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袁响林教授静脉血栓栓塞疾病课件

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袁响林 教授 静脉 血栓 栓塞 疾病 课件
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Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 肿瘤治疗热点问题 静脉血栓栓塞 同济医院肿瘤科 袁响林 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 近几年发表相关文章 The new England journal o f medicine 6 篇 JAMA 3 篇 Lancet 3 篇 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 北大教授熊卓为女篮运动员王凡 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 概述 危险因素评估 诊断 预防与治疗 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 静脉血栓栓塞 Venous thromboembolism VTE p深静脉血栓形成 Deep venous thrombosis DVT l上肢 l下肢 远端 如小腿 l 中心 近段 如上 下腔静脉 盆腔 髂区 股区及膝部 l 导管相关性 p肺栓塞 Pulmonary embolism PE VTE的分类 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 79 的PE患者合并下肢DVT 近50 近端DVT患者会发生PE 若栓子在膝静脉或之上 PE的风 险增加 PE与下肢DVT关系密切 VTE的发生率 临床报道 J clin Oncol 2006 24 484 490 1995年 2002年 美国115家医疗中心 66106名成人肿瘤患者 回顾性研究 2 74 10 10 的肿瘤患者在首次住院过程中发生 过VTE Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial VTE是主要致死性疾病之一 VTE的年死亡人数是乳腺癌或艾滋病死亡数的4 5 倍1 2 美国每年肺栓塞症 PE 约30万人死亡1 VTE住院患者致死率12 1 PE 老年患者年死亡率达 39 3 DVT 老年患者年死亡率达 21 3 1 ACS Breast cancer facts and figures 2001 2 Anderson et al Arch Intern Med 1991 3 Kniffin WD Jr et al Arch Intern Med 1994 154 8 861 6 4 Clagett et al Chest 1995 108 312S 334S 概述 流行病学 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 1865年 法国医师 Armand Trousseau 首次报 道癌症患者合并静脉血栓性栓塞症 Armand Trousseau MD 肿肿瘤相关VTE 概述 流行病学 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 所有肿瘤患者 n15 发生有症状的VTE n50 尸检发现VTE n20 反复发生VTE n25 发生双侧DVT Lee AY Circulation 2003 Bura et al J Thromb Haemost 2004 2 445 51 概述 流行病学 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 肿瘤VTE风险较非肿瘤增加4 6倍 生存率下降1 2 肿瘤大手术PE 4 10 致命性PE 1 5 3 1 DHeit JA Silverstein MD Mohr DN et al 2000 2 Blom JW Doggen CJ santo S et al 2005 3 ACCP 7 概述 流行病学 肿肿瘤相关VTE 常见肿瘤中VTE的发生率如下 卵巢癌 6 5 肺癌 7 00 胃癌 7 14 子宫内膜 宫颈癌 8 96 头部肿瘤 9 50 胰腺癌 12 10 VTE的发生率 临床报道 J clin Oncol 2006 24 484 490 VTE的发生率 尸检报道 1960 1984年 21530次尸检 其中6197名为肿瘤患者 PE的发生率分别为 卵巢癌 34 6 肝内胆管癌 31 7 胃癌 15 2 J Clin Pathol 1989 42 805 809 VTE对生存率的影响 对照组 6668名无VTE的 肿瘤患者 观察组 668名同时合并VTE 的肿瘤患者 N Engl J Med 2000 343 1846 1850 肿瘤患者VTE的发生率高 且尸检报道更高 合并VTE的肿瘤患者死亡率高 临床上对VTE关注程度不够 总结 1 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 概述 发病机制 Virchow s理论论 高凝状态态血液淤滞血管壁损伤损伤 Rudolf Virchow 1821 1902 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 概述 发病机制 高凝状态血液淤滞血管壁损伤 肿瘤相关 促凝因子 细胞因子 促凝反应 肿瘤相关 卧床 体弱 瘤栓 瘤压迫 肿瘤相关 直接侵蚀 中心静脉置管 抗癌损伤内皮 C因子伤内皮C Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 概述 危险因素评估 诊断 预防与治疗 