妇科盆腔术后深静脉血栓的诊治体会

目的探讨妇科盆腔术后并发下肢深静脉血栓(DVT)的诊断治疗要点及预防措施。方法回顾性分析我院5例妇科DVT患者的临床特点及诊断、治疗和预防的方法。结果 5例临床有症状的可疑DVT患者,血浆D二聚体测定均大于500μg,通过彩色多普勒超声(彩超)确诊。确诊后采用尿激酶溶栓和肝素或低分子肝素抗凝及口服华法令等治疗,血栓完全溶解3例,部分溶解2例,症状均明显改善,无肺栓塞发生。结论通过彩色多普勒超声检查结合D二聚体升高及典型临床表现能明确诊断深静脉血栓,及时进行抗凝、溶栓治疗对DVT有较好疗效。术前纠正贫血,术中操作精细、减轻对髂静脉及其属支的刺激,术后鼓励患者早期下床活动是预防深静脉形成的主要方法;对有高危因素者术后可考虑预防性抗凝治疗。     

术后肺不张与下肢深静脉血栓形成的预防与护理

目的探讨预防术后肺不张与下肢深静脉血栓形成的预防与护理措施并评价其效果。方法回顾性分析2005年10月以来我院施行的部分腹部和大隐静脉手术的病人并发肺不张和下肢深静脉血栓的情况及其护理措施。结果85例病人中并发肺不张7例,发生率8％,其中1例死于MOF,其余病例经雾化吸入、祛痰、训练正确深呼吸等措施;并发下肢深静脉血栓形成5例,占6％,给予低分子肝素抗凝治疗,其中股青肿1例应用溶栓治疗留有明显后遗症,余均完全或部分再通。结论雾化吸入、祛痰、正确训练深呼吸是预防术后肺不张发生的有效措施;促进下肢静脉回流防止血液淤滞可有效减少DVT的发生。     

缺血性脑卒中病人并发下肢深静脉血栓38例的临床分析

目的通过对38例缺血性脑卒中(cerebral infarction CI)病人并发的下肢深静脉血栓形成(deep veins thrombosis in lower limb LDVT)进行临床分析,探讨其临床表现、诊断、治疗及预防的对策。方法本文对38例CI后LDVT患者的原始资料进行回顾性分析,分析这些患者的一般状况、临床特点,并对其进行了静脉尿激酶溶栓和肝素或低分子肝素抗凝治疗。结果CI病人并发LDVT的发病率为14%,70岁以上为61%;最多见的原发病为脑梗塞18例(33%),脑栓塞14例(26%).下肢高度水肿伴疼痛为其主要症状。通过静脉尿激酶溶栓和肝素/低分子肝素抗凝治疗,7～14d内所有深静脉血栓的症状逐渐消失。结论下肢深静脉血栓的发病率高,静脉壁损伤,血流缓慢和高凝状态是CI患者发生LDVT的因素,应对高龄的、长期卧床的并有深静脉血栓倾向的中风病人给予必要的预防;溶栓与抗凝疗法是治疗深静脉血栓的有效手段之一。尿激酶溶栓是本病治疗的良药。早期预防和早期治疗至关重要。     

腹腔镜子宫全切术后应用抗凝药物预防下肢深静脉血栓形成的临床研究

目的 探讨腹腔镜子宫全切术后应用抗凝药物预防下肢深静脉血栓形成的临床意义.方法 选取行腹腔镜子宫全切100例患者为研究对象,根据发生深静脉血栓(DVT)的风险程度分成观察高、中、低危组,再将每组随机分配到观察组(50例)和对照组(50例),A组术后24 h使用低分子肝素钙(澳思达)4 100 U皮下注射,1次/d,连用5 d,对照组术后不给予抗凝药物预防.结果 观察组下肢深静脉血栓的患肢发生率为0(0/50),对照组为8%(4/50),观察组明显低于对照组(P<0.05).结论 腹腔镜子宫全切术后的患者应用低分子肝素钙可以明显减少术后下肢深静脉血栓的发生.妇科腹腔镜子宫切除术后应用抗凝药物对预防下肢深静脉血栓有显著的临床意义.     

