骨科讲义.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,1,美国泰科医疗器材有限公司,常需医疗用品事业部,骨科病人,DVT&PE,预防性治疗的应用,DVT&PE,2,名 词 介 绍,肺栓塞（,pulmonary embolism,，,PE,）,肺血栓栓塞症,:,占,PE,的,90%,（,pulmonary thromboembolism,，,PTE,）,肺梗死（,pulmonary infarction,，,PI,）,深静脉血栓形成（,deep venous thrombosis,，,DVT,）,静脉血栓栓塞症,VTE:DVT+PTE,（,venous thromboembolism,，,VTE,）,3,1856,年法国人,Virchow,提出：,深静脉血栓形成三因素,血流缓慢,血管壁损伤,凝结改变,深静脉血栓形成因素,血流缓慢,凝结改变,血管壁,损伤,Virchow,三角,血管壁,血液成分,血流,改变,4,围术期,DVT,形成因素分析,血流缓慢,术前活动减少,麻醉及术中静止不动,术后制动和长期卧床,血管壁损伤,手术操作和体位,关节置换手术骨水泥的热效应,大腿止血带,凝血改变,麻醉及创伤后组织因子释放,外源性凝血系统激活,凝血抑制因子缺陷导致的高凝状态,5,DVT,常见部位,左髂静脉,股静脉,股深静脉末端,位于内收肌管的腘静脉,腓肠肌肌内静脉,胫骨后静脉,6,7,疾病人群,DVT,发生率,普通外科手术,15-40%,神经外科手术,15-40%,胫骨骨折,20-70%,髋部或膝盖手术,40-60%,脊髓损伤,60-80%,肺切除术：,26-60%,冠脉搭桥手术：,17-45%,大创伤,40-70%,胸腹联合伤：,50-60%,心肺移植：,12-27%,Geerts WH,et al.Prevention of venous thromboembolism.,CHEST 2004,；,126,外科手术并发症,PTE-DVT,流行病学,8,PE,尸检研究,7,国外,出处,病例数,尸检确定,PE,的病例,有,PE,但死前没有诊断出来的病例,病例数,病人数,%,Freiman,1965,61,39,64,36,92,Modan,1972,2,107,353,17,235,67,Rossman,1974,250,16*,6.4,8,50,Coon,1976,4,600,567,12,514,91,Goldhaber,1982,1,455,54*,3.7,38,70,Goldman,1983,300,24*,8.0,15,63,Rubinstein,1988,1,276,44*,3.4,30,68,Landefeld,1988,233,15*,6.4,11,73,Karwinski&Svendsen,1989,21,529,67*,0.359,88,Rao&Rangwala,1990,213,18*,7.8,11,61,Hauch,1990,131,16*,12,10,63,McKelvie,1994,132,16,12,13,81,Morgenthaler&Ryu,1995,2,427,92*,3.8,63,68,Stein&Henry,1995,404,20*,5.0,14,70,*,PE,是直接死亡原因,9,北大医院,时间：,2003,年,24,月,病例数：,233,例大手术病人,检测方法：加压超声成像,DVT,检出：,111,例（,47.64%,，,其中近端,3,例，远端,108,例）,静脉血栓栓塞的流行病学（中国）10,VTEDVT+PE,沉默的杀手,11,VTE:,经常得不到及时诊断,所有致死性,PE,病例在死亡前得到诊断的不足一半,1,约,80%DVT,病例无临床表现,2,3,1.Goldhaber SZ,et al.,American Journal of Medicine,1982;73:822-826.,2.Lethen H,et al.,American Journal of Cardiology,1997;80:1066-1069.,3.Sandler DA,et al.,J.Royal Soc.Med.,1989;82:203-205.,DVT,致死性,PE,12,沉默的杀手,大多数的DVT,是没有症状的,只有,25%,的,DVT,病人有临床症状。,临床症状多为呼吸困难，气促，胸痛，晕厥，咯血等，不明显，不典型。,在成年病人的常规尸解中检出,1.5-30%,的病例有血栓。,众所周知,DVT,很可能没有症状而首发表现就是致命的肺栓塞。