中危（次大面积）急性肺栓塞患者是否需要溶栓治疗

中危（次大面积）急性肺栓塞患者是否需要溶栓治疗已经争论了很多年。中危肺栓塞患者具有较高的死亡风险。因此,有人建议给予中危肺栓塞患者溶栓治疗,溶栓治疗可以更快地溶解血栓,从而降低中危肺栓塞患者的病死率。但也有研究表明,与单纯抗凝治疗比较,溶栓治疗不能进一步降低中危急性肺栓塞患者的病死率和复发率,且并发出血率较高。该文就中危急性肺栓塞溶栓治疗的有效性及安全性作一综述。     

重组组织型纤溶酶原激活剂与尿激酶治疗急性肺栓塞的对比研究

急性肺栓塞临床并不少见,病死率高,如果能及时诊断并给予溶栓治疗可明显降低病死率.溶栓治疗已成为急性肺栓塞治疗常规之一.溶栓药物以尿激酶(UK)应用比较广泛,也取得了较好的疗效,但有时会出现出血等并发症.重组组织型纤溶酶原激活剂(rt-PA)是新型溶栓剂,采用细胞重组DNA技术生产,不具有抗原性,其直接将纤溶酶原转变成纤溶酶,对纤维蛋白比UK更具有特异性,国内外均已开始用于急性肺栓塞的溶栓治疗.我们以我院呼吸内科收治的急性肺栓塞患者为研究对象,探讨rt-PA及UK在急性肺栓塞溶栓治疗中的应用价值.     

9例急性肺栓塞患者溶栓的急救护理

目的：总结急性肺栓塞溶栓的护理体会。方法：对9例急性肺栓塞溶栓患者加强呼吸道的护理、合理使用静脉、准确及时的应用溶栓药物、严密观察病情变化、预防出血并发症的发生、严格执行各项操作规程以防感染的发生。结果：本组9例中治愈7例,好转2例。结论：探讨急性肺栓塞患者早期实施溶栓治疗,并给予全面的护理,可有效减少并发症,降低死亡率,提高抢救成功率。     

尿激酶溶栓治疗急性肺栓塞近远期疗效评价

目的探讨采用尿激酶溶栓治疗急性肺栓塞的近期、远期疗效。方法随机将急性肺栓塞病例67例分为治疗组34例、对照组33例,两组均采用抗凝治疗,治疗组另加用尿激酶溶栓治疗。结果治疗组总有效率94.1%,明显高于对照组总有效率72.7%(24/33),差异有显著性(χ2=5.58,P<0.05);两组出血发生率比较无统计学差异(P>0.05);67例患者均获得24个月随访,两组肺栓塞再发率比较无显著差异(P>0.05)。结论对急性肺栓塞患者给予尿激酶溶栓治疗近期疗效明显,且不增加远期肺栓塞再发率,安全可行。     

大面积急性肺栓塞11例急诊溶栓治疗

急性肺血栓栓塞症(肺栓塞)是严重威胁人类健康的疾病.国内近年对该病的发现越来越多.肺栓塞(PE)的溶栓治疗始于20世纪60年代,当时被医学界视为"勇敢"的最后治疗手段,在临床上很少使用.尽管几乎所有的临床试验都能肯定溶栓治疗的神奇疗效,但对于溶栓治疗可能带来大出血并发症(出血发生率3%～30%),特别是致死性颅内出血(12%～16%)的风险,致使许多医务工作者对溶栓治疗PE甚为担忧.     

不同评分系统对急性脑梗死静脉溶栓后出血转化风险预测差异的比较研究

目的探析不同评分系统对不同时间窗急性脑梗死静脉溶栓后出血转化风险预测差异的应用效果。方法选取我院2017年3月至2018年3月收治的64例急性脑梗死静脉溶栓患者,随机将其等分为对照组和研究组,对照组患者采用MSS模型量表测评,研究组采用HAT模型量表,比较两组患者静脉溶栓后出血转化预测发生率和出血转化预测满意度。结果研究组患者出血转化发生率高于对照组(P0.05);在对两组患者静脉溶栓后出血转化进行预测时,研究组患者满意度高于对照组(P0.05)。结论急性脑梗死发病迅速,死亡率较高,在发病4.5 h内给予静脉溶栓至关重要,HAT评分系统对静脉溶栓后转化具有更高的预测价值。     

胸部手术后急性肺栓塞的诊疗

目的　总结胸部手术后急性肺栓塞的诊治体会。方法　回顾性总结 13例胸部手术后急性肺栓塞的病例。结果　抢救成功 8例 ,死亡 5例 ,死亡率 38 4 %。溶栓后胸内出血 4例 ,死亡与胸内出血无关。结论　胸部手术后急性肺栓塞患者要及时给予气管内插管、机械通气支持及溶栓治疗 ,溶栓后有引起胸腔内出血的可能 ,但溶栓是必要的。     

一例肺栓塞心肺复苏中应用溶栓治疗的救护

急性肺栓塞是临床常见致死性疾病,如果得不到及时正确的诊断及治疗,肺栓塞的病死率高达30%[1].近年来,临床上开始对心肺复苏后的严重性肺栓塞患者采取溶栓治疗,获得成功救治的报道已陆续可见,但在心肺复苏进程中同时应用溶栓治疗的报道尚不多见.     

