围手术期静脉血栓栓塞(VTE)的防治
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low-molecular-weight heparin(LMWH) (2B), low-dose unfractionated heparin(LDUH) (2B),or mechanical prophylaxis, preferably with IPC (2C) mechanical prophylaxis, preferably with IPC (2C)
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):7S–47S.
Baidu Nhomakorabea
Prevention of VTE in General and Abdominal-pelvic Surgical Patients
Risk Prophylaxis for normal paitients Prophylaxis for patients at high risk for major bleeding complications
Acute myocardial infarction
Congestive heart failure (< 1 mo) History of inflammatory bowel disease Oral contraceptives or hormone replacement
Immobilizing plaster cast Central venous access
Recommendations are classified as strong (Grade 1) or weak (Grade 2), 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 (Grade A), moderate (Grade B), or low (Grade C) according to factors that include the risk of bias, precision of estimates, the consistency of the results, and the directness of the evidence.
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 Sepsis, pancreatic leak, sentinel bleed Hepatic resection Number of segments, concomitant extrahepatic organ resection, primary liver malignancy, lower preoperative hemoglobin level, and platelet counts
Pulmonary Embolism (PE)
Deep Venous Thrombosis (DVT)
VTE-related deaths
200,000 per year in US 1/3 occur following surgery
2~3-fold for cancer patients
危险因素 得分：2分
年龄61-74岁 关节镜手术 开放式手术（>45min） 腹腔镜手术（>45min） 恶性肿瘤 卧床（>72h） 石膏固定 中央静脉通路
败血症（1个月内） 静脉曲张
肺功能异常 急性心肌梗塞 充血性心力衰竭 （1个月内） 肠炎病史 口服避孕药或激素替代 治疗
危险因素 得分：3分
年龄≥75岁 VTE病史 狼疮抗凝物阳性 抗心磷脂抗体阳性 血清同型半胱氨酸升高 肝素诱导的血小板减少症 其他先天性或获得性血栓症
Active bleeding Previous 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 thrombolytic drugs
0 1-2 3-4 ≥5
Observed Risk of Symptomatic VTE, %
0 0.7 1.0 1.9
Including GI, Urological, Vascular, Breast, and Thyroid Procedures
Risk Factors for Major Bleeding Complications General risk factors
3 Points
Age ≥ 75 y History of VTE Family history of VTE Factor V Leiden Prothrombin 20210A Lupus anticoagulant Anticardiolipin Antibodies Elevated serum Homocysteine Heparin-induced thrombocytopenia Other congenital or acquired thrombophilia
Caprini Risk Assessment Model
1 Point
Age 41-60 y Minor surgery BMI>25 kg/㎡ Sepsis (< 1 mo) Varicose veins Swollen legs Age 61-74 y Arthroscopic surgery Major open surgery (> 45 min)
5 Points
Stroke (< 1 mo)
Hip, pelvis, or leg fracture
Elective arthroplasty
Acute spinal cord injury (< 1 mo)
Caprini风险评分
危险因素 得分：1分
年龄41-60岁 小手术
BMI>25 kg/㎡ 下肢水肿 严重肺部疾病，包括肺 炎（1个月内） 妊娠期或产后 不能解释或二次自然流 产病史 需要卧床休息的患者
Risk Factors for Major Bleeding Complications
Procedures in which bleeding complications may have especially severe consequences
Craniotomy Spinal surgery Spinal trauma Reconstructive procedures involving free flap
very low risk
no specific pharmaclogic (1B) or mechanical (2C) prophylaxis be used other than early ambulation
low risk
moderate risk
mechanical prophylaxis, preferably with intermittent pneumatic compression (IPC) (2C)
危险因素 得分：5分
脑卒中（1个月内） 髋关节、骨盆或下肢骨折
VTE家族史 因子V Leiden 阳性 凝血酶原20210A阳性
择期关节置换术
急性脊柱损伤（1个月内）
VTE Risk For General Surgery
VTE Risk
Very low Low Moderate High
Caprini Score
Prevention of VTE in General and Abdominal-pelvic Surgical Patients
Risk Prophylaxis for normal paitients Prophylaxis for patients at high risk for major bleeding complications pharmacologic prophylaxis with LMWH (1B) or LDUH (1B), mechanical prophylaxis with elastic stockings (ES) or IPC should be added to pharmacologic prophylaxis (2C) extended-duration pharmacologic prophylaxis (4 weeks) with LMWH (1B) mechanical prophylaxis, preferably with IPC, until the risk of bleeding diminishes and pharmacologic prophylaxis may be initiated (2C)
2 Points
Malignancy Confined to bed (> 72 h) Laparoscopic surgery (> 45 min)
Abnormal pulmonary function Serious lung disease, including pneumonia (< 1 mo) Pregnancy or postpartum History of unexplained or recurrent spontaneous abortion Medical patient at bed rest
Prophylaxis?
VTE ↓71% Death ↓46% Major bleeding ↑103% Wound hematoma ↑ 88%
VTE
Bleeding
Mismetti P, et al. Meta-analysis of low molecular weight heparin in the prevention of venous thromboembolism in general surgery .Br J Surg . 2001 ; 88 ( 7 ): 913 - 930 .
