減少入院患者靜脈

1、 R REDUCINGEDUCING THETHE RISKRISK OFOF VENOUSVENOUS THROMBOEMBOLISMTHROMBOEMBOLISM ( (DEEPDEEP VEINVEIN THROMBOSISTHROMBOSIS ANDAND PULMONARYPULMONARY EMBOLISMEMBOLISM) ) ININ PATIENTSPATIENTS ADMITTEDADMITTED TOTO HOSPITALHOSPITAL減少入院患者靜脈血栓栓塞（深靜脈和肺栓塞）的風(fēng)險減少入院患者靜脈血栓栓塞（深靜脈和肺栓塞）的風(fēng)險This guideline updat

2、es NICE clinical This guideline updates NICE clinical guideline 46 and replaces itguideline 46 and replaces it（NICE clinical guideline 92 ）該指南更新于該指南更新于NICENICE指南指南4646，并取代它，并取代它（NICENICE臨床指南臨床指南9292）廣東省中醫(yī)院芳村醫(yī)院廣東省中醫(yī)院芳村醫(yī)院腎內(nèi)科腎內(nèi)科撰寫機構(gòu) NICE CLINICAL GUIDELINE 92 DEVELOPED BY THE NATIONAL COLLABORATING CEN

3、TRE FOR ACUTE AND CHRONIC CONDITIONSNICE臨床指南92是由英國國家急慢性病合作中心撰寫CONTENTS 內(nèi)容INTRODUCTION 簡介The House of Commons Health Committee reported in 2005 that an estimated 25,000 people in the UK die from preventable hospital-acquired venous thromboembolism (VTE) every year. This includes patients admitted to

4、hospital for medical care and surgery. 下議院衛(wèi)生委員會在2005年已經(jīng)發(fā)表報告，該報告評估了約2500人，他們選自每年死于可以預(yù)防的醫(yī)院獲得性靜脈血栓栓塞患者。這些患者是來自于內(nèi)科和外科的住院患者。INTRODUCTION 簡介The inconsistent use of for VTE in hospital patients has been widely reported. 對住院的靜脈血栓栓塞患者采取不合理的防范措施已經(jīng)被廣泛的報道。A UK survey suggested that 71% of patients assessed to b

5、e at medium or high risk of developing deep vein thrombosis did not receive any form of mechanical or pharmacological VTE prophylaxis.一項英國調(diào)查發(fā)現(xiàn)71%的患者存在發(fā)生中重度深靜脈血栓的風(fēng)險，但是他們沒有接收任何形式的機械的或者藥理學(xué)的靜脈血栓栓塞的預(yù)防方法。INTRODUCTION簡介VTE is an important cause of death in hospital patients, and treatment of non-fatal symp

6、tomatic VTE and related long-term morbidities is associated with considerable cost to the health service.靜脈血栓栓塞是住院患者的一個重要死亡原因，治療非致命的、有癥狀的靜脈血栓栓塞及相關(guān)的長期并發(fā)癥，花費了健康醫(yī)療的相當(dāng)大的開銷。KEY PRIORITIES FOR IMPLEMENTATION 重點實施Assessing the risks of VTE and bleeding Assessing the risks of VTE and bleeding 重點評估重點評估VTEVTE

7、和出血風(fēng)險和出血風(fēng)險Reducing the risk of VTE Reducing the risk of VTE 減少減少VTEVTE的風(fēng)險的風(fēng)險Using VTE prophylaxis Using VTE prophylaxis 使用使用VTEVTE預(yù)防方法預(yù)防方法Anti-embolism stockingsAnti-embolism stockings抗栓襪抗栓襪all patientsall patientsASSESSING THE RISKS OF VTE 重點評估VTE風(fēng)險medical patientshad or are expected to have signif

8、icantly reduced mobility for 3 days or more or or are expected to have ongoing reduced mobility relative to their normal state.已經(jīng)或預(yù)期3天或以上有顯著減少的血流，或預(yù)計較相對正常狀態(tài)血流持續(xù)減少的流動。Assess all patients on admission to identify those who are at increased risk of VTE.對所有入院患者進行評估，辨別發(fā)生VTE的高危人群surgical patients and pati

