急性肺動(dòng)脈栓塞及進(jìn)展-心內(nèi)科何國(guó)祥課件

急性肺栓塞診療指南及進(jìn)展GuidelinesandProgressontheDiagnosisandManagementofAcutePulmonaryEmbolism

SouthwestHospital何國(guó)祥Prof.GuoxiangHE第三軍醫(yī)大學(xué)西南醫(yī)院重慶市介入心臟病學(xué)研究所SouthwestHospitalTheThirdMilitaryMedicalUniversityChongqingInstituteofInterventionalCardiology

SouthwestHospitalUpdatein2021中國(guó)急性肺血栓栓塞癥診斷治療專(zhuān)家共識(shí)

GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalGuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalGuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalFIG1.Venousthromboembolism(VTE)/100,000population/yearfrom1990through1999.(DatafromSteinetal.3-5)CurrProblCardiol2021;35:314-376GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalFIG2.Deepvenousthrombosis(DVT)/100,000population/yearshownaccordingtoagefortheyear1999.6,7(Reprintedwithpermission.10)CurrProblCardiol2021;35:314-376GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalFIG3.Pulmonaryembolism(PE)/100,000population/yearshownaccordingtoagefortheyear1999.(DatafromSteinetal.5,6)(Reprintedwithpermission.10)CurrProblCardiol2021;35:314-376GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalFIG12.EstimatedcasefatalityratesforPEaccordingtodecadesofage.(Reprintedwithpermission.23)CurrProblCardiol2021;35:314-376GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalFIG4.PEandDVTinchildren.(DatafromSteinetal.7)CurrProblCardiol2021;35:314-376GuidelinesandProgressontheDiagnosisandManagementofAcutePE

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Majorriskfactorsforvenousthrombosis?Majorsurgery?Orthopaedicsurgerytolowerlimb/lowerlimbtrauma?Historyofpreviousvenousthrombosis?Cancer?Pregnancy/puerperium?Reducedmobility–majorillnesswithprolongedbedrest?Age>70years?Thrombophilias:antithrombindeficiencyproteinCdeficiencyproteinSdeficiencyantiphospholipidantibodiesGuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalGuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalTABLE5.Electrocardiographicmanifestations:patientswithoutpriorcardiacorpulmonarydiseaseDatafromSteinetal.29,57Reprintedwithpermission.10Somepatientshadmorethan1abnormality.CurrProblCardiol2021;35:314-376GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalTABLE6.PlainchestradiographinpatientswithacutepulmonaryembolismandnopriorcardiopulmonarydiseaseDataarefromSteinetal.29,63Reprintedwithpermission.10aAmongpatientswithapleuraleffusion,86%hadonlybluntingofthecostophrenicangle.Nonehadapleuraleffusionthatoccupiedmorethanonethirdofahemithorax.bProminentcentralpulmonaryarteryanddecreasedpulmonaryvascularity.GuidelinesandProgressontheDiagnosisandManagementofAcutePE肺實(shí)質(zhì)異常肺不張/萎陷肺實(shí)變胸水

SouthwestHospitalFIGURE2.V/QSPECTforthedetectionofpulmonaryembolismV/QSPECTthermalimagingcoronalposteriorsectionsinafemalepatientshowmultiplelargepulmonary-ventilatoryareasofmismatchthatindicatepulmonaryembolithatinvolvetheupperandlowerlobesoftherightlung(whitearrows).V/QSPECT,ventilationandperfusionsinglephotonemissioncomputedtomography.GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalFIG19.RelativeuseofdiagnosticimagingtestsinpatientshospitalizedwithPEfrom1979through2006.V/Q,ventilation/perfusion;ANGIOS,pulmonaryangiograms.(Reprintedwithpermission.10)CurrProblCardiol2021;35:314-376GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalFIG20.CTpulmonaryangiogramshowingPEintherightpulmonaryartery.CurrProblCardiol2021;35:314-376GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalFIG21.CTvenousphaseimageshowingrightpoplitealveinthrombosis(arrow).CurrProblCardiol2021;35:314-376GuidelinesandProgressontheDiagnosisandManagementofAcutePE