低分子肝素预防人工全髋关节置换术后下肢深静脉血栓形成的临床疗效

目的 探讨低分子肝素(LMWH)预防人工全髋关节置换术(THR)后下肢深静脉血栓(DVT)形成的疗效和安全性.方法 选择40岁以上全髋关节置换病人43例,3个月内无血栓栓塞性疾病史,无凝血功能障碍,术前经彩色多普勒超声法筛查,双下肢无DVT.随机分成两组:预防组21例,应用LMWH预防DVT;对照组22例,不采用任何预防措施.术后第7天行彩色多普勒超声检查,评价下肢深静脉通畅情况.结果 对照组中9例发生DVT,占40.9%;预防组中3例发生DVT,占14.3%(P＜0.05).两组均未发生明显的出血并发症.结论 LMWH能安全、有效地预防全髋关节术后深静脉血栓形成.     

下肢深静脉血栓形成临床分析

深静脉血栓形成(DVT)是指血液成分在深静脉系统血管腔内不正常凝结,阻塞静脉管腔,导致的静脉回流障碍。DVT多发生于下肢深静脉。我院1998年12月至2011年3月共收住院治疗下肢深静脉血栓形成患者660例,其中只有8例因急性股青肿行手术取栓治疗,对652例采用了经患肢静脉点滴尿激酶区域性溶栓,同时辅以抗凝、祛聚集治疗,后期口服华法令     

多导管介入治疗下肢深静脉血栓形成

目的探索联合介入治疗下肢深静脉血栓(DVT)的方法。方法回顾性分析近4年来治疗的101例下肢DVT的临床资料。结果本组101例中98例术中股、髂静脉获得通畅,通畅率97．0％。结论联合介入治疗下肢深静脉血栓是治疗下肢深静脉血栓的有效方法。     

急性下肢深静脉血栓形成的手术治疗进展

下肢深静脉血栓形成(deep venous thrombosis,DVT)并非少见,文献报告的尸检发现率为35%～52%[1],经静脉造影证实有症状的DVT发病率1.6%[2].对于急性下肢静脉血栓形成的治疗,目前仍存在很大争议.多数学者认为应采取抗凝、溶栓等非手术治疗方式.但血栓完全溶解率低,有资料显示髂股静脉血栓溶解成功率只有28%[3],且难以有效避免深静脉血栓后综合征的发生[4].近年来,随着在手术取栓后联合加作临时性的动静脉瘘以及手术联合溶栓、抗凝、祛聚等综合治疗的研究,使手术治疗DVT又得以发展并受到重视.     

经股静脉径路置入临时心脏起搏器致下肢深静脉血栓的护理体会

目的:总结经股静脉径路置入临时心脏起搏器致下肢深静脉血栓的护理体会.方法:对5例经股静脉径路致下肢深静脉血栓的患者采取积极、有效、全面的治疗及护理措施.结果:5例患者均痊愈出院.结论:密切观察患者术肢的颜色、皮温、腿围及有无疼痛.一旦形成血栓应积极配合医生进行治疗和护理,防止血栓脱落造成重要要脏器的栓塞,确保患者生命安全.     

普通外科围手术期深静脉血栓的防治

研究证实我国深静脉血栓（DVT）发病率与发达国家巳无明显区别。普通外科围手术期DVT的发生率也逐渐增多，其特点是盆腔肿瘤和胆道手术后发病率较高，经下肢静脉大剂量注射各种药物成为诱发DVT的原因。DVT不但增加了肺动脉栓塞（PE）的危险，并且明显增加了住院时间和治疗费用。安全有效地抗凝溶栓治疗对降低并发症、死亡率和缩短住院时间有重要意义。     

Cost-effectiveness of Argatroban Versus Heparin Anticoagulation in Adult Extracorporeal Membrane Oxygenation Patients

