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Re: Профилактика тромбоэмболических осложнений при эндопротезировании тазобедренного сустава
послал дмитрий бондарь 01 Февраль 2009, 00:00
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Доброго времени суток , коллеги ! Мы применяем клексан 0,4 за 12 часов до операции , затем по 0.4 1 раз в течении 7 суток . Затем на фоне клексана подключаем Варфарин . Обязательная эластичная компрессия конечностей , тщательное прмывание канала . Вот выдержка из "Rockwood and Green's Fractures in Adults (2-Volume Set), 6th ed."
Pulmonary embolism is the fourth most common cause of death in hip fracture patients. Bleeding can be a major problem if prophylaxis is undertaken, occurring in as high as 24% of patients. In the older age-group, prophylactic agents can have a rapid effect, and can be quite hard to control.
Without prophylaxis, deep vein thrombosis risk has been reported to be greater than 50% and fatal pulmonary embolism 0.5% to 2%. Review of prophylactic treatment for prevention of deep vein thrombosis in fractured hip patients indicate: (a) placebo has a relative risk reduction (RRR) of 0; (b) aspirin has a relative risk reduction of 29%; (c) regular heparin (unfractionated) has a RRR of 44%; (d) low molecular weight heparin has a RRR of 44%; and (e) warfarin has RRR of 48%. The duration of prophylaxis is controversial, with recent European studies extending prophylaxis to 6 weeks, whereas North American studies seem to reject out of hospital prophylaxis for this group of patients. In European studies looking at low molecular weight heparin, Plancher and Donshik (204), Pertananen et al (134), and Davis et al (205) showed a substantial incidence of asymptomatic deep vein thrombosis, ranging from 19% to 26% in the 29 to 35 days after surgery. North American studies of Laclerc, Anderson and Leighton, and Colwell et al indicated that clinically relevant deep vein thrombosis occurs in only 3% to 4% of patients receiving warfarin or low molecular weight heparin after 7 to 10 days in the hospital. Fatal pulmonary embolus occurred in only 0.08% of patients. Surveillance is, of course, expensive, and has not been shown to reduce the incidence of venous thrombosis in fatal embolus.
AUTHORS' PREFERRED TREATMENT
At my institution, low molecular weight heparin (Fragmin 5,000 units) subcutaneously once a day is initiated on patient's admission to hospital or the night after surgery, if surgery is done within 24 hours of admission. The only reason for delay of thromboprophylaxis is if anesthesia contemplates doing a spinal anesthetic, because there have been known complications of epidural bleeds occurring on patients who have received low molecular weight heparin before the surgery.
While in hospital, patients are kept on low molecular weight heparin and in some instances (high-risk patients) are discharged home on Fragmin or aspirin for 6 weeks, if it is not contraindicated. However the majority of fractured hip patients are discharged home without any at-home prophylaxis.
С уважением Д.Б.
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