肾病综合征患者血栓形成的风险评估及多维度护理干预

目的探讨预防肾病综合征患者静脉血栓形成的有效方法。方法将80例肾病综合征患者按照住院时间先后分为对照组和观察组各40例。对照组采用常规护理方法;观察组应用静脉血栓形成风险评估表对患者进行评估,按照血栓形成的风险程度,采取饮食、认知、行为干预等。比较两组患者血栓形成情况和相关知识掌握程度及满意度。结果观察组无一例静脉血栓形成,对照组发生4例。观察组患者满意度及相关知识知晓率显著高于对照组(均P<0.05)。结论对肾病综合征患者进行血栓风险评估能够为护理干预提供科学依据,有助于预防静脉血栓形成,保证患者安全。     

Risk factors for predicting venous thromboembolism in patients with nephrotic syndrome: focus on haemostasis-related parameters

Purpose

The venous thromboembolic events (VTE) incidence is high in nephrotic syndrome (NS). We aimed to assess prospectively the risk of VTE in a large cohort of NS patients and to identify predictive factors for VTE, especially haemostasis-related parameters.

Methods

This is the prospective, observational study conducted in 256 adults with idiopathic NS. VTE were the study outcome. Clinical data, proteinuria, albuminuria, haemostasis and fibrinolysis parameters, and D-dimers were evaluated every 6 months.

Results

Median follow-up time was 24 [IQR 12–72] months. VTE cumulative and rate incidence were 11 % and 4.4 per 100 patient-years. Baseline higher proteinuria, lower serum albumin, low antithrombin III activity, and, surprisingly, high ionized calcium were VTE independent predictors. Proteinuria and serum albumin cut-offs, and positive and negative predictive values (PPV and NPV) for VTE were 9.0 g/24 h (30 % PPV and 90 % NPV) and 1.5 g/dL (69 % PPV and 93 % NPV).

Conclusions

The rate of VTE incidence of 4.4 per 100 patient-years found in this prospective study confirms the idiopathic nephrotic syndrome as a thromboembolism-generating condition. Severe and unremitting proteinuria and hypoalbuminemia, low antithrombin III activity, and, surprisingly, high ionized calcium are independent VTE predictors.     

Risk factors of venous thromboembolism in focal segmental glomerulosclerosis with nephrotic syndrome

Background

Venous thromboembolism (VTE) is an important and potentially life-threatening complication in focal segmental glomerulosclerosis (FSGS). The aim of this study was to investigate the prevalence and predisposing risk factors of venous thromboembolism in patients with FSGS with nephrotic syndrome.

Methods

A total of 120 FSGS patients with nephrotic syndrome were enrolled in this study. Venous thromboembolism was confirmed by contrast-enhanced dual-source computed tomography angiography or magnetic resonance venography. Potential clinical and laboratory risk factors for VTE were screened.

Results

Venous thrombosis was demonstrated in 12 (10 %) patients. Venous thrombosis occurred during the first episode of nephrotic syndrome in 3 patients and during a relapse in 9 patients. Eight patients had a pulmonary embolism, four had a renal vein thrombosis, three had a lower limb deep vein thrombosis, one had a cerebral sinovenous thrombosis, and one had a portal vein thrombosis. The positive predictive value for the D-dimer level was 22.4 % in the patients with FSGS, and the negative predictive value for the D-dimer level was 100 %. Of the screened risk factors, higher hematocrit and relapse of nephrotic syndrome were risk factors for VTE. Other risk factors, such as proteinuria, hypoalbuminemia, platelet count, fibrinogen level, and antithrombin III level, were not risk factors for VTE in patients with FSGS.

Conclusion

We found that the prevalence of venous thromboembolism is approximately 10 % in FSGS patients with nephrotic syndrome. Most of the patients had a PE. Hemoconcentration and relapse of nephrotic syndrome were risk factors for the development of VTE in FSGS. Negative D-dimer may exclude venous thromboembolism in patients with nephrotic syndrome.