Purpose: The purpose of this study was to evaluate the cost effectiveness of argatroban compared to heparin during extracorporeal membrane oxygenation (ECMO) therapy. Methods: This was a retrospective study of patients who received argatroban or heparin infusions with ECMO therapy at a community hospital between January 1, 2017 and June 30, 2018. Adult patients who received heparin or argatroban for at least 48 hours while on venovenous (VV) or venoarterial (VA) ECMO were included. Patients with temporary mechanical circulatory assist devices were excluded. Each continuous course of anticoagulant exposure that met the inclusion criteria was evaluated. The primary endpoint was the total cost of anticoagulant therapy for heparin versus argatroban, including all administered study drugs, blood or factor products, and associated laboratory tests. Secondary endpoints included safety and efficacy of anticoagulation with each agent during ECMO. Documentation of bleeding events, circuit clotting, and ischemic events were noted. Partial thromboplastin time (PTT) values were evaluated for time to therapeutic range and percentage of therapeutic PTTs. Results: A total of 11 courses of argatroban and 24 courses of heparin anticoagulation were included in the study. The average cost per course of argatroban was less than the average cost per course of heparin ($7,091.98 vs $15,323.49, respectively; P value = 0.15). Furthermore, argatroban was not associated with an increased incidence of bleeding, thrombotic, or ischemic events. Conclusion: Argatroban may be more cost-effective during ECMO therapy in patients with low antithrombin III levels without increased risk of adverse events.     

人工肝支持系统治疗肝衰竭术后并发下肢深静脉血栓形成的处理策略

目的明确人工肝支持系统(ALSS)治疗肝衰竭(LF)病人术后并发下肢深静脉血栓形成的处理策略。方法回顾性分析2019年1月至2021年9月安徽医科大学第一附属医院收治的经ALSS治疗的肝衰竭病人216例，选择有临床症状并经彩     

Current Management of Acute Symptomatic Deep Vein Thrombosis

Venous thromboembolism is a common and potentially fatal disease. If properly used, anticoagulation therapy is effective in preventing recurrence of venous thromboembolism and in improving survival. Symptomatic patients with an objective diagnosis of acute deep vein thrombosis (DVT) or pulmonary embolism (PE) should receive immediate systemic heparin anticoagulation at dosages sufficient to rapidly prolong the activated partial thromboplastin time into the laboratory-specific therapeutic range; this range corresponds to a plasma heparin concentration of 0.2 to 0.4 IU/ml (as measured by protamine sulfate titration), or 0.3 to 0.7 anti-Xa IU/ml. An oral vitamin K antagonist (e.g. warfarin) should be started within 24 hours after starting heparin; the starting dose should be the estimated patient-specific daily dose with no loading dose. Heparin and warfarin anticoagulation should be overlapped for at least 4 to 5 days and until the international normalized ratio (INR) is within the therapeutic range (2.0 to 3.0) on 2 measurements made at least 24 hours apart. The duration of warfarin anticoagulation should be individualized based on the respective risks of venous thromboembolism recurrence and anticoagulant-related bleeding. In general, warfarin should be continued for at least 3 months, and longer for patients with recurrent or idiopathic venous thromboembolism, malignant neoplasm, neurologic disease with extremity paresis, obesity, or laboratory evidence of a lupus anticoagulant/anticardiolipin antibody, homozygous carrier or combined heterozygous carrier for the factor V R506Q (Leiden) and prothrombin G20210A mutations, and possibly deficiency of either antithrombin, protein C, or protein S. Low molecular weight heparin (LMWH) is effective and well tolerated as acute therapy for patients with DVT or stable PE, and does not require laboratory monitoring or dose adjustment. Outpatient LMWH therapy is also well tolerated and cost effective for most patients with DVT, and possibly for selected patients with PE.     

低分子肝素合用阿司匹林肠溶片治疗脑梗死患者DVT的临床观察

目的观察脑梗死患者下肢深静脉血栓形成后抗凝剂加血小板抑制剂的临床疗效。方法低分子肝素0．4ml皮下注射（腹部），1次／12h，疗程2周，合用阿司匹林肠溶片0．3g，1次／d。结果11例患者除1例发生皮下出血外均治愈或好转。结论抗凝与抗血小板聚集对脑梗死患者并发DVT治疗安全、有效。     

Periprocedural bridging therapy in patients receiving chronic oral anticoagulation therapy