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Threeimagesfromasinglecomputedtomographypulmonaryangiography(CTPA)studyperformedwithahighclinicalsuspicionofpulmonaryembolism(PE).Image1demonstratesalargePEintheproximalrightpulmonaryartery.Image2showsasignificantconcurrentpneumothorax.Image3demonstratesanRV/LVratio>1signifyingsignificantrightventricular(RV)dysfunction.TogethertheseimagesshowthehighutilityofCTPAindiagnosis/exclusionofPE,diagnosis/exclusionofdifferentialdiagnoses,andinriskstratifyingapatientsoastoguidetherapy.GuidelinesandProgressontheDiagnosisandManagementofAcutePE

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CausesofaraisedD-dimer?venousthromboembolicdisease?increasingage?cancer?infection?haematoma?postsurgery?inflammation?pregnancy?peripheralvasculardisease?liverdiseaseGuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalTheThrombo-EmbolismLactateOutcomeStudy

血栓-栓塞乳酸鹽轉(zhuǎn)歸研究

PrognosticValueofPlasmaLactateLevelsAmongPatientsWithAcutePulmonaryEmbolism

血漿乳酸鹽水平在PE患者中的預(yù)后價(jià)值A(chǔ)nnEmergMed.2021;xx:xxxTable2.Descriptionof30-dayoutcomeofpatientsinvestigated(n=270).*GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalFigure3.All-causedeathandcompositeendpointincidenceinpatientswithincreasingvaluesofplasmalactatelevel.乳酸鹽水平與全因死亡和復(fù)合終點(diǎn)AnnEmergMed.2021;xx:xxxGuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalFigure4.Coxproportionalhazardanalysisoftherelationshipbetweenplasmalactatelevelgreaterthanorequalto2mmol/Landoutcomein270patientswithacutepulmonaryembolism.AnnEmergMed.2021;xx:xxx全因死亡復(fù)合終點(diǎn)GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalFigure5.Receiveroperatingcharacteristiccurveanalysisofplasmalactatelevel,troponinIlevel,andsPESIvaluesin270patientswithacutepulmonaryembolism.AnnEmergMed.2021;xx:xxxGuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalElevatedHeart-TypeFattyAcid-BindingProteinLevelsonAdmissionPredictanAdverseOutcomeinNormotensivePatientsWithAcutePulmonaryEmbolism

心肌脂肪酸結(jié)合蛋白水平升高預(yù)測(cè)血壓正常的APE病人不良轉(zhuǎn)歸(JAmCollCardiol2021;55:2150–7)Figure1PrognosticSensitivityandSpecificityofH-FABP,cTnT,andNT-proBNPReceiveroperatingcharacteristiccurvesforheart-typefattyacid-bindingprotein(H-FABP),cardiactroponinT(cTnT),andN-terminalpro-brainnatriureticpeptide(NT-proBNP)levelsonadmissionwithregardtoacomplicated30-dayoutcome.AUCareaunderthecurve.GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalFigure2CombinationofH-FABPWithClinicalParametersThenumberofpatientswithcomplicationsandtheoverallnumberofpatientsaregiven,alongwithpercentages,foreachcolumn.H-FABPheart-typefattyacidbindingprotein;HRheartrate;RVrightventricular.GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalFigure3ProbabilityofLong-TermSurvivalinPatientsWithorWithoutElevationofH-FABP,cTnT,andNT-proBNPBiomarkerlevelsweredichotomized,andelevatedconcentrationsweredefinedasthose6ng/mlforH-FABP,0.04ng/mlforcTnT,and1,000pg/mlforNT-proBNP.Redlineselevatedvalues;bluelinesnormalvalues;pvalueswerecalculatedbythelog-ranktest.AbbreviationsasinFigure1.JACC2021;55(19):2150–7GuidelinesandProgressontheDiagnosisandManagementofAcutePE

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Fig.1.Pathophysiologyofrightventriculardysfunctionduringacutepulmonaryembolism.