1例急性肠系膜上静脉血栓形成患者行肠部分切除术后并发急性肺栓塞的护理

总结1例急性肠系膜上静脉血栓形成患者行肠部分切除术后并发急性肺栓塞救治成功的护理经验。护理要点：入院时重视血栓风险评估及预见性护理,溶栓治疗时严密观察病情,警惕出血;对急性肺栓塞先兆症状提高警惕,及时报告,严密观察;肺栓塞溶栓期间,警惕二次栓塞和出血;再次手术后,及时排查血栓风险,做好术后康复护理,防止病情复发。经过精心治疗及护理,本例患者治愈出院。出院前未见血栓形成,肠道缺血症状明显改善,已行全肠内营养支持,无腹痛、腹胀等不适。     

急性肺栓塞患者应用rt-PA溶栓8例护理体会

目的：总结护理在急性肺栓塞患者应用rt-PA溶栓疗法中的作用。方法：应用rt-PA为急性肺栓塞8例进行溶栓治疗。结果：8例溶栓均获成功。结论：急性肺栓塞早期应用rt-PA溶栓，效果优于其他溶栓药物。溶栓疗法专业性强，护士不但要熟练掌握护理基础理论及技术操作，而且要认识和掌握rt-PA溶栓的要点和操作步骤，加强对病情的监护，促进急性肺栓塞患者早日康复。     

Thrombolysis in cardiopulmonary resuscitation

The prognosis of patients suffering cardiac arrest is still poor. Until today, no drug therapy has shown to improve longterm survival after cardiac arrest. Thrombolysis has been shown to be an effective therapy in patients with acute myocardial infarction (AMI) or massive pulmonary embolism (PE). Since 50-70% of cardiac arrests are caused by AMI or massive PE, the combination of cardiopulmonary resuscitation (CPR) and thrombolytic therapy appears to be sensible. As experimental studies have shown, thrombolytic therapy during CPR may not only be a causal treatment for coronary or pulmonary arterial obstruction by thrombi, but may also improve microcirculatory reperfusion after cardiac arrest. Although numerous small clinical studies have shown the efficacy of thrombolysis during CPR in selected patients, the generalized treatment of patients suffering cardiac arrest with thrombolytics can not be recommended based on current clinical evidence. According to the recent CPR guidelines, thrombolysis may be considered in cardiac arrest patients with suspected massive PE or as a so-called rescue therapy after unsuccessful conventional CPR in patients with a suspected thrombotic cause of cardiac arrest. The risk of severe bleeding complications following thrombolysis during CPR seems to be outweighed by the potential benefit of this therapy in selected patients.     

Thrombolytic therapy and outcome of patients with an acute symptomatic pulmonary embolism

Background:  While the primary therapy for most patients with a pulmonary embolism (PE) consists of anticoagulation, the efficacy of thrombolysis relative to standard therapy remains unclear. Methods:  In this retrospective cohort study of 15 944 patients with an objectively confirmed symptomatic acute PE, identified from the multicenter, international, prospective, Registro Informatizado de la Enfermedad TromboEmbólica (RIETE registry), we aimed to assess the association between thrombolytic therapy and all‐cause mortality during the first 3 months after the diagnosis of a PE. After creating two subgroups, stratified by systolic blood pressure (SBP) (< 100 mm Hg vs. other), we used propensity score‐matching for a comparison of patients who received thrombolysis to those who did not in each subgroup. Results:  Patients who received thrombolysis were younger, had fewer comorbid diseases and more signs of clinical severity compared with those who did not receive it. In the subgroup with systolic hypotension, analysis of propensity score‐matched pairs (n = 94 pairs) showed a non‐statistically significant but clinically relevant lower risk of death for thrombolysis compared with no thrombolysis (odds ratio [OR] 0.72; 95% confidence interval [CI], 0.36–1.46; P = 0.37). In the normotensive subgroup, analysis of propensity score‐matched pairs (n = 217 pairs) showed a statistically significant and clinically meaningful increased risk of death for thrombolysis compared with no thrombolysis (OR 2.32; 95% CI, 1.15–4.68; P = 0.018). When we imputed data for missing values for echocardiography and troponin tests in the group of normotensive patients, we no longer detected the increased risk of death associated with thrombolytic therapy. Conclusions:  In normotensive patients with acute symptomatic PE, thrombolytic therapy is associated with a higher risk of death than no thrombolytic therapy. In hemodynamically unstable patients, thrombolytic therapy is possibly associated with a lower risk of death than no thrombolytic therapy. However, study design limitations do not imply a causal relationship between thrombolytics and outcome.     