,下表,O,MEARA 1998,From the,“,Department of Orthopedic Surgery,”,PE,引起的死亡人数,195,死前有,DVT,症状的百分比,37,（,19%,）,入院时有,PE,临床症状的人数,4,（,2,）,13,骨科大手术发病率,术式,DVT PTE,总发生率 近端发生率 总发生率 致命性,全髋置换 4257 1836 0.928 0.12.0,全膝置换 4185 522 1.510.0 0.10.7,髋部骨折 4660 2330 3.011.0 2.57.5,14,血栓形成的部位,股静脉（国外一组资料）,Hill,美国外科杂志,2,654,例病人使用多普勒超声检测出,DVT,，其中,49%,的,DVT,发生在大腿和腘窝处，并且都不是由远端,DVT,延伸而来的。,Stamatakis,英国医学杂志,经静脉造影证实，,57%,的,DVT,是股静脉原生的。,15,血栓形成的部位,股静脉,OMeara,骨科杂志,肺栓塞主要都是从近端,DVT,而来，,75%,的致命性肺栓塞都与股静脉,DVT有关。,骨科病人,80-90%,的,DVT,都发生在手术肢。,股静脉血栓可自行生成，不需由小腿血栓向近端延伸。,16,术中及术后,DVT,的风险时段,机械预防有效,DVT,风险程度,时间（小时）,手术,PACU,住院,出院,家,0-22-29 29-72 72+,17,抗凝剂的副反应,一个前瞻性随机对照实验对,10,000,个病人中的,52,个进行了研究，证明了抗凝剂在择期全髋置换术病人中的出血并发症的危险性。,16,全髋成形术出血危险,大出血,小渗血,18,血栓形成的时间,手术当日,OMeara,骨科杂志,术中和手术当日,DVT,的发生率为,50%,，术后,48,小时,DVT,发生率为,75%,。,Nicolaides,血栓病理,45%,的血栓发生在手术当日。,Maynard,临床骨科及相关研究,膝关节置换术后当日使用静脉造影检测,DVT,，单肢手术组的发生率为,86%,，双下肢手术组的发生率为,85%,。,19,危险因素,每个危险因素代表下列分值,7,1,分因素,2,分因素,3,分因素,5,分因素,肥胖,年龄,41-60,岁,大手术史,静脉曲张,小手术（,45,分钟）,预计卧床时间,72,小时,石膏固定,恶性肿瘤,DVT/PE,病史,蛋白,C,或,S,缺乏,抗莱顿因子,V/,活化蛋白,抗凝因子,III,缺乏,血纤维蛋白原缺乏,肝素引起的血小板减少症,抗磷脂抗体,凝血素,20210A,择期下肢大手术,髋骨、盆腔及腿部骨折,急性脊髓损伤（瘫痪）,总分：,IPC=,间歇充气压力泵；,GCS=,梯度压力袜；,LMWH=,低分子肝素；,LDUH=,低剂量肝素,低危,（,1,分）,中危,（,2,分）,High Risk,(3 4 factors),Highest Risk,(5 or more factors),无须特别措施,尽早活动,IPC,或,LDUH,或,LMWH,或,GCS,GCS,和,IPC,或,LDUH,或,LMWH,GCS,和,IPC+,（,LDUH,或,LMWH,）,危险因素分级推荐预防方案,7,20,深静脉血栓形成的预防方法,物理（机械）方法,方便，无副作用早期活动，抬高下肢,梯度压力弹力袜（,ES,）,间歇充气压力泵（,IPC,）,药物方法,有出血副作用,低分子肝素（,LMWH,）,低剂量肝素（,LDH,）,口服抗凝剂,21,SCD EXPRESS*all-in-one,抗栓压力系统,-,IPC,技术的领导者,All-in-One Controller,22,SCD,的设计思想,人体工程学,来源于临床实践,被临床实践结果所证实,23,SCD,抗栓泵,“金标准”的梯度压力模式,续贯、圆周压力,静脉再充盈检测技术,良好的依从性,大量临床文献证实,腿部压力：流速,240-260%,足部压力：峰值,145%,24,独有的,VRD,技术,专利技术,25SCD Express,静脉再充盈检测（,VRD,）,腿套充气模式,VRD,步骤,腿套对腿部进行临床验证的,11,秒充气,腿套开始放气，在小腿腔留,6mmHg,压力,系统,60,秒内保持并监测小腿的检测压力，这样可以测得小腿静脉压力的增加,当小腿静脉压力,10,秒内停止增加，表示静脉充盈完成,系统按上述测得的时间设定每个压力循环时间（,11,秒充气时间,+,放气即静脉再充盈时间（,VRT,）,系统每,30,分钟自动重新检测静脉再充盈时间（,VRT,）,26,SCD Express,静脉再充盈检测（,VRD,）,脚套充气模式,VRD,步骤,脚套对脚进行临床验证的,5,秒充气,脚套开始放气，但在充气腔内留,6mmHg,压力,系统,60,秒内保持并监测脚底静脉的检测压力，这样可以测得脚底静脉压力的增加,当脚底静脉压力,10,秒内停止增加，表示静脉充盈完成,系统按上述测得的时间设定每个压力循环时间（,5,秒充气时间,+,放气即静脉再充盈时间（,VRT,）,系统每,30,分钟自动重新检测静脉再充盈时间（,VRT,）,27,TED,压力抗栓带（专利技术）,获得最佳增加血流速度的方式,，,被证明可以增加血流速度至,138%。