RV:Rightventricule;LV:Leftventricle;TXA2:Thromboxane-A2;ET:Endothelin;PGF2a:ProstaglandinF2a;PGI2:Prostacyclin.Greyarrowindicatesthatallconstitutedaviciouscycle.Blackarrowindicatespathophysiologychange.JMedCollPLA2021；25：235-246GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalTable2EchocardiographicriskassessmentinPE1.DiagnosticcriteriaforRVdysfunctionRV功能不全的標(biāo)準(zhǔn)

A.RVwallhypokinesis-Moderateorsevere-McConnell'ssignregionalRVhypokinesisinwhichtheapexisspared

B.RVdilatation-End-diastolicdiameter>30mminparastemalview-RVlargerthanLVinsobcostalorapicalview-Increasedtricuspidvelocity>26m/sec-ParadoxicalRVseptalsystolicmotionC.Pulmonaryarteryhypertension-Pulmonaryarterysystolicpressure>30mmHg-DilatedIVCwithlackofrespiratorycollapse2.OtherfactorsassociatedwithincreasedmortalityA.PatentforamenovaleB.Free-floatingnight-heatthrombusGuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalFig.1PhysicianassessmentofpatientswithPE.GuidelinesandProgressontheDiagnosisandManagementofAcutePEPE的臨床評(píng)估

SouthwestHospitalGuidelinesandProgressontheDiagnosisandManagementofAcutePE

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AssessmentofclinicalprobabilityRevisedGenevaScore

PointsAge>60years1PreviousVTE3Surgery/fracturelowerlimbinlastmonth2Activemalignancy2Unilaterallowerlimbpain3Haemoptysis2Heartrate75–943Heartrate>955Painonlowerlimbdeepvenouspalpationandunilateraloedema4ClinicalprobabilityTotalpointsLow0–3Intermediate4–10High>10GuidelinesandProgressontheDiagnosisandManagementofAcutePE

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ModifiedWellsscore6

PointsSymptomsofaDVT3Noalternativediagnosis3Heartrate>1001.5Immobilizationorsurgeryinthepreviousmonth1.5PreviousVTE1.5Malignancy1.5Haemoptysis1.5Score4orless,PEunlikelyGuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalTABLE12.PositivepredictivevaluesofCTAandCTA/CTVinrelationtopriorclinicalassessmentOnlypatientswithareferencetestdiagnosisbyV/QscanorconventionalpulmonaryDSAwereincluded.Abbreviations:CTA,computedtomographicpulmonaryangiography;CTV,venousphasevenogram.Reprintedwithpermission.14CurrProblCardiol2021;35:314-376GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalTABLE13.NegativepredictivevaluesofCTAandCTA/CTVinrelationtopriorclinicalassessmentOnlypatientswithareferencetestdiagnosisbyV/QscanorconventionalpulmonaryDSAwereincluded.Abbreviations:CTA,computedtomographicpulmonaryangiography;CTV,venousphasevenogram.Reprintedwithpermission.14CurrProblCardiol2021;35:314-376GuidelinesandProgressontheDiagnosisandManagementofAcutePE

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BTSscore

PointsIsaPEareasonablediagnosis?1PE的診斷合理?Isanalternativediagnosislesslikely?1可能性小?Isamajorriskfactorpresent?1存在主要危險(xiǎn)因素?1point,lowclinicalprobability;2points,intermediateclinicalprobability;3points,highclinicalprobability.GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalGuidelinesandProgressontheDiagnosisandManagementofAcutePE

AcutePulmonaryArteryEmbolism

SouthwestHospitalFig.3PathophysiologyofRVdysfunctionanddeathinPE.

