Department of Anaesthesiology and Intensive Care Medicine, Hotel-Dieu University Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris Descartes, Paris, France.
Curr Opin Anaesthesiol. 2011 Apr;24(2):166-70. doi: 10.1097/ACO.0b013e328343cd4b.
To critically evaluate the benefit/risk ratio of some strategies for venous thromboembolism prophylaxis (VTE) RECENT FINDINGS: A growing body of evidence shows that graduated elastic stockings are not effective in medical patients. Special surgical settings as bariatric surgery deserve attention with a high VTE risk and no evidence-based data with regard to prophylaxis. Extended prophylaxis is being evaluated in these patients, whereas its efficacy has been demonstrated in abdominal and pelvic surgery for cancer. New oral anticoagulants are about to change the clinical landscape but yet some issues are not solved: no antidote, no monitoring, no standardization for the perioperative bridging in patients with therapeutic doses. In addition, they have not been tested in fragile patients in whom an increased bleeding risk could be feared. Finally, a large bunch of guidelines are now available to help the physician in the decision-making process.
Studies evaluating the benefit/risk ratio of graduated elastic stockings should now take place in surgery. Increasing and splitting the anticoagulant dose (mainly low molecular weight heparins) by two injections a day could be recommended in bariatric surgery and morbidly obese patients. New anticoagulant agents should also be tested in special populations, following the European Medicines Agency guidance. The methodology of clinical trials in VTE prophylaxis has to be moved forward, pending the choice of debatable surrogate end-points as asymptomatic venous thrombosis and disputed issues on the assessment of major bleeding.
批判性评估一些静脉血栓栓塞症（VTE）预防策略的获益/风险比
越来越多的证据表明，梯度压力弹力袜在非手术患者中无效。特殊手术环境（如肥胖症手术）风险高，没有基于证据的预防数据，需要特别关注。正在这些患者中评估延长预防，而其在腹部和骨盆癌症手术中的疗效已经得到证实。新型口服抗凝剂即将改变临床格局，但仍存在一些尚未解决的问题：没有解毒剂，没有监测，没有治疗剂量患者围手术期桥接的标准化。此外，它们尚未在出血风险增加的脆弱患者中进行测试。最后，现在有大量的指南可帮助医生在决策过程中。
应在手术中开展评估梯度压力弹力袜获益/风险比的研究。在肥胖症手术和病态肥胖患者中，每天两次注射增加和分割抗凝剂剂量（主要是低分子量肝素）可能是推荐的方法。新型抗凝剂也应根据欧洲药品管理局的指导意见，在特殊人群中进行测试。VTE 预防临床试验的方法学需要向前推进，等待有争议的替代终点（无症状静脉血栓形成）和对大出血评估的争议问题的选择。