Risk Factors for Major Bleeding Complications Procedure-specific risk factors
Cardiac surgery Use 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
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):7S–47S.
Baidu Nhomakorabea
Prevention of VTE in General and Abdominal-pelvic Surgical Patients
Risk Prophylaxis for normal paitients Prophylaxis for patients at high risk for major bleeding complications
Acute myocardial infarction
Congestive heart failure (< 1 mo) History of inflammatory bowel disease Oral contraceptives or hormone replacement
Immobilizing plaster cast Central venous access
Recommendations are classified as strong (Grade 1) or weak (Grade 2), 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 (Grade A), moderate (Grade B), or low (Grade C) according to factors that include the risk of bias, precision of estimates, the consistency of the results, and the directness of the evidence.
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 Sepsis, pancreatic leak, sentinel bleed Hepatic resection Number of segments, concomitant extrahepatic organ resection, primary liver malignancy, lower preoperative hemoglobin level, and platelet counts
Pulmonary Embolism (PE)
Deep Venous Thrombosis (DVT)
VTE-related deaths
200,000 per year in US 1/3 occur following surgery
2~3-fold for cancer patients
危险因素 得分：2分
年龄61-74岁 关节镜手术 开放式手术（>45min） 腹腔镜手术（>45min） 恶性肿瘤 卧床（>72h） 石膏固定 中央静脉通路
败血症（1个月内） 静脉曲张
肺功能异常 急性心肌梗塞 充血性心力衰竭 （1个月内） 肠炎病史 口服避孕药或激素替代 治疗
危险因素 得分：3分
年龄≥75岁 VTE病史 狼疮抗凝物阳性 抗心磷脂抗体阳性 血清同型半胱氨酸升高 肝素诱导的血小板减少症 其他先天性或获得性血栓症
Active bleeding Previous 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 thrombolytic drugs
0 1-2 3-4 ≥5
Observed Risk of Symptomatic VTE, %
0 0.7 1.0 1.9
Including GI, Urological, Vascular, Breast, and Thyroid Procedures
Risk Factors for Major Bleeding Complications General risk factors
3 Points
Age ≥ 75 y History of VTE Family history of VTE Factor V Leiden Prothrombin 20210A Lupus anticoagulant Anticardiolipin Antibodies Elevated serum Homocysteine Heparin-induced thrombocytopenia Other congenital or acquired thrombophilia
Caprini Risk Assessment Model
1 Point
Age 41-60 y Minor surgery BMI>25 kg/㎡ Sepsis (< 1 mo) Varicose veins Swollen legs Age 61-74 y Arthroscopic surgery Major open surgery (> 45 min)
5 Points
Stroke (< 1 mo)
Hip, pelvis, or leg fracture
Elective arthroplasty
Acute spinal cord injury (< 1 mo)
Caprini风险评分
危险因素 得分：1分
年龄41-60岁 小手术
BMI>25 kg/㎡ 下肢水肿 严重肺部疾病，包括肺 炎（1个月内） 妊娠期或产后 不能解释或二次自然流 产病史 需要卧床休息的患者
Risk Factors for Major Bleeding Complications
Procedures in which bleeding complications may have especially severe consequences
Craniotomy Spinal surgery Spinal trauma Reconstructive procedures involving free flap
very low risk
no specific pharmaclogic (1B) or mechanical (2C) prophylaxis be used other than early ambulation
low risk
moderate risk
mechanical prophylaxis, preferably with intermittent pneumatic compression (IPC) (2C)
危险因素 得分：5分
脑卒中（1个月内） 髋关节、骨盆或下肢骨折
VTE家族史 因子V Leiden 阳性 凝血酶原20210A阳性
择期关节置换术
急性脊柱损伤（1个月内）
VTE Risk For General Surgery
VTE Risk
Very low Low Moderate High
Caprini Score
Prevention of VTE in General and Abdominal-pelvic Surgical Patients
Risk Prophylaxis for normal paitients Prophylaxis for patients at high risk for major bleeding complications pharmacologic prophylaxis with LMWH (1B) or LDUH (1B), mechanical prophylaxis with elastic stockings (ES) or IPC should be added to pharmacologic prophylaxis (2C) extended-duration pharmacologic prophylaxis (4 weeks) with LMWH (1B) mechanical prophylaxis, preferably with IPC, until the risk of bleeding diminishes and pharmacologic prophylaxis may be initiated (2C)
2 Points
Malignancy Confined to bed (> 72 h) Laparoscopic surgery (> 45 min)
Abnormal pulmonary function Serious lung disease, including pneumonia (< 1 mo) Pregnancy or postpartum History of unexplained or recurrent spontaneous abortion Medical patient at bed rest
Prophylaxis?
VTE ↓71% Death ↓46% Major bleeding ↑103% Wound hematoma ↑ 88%
VTE
Bleeding
Mismetti P, et al. Meta-analysis of low molecular weight heparin in the prevention of venous thromboembolism in general surgery .Br J Surg . 2001 ; 88 ( 7 ): 913 - 930 .
Risk Factors for Major Bleeding Complications Procedure-specific risk factors
Cardiac surgery Use 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