SouthwestHospitalANAESTHESIAANDINTENSIVECAREMEDICINE2021；11:12AcutePulmonaryArteryEmbolism

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Anticoagulation抗凝：有充分理由支持診斷PE：開(kāi)始全劑量的LMUH治療由影像學(xué)證實(shí)和確診PE：停LMUH改為warfarin〔INR=2-3，目標(biāo)=2.5〕為門(mén)診病人安排監(jiān)測(cè)INRAcutePulmonaryArteryEmbolism

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Suggesteddosing,heparintherapyANAESTHESIAANDINTENSIVECAREMEDICINE2021；11:12AcutePulmonaryArteryEmbolism

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Howlongtotreat?根據(jù)PE的原因而異通常6W-3M可能足夠病因持續(xù)存在:抗凝持續(xù)

原發(fā)/先天性PE,一旦停止治療,復(fù)發(fā)率4–10%/年，4年以上遠(yuǎn)期事件率20%因此,I級(jí)事件后應(yīng)終身抗凝治療,但需要權(quán)衡治療的獲益與風(fēng)險(xiǎn)嚴(yán)重出血(顱內(nèi)出血；腹膜后出血；Hb降低需要輸血者〕：≤75歲1%/年＞75歲5%/年

決策治療療程前與病人/家屬討論利弊是明智/必要的AcutePulmonaryArteryEmbolism

SouthwestHospitalFig.2.Percentageandsizeofresidualpulmonarythrombi.Greater,similarandsmallerocclusionmeanbigger,sameandlessersizeofpulmonarythrombirespectivelyasseeninsecondcomputedtomography.EurJIntMed2021；23：379–383EurJIntMed2021；23：379–383Residualpulmonarythromboemboliafteracutepulmonaryembolism繼發(fā)于肺栓塞的剩余肺血栓AcutePulmonaryArteryEmbolism

SouthwestHospitalEurJIntMed2021；23：379–383Residualpulmonarythromboemboliafteracutepulmonaryembolism繼發(fā)于肺栓塞的剩余肺血栓AcutePulmonaryArteryEmbolism

SouthwestHospitalTable1Causesofnon-repeatedCTangiographyCausesN(%)Cognitiveimpairment5(11)Mobilityimpairment17(37)Renalfailure4(9)Death9(19)Livingoutofourcommunity6(13)Pregnancy1(2)Rejection4(9)EurJIntMed2021；23：379–383Residualpulmonarythromboemboliafteracutepulmonaryembolism繼發(fā)于肺栓塞的剩余肺血栓AcutePulmonaryArteryEmbolism

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Lifelongtreatmentisappropriateif:TheinitialPEwaslifethreateningPE威脅生存Thepatienthassignificantcardiorespiratorydisease患者有顯著的心肺疾病Wherebyafurther,evensmall,PEcouldhavefatalconsequences;orthepatienthasasecond,unprovokedeventPE可能有致命性后果，或有再次無(wú)緣無(wú)故的事件AcutePulmonaryArteryEmbolism

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INR達(dá)標(biāo):PE的復(fù)發(fā)是罕見(jiàn)的如果復(fù)發(fā)：增加warfarin、增大目標(biāo)INR癌癥患者〔復(fù)發(fā)更常見(jiàn)〕：轉(zhuǎn)換為L(zhǎng)MWH在抗凝治療中仍存在DVT，或抗凝禁忌：腔靜脈濾器〔可回收式〕

GuidelinesandProgressontheDiagnosisandManagementofAcutePE

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抗凝：嚴(yán)重出血并發(fā)癥<3%漏診PE：死亡風(fēng)險(xiǎn)30%提示：確診的PE、臨床高度PE風(fēng)險(xiǎn)者均應(yīng)抗凝，除非有明確禁忌癥ANAESTHESIAANDINTENSIVECAREMEDICINE2021；11:12GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalNewDrugReviewDabigatranEtexilate:AnOralDirectThrombinInhibitorfortheManagementofThromboembolicDisorders