BACKGROUND: In patients receiving chronic oral anticoagulation with vitamin K antagonists (VKAs) it may be necessary to temporarily discontinue VKA therapy to allow surgery or other invasive procedures to be performed, as maintaining treatment may increase the risk of bleeding during the procedure. This, however, creates a clinical dilemma, since discontinuing VKAs may place the patient at risk of thromboembolism. SCOPE: We undertook a systematic narrative review of patients on chronic oral anticoagulation, requiring a periprocedural bridging therapy with heparin during invasive procedures. FINDINGS AND RECOMMENDATIONS: For patients requiring temporary discontinuation of VKA, current guidelines recommend the use of 'bridging' therapy with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) in patients considered to be at intermediate-to-high risk of thromboembolism, such as those with prosthetic heart valves or atrial fibrillation. Recent studies show that LMWHs are associated with low rates of thromboembolism and, when compared with UFH, are as effective and safe as UFH when used as periprocedural bridging therapy in such patients. LMWHs also offer advantages such as ease of administration and predictable anticoagulant effects. Moreover, outpatient-based periprocedural bridging therapy with LMWH has been shown to result in significant cost savings compared with in-hospital UFH. CONCLUSIONS: The decision to provide bridging therapy requires careful consideration of the relative risks of thromboembolism and bleeding in each patient. Based upon the studies reviewed we recommend a therapeutic dose of UFH or LMWH for patients at intermediate-to-high thromboembolic risk requiring interruption of VKA, especially for low bleeding risk procedures. We would like to propose upgrading the American College of Chest Physicians (ACCP) guideline recommendations from 2C to 1C. However, there is still a need for a randomized controlled trial on the efficacy and safety of the available bridging strategies, including heparin and placebo comparators, in preventing thromboembolism for specific patients and procedures.     

术后下肢深静脉血栓形成15例诊治分析

目的探讨术后下肢深静脉血栓形成（DVT）的高危因素、诊断、治疗要点及预防措施。方法回顾性分析15例术后下肢深静脉血栓形成患者的诊断及治疗方法。结果 15例患者均治愈,其中1例出血,1例反复。无肺栓塞及血栓形成后综合征发生。结论对存在高危因素患者注重预防,低分子肝素、尿激酶和改善循环的中成药对DVT治疗效果较好。     

Early postoperative bleeding in polytrauma patients treated with fondaparinux: literature review and institutional experience

Surgery for pelvic or acetabular fractures carries a high risk of deep-vein thrombosis (DVT). Reports indicate that fondaparinux is a more effective thromboprophylactic agent than low molecular weight heparin (LMWH) after major orthopaedic surgery. The safety and efficacy of fondaparinux was evaluated in a new protocol used for DVT prophylaxis. One hundred and twenty seven patients with pelvic or acetabular fractures received either fondaparinux or enoxaparin and were analysed in a historical non-concurrent study. Specific review points included clinical deep-vein thrombosis (DVT) or pulmonary embolism (PE) and evidence of adverse effects such as bleeding or allergic reactions. Two patients that received enoxaparin were found to have a DVT and one patient had a PE. There was no documented DVT or PE in patients that received fondaparinux. The mean number of units of blood transfused postoperatively was higher in the enoxaparin group; however, multivariate regression modelling demonstrated no significant difference between the groups. The most current large randomised controlled studies investigating the administration of fondaparinux following joint arthroplasty or hip fracture surgery, have demonstrated a slight increase or a similar number of bleeding events in patients treated with fondaparinux when compared to those treated with enoxaparin. The current report supports that fondaparinux, in patients with pelvic and acetabular fractures, can be equally effective as enoxaparin and not associated with adverse bleeding events.     