Successful thrombolysis after pulmonary embolectomy for persistent massive postoperative pulmonary embolism

Massive postoperative pulmonary embolism (PE) is associated with a poor prognosis in patients presenting with haemodynamic instability. Since recent surgery is a commonly accepted contraindication for thrombolytic therapy, pulmonary embolectomy is an appropriate therapeutic approach in these patients. If life-threatening symptoms of PE persist after pulmonary embolectomy, however, very few other therapeutic options are available. We report the successful use of locally administered low-dose thrombolysis 2 days after pulmonary embolectomy in a patient with postoperative PE and persistent severe hypoxaemia and pulmonary hypertension. During and after thrombolysis, no bleeding complications occurred. We conclude that low-dose thrombolysis for PE may be considered even in patients who have recently undergone major thoracic and abdominal surgery if embolectomy and continued intravenous heparin have failed to be successful and life-threatening symptoms of PE persist.     

Evolving paradigm of thrombolysis in pulmonary embolism: Comprehensive review of clinical manifestations,indications, recent advances and guideline

Thrombolytic therapy has been the mainstay for patients with pulmonary embolism (PE). Despite being linked to a higher risk of significant bleeding, clinical trials demonstrate that thrombolytic therapy should be used in patients with moderate to high-risk PE, in addition to hemodynamic instability symptoms. This prevents the progression of right heart failure and impending hemodynamic collapse. Diagnosing PE can be challenging due to the variety of presentations; therefore, guidelines and scoring systems have been established to guide physicians to correctly identify and manage the condition. Traditionally, systemic thrombolysis has been utilized to lyse the emboli in PE. However, newer techniques for thrombolysis have been developed, such as endovascular ultrasound-assisted catheter-directed thrombolysis for massive and intermediate-high submassive risk groups. Additional newer techniques explored are the use of extracorporeal membrane oxygenation, direct aspiration, or fragmentation with aspiration. Because of the constantly changing therapeutic options and the scarcity of randomized controlled trials, choosing the best course of treatment for a given patient may be difficult. To help, the Pulmonary Embolism Reaction Team is a multidisciplinary, rapid response team that has been developed and is used at many institutions. Hence to bridge the knowledge gap, our review highlights various indications of thrombolysis in addition to the recent advances and management guidelines     

Bolus injection of thrombolytic agents during cardiopulmonary resuscitation for massive pulmonary embolism

Thrombolytic therapy has proved to be efficacious in the treatment of massive and fulminant pulmonary embolism (PE), but thrombolysis has been considered as contraindicated during cardiopulmonary resuscitation (CPR). This review on the administration of thrombolytic agents in patients who have suffered massive PE necessitating CPR summarises 14 anecdotal reports and three case series involving 34 patients. The case series revealed an overall initial survival rate of 55–100% following bolus administration of thrombolytic agents. In general, bleeding complications were managed conservatively. The establishment of the diagnosis may be feasible using echocardiography or bedside angiography during CPR. However, therapeutic measures should be taken without delay; the patient's history and the clinical picture may thus be the only diagnostic criteria. Even where myocardial infarction is misinterpreted as PE during CPR, bolus injection of a thrombolytic agent can be an appropriate therapeutic option. An alternative may be mechanical catheter fragmentation of the thrombus with subsequent local thrombolysis. Surgery may be restricted to hospitals with ready access to extracorporeal circulation. We conclude that early administration of thrombolytic agents during PE necessitating CPR may help to reduce mortality. We favour the administration of urokinase (2– to 3 000 000-U bolus) or rt-PA.     

急性缺血性脑卒中阿替普酶静脉溶栓后24小时内出血并发症分析#br#

目的 分析阿替普酶静脉溶栓治疗急性脑梗死24小时内出血并发症和相关风险因素。方法 收集我科在时间窗内的阿替普酶静脉溶栓治疗急性脑梗死200例患者资料，包括年龄、性别、既往病史、不良嗜好、血压、血糖、血脂、肝肾功能、血小板计数、凝血功能等，分析溶栓后出血并发症情况和相关影响因素。结果 200例溶栓患者中发生系统和颅内出血41例，出血率为20.5%(41/200)，脑内出血转换率仅为1.5%（3/200）。包括牙龈出血21例、舌部出血9例、舌部+牙龈出血2例、皮下出血1例、消化道出血3例、泌尿道出血1例、梗死灶内出血2例、舌部+梗死灶内出血1例、脑室内出血1例；所有出血患者中无严重致残、致死病例。回归分析结果显示，心房颤动是患者溶栓后发生出血的独立危险因素（P<0.05）。结论 阿替普酶静脉溶栓出血转换率非常低，心房颤动是患者溶栓后发生出血的独立危险因素。阿替普酶静脉溶栓治疗急性脑梗死是有效、安全的，但治疗要个体化。     