達(dá)比加群：口服的直接凝血酶抑制劑ClinTher.2021;34:766–787TableI.PertinentdruginteractionswithdabigatranGuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalTableII.Pertinentclinicalstudiesontheuseofdabigatran.GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalBISTROIBoehringerIngelheimStudyinThrombosisI;DEdabigatranetexilate;DVTdeepveinthrombosis;PEpulmonaryembolism;QDdaily;RE-NOVATEPreventionofVenousThromboembolismAfterTotalHipReplacement;VTEvenousthromboembolism;RE-MODELThromboembolismPreventionAfterKneeSurgery;RE-MOBILIZEDabigatranVersusEnoxaparininPreventingVenousThromboembolismFollowingTotalKneeArthroplasty;RE-COVERDabigatranVersusWarfarinintheTreatmentofAcuteVenousThromboembolism;INRinternationalnormalizedratio;PETROPreventionofEmbolicandThromboticEventsinPatientsWithPersistentAtrialFibrillation;AFatrialfibrillation;RE-LYRandomizedEvaluationofLong-termAnticoagulationTherapy;Postoppostoperation.*P0.05forenoxaparin.?P0.05indicatingnon-inferiortoenoxoparin.?P0.0001indicatingnon-inferiortowarfarin.§P0.05significantlydifferentfromwarfarin.P0.001indicatingnon-inferiortowarfarin.?P0.001indicatingsuperiortowarfarin.GuidelinesandProgressontheDiagnosisandManagementofAcutePE

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Thrombolysis溶栓巨大PE：常伴心血管病，有或無(wú)紫紺、靜脈怒張、搏動(dòng)，P2亢進(jìn)雖然確診應(yīng)該基于影象結(jié)果，因?yàn)榇蟮腜E危急，通常難以轉(zhuǎn)送至放射科進(jìn)行CTPA床旁UCG可提供有價(jià)值的信息：急性右心負(fù)荷過(guò)重不能解釋的心肺衰竭病人，因?yàn)椴∏樘环€(wěn)定，無(wú)法CTPA、甚至床旁UCG，假定基于危險(xiǎn)評(píng)估和臨床表現(xiàn)而擬診PE：alteplase〔阿替普酶〕50mg巨大PE，顯著或進(jìn)行性血?jiǎng)恿W(xué)不穩(wěn)定〔溶栓可能戲劇性改善血?jiǎng)恿W(xué)和氧合狀態(tài)病死率和PE復(fù)發(fā)率低于肝素療法，但幾天內(nèi)血凝塊的解析度那么不如，缺乏頭對(duì)頭研究結(jié)果，meta-analysis傾向溶栓療法，因?yàn)轱@著降低了病死率submassivePE患者，溶栓后顯著減少了進(jìn)CCU的需求程度

ANAESTHESIAANDINTENSIVECAREMEDICINE2021；11:12GuidelinesandProgressontheDiagnosisandManagementofAcutePE

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溶栓劑和方案〔Thrombolyticagentsandregimens〕

Streptokinase

250,000Uasaloadingdoseover30min,鏈激酶

followedby100,000Uperhourover12–24h

Acceleratedregimen:1.5millionIUover2hUrokinase

4400Uperkilogramofbodyweightasaloadingdoseover10min,

尿激酶

followedby4400U/kg/hover12–24h

Acceleratedregimen:3millionUover2hAlteplase

100mgover2h阿替普酶

Acceleratedregimen:0.6mg/kgover15minReteplase

Twobolusinjectionsof10U30minapart瑞替普酶Tenecteplase

30–50mgbolusover5–10s替奈普酶adjustedforbodyweight:<60kg:30mg60–<70kg:35mg70–<80kg:40mg80–<90kg:45mg90kg:50mg