（,Archives of Surgery Vol.110,February 1975,）,膝部压力释放,28,参考文献：,Geerts,W.H.,et al.,Prevention of Venous Thromboembolism:The Seventh ACCP Conference on Antithrombotic And Thrombolytic Therapy.CHEST.2004;126:338S 400S.,OMeara,P.M.,et al.Prophylaxis for Venous Thromboembolism in Total Hip Arthroplasty:A Review.ORTHOPEDICS.February 1990;13:173-178.,Reitman,R.D.,et al.A Multimodality Regimen for Deep Venous Thrombosis in Total Knee Arthroplasty.THE JOURNAL OF ARTHROPLASTY.2003;18:161-168.,Planes,A.,et al.Total Hip Replacement and Deep Vein Thrombosis.JOURNAL OF BONE AND JOINT SURGERY(British).January 1990;72-B:9-13.,OBryne,Margaret.Post-Thrombotic Syndrome After Orthopaedic Surgery.TECHNIQUES IN ORTHOPEDICS.2004.19(4):347-357.,Maynard,M.,et al.Progression and Regression of DVT after Total Knee Arthroplasty.CLINICAL ORTHOPEDICS AND RELATED RESEARCH.December,1991.,Based on:GP Claggett,MD et al:Prevention of Venous Thromboembolism.Chest 1998;114:531S-560S;1997 International Consensus Statement:Prevention of Venous Thromboembolism,Guidelines According to Scientific Evidence;and Caprini JA,Arcelus JI et al:Clinical assessment of venous thromboembolism risk in surgical patients.Semin Thromb Hemost 1991;17(suppl3):304-312.Preliminary draft submitted for publication.Provided as an educational service by The Kendall Company.,Hooker,J.A.,et al.Efficacy of Prophylaxis Against Thromboembolism with Intermittent Pneumatic Compression After Primary and Revision Total Hip Arthroplasty.THE JOURNAL OF BONE AND JOINT SURGERY,INC.May 1999;81-A:690-696.,Woolson,S.T.,et al.,Deep Venous Thrombosis Prophyxis for Knee Replacement:Warfarin and Pneumatic Compression.THE AMERICAN JOURNAL OF ORTHOPEDICS.April 1998:299-304.,Carprini,J.A.,et al.,A Comprehensive,Combination-Treatment Approach to Thrombosis Prophylaxis Following Total Knee Arthroplasty.American Venous Forum.Poster presentation2005.,Ramos,R.,et al.The Efficacy of Pneumatic Compression Stockings in the Prevention of Pulmonary Embolism After Cardiac Surgery.CHEST.January 1996;109:82-85.,OReily,R.F.,et al.,The Prevalence of Venous Thromboembolism After Hip and Knee Replacement Surgery.MJA.February 2005;182-4:154-159.,Turpie A.G.,et al.,Fondaparinux Combined with