     

Risk stratification for recurrent venous thromboembolism in unprovoked venous thromboembolism patients

Unprovoked venous thromboembolism (VTE) patients are at much higher risk of a recurrent VTE event than provoked VTE patients. Oral anticoagulation therapy (OAT) after a first unprovoked VTE has proved to effectively reduce the risk of recurrence during therapy however this benefit is lost after discontinuing OAT. A minimum of 6 to 12 months of OAT is recommended for first unprovoked VTE patients to prevent recurrence. However, there is evidence indicating that some patients are at ongoing high risk of recurrent VTE after discontinuation of therapy and that these patients may need indefinite anticoagulation to effectively prevent recurrences. Several risk factors for recurrent VTE have been identified that may be helpful to physicians when deciding whether OAT should be continued or discontinued in unprovoked VTE patients after initial therapy. The present article reviews risk factors for recurrent VTE including D-Dimer levels after discontinuation of OAT, elevated levels of Factor VIII, residual venous obstruction, post-thrombotic syndrome, male gender, and older age. Research is also underway to determine the predictive ability of these known VTE recurrence risk factors, combinations of these risk factors and their interrelationships as well as to actively search for additional potential predictors.     

Risk factors associated with venous thromboembolism in 49,028 mastectomy patients

Venous thromboembolism (VTE) is a potentially preventable disease that carries significant morbidity and mortality. Although malignancy is associated with increased risk for VTE, it varies according to cancer type. Despite the fact that breast cancer is the most common form of cancer in women, the incidence and risk factors associated with VTE in patients undergoing mastectomy have not been well characterized. To address this we utilized the ACS-NSQIP database to identify and characterize independent risk factors for VTE in 49,028 mastectomy patients. We identified 116 cases of VTE in the 49,028 cases analyzed (0.23%). Obesity (BMI > 30, OR = 1.91, p < 0.001), inpatient status (OR = 3.75, p < 0.001), venous catheterization (OR = 2.67, p = 0.012), prolonged operative time >3 h (OR = 4.36, p < 0.001), and immediate reconstruction (OR = 3.23, p < 0.001) were found to be independent risk factors for VTE. While the incidence of VTE is rare in mastectomy patients, the heightened awareness and increased VTE prophylaxis should be considered in high risk groups.     

Guidelines for the prevention of venous thromboembolism in hospitalized patients with pelvi-acetabular trauma

BackgroundVenous thromboembolism is a dreaded complication leading to increased morbidity and mortality in patients having pelvi-acetabular fractures.ObjectivesThese evidence based guidelines aim to provide the decision making ability in the prevention of venous thromboembolism in patients with pelvi-acetabular trauma planned for operative or non operative treatment.MethodsThe patients were subclassified into 5 categories. The PICO framework was used to devise research questions in each category. The systematic reviews were performed for each research question. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess outcomes of critical interest. The guideline panel consisting of expert members of different subspecialties, analyzed the evidence and made recommendations.ResultsThe guideline panel proposed 21 recommendations. There are five recommendations in category 1 to 3, two recommendations in category 4 and four recommendations in category 5.ConclusionIn pelvi-acetabular fractures there is strong evidence to suggest that thromboprophylaxis should be given. It should be initiated as early as possible after control of hemorrhage. The chemical prophylaxis is the preferred mode and LMWH is the preferred agent of choice. The mechanical methods can be used as an adjunct. The routine prophylactic use of IVC filters is not recommended. However, the use of retrievable IVC filters in high risk patients with established VTE in preoperative period can be considered. The use of newer directly acting oral anticoagulants is gaining importance.     

Guidelines for the prevention of venous thromboembolism in hospitalized patients with pelvi-acetabular trauma

BackgroundVenous thromboembolism is a dreaded complication leading to increased morbidity and mortality in patients having pelvi-acetabular fractures.ObjectivesThese evidence based guidelines aim to provide the decision making ability in the prevention of venous thromboembolism in patients with pelvi-acetabular trauma planned for operative or non operative treatment.MethodsThe patients were subclassified into 5 categories. The PICO framework was used to devise research questions in each category. The systematic reviews were performed for each research question. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess outcomes of critical interest. The guideline panel consisting of expert members of different subspecialties, analyzed the evidence and made recommendations.ResultsThe guideline panel proposed 21 recommendations. There are five recommendations in category 1 to 3, two recommendations in category 4 and four recommendations in category 5.ConclusionIn pelvi-acetabular fractures there is strong evidence to suggest that thromboprophylaxis should be given. It should be initiated as early as possible after control of hemorrhage. The chemical prophylaxis is the preferred mode and LMWH is the preferred agent of choice. The mechanical methods can be used as an adjunct. The routine prophylactic use of IVC filters is not recommended. However, the use of retrievable IVC filters in high risk patients with established VTE in preoperative period can be considered. The use of newer directly acting oral anticoagulants is gaining importance.     