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Nostudyhasshownasignificantdifferenceintheefficacyofdifferentthrombolyticagents尚無(wú)研究說(shuō)明不同溶栓劑效果有顯著差異Asuggestedprotocoloftwo10unitdosesofReteplase,separatedby30minutes,iseffectiveandsimple建議2個(gè)10u瑞替普酶，間隔30minThereisnoevidencethatusingacentralvenousorpulmonaryartery(PA)catheterforadministeringthrombolyticsconfersatreatmentadvantageoranyreductioninbleedingcomplications，mayresultinarterialinjury，pneumothorax沒(méi)有證據(jù)說(shuō)明使用CV/PA導(dǎo)管給藥具有治療優(yōu)勢(shì)和減少出血并發(fā)癥，而可致動(dòng)脈損傷、氣胸Majorbleeding：10%vs.<3%withheparininfusionalone,Intracerebralhaemorrhage：<0.5%嚴(yán)重出血并發(fā)癥10%，顱內(nèi)出血<0.5%GuidelinesandProgressontheDiagnosisandManagementofAcutePE

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Massivepulmonaryembolism巨大PEPEcausingsustained(>15minutes)hypotension(systolicBP<90mmHg)orasustainedsignificantdropinsystolicbloodpressure(>40mmHg)持續(xù)低BP〔>15min〕，或SBP持續(xù)顯著下降(>40mmHg〕Mortalityexceeding25%(65%ifcardiopulmonaryresuscitationisrequired)65%需要CPR者，病死率超過(guò)25%AcuteRVfailureisaverycommonfeature急性RVF十分常見(jiàn)Theremayonlybeabriefwindowofopportunitytoidentifyandaddressthecondition可供識(shí)別和處理的時(shí)間窗很短Patientsremainatsignificantriskofdeathforseveraldaysafteranevent幾天內(nèi)死亡風(fēng)險(xiǎn)仍很高GuidelinesandProgressontheDiagnosisandManagementofAcutePE

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SubmassivePE次大PETypicallydescribesotheracutePEs典型的急性PE病癥Normalbloodpressure血壓正常PatientsmayhaveevidenceofRVdysfunction(bestconfirmedwithechocardiography,butalsopossiblyshownonCT)右心室功能不全的病癥〔UCG，CT〕Thissubgrouphasuptofourtimesthemortalityriskandincreasedratesofrecurrence,mayalsogoontodevelopshockorRVthrombus也可發(fā)生休克或RV血栓，那么死亡增加4倍、復(fù)發(fā)風(fēng)險(xiǎn)增加Removeclotsuchasthrombolysismayhavearoleinthisgroup溶栓可能有作用Preventionofrecurrenceisapriority預(yù)防復(fù)發(fā)優(yōu)先GuidelinesandProgressontheDiagnosisandManagementofAcutePE

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AllotherpatientswithPE其他PE者Haemodynamicallystable血?jiǎng)恿ρ€(wěn)定NormalRVfunction,RV功能正常Majoritytendtofollowanuneventfulcourse(<2%mortality)unlessfurtherPEoccurs病死率<2%，除非進(jìn)一步的PE發(fā)生GuidelinesandProgressontheDiagnosisandManagementofAcutePE

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Aim：preventionoffurtherembolizationandthrombosis目的：預(yù)防進(jìn)一步血栓形成和栓塞Method:anticoagulationinferiorvenacavafiltersremovalofestablishedclot(thrombolysisandembolectomy)方法：抗凝下腔靜脈濾器祛除血凝塊：溶栓和血栓切除GuidelinesandProgressontheDiagnosisandManagementofAcutePE

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BestPractice&ResearchClinicalHaematology2021(25):379–389