106例心动过缓高龄病人的麻醉处理

目的：报告106例心动过缓的高龄病人的麻醉处理。方法：根据心血管系统异常程度,有20例麻醉前放置临时起搏器,选用全麻;其余86例未放置起搏器,选择硬膜外加全麻,测定诱导后10分钟,切皮时,拔管时BP、HR、SpO以及围手术期心电图的变化,结果：诱导后10分钟BP均下降明显,未安起搏器86例患者中,有26例心率低于60次／分,需要给阿托品提高心率,其中5例给阿托品2mg无效,改给麻黄素后心率上升＞60次／分,1例心率＜50次／分,给阿托品、麻黄素无效,停手术,次日放置临时起搏器后顺利完成手术,拔管时患者BP、HR无明显变化。结论：老年心动过缓的手术患者,术前可视病情安置临时起搏器,并选用全麻或硬膜外加全麻,对循环功能影响小,有利于术后镇痛,减少围手术期心律失常的发生率。     

Pathophysiology and treatment of deep-vein thrombosis and pulmonary embolism

The pathophysiology of deep-vein thrombosis (DVT) and pulmonary embolism (PE) is briefly discussed, and the efficacy, dosage and administration, laboratory monitoring, and adverse effects of thrombolytic agents, heparin, and warfarin are reviewed. Acute therapy of DVT and PE is usually initiated with intravenous heparin; however, thrombolytic agents such as streptokinase and urokinase may be preferred in patients with massive PE or severe DVT when clot lysis rather than clot stabilization is deemed necessary. For DVT or PE, an intravenous loading dose of streptokinase or urokinase is given, followed by a continuous infusion of the drug. Therapy with streptokinase is continued for 24 hours in patients with PE and for 72 hours in those with DVT; urokinase is continued for 12 hours in patients with PE. Monitoring of blood coagulation tests during thrombolytic therapy is recommended primarily for ensuring that a lytic state is achieved. Intravenous heparin is preferred for acute treatment of DVT or PE; controversy exists regarding whether administration by continuous infusion or intermittent bolus injection is superior. Heparin dosage is usually adjusted to maintain the activated partial-thromboplastin time (APTT) ratio between 1.5 and 2.5; however, the ideal therapeutic range has never been firmly established. After acute treatment with heparin, most patients should continue to receive either warfarin or subcutaneous heparin for several months to prevent recurrent thromboembolism. Bleeding is the major adverse effect of thrombolytic agents and anticoagulants. The risk of bleeding with heparin and warfarin therapy increases with excessive prolongation of the APTT and prothrombin time (PT), respectively. Future clinical trials should further define the role of thrombolytic agents in the treatment of DVT and PE and the efficacy of less-intense warfarin therapy for pulmonary embolism or arterial thromboembolic events.     

Periprocedural bridging therapy in patients receiving chronic oral anticoagulation therapy

ABSTRACT

Background: In patients receiving chronic oral anticoagulation with vitamin K antagonists (VKAs) it may be necessary to temporarily discontinue VKA therapy to allow surgery or other invasive procedures to be performed, as maintaining treatment may increase the risk of bleeding during the procedure. This, however, creates a clinical dilemma, since discontinuing VKAs may place the patient at risk of thromboembolism.

Scope: We undertook a systematic narrative review of patients on chronic oral anticoagulation, requiring a periprocedural bridging therapy with heparin during invasive procedures.

Findings and recommendations: For patients requiring temporary discontinuation of VKA, current guidelines recommend the use of ‘bridging’ therapy with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) in patients considered to be at intermediate-to-high risk of thromboembolism, such as those with prosthetic heart valves or atrial fibrillation. Recent studies show that LMWHs are associated with low rates of thromboembolism and, when compared with UFH, are as effective and safe as UFH when used as periprocedural bridging therapy in such patients. LMWHs also offer advantages such as ease of administration and predictable anticoagulant effects. Moreover, outpatient-based periprocedural bridging therapy with LMWH has been shown to result in significant cost savings compared with in-hospital UFH.

Conclusions: The decision to provide bridging therapy requires careful consideration of the relative risks of thromboembolism and bleeding in each patient. Based upon the studies reviewed we recommend a therapeutic dose of UFH or LMWH for patients at intermediate-to-high thromboembolic risk requiring interruption of VKA, especially for low bleeding risk procedures. We would like to propose upgrading the American College of Chest Physicians (ACCP) guideline recommendations from 2C to 1C. However, there is still a need for a randomized controlled trial on the efficacy and safety of the available bridging strategies, including heparin and placebo comparators, in preventing thromboembolism for specific patients and procedures.