静脉血栓栓塞症患者护理随访系统的设计与应用

目的 设计针对静脉血栓栓塞症出院患者的护理随访系统,观察并评价其应用效果.方法 组建研究团队,基于护理程序设计结构化随访表单,构建静脉血栓栓塞症出院患者健康教育知识库,以医院信息系统为支撑平台构建结构化护理随访系统,于2018年1月正式投入使用,统计运行期间各质量评价指标及随访结果.结果 截至2020年6月,随访静脉血...     

髋部骨折术后静脉血栓栓塞症的风险预警及多模式预防

目的:探讨采用多模式方式对髋部骨折术后静脉血栓栓塞症预防的有效性和安全性。方法:2009年3月至2011年7月,根据血栓形成危险因素将患者分为2组,低风险组112例,男47例,女65例;年龄42～88岁,平均(72.40±13.29)岁;高风险组26例,男12例,女14例;年龄65～84岁,平均(78.50±12.76)岁。2组入院后即给予间歇充气加压装置,高风险组术后第1天予低分子肝素0.4ml,皮下注射,每日1次,连续14d;低风险组术后给予口服拜阿司匹林100mg,每日1次,连续14d;在出院前24h行多普勒超声检查。术后随访3个月,分别记录下肢深静脉血栓、肺栓塞的发生率和出血并发症的发生情况。结果:所有患者未发生致命性肺栓塞,1例有症状的肺栓塞发生在低风险组,而高风险组未发现肺栓塞。低风险组术后出现深静脉血栓6例,高风险组术后出现深静脉血栓2例。选取例数较多的骨折切开复位内固定患者比较术后出血量、血红蛋白下降量、血肿及胃肠出血病例数。低风险组分别是(538.10±390.20)ml,(30±19)g/L,0例,1例;高风险组分别是(585.95±403.96)ml,(32±20)g/L,1例,1例,2组比较差异均无统计学意义。结论:阿司匹林加间歇充气加压装置在预防髋部骨折术后静脉血栓栓塞症方面的疗效与低分子肝素加间歇充气加压装置无明显差别,但在降低出血性并发症和减少心脑血管并发症方面具有潜在优势。多模式血栓栓塞预防方案可以保护患者,作为髋部骨折术后常规预防术后静脉血栓栓塞症的方法。     

Venous thromboembolism in pediatric nephrotic syndrome

Childhood nephrotic syndrome (NS) is one of the most common pediatric kidney diseases, with an incidence of 2–7 per 100,000. Venous thromboembolism (VTE) is associated with significant morbidity and mortality, and occurs in ～3 % of children with NS, though incidence approaches 25 % in high-risk groups. VTE etiology is multifactorial, with disease-associated coagulopathy thought to be a significant contributor. Other risks include age, disease severity, and treatment-related hazards, such as the presence of central venous catheters. Non-pharmacologic preventive measures such as ambulation and compression stockings are recommended for patients with identified VTE risks. Central venous catheters should be avoided whenever possible. Symptoms of VTE include venous catheter dysfunction, unilateral extremity symptoms, respiratory compromise, flank pain, and gross hematuria. When VTE is suspected, confirmatory imaging studies should be obtained, followed by appropriate laboratory evaluation and treatment. Therapeutic goals include limiting thrombus growth, extension, and embolization by early institution of anticoagulant therapy. Anticoagulation is recommended for a minimum of 3 months, but should be continued until NS remission is achieved. Further studies are necessary to identify VTE-risk biomarkers and optimal therapeutic regimens. Observational cohort studies are needed to identify VTE-risk groups who may benefit from thromboprophylaxis and to define disease-specific treatment algorithms.     