9、ents with trauma1.surgical procedure with a total anaesthetic and surgical time of more than 90 minutes, or 60 minutes if the surgery involves the pelvis or lower limb .1.外科手術(shù)總的麻醉時間超過90min，或骨盆、下肢手術(shù)總的麻醉時間超過60min。2. acute surgical admission with inflammatory or intra-abdominal condition .2.有炎癥或腹腔內(nèi)急診手術(shù)

10、。3.expected significant reduction in mobility .3.預(yù)計有明顯血流減少的情況。VTE危險因素BOX1 VTE危險因素1.活動的癌癥或癌癥治療者2.年齡大于60歲3.新收的危重護理病人4.脫水5.已知的血栓形成傾向6.肥胖（BMI30kg/m2）7. 1個或以上明顯的內(nèi)科并發(fā)癥，如心臟??；代謝的、內(nèi)分泌、呼吸的病理疾??；急性傳染性疾??；炎癥等。8. VTE個人史或直系親屬9.使用激素替代治療10.使用含雌二醇的避孕療法11.靜脈曲張靜脈炎12.孕婦在分娩前6周ASSESSING THE RISKS OF BLEEDING重點評估出血風(fēng)險 Assess

11、 all patients for risk of bleeding before offering pharmacological VTE prophylaxis.在為患者提供VTE藥物預(yù)防方法前評估出血風(fēng)險。 Do not offer pharmacological VTE prophylaxis to patients with any of the risk factors for bleeding shown in box 2。不要為存在出血風(fēng)險的患者提供VTE藥物預(yù)防方法。unless the risk of VTE outweighs the risk of bleeding.

12、除非VTE的風(fēng)險比出血風(fēng)險嚴重。 BOX2 RISK FACTORS FOR BLEEDING 出血的危險因素出血風(fēng)險因素1.活動出血2.獲得性出血性疾病（如急性肝衰竭）3.已知同時使用抗凝劑會增加出血風(fēng)險（如國際標(biāo)準(zhǔn)比值INR高于2時使用華法林）4.腰椎穿刺或硬膜外脊髓麻醉后12小時內(nèi)5.腰椎穿刺或硬膜外脊髓麻醉前4小時內(nèi)6.急性中風(fēng)7.血小板減少癥（血小板低于75109L）8.不受控制的收縮性高血壓（230120mmHg以上）9.未治療的遺傳性出血疾?。ㄈ缪巡『脱苄匝巡。〢SSESSING THE RISKS OF VTE AND BLEEDING 重點評估VTE和出血風(fēng)險REDUC

13、ING THE RISK OF VTE 減少VTE的風(fēng)險1.除非臨床指征需要，否者不要讓病人處于脫水狀態(tài)。 2.盡可能的鼓勵患者走動。 3.不要認為阿司匹林或其他抗血小板藥物足以預(yù)防VTE的發(fā)生。 4.對于VTE高風(fēng)險的患者，如以前的VTE事件或一個活躍的惡性腫瘤患者）和對機械和藥物預(yù)防靜脈血栓栓塞都有禁忌的患者，應(yīng)考慮提供臨時下腔靜脈過濾器。下腔靜脈過濾器下腔靜脈濾器置入的方法：1.先行患肢的靜脈造影檢查，以確定深靜脈血栓形成的診斷。2.根據(jù)深靜脈血栓累及的范圍選擇適當(dāng)?shù)那混o脈濾器置入部位。3.患者置于有熒光屏監(jiān)測的DSA室，4.濾器最常用的置入途徑是健側(cè)股靜脈，當(dāng)下腔靜脈出現(xiàn)血栓時，可選用

14、頸內(nèi)靜脈。其他可供選擇的途徑有肱靜脈和頸外靜脈。 機械預(yù)防法藥物預(yù)防法Using VTE prophylaxis 使用VTE預(yù)防方法1.anti-embolism stockings (thigh or knee length) 抗栓襪（大腿或膝蓋的長度）2.foot impulse devices 腳脈沖裝置3.intermittent pneumatic compression devices (thigh or knee length).間歇充氣加壓裝置（大腿或膝蓋的長度）。Base the choice of pharmacological VTE agents on local po