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial p患者相关性 p治疗相关性 p可改变的 危险因素分类 患者相关性因素 p活动性肿瘤 进展期肿瘤 p高危的肿瘤类型 膀胱 颅内 妇科 肺 淋巴瘤 骨髓增 生性肿瘤 胰腺 胃 睾丸 p局部淋巴结肿大伴血管受压 p遗传性或获得性高凝状态 p内科合并症 感染 肾病 肺病 心衰 动脉血栓栓塞 p一般状态差 年老 JAMA February 9 2005 Vol 293 No 6 转移性肿瘤发生VTE的风险增加 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial VTE的危险因素 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial VTE的危险因素 遗传因素 临临床特点 复发发性VTE 年轻轻患者 无特殊诱诱因而发发生VTE 的患者 在少见见部位出现现血栓 颅颅内静脉 肠肠系膜静 脉 门门静脉或肝静脉 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 治疗相关性因素 p 大手术 p 中心静脉导管 p 化疗 尤其是使用贝伐单抗 沙利度胺 来那度胺 地塞米松 p 外源性雌激素 激素替代治疗 口服避孕药 他莫 昔芬 雷洛昔芬 己烯雌酚 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 贝伐单抗增加VTE风险 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 贝伐单抗增加VTE风险 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 贝伐单抗增加VTE风险 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 促红细胞生成素刺激剂 ESAs 增加VTE风险 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 促红细胞生成素刺激剂 ESAs 增加VTE风险 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 可改变的危险因素 p抽烟 饮酒 p肥胖 p活动水平 锻炼 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Blood 15 MAY 2008 Volume111 Number10 低危 0分 0 3 0 8 中危 1 2分 1 8 2 高危 3分或以上 6 7 7 1 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 诊断 风险评估 肺栓塞严重程度评分 PESI Donze J Throm Haemost 2008 100 943 948 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 多发性骨髓瘤的危险因素 pM蛋白 1 6g dL p疾病进展 p血液高粘滞度 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 危险因素 l患者相关的 l治疗相关 l可改变的 危险因素越多 发生VTE风险越大 总结 2 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 概述 危险因素评估 诊断 预防与治疗 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 典型症状 l疼痛 l单侧肢体远端肿胀 l沉重感 l锁骨上区的水肿 DVT的诊断 症状 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial D 二聚体 l特异性低 l肿瘤患者中假阳性高 静脉超声 l无创 经济方便 l静脉狭窄程度 血流图象 l中心静脉诊断困难 l下肢远端血管敏感性差 增强CT 如间接CT血管造影 磁共振 DVT的诊断 检查 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 肺栓塞的发生 无症状 死亡率高 发生突然 容易发生医疗纠纷 血栓性疾病目前是第三大血管疾病 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial lDVT的病史 l突然出现现呼吸困难难 有窒息感 l剧剧烈胸痛 可伴大汗淋漓 甚至昏厥 l咳嗽 咯血或血痰 l心动过动过 速 l呼吸过过快 l氧饱饱和度下降 PE的诊断 症状与体征 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial PE的诊断 检查 血浆D dimer 特异性低 ELISA D dimer 敏感度96 98 胸片或心电图 特异性和敏感性均差 CT肺血管造影 首选 肺通气 灌注扫描 l适合妊娠 肾功能不全 碘过敏 l敏感性不如CTA Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 图A 箭头所示两侧肺栓塞图B 星号提示由于急性肺栓 塞所致的右心室扩大 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 临床怀疑急性PE的诊断流程 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial DVT的诊断 症状 静脉超声 必要时CT PE的诊断 症状 CT肺血管造影 特殊患者 行肺通气 灌注扫描 总结 3 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 概述 危险因素评估 诊断 预防与治疗 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial p连续性压迫装置 