Intermittent Pneumatic Compression(IPC)Versus Prevention IPC alone in the prevention of VTE after major abdominal surgery:Results of the APOLLO Study.JOURNAL OF THROMBOSIS AND HAEMOSTASIS.2005;3-1:1046.,Agnelli,G.,et al.Randomized clinical trial of postoperative fondaparinux verus perioperative dalteparin for prevention of venous thromboembolism in high-risk abdominal surgery.BRITISH JOURNAL OF SURGERY.October 2005;92-10:1212-1220.,Lacut,M.D.,et al.,Prevention of venous thrombosis in patients with acute intracerebral hemorrhage.NEUROLOGY.2005;65:865-869.Freedman,K.B.,et al.A Meta-Analysis of Thromboembolic Prophylaxis Following Elective Total Hip Arthroplasty.THE JOURNAL OF BONE AND JOINT SURGERY.2000;82-A(7):929-938.,Nicolaides,a.et al.Cost-Effectiveness of LMWH and Intermittent Pneumatic Compression with Graduated Elastic Compression Stockings as Prophylaxis for DVT.American Venous Forum.Poster presentation.2005,29,1、卧床或制动时间超过,72,小时；,2、年龄超过,60,岁,3、多发性创伤特别是盆腔、髋部或下肢骨折，脊髓损伤,导致截瘫、偏瘫；,4、大中型手术中及术后；,5、静脉血管损伤如静脉曲张、静脉炎患者；,6、血液粘稠度增高者如严重感染、脱水患者；,7、血液高凝状态；,8、既往有深静脉血栓或肺栓塞病史者；,9、合并有心衰、呼衰、中风或恶性肿瘤等各种高危因素的患者群。,适用范围：,30,禁忌症：,1、,腿部有下列疾患的：,A，,皮炎,B，,坏疽,C，,近期进行皮肤移植、静脉结扎,2、严重的动脉硬化或缺血萎缩性血管疾病,3、由充血性心衰引发的下肢大面积水肿或肺水肿,4、下肢严重变形,5、怀疑有深静脉血栓存在,31,成本效益分析,黑龙江物价规定,压力治疗（每部位,20,元）,物价编码,32,谢 谢！,Q&A,Sensing Refill Time,0,10,20,30,40,50,11 seconds,Normal Inflation Cycle,Ankle,Calf,Thigh,0,10,20,30,40,50,6 mmHg,Sensing Refill Time,10-second window,0,10,20,30,40,50,Within,0.3mmHg?,Sensing Refill Time,10-second window,0,10,20,30,40,50,Within,0.3mmHg?,Sensing Refill Time,10-second window,0,10,20,30,40,50,Within,0.3mmHg?,Sensing Refill Time,10-second window,0,10,20,30,40,50,Within,0.3mmHg?,Sensing Refill Time,10-second window,0,10,20,30,40,50,Within,0.3mmHg?,Sensing Refill Time,10-second window,0,10,20,30,40,50,Within,0.3mmHg?,Sensing Refill Time,10-second window,0,10,20,30,40,50,Within,0.3mmHg?,Sensing Refill Time,10-second window,0,10,20,30,40,50,Within,0.3mmHg?,Sensing Refill Time,10-second window,0,10,20,30,40,50,Within,0.3mmHg?,Sensing Refill Time,10-second window,0,10,20,30,40,50,Within,0.3mmHg?,YES,Sensing Refill Time,