最新下肢深静脉血栓形成防治-PPT文档.ppt
Introduction,下肢深静脉血栓形成 Deep vein thrombosis DVT 发生率 32-88%（无预防措施） 15-30%（有预防措施） 治疗效果不够理想 常遗留下肢深静脉阻塞或静脉瓣膜功能不全 严重者可发生肺动脉栓塞（Pulmonary embolism PE）,Pathology of DVT,Virchow三联定律 （virchow triad,19461956） 静脉血流滞缓 静脉壁损伤 血液高凝状态,Pathology of DVT,Classification of DVT,（1）周围型 （2）中央型 （3）混合型,Clinical manifestation of DVT,肿胀明显,股青肿 小腿部疼痛或胀感，腓肠肌有压痛 Homans征阳性 浅静脉扩张 发烧，但一般不超过38.5,Risk Factors for DVT,以前有 DVT史或家族史 长时间制动如：长期卧床，坐飞机，火车等 近期手术，尤其下肢骨科手术 年龄大于40 激素治疗或口服避孕药 怀孕或产后 恶性肿瘤 慢性肺病 肥胖 凝血异常 手术时间过长（4h）,Diagnosis of DVT,高危因素 临床表现 辅助检查 彩色Dopplar MRI 静脉造影(金标准),Ultrasonography for DVT,Venography for DVT,Prevention for DVT,机械预防方法 早期活动、抬高床脚，尽早下床活动 多作深呼吸及咳嗽动作 下肢按摩 穿长腿弹力袜（elastic stocking） 静脉脉冲泵(venous impulse pump) 充气裤 (pneumatic compression trouses),Prevention for DVT,Designed to offer graduated compression of the foot, ankle and calf muscle. Helps reduce swelling, aching and the risk of Deep Vein Thrombosis - DVT. Combines the comfort of Cotton with a high percentage of Lycra to produce graduated compression. Looks and feels like an everyday sock. Are available in 3 sizes for a perfect fit. flightsocks,Prevention for DVT,Prevention for DVT,药物预防 口服华法令：起效慢 阿斯匹林与低右（Dextran）：作用不确实 普通肝素（UFHs）：副作用大 低分子量肝素（LMWHs） 作用确实，广泛应用 a拮抗剂：fondaparinux 作用确实，未广泛应用,DVT prevention after joint arthroplasty,Complication Rates by Agent,Prevention for DVT,Prevention for DVT,（LMWHs） enoxaparin，fondaparinux， ximelagatran 开始时间：术前一天（欧洲） 术后12-24小时（北美） 持续时间：7d-21d 检测凝血指标 减少DVT发生率40-70%,Prevention for DVT,OREF一致认为,Orthopedic research education foundation 2002,CA,USA,DVT要进行预防,Prevention for DVT,OREF Oral warfarin (18.7%) Aspirin (18.2%) Elastic stocking (18.2%) LMWHs (16.6%) UFHs (10%) Pentosacharides (8.9%),Treatment of DVT,溶栓治疗 尿激酶 介入治疗 下腔静脉滤网成形术 取栓术：DVT早期，价格昂贵,髂股静脉Fogarty导管取栓术,髂股静脉Fogarty导管取栓术,Outcome of DVT,部分再通(revascularization) 下肢深静脉血栓形成后综合征 (post-DVT syndrome) 发生PE,Introduction of PE,预防DVT主要目的是避免PE的发生 发生率 DVT PE THA 45-57% 0.1-0.4% TKA 40-84% 0.2-0.7% 髋部骨折 36-60% 3.6-12.9%,Incidence of PE,4.70% (1990s) 0.21% (1960s),?,Clinical manifestation of PE,Symptoms of Pulmonary Embolism The symptoms are frequently nonspecific and can mimic many other cardiopulmonary events. Shortness of breath Rapid pulse Sweating Sharp chest pain Bloody sputum (coughing up blood) Fainting,PE in USA,It is estimated that each year more than 600,000 patients suffer a pulmonary embolism. PE causes or contributes to up to 200,000 deaths annually in the United States. One in every 100 patients who develop DVT die due to pulmonary embolism. A majority of pulmonary embolism are caused by DVT. If pulmonary embolism can be diagnosed and appropriate therapy started, the mortality can be reduced from approximately 30 percent to less than ten percent.,Summary,预防DVT主要目的是避免PE的发生 临床医生尤其骨科医生应重视DVT 应进行DVT的预防，尤其是高危患者 推荐一种机械方法结合一种药物方法 前者：逐渐加压式充分裤 后者：LMWHs-既有效又安全 DVT的治疗方式选择应根据病情程度和病人的经济状况来权衡 PE发生率低，一旦发生后果严重，积极治疗可将死亡率由30%降至10%,Prevention for DVT,
