Geerts William H
Thromboembolism Program, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, Canada.
Hematology Am Soc Hematol Educ Program. 2006:462-6. doi: 10.1182/asheducation-2006.1.462.
The prevention of venous thromboembolism (VTE) in patients recovering from major trauma, spinal cord injury (SCI), or other critical illness is often challenging. These patient groups share a high risk for VTE, they often have at least a temporary high bleeding risk, and there are relatively few thromboprophylaxis trials specific to these populations. A systematic literature review has been conducted to summarize the risks and prevention of VTE in these three groups. It is concluded that routine thromboprophylaxis should be provided to major trauma, SCI and critical care patients based on an individual assessment of their thrombosis and bleeding risks. For patients at high risk for VTE, including those recovering from major trauma and SCI, prophylaxis with a low molecular weight heparin (LMWH) should commence as soon as hemostasis has been demonstrated. For critical care patients at lower thrombosis risk, either LMWH or low-dose heparin is recommended. For those with a very high risk of bleeding, mechanical prophylaxis should be instituted as early as possible and continued until pharmacologic prophylaxis can be initiated. The use of prophylactic inferior vena caval filters is strongly discouraged because their potential benefit has not been shown to outweigh the risks or substantial costs. Implementation of thromboprophylaxis in these patients requires a local commitment to this important patient safety priority as well as a highly functional delivery system, based on the use of pre-printed orders, computer prompts, regular audit and feedback, and ongoing quality improvement efforts.
预防严重创伤、脊髓损伤（SCI）或其他危重病康复患者的静脉血栓栓塞（VTE）往往具有挑战性。这些患者群体VTE风险高，通常至少有暂时的高出血风险，而且针对这些人群的血栓预防试验相对较少。已进行系统的文献综述以总结这三组患者VTE的风险和预防措施。得出的结论是，应根据对严重创伤、SCI和重症监护患者血栓形成和出血风险的个体评估，为其提供常规血栓预防。对于VTE高风险患者，包括严重创伤和SCI康复患者，一旦证实止血，应立即开始使用低分子量肝素（LMWH）进行预防。对于血栓形成风险较低的重症监护患者，建议使用LMWH或小剂量肝素。对于出血风险非常高的患者，应尽早采用机械预防措施，并持续至可以开始药物预防。强烈不建议使用预防性下腔静脉滤器，因为其潜在益处尚未显示超过风险或巨大成本。在这些患者中实施血栓预防需要当地对这一重要的患者安全重点作出承诺，以及基于使用预印医嘱、计算机提示、定期审核和反馈以及持续质量改进努力的高效实施系统。