15、licies and individual patient factors, including clinical condition (such as renal failure) and patient preferences.VTE藥物的基本選擇要參考當(dāng)?shù)氐恼吆筒∪说膫€體差異，包括臨床表現(xiàn)（如腎衰竭）和病人的喜好。ANTI-EMBOLISM STOCKINGS抗栓襪抗栓襪使用禁忌癥1.可疑或已證明的外周動脈疾病；2.外周動脈旁路移植術(shù)3.周圍神經(jīng)病變或其他原因引起的感覺障礙4.在現(xiàn)存的條件下，襪子可能造成損害，如脆弱的面巾紙樣的皮膚，皮炎，壞疽或最近有皮膚移植者。5.對材料過敏6.心力

16、衰竭7.小腿嚴重水腫，或充血性心力衰竭引起的肺水腫8. 腿的大小或形狀與以往不同9.主要肢體畸形時使用預(yù)防裝置來正確安裝10.有靜脈曲張或皮膚損傷者要正確小心使用。Do not offer anti-embolism stockings to patients who have: suspected or proven peripheral arterial disease peripheral arterial bypass grafting peripheral neuropathy or other causes of sensory impairment any local condi

17、tions in which stockings may cause damage, for example fragile tissue paper skin, dermatitis, gangrene or recent skin graft known allergy to material of manufacture cardiac failure severe leg oedema or pulmonary oedema from congestive heart failure unusual leg size or shape major limb deformity prev

18、enting correct fit. Use caution and clinical judgement when applying anti-embolism stockings over venous ulcers or wounds.抗栓襪使用注意事項1. 確保那些需要抗栓襪患者已經(jīng)測量過腿圍，并為患者提供正確的尺寸?？顾ㄒm應(yīng)正確佩戴，專業(yè)人員應(yīng)指導(dǎo)患者如何正確使用抗栓襪。2.當(dāng)患者出現(xiàn)水腫或術(shù)后肢體腫脹時應(yīng)確保重測量腿圍，并重新佩戴抗栓襪。3.如果懷疑有動脈疾病，在佩戴抗栓襪前征詢專家的意見。4.使用抗栓襪后，應(yīng)保證患肢受壓均勻，使小腿產(chǎn)生14-15毫米汞柱壓力。5.鼓勵病人全天都

19、穿抗栓襪，直到他們不再有顯著性的血流減慢。1.Ensure that patients who need anti-embolism stockings have their legs measured and that the correct size of stocking is provided. Anti-embolism stockings should be fitted and patients shown how to use them by staff trained in their use. 2.Ensure that patients who develop oedem

20、a or postoperative swelling have their legs re-measured and anti-embolism stockings refitted. 3.If arterial disease is suspected, seek expert opinion before fitting anti-embolism stockings. 4.Use anti-embolism stockings that provide graduated compression and produce a calf pressure of 1415 mmHg. 5.E

21、ncourage patients to wear their anti-embolism stockings day and night until they no longer have significantly reduced mobility. 抗栓襪使用注意事項6. 每天取下抗栓襪進行患者的衛(wèi)生保健和檢查皮膚狀況。當(dāng)患者的血流顯著減少，皮膚完整性差或感覺喪失時，每天應(yīng)檢查肢體皮膚兩次或三次，尤其是在腳骨突起處。7.如果抗栓襪使用到期；皮膚起泡或變色，特別是在腳跟和骨突出；患者經(jīng)歷疼痛或不適。如果條件可以，提供腳脈沖裝置或間歇充氣加壓裝置作為替代治療。8.告訴患者如何正確使用抗栓襪，

22、并確保他們明白這將減少患靜脈血栓栓塞的風(fēng)險。9.監(jiān)測抗栓襪的使用情況，當(dāng)患者沒有被正確佩戴時，提供幫助。10.不要為知道自己對材料過敏的患者提供腳脈沖裝置或間歇充氣加壓裝置。11.鼓勵病房使用腳脈沖裝置或間歇充氣加壓裝置的患者盡可能多的運用裝置，不管是躺在床上，還是坐在凳子上。6.Remove anti-embolism stockings daily for hygiene purposes and to inspect skin condition. In patients with a significant reduction in mobility, poor skin integrity or any sensory loss, inspect the skin two or three times per day, particularly over the heels and bony prominences. 7.Discontinue the use of anti-embolism stockings if there is marking, blistering or discolouration of the skin, particularly over the heels and bony prominences