预防骨科患者静脉血栓栓塞症的循证实践

目的基于前期构建的骨科患者静脉血栓栓塞症的预防方案,开展骨科患者静脉血栓栓塞症规范化分级预防的循证实践。 方法制订相应的护理质量审查指标及审查方法,根据基线审查结果分析障碍因素及促进因素,制订行动策略,并通过随机对照研究选取343例患者进行效果验证,试验组进行循证实践,对照组为常规预防。 结果根据循证方案,选择5条指标（血栓风险评估、出血风险评估、分级预防、弹力袜穿戴、护理记录）作为审查依据。循证实践后,试验组患者症状性静脉血栓栓塞症发生较对照组有所下降（住院期间2.45% vs. 2.78%;出院后1个月1.23% vs. 2.22%;出院后3个月1.23% vs. 2.22%）,差异无统计学意义;出院前患者血栓预防知识得分试验组（78.79±8.60）分明显高于对照组（66.05±7.68）分,差异有统计学意义（P<0.001）;护士对静脉血栓栓塞症相关知识的认知水平（危险因素与好发部位、临床表现、风险评估、机械预防、药物预防维度）得分明显提高,差异有统计学意义;护士对审查条目的执行率由循证实践前的36.92%、20% 、67.69%、58.46%、66.15%上升至100%、82.2%、100%、100%、98.16%,差异有统计学意义（P<0.001）。 结论基于证据的循证实践方案的转化可帮助减少患者症状性血栓发生,提高护士和患者认知水平,促进临床依从性,规范护理行为。     

静脉血栓栓塞症复发现状及风险评估工具研究进展

静脉血栓栓塞症（VTE）复发率较高,严重影响患者生活质量,增加医疗风险及疾病负担。但VTE复发在很大程度上可以预防,准确评估患者VTE复发风险及给予复发风险分层是医护人员针对VTE复发防控工作的第一步。笔者综述VTE复发现状及危险因素,对国外VTE复发风险评估工具进行分析与总结,以期提高医护人员对VTE复发现状及危险因素的认知,为临床评估VTE复发风险提供可操作性指导,为VTE复发的医疗安全预警及风险管理提供参考。     

静脉应用胺碘酮治疗心房颤动的综合护理干预

目的 根据静脉应用胺碘酮治疗心房颤动(下称房颤)的特点,对患者实施综合性护理干预,减少不良事件,提高生存质量和疗效.方法 将入选的40例静脉应用胺碘酮治疗的房颤患者随机分为对照组和观察组各20例,对照组按常规护理,观察组给予心理护理、危险分层评估、药品入量监测及调整等综合护理干预.比较两组患者疗效、睡眠质量和不良反应发...     

Risk of venous thromboembolism in patients undergoing surgery for pelvic organ prolapse

Introduction and hypothesis

We sought to determine the incidence of venous thromboembolism (VTE) in patients undergoing surgery for pelvic organ prolapse (POP) based on surgical approach.

Methods

The American College of Surgeons National Quality Improvement Program (NSQIP) database was used to select all surgeries performed for POP from 2005 to 2013. CPT-4 codes were grouped based on surgical approach: vaginal (VAG), laparoscopic sacrocolpopexy (LSC), or open abdominal sacrocolpopexy (ASC). Patient demographics, preoperative American Society of Anesthesiologists (ASA) classification system scores, and 30-day postoperative complications were obtained.

Results

Of the 26,103 women who underwent surgery for POP, 21,311 (81.7 %) underwent VAG, 3,346 (12.8 %) LSC, and 1,426 (5.5 %) ASC. VTE occurred in 36 patients (0.17 %) in the VAG group, 8 (0.24 %) in the LSC group, and 9 (0.63 %) in the ASC group. The ASC group had a significantly higher incidence of VTE compared with the VAG group (p?<?0.01). Upon multivariate analysis, factors associated with a greater incidence of VTE included BMI greater than 30 kg/m² (p?=?0.048), ASA score of 3, 4, or 5 (p?=?0.027), and length of stay above the 75th percentile (p?<?0.01). The procedure group did not retain statistical significance in multivariate modeling.

