日本肺栓塞及深靜

1、流行病學(xué),發(fā)病率逐漸升高美國500/百萬，日本62/百萬2006年，圍手術(shù)期4.41-2.79，女性發(fā)病率增高較快，好發(fā)年齡60-70歲。,危險因素,Interrupted blood flow長期臥床肥胖懷孕心肺疾病 (如充血性心力衰竭、慢性肺心病等)全麻下肢麻醉下肢制動下肢靜脈曲張Endothelial dysfunction手術(shù)外傷、骨折中心靜脈置管導(dǎo)管介入檢查或治療血管炎抗磷脂綜合癥Hyperh

2、omocysteinemia（高同型半胱氨酸血癥，遺傳或獲得性）,,Hypercoagulability惡性腫瘤懷孕手術(shù)、創(chuàng)傷、骨折燒傷藥物 (如口服避孕藥、雌激素等)感染腎病綜合征炎性腸病骨髓增生性疾病，紅細胞增多癥陣發(fā)性睡眠型血紅蛋白尿抗磷脂綜合癥脫水,,抗凝酶缺乏蛋白C缺乏蛋白S缺乏纖溶酶原異常纖維蛋白原異常組織纖溶酶原活化抑制因子增多血栓調(diào)節(jié)素異常蛋白C活化抵抗凝血酶原基因變異 (G202

3、10A)*,癥狀、體征,缺乏特異性呼吸困難、胸痛典型者是起床活動、排便排尿或體位改變時出現(xiàn),嚴(yán)重程度的判別,急性肺栓塞診斷步驟,Start heparin therapy when pulmonary embolism is suspected. Examine for deep vein thrombosis at once. *1Screen the patient with chest X-ray, ECG, arteria

4、l blood gas analysis, transthoracic echocardiography, and blood chemistry. *2When PCPS is not available, maintain circulation with cardiac compressionand vasopressors. CT, computed tomography; PCPS, percutaneous cardio

5、pulmonary support. Adapted from Therapeutic Research 2009; 30: 744 – 747.,處理程序,*1 When risk of bleeding is high. *2 Treat complications appropriately with available methods.*3 Unstable hemodynamics consistent with shoc

6、k or prolonged hypotension.*4 Condition requiring cardiopulmonary resuscitation or prolonged severe shock. *5 Consider PCPS according to hospital equipments and patient condition. *6 Select appropriate treatment accor

7、ding to hospital equipments and patient condition.*7 Evaluate based on right ventricular enlargement on echocardiography and severity of pulmonary hypertension.*8 Presence/absence of DVT which may have serious effects

8、if it releases emboli causing recurrent embolism. The above algorithm is an example.Each institution should select appropriate methods according to its healthcare resources. DVT, deep vein thrombosis;PCPS, percutaneous

9、 cardiopulmonary support; IVC, inferior vena cava.,肝素抗凝劑量調(diào)整及監(jiān)測,普通肝素首劑5,000 units靜滴, 繼以1,400 units/hr的速度持續(xù)維持. 首劑后6hr監(jiān)測 APTT ，按照上表調(diào)整劑量*1Use this table for APTT reagents with a therapeutic range of 1.9 to 2.7 times the con

10、trol.*2 When unfractionated heparin is administered at a concentration 40 units/mL.APTT, activated partial thromboplastin time; Bolus, bolus dose for repeated administration; Hold, duration of suspension of continuous

11、infusion; Rate change, change in infusion rate during continuous infusion; Dose change, change in dose during continuous infusion.,藥物治療,肝素治療應(yīng)在擬診階段，首劑80u/kg或5000u，繼以18u/kg/hr或1300u/hr維持。同時給予華法林3-5mg/日口服，3-5天后停肝素。Rt-PA，（蒙

12、替普酶Monteplase）13,750 -27,500 u/kg 2分鐘內(nèi)靜注。藥物治療的標(biāo)準(zhǔn)(1) 抗凝治療適合于血壓正常、無右心功能障礙的急性肺栓塞患者.(2) 血壓正常而右心功能不全的患者需要權(quán)衡溶栓治療的出血風(fēng)險 (3) 溶栓治療適應(yīng)于持續(xù)低血壓及休克的患者,華法林抗凝治療的期限,華法林（2011版英國指南）,VTE初發(fā) VTE should be treated with an INR target of 2.5

13、必須同時使用unfractionated heparin, low molecular weight heparin or fondaparinux at least 5 d and until the INR is ≥2 for at least 24 h 復(fù)發(fā) VTE the INR target to 3.5.Antiphospholipid syndrome (APS) INR should be 25房顫 2.5心

14、臟電復(fù)律術(shù)前3周，術(shù)后4周，INR2.5-3.0心臟瓣膜病二尖瓣狹窄或關(guān)閉不全，atrial fibrillation (1A) or a history of systemic embolism or left atrial thrombus or an enlarged left atrium should receive warfarin with an INR target of 2.5,抗凝期限,深靜脈血栓及肺栓塞，至少抗

15、凝3月；如診斷明確的腓靜脈血栓，則限于6周；腫瘤相關(guān)的深靜脈血栓，使用治療劑量的低分子肝素抗凝6月而不用華法林。長期抗凝不適用與手術(shù)及懷孕等短期激發(fā)因素所導(dǎo)致的血栓形成；對于非短期激發(fā)因素所導(dǎo)致的血栓需要長期抗凝，但需權(quán)衡獲益與風(fēng)險的關(guān)系；血栓局限與腓靜脈不推薦長期抗凝。,華法林劑量,無證據(jù)表明10mg起始劑量優(yōu)于5mg，老年患者可能低劑量或年齡校正的劑量更為適合。對于不需要迅速抗凝的門診房顫患者，大多數(shù)可用緩慢增加劑量在3-4周達

16、到抗凝治療效果有高出血風(fēng)險的患者術(shù)后至少48小時可以開始抗凝治療對于大出血患者，可用4種因子的促凝復(fù)合體進行逆轉(zhuǎn)，同時給予vitK5mg iv；如沒有促凝因子復(fù)合體，可以用新鮮冰凍血漿；對于一般出血，可用vitK1-3mg iv。INR≥5，停止1-2次華法林，需尋找原因；≥8時，1-5mg vitK口服口服華法林患者如發(fā)生腦外傷，需要查INR及腦CT；如懷疑腦出血，需要逆轉(zhuǎn)華法林的作用。,慢性肺栓塞,慢性PTE是指肺血流分布異