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Relative相對(duì)禁忌癥Transientischemicattackinprevious6months6個(gè)月內(nèi)TIA史Oralanticoagulation口服抗凝劑Pregnancyorfirstpostpartumweek妊娠或產(chǎn)后1周Non-compressiblepuncturesites不可壓迫的穿刺部位Traumaticresuscitation外傷性復(fù)蘇Refractoryhypertension(systolicbloodpressure>180mmHg)頑固性高血壓〔SBP>180mmHg)Advancedliverdisease肝病晚期Infectiveendocarditis感染性心內(nèi)膜炎Activepepticulcer活動(dòng)性消化道潰瘍

SouthwestHospitalTable1ContraindicationstofibrinolyticuseinPECardiacarrest:1.Absolutecontraindications-None2.Relativecontraindications-Activeinternalbleeding-RecentintracranialbleedingMassivePE:1.Absolutecontraindications-Activeinternalbleeding-Recentintracranialbleeding2.Relativecontraindications-Intracranialtumororseizurehistory-Ischemicstokeuntil2months-Neurosurgerywithinpastmonth-Recentsurgerywithin10days-Punctureofnoncompressiblevesselwithin10days-Traumawithin15days-Uncontrolledhypertension(SBP>180mmHg,DBP>110mmHg)-Hemorrhagicdisorderofthrombocytopenia(<100,000)-Impairedhepaticorrenalfunction-GIbleedingwithin10days-PregnancyGuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalSubmassivePE:1.Absolutecontraindications-Intracranialprocessorseizurehistory-Ischemicstrokewithin2months-Neurosurgerywithinpastmonths-Recentsurgerywithin10days-Punctureofnon-compressiblevesselwithin10days-Traumawithin15days-Uncontrolledhypertension(SBP>180mmHg,DBP>110mmHg)-Hemorrhagicdisorderorthrombocytopenia(<100,000)-Impairedhepaticorrenalfunction-GIbleedingwithin10days-Pregnancy2.Relativecontraindications-Age>65GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalTable4FibrinolyticdosingregimensinPECardiacarrest:1.UK、SK、r-tpA(任一種)2.Alteplase(FDA-appointed)阿替普酶〔FDA指定〕a.50-mgIVbolus50mg彈丸式IVb.Mayrepeat50-mgIVbolusin15minifnoROSC15min內(nèi)如未恢復(fù)，可重復(fù)1次3.Reteplase瑞替普酶a.20-UIVbolus20-UIV彈丸式IV3.Tenecteplase替奈普酶a.0.5-mg/kgIVbolus(max50mg)MassiveandsubmassivePE:1.Alteplase(FDAapproved)a.10-mgIVbolusb.Followedby90-mgIVillusionover2h2.Reteplasea.10-UIVbolus,b.Followedin30minbyanother10-UIVbolus3.Tenecteplasea.0.5-mg/kgIVbolus(max50mg)1次GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospital

Inferiorvenacava(IVC)filters：下腔靜脈濾器RetrievableDecreasetherateofrecurrentPEandlower90-daymortalitybutincreasetherateofDVTANAESTHESIAANDINTENSIVECAREMEDICINE2021；11:12GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospital

Suggestedindicationsforinsertionofinferiorvenacava(IVC)filterANAESTHESIAANDINTENSIVECAREMEDICINE2021；11:12GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalFig.2.Thesamepatientonthe10thdayaftercaesareandelivery.(A)Follow-upcavographyjustbeforeextractionofthefilter.Nolargethrombiareseen.Moderatetiltingofthefilterafterthedelivery.(B)Filterhookengagementbyretrievalloop.(C)Follow-upcavographyafterfilterextraction,noextravasation,IVCstenosisorveinwallinjuryisvisible.RetrievableGuntherTulipVenaCavaFilterinthepreventionofpulmonaryembolisminpatientswithacutedeepvenousthrombosisinperinatalperiod

下腔靜脈濾器預(yù)防圍產(chǎn)期深靜脈血栓患者PEEurJRadio2021；70：165–169GuidelinesandProgressontheDiagnosisandManagemento