超声辅助导管溶栓在肺血栓栓塞症中的应用进展

肺血栓栓塞症(pulmonary thromboembolism, PTE)是心血管疾病中导致患者死亡的第三大常见原因。在真实世界中,因担心出现大出血等风险,仅20%～30%的高危PTE患者接受了系统性溶栓治疗,虽然中危PTE患者接受系统性溶栓可降低死亡率,但出血风险远高于获益。超声辅助导管溶栓可在血栓部位直接释放溶栓药物,所需药物剂量更低,且超声波可促进血栓溶解,有望成为一种安全、有效的溶栓新手段。本文将介绍超声辅助导管溶栓的机制、所需设备与操作程序、安全性与有效性等,并对未来的研究方向提出展望。     

Thrombolytic therapy in acute myocardial infarction: Part I

Thrombolytic therapy with pharmacologic agents is an exciting approach to the treatment of myocardial infarction. The results of several clinical studies indicate that perfusion can be restored with intravenous therapy and may be associated with a reduction in infarct size and improved left ventricular function. In a trial involving more than 11,000 patients, thrombolytic therapy reduced acute and long term mortality. Pharmacologic thrombolysis, however, is not without problems. When administered intravenously, the agents currently available, streptokinase and urokinase, are associated with a relatively low recanalization rate as well as a risk of adverse effects, most commonly a systemic lytic state and risk of bleeding complications. Although intracoronary administration is associated with a higher rate of recanalization, the need for cardiac catheterization limits its applicability and results in a delay in the initiation of thrombolytic therapy (which diminishes salvage of myocardium). The trials assessing the existing agents have shown that time is a critical variable in the success of thrombolytic therapy. This had led investigators to focus more attention on intravenous agents that can be administered rapidly. The newer agents now under investigation, acylated streptokinase and single-chain urokinase, may represent improvements of currently available products and may offer potentially increased benefits. A fibrinogen-sparing agent, such as t-PA, in addition to being highly effective, may offer advantages through minimizing the systemic lytic effect. Additional randomized, controlled clinical trials currently are underway to determine the effect on mortality of this "fibrinolytic" therapy as part of a total treatment regimen. The current status of our knowledge concerning thrombolytic therapy in acute myocardial infarction can be summarized as follows: 1. Transmural (that is, Q wave) myocardial infarction usually is caused by an obstructing coronary thrombus. 2. The thrombus can be lysed with intravenous therapy in the majority of cases, particularly with newer, well-tolerated fibrin-specific agents. 3. There is considerable evidence suggesting that reperfusion reduces the acute morbidity and mortality when therapy is administered successfully within the initial 3 to 4 hours (and possibly up to 6 hours) after onset of symptoms. 4. Data on long term prognosis after thrombolysis are very encouraging, although limited. 5. Conventional agents lead to significant fibrinogen depletion and therefore an increased risk of bleeding; the new fibrin-selected agents cause less fibrinogen degradation and may reduce the risk of hemorrhagic complications.(ABSTRACT TRUNCATED AT 400 WORDS)     

Prehospital thrombolysis during cardiopulmonary resuscitation

Although prehospital cardiac arrest has an incidence of 40-90/100,000 inhabitants per year, there has been a lack of therapeutic options to improve the outcome of these patients. Of all cardiac arrests, 50-70% are caused by acute myocardial infarction (AMI) or massive pulmonary embolism (PE). Thrombolysis has been shown to be a causal and effective therapy in patients with AMI or PE who do not suffer cardiac arrest. In contrast, experience with the use of thrombolysis during cardiac arrest has been limited. Thrombolysis during cardiopulmonary resuscitation (CPR) acts directly on thrombi or emboli causing AMI or PE. In addition, experimental studies suggest that thrombolysis causes an improvement in microcirculatory reperfusion after cardiac arrest. In-hospital and prehospital case series and clinical studies suggest that thrombolysis during CPR may cause a restoration of spontaneous circulation and survival even in patients that have been resuscitated conventionally without success. In addition, there is evidence for an improved neurological outcome in patients receiving a thrombolytic therapy during during CPR. A large randomized, double-blind multicenter trial that has started recently is expected to show if this new therapeutic option can generally improve the prognosis of patients with cardiac arrest.