sequential compression device p弹力袜 graduated compression stocking p腔静脉滤网 vena cava filters 机械性装置 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial sequential compression device Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial graduated compression stocking 2518名中风患者 1256名使用GCS1262名不使用GCS 126名患者发生DVT 10 0 133名患者发生DVT 10 5 GCS不能减少中风患者发生DVT的风险 The Lancet 2009 373 1958 1965 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial The Lancet 2009 373 1958 1965 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 下腔静脉滤网 预防下肢DVT发生PE 增加DVT风险 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 抗凝药物 p低分子肝素 LMWH p普通肝素 UFH p a因子特异性抑制剂 p华法令 p凝血酶直接抑制物 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial LMWH与UFH的区别 大部分LMWH的糖基侧链都不到18个碳 所以 与UFH不同的是 LMWH不能结合 a LMWH仍具有与AT 结合的功能位点 所以 UFH 和LWMH结合 a的能力没有差别 UFH anti a anti a 1 LMWH anti a anti a 2 4 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 使用使用UFHUFH的注意事项的注意事项 ppUFHUFH在不同患者体内的代谢情况相差悬殊 在不同患者体内的代谢情况相差悬殊 难以预测难以预测 ppUFHUFH的排泄与剂量不成比例 因此给药剂量的排泄与剂量不成比例 因此给药剂量 不同 不同 T T1 2 1 2不恒定 难以掌握 不恒定 难以掌握 ppUFHUFH用药原则 静脉持续点滴 首剂给予负用药原则 静脉持续点滴 首剂给予负 荷量 快速达到预期荷量 快速达到预期APTTAPTT Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 使用使用LMWHLMWH的注意问题的注意问题 pp一般情况下使用一般情况下使用LMWHLMWH不需监测不需监测 pp两种情况例外 两种情况例外 LMWHLMWH剂量难以确定 剂量难以确定 l l 肥胖患者 肥胖患者 80 100kg80 100kg l l 肾功能衰竭患者肾功能衰竭患者 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial p监测INR p肾功能不全患者适用 p药物相互作用 使用华法令的注意事项 使用华法令的注意事项 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 抗凝药物治疗的禁忌证 抗凝药物治疗的禁忌证 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial VTEVTE的预防 的预防 住院患者 卧床住院患者 卧床 4 4天 天 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 非住院患者抗凝预防推荐 高危肿瘤非住院患者进行VTE的预防性治疗 n腹部或骨盆手术后患者 n有VTE既往史的外科肿瘤患者包含下列危险因素 n麻醉时间 2小时 n晚期癌症 n卧床休息 4天 n患者年龄 60岁 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial DVT治疗 DVT治疗疗流程 DVT部位 盆腔静脉 腘腘静脉 下腔静脉 股静脉 骶静脉 否 抗凝治 疗疗禁忌 腓肠肠静脉 上肢静脉 上腔静脉 SVC 抗凝治 疗疗禁忌 抗凝治 疗疗禁忌 是 否 是 否 是 抗凝治疗疗 巨大DVT者酌情导导管引导导下药药物溶 栓 GCS IVC滤滤器 禁忌症持 续续存在 抗凝治疗疗 追踪最初一周 的DVT进进展 IVC滤滤器 随访访直至禁忌症消除或DVT进进展 否 是 否 是 禁忌症持 续续存在 进进展 无进进展 抗凝治疗疗 在适宜的大面积积DVT患者 考虑导虑导 管直接药药物联联合溶栓治疗疗 抗凝治疗疗 考虑滤虑滤器拆除 如有临临床必要 可重 新评评估 DVT治疗疗 重新评估抗凝治 疗的风险 效益 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial PE治疗 PE治疗疗流程 肺栓塞严严 重程度指 数评评分 PESI 是 PESI评评 分 86 高风险风险 PESI评评 分 85 低风险风险 否 正常 异常 抗凝治疗疗禁忌 评评估癌症状态态并考虑虑 大面积积PE或次大面积积PE伴中重 度右心室扩张扩张 症或功能不全者 溶栓治疗疗 栓子切除术术 导导管或手术术 IVC滤滤器 IVC滤滤器 紧紧急处处理 抗凝治疗疗 考虑虑截肢术术治疗疗或短期住院 入院时时 肌钙钙蛋白 ECHO或评评估 CT CT血管造影 术评术评 价右心室增 大或扩张扩张 紧紧急处处理 抗凝治疗疗 抗凝治疗疗禁忌 是 否 频频繁随访临访临 床 状态态或抗凝禁 忌的变变化 紧紧急处处理 抗凝治疗疗 缓缓解 未缓缓解 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial VTE治疗推荐 1 一旦确诊静脉血栓栓塞症 应立即开始治疗 疗程5 7天 可选普通肝素 IV 或低分