beyond 3 months) same as the first 3 months (2C),Clinical Suspicion of Acute VTE,High clinical suspicion: trea

18、tment with parenteral anticoagulants while awaiting the results of diagnostic tests (2C) Intermediate clinical suspicion: treatment with parenteral anticoagulants if the results of diagnostic tests are expected to be delayed for more than 4 h (2C) Low clinical suspicion: not treating with parenteral

19、 anticoagulants while awaiting the results of diagnostic tests, provided test results are expected within 24 h (2C),Initial Treatment of DVT,In patients with acute DVT, we recommend early initiation of VKA (eg, same day as parenteral therapy is started), and continuation of parenteral anticoagulatio

20、n (LMWH, fondaparinux, IV UFH, or SC UFH) for a minimum of 5 days and until the INR is 2.0 or above for at least 24 h (1B) . early ambulation over initial bed rest (2C) anticoagulant therapy alone over catheter-directed thrombolysis (CDT) (2C) , systemic thrombolysis (2C), operative venous thrombect

21、omy(2C), IVC filter(1B),Initial Treatment of Acute PE,In patients with acute PE, we recommend early initiation of VKA (eg, same day as parenteral therapy is started), and continuation of parenteral anticoagulation (LMWH, fondaparinux, IV UFH, or SC UFH) for a minimum of 5 days and until the INR is 2

22、.0 or above for at least 24 h (1B) .,Intensity of Anticoagulant Effect,In patients with VTE who are treated with VKA, we recommend a therapeutic INR range of 2.0 to 3.0 (target INR of 2.5) over a lower (INR , 2) or higher (INR 3.0-5.0) range for all treatment durations (1B) .,Duration of Anticoagula

23、nt Therapy,Systemic Thrombolytic Therapy,In patients with hypotension who do not have a high risk of bleeding, we suggest systemically administered thrombolytic therapy over no such therapy (2C) . In most patients without hypotension, we recommend against systemically administered thrombolytic thera

24、py (1C) . In selected patients without hypotension and with a low risk of bleeding whose initial clinical presentation or clinical course after starting anticoagulant therapy suggests a high risk of developing hypotension, we suggest administration of thrombolytic therapy (2C) .,Catheter-Based Thrombus Removal,In patients with hypotension, we suggest surgical catheter-assisted thrombus removal if they have contraindications to thr