Conclusions

Venous thromboembolism is rare following surgery for POP. Although differences in VTE rates between procedure groups failed to maintain statistical significance after multivariate analysis, we were able to identify risk factors associated with an increased VTE risk in surgery for POP. Women with obesity, an increased length of stay, or ASA score of 3 or higher are at an increased risk for developing VTE after undergoing surgery for POP.

     

Prevention of postoperative venous thromboembolism. Risk assessment and methods of prophylaxis

Purpose

To describe risk assessment models that have been developed to stratify patients into different risk levels of postoperative venous thromboembolism (VTE) and then to review the different methods of prophylaxis and to outline the evidence supporting their effectiveness and safety.

Source

Our review of the literature is focused on consensus documents, recent large randomized trials and meta-analyses.

Principal findings

The risk of VTE is determined by the type of surgery and underlying patient factors. Risk assessment models are useful in stratifying patients into different VTE risk levels. However, multiple risk factors are often present in the same patient and in practice the evaluation of their relative contribution to the overall risk remains difficult. A variety of prophylactic strategies including physical and pharmacological methods have been shown to be effective in different patient groups. Patients with a moderate or high risk of VTE should receive prophylaxis consisting of an antithrombotic agent, unless contraindicated, used alone or in combination with a mechanical method. Recommendations concerning which prophylaxis to use and how intensive it should be are based mainly on data from trials using surrogate endpoints, and do not translate easily into practical decisions aiming to reduce the incidence of symptomatic events.

Conclusion

Although risk assessment models and recommendations provided by consensus documents are of practical assistance, a decision concerning any patient is best made by combining recommendations of the literature with clinical judgment, including individual patient risk factors for thrombosis and bleeding.

Objectif

Dêcrire les modèles ďêvaluation du risque dêveloppês pour classer les patients selon diffêrents niveaux de risque de thromboembolie veineuse postopêratoire (TEV) et ensuite, revoir les mêthodes de prophylaxie et êbaucher la preuve de leur efficacitê et de leur sêcuritê.

Source

Notre revue de la littêrature est centrêe sur des documents de consensus, de rêcentes grandes êtudes randomisêes et mêta-analyses.

Constatations principales

Le risque de TEV dêpend du type de chirurgie et de facteurs sous-jacents reliês au patient. Les modèles ďêvaluation du risque sont utiles pour classer les patients selon diffêrents niveaux de risque de TEV. Cependant, de multiples facteurs de risque sont souvent prêsents chez le même patient et, en pratique, ľêvaluation de leur contribution relative au risque global demeure difficile. Diverses stratêgies prophylactiques, dont des mêthodes physiques et pharmacologiques, se sont rêvêlêes efficaces auprès de diffêrents groupes de patients. Les patients à risque modêrê ou êlevê de TEV devraient recevoir une thêrapie prêventive avec des antithrombotiques, à moins de contre-indication, utilisês seuls ou en combinaison avec une mêthode mêcanique. Les recommandations sur le choix de la prophylaxie à utiliser et sur son importance sont fondêes principalement sur les donnêes ďessais qui utilisent des paramètres indirects et ne se traduisent pas facilement en dêcisions pratiques visant à rêduire ľincidence ďêvênements symptomatiques.

Conclusion

Même si les modèles ďêvaluation du risque et les recommandations fournies par les documents de consensus sont pratiques, toute dêcision concernant un patient est plus juste si on combine recommandations de la littêrature et jugement clinique, comprenant les facteurs de risque individuels de thrombose et ďhêmorragie.

     

腹膜癌静脉血栓栓塞症高危患者围手术期预防护理

目的 总结腹膜癌患者围手术期静脉血栓栓塞症防治的规范化护理经验。方法依据腹膜癌患者围手术期的静脉血栓栓塞症防治技术,制订并实施腹膜癌患者手术期静脉血栓栓塞症防治的临床护理路径,并应用于256例腹膜癌静脉血栓栓塞症高危患者。结果术后发生静脉血栓栓塞症14例,其中深静脉血栓13例,均为下肢肌间静脉血栓,肺栓塞1例;通过定期随访,截至2022年1月1日,14例患者静脉血栓栓塞症均恢复良好。结论腹膜癌患者围手术期静脉血栓栓塞症防治临床护理路径的建立与实施,使围术期静脉血栓栓塞预防规范化,促进了患者术后康复。