Gumulec J, Penka M, Bezdĕk R, Czudek S, Stursa M, Wróbel M, Brejcha M, Klodová D, Sumná E, Králová S
Centrum pro trombózu a hemostázu pri Onkologickém centru J.G. Mendla, Nový Jicín.
Vnitr Lek. 2006 Mar;52 Suppl 1:41-50.
The article summarizes published data regarding the prophylaxis of venous thromboembolism in surgery, in laparoscopic surgery, in venous surgery and in urology. In surgical patients with low risk, no specific thromboprophylaxis is needed. Patients with moderate risk levels are the candidates for administration of subcutaneous low molecular weight heparin (LMWH) at doses under 3 400 anti-Xa units a day and patients with increased risk at doses higher than 3 400 anti-Xa units a day during the period of higher risk. In order to decrease the risk of bleeding, a half dose 2 hours prior or 4-6 hours after the operation can be administered. Under the highest risk conditions, there is a recommendation to combine LMWH over 3 400 anti-Xa units with elastic panty-hose or, alternatively, with intermittent pneumatic compression (IPC). At moderate risk levels, subcutaneous administration of unfractionated heparin at the doses of 5 000 units twice a day is also possible and at increased risk levels, a TID administration (LDUH) over the increased risk period. In patients with a significant bleeding risk, the physical method of thromboprophylaxis can be used and pharmacological prophylaxis can set in after the risk of bleeding has passed. Fondaparinux is the alternative to LMWH in people with a history of heparin induced thrombocytopenia over the past three months. The sole use of acetylsalycilic acid is not recommended. While undertaking epidural anaesthesia or analgesia, it is necessary to follow strictly the guidelines of the use of pharmacological thromboprophylaxis. Thromboprophylaxis with LMWH, LDUH, elastic panty-hose or IPC is indicated only in those patients who undergo laparoscopic surgeries and who moreover display the additional thrombosis factors. Patients with additional risk thrombosis factors undergoing major venous reconstructions require prophylaxis with LMWH (or LDUH). Uncomplicated patients undergoing transurethral or other low risk urologic surgery require no specific thromboprophylaxis. If they undergo a major intervention and/or they display additional risk thrombosis factors, they require the administration of LMWH or LDUH. Elastic panty-hose and/or intermittent pneumatic compression have the same indication as in abdominal surgeries.
本文总结了已发表的关于外科手术、腹腔镜手术、静脉手术和泌尿外科手术中静脉血栓栓塞预防的相关数据。对于低风险的外科手术患者，无需进行特殊的血栓预防。中度风险水平的患者适合每天皮下注射剂量低于3400抗Xa单位的低分子肝素（LMWH），而高风险期间风险增加的患者适合每天皮下注射剂量高于3400抗Xa单位的低分子肝素。为降低出血风险，可在手术前2小时或手术后4 - 6小时给予半剂量。在最高风险条件下，建议将超过3400抗Xa单位的低分子肝素与弹力裤袜联合使用，或者与间歇性气动压迫（IPC）联合使用。在中度风险水平时，也可每天两次皮下注射5000单位的普通肝素，在风险增加水平时，在风险增加期间每天三次给药（LDUH）。对于有显著出血风险的患者，可采用物理方法进行血栓预防，待出血风险过去后再进行药物预防。对于过去三个月有肝素诱导的血小板减少症病史的患者，磺达肝癸钠是低分子肝素的替代药物。不推荐单独使用乙酰水杨酸。在进行硬膜外麻醉或镇痛时，必须严格遵循药物性血栓预防的使用指南。仅在接受腹腔镜手术且伴有其他血栓形成因素的患者中，才建议使用低分子肝素、普通肝素、弹力裤袜或间歇性气动压迫进行血栓预防。接受主要静脉重建且伴有其他血栓形成风险因素的患者需要使用低分子肝素（或普通肝素）进行预防。接受经尿道或其他低风险泌尿外科手术的无并发症患者无需进行特殊的血栓预防。如果他们接受重大手术和/或伴有其他血栓形成风险因素，则需要使用低分子肝素或普通肝素。弹力裤袜和/或间歇性气动压迫的适用情况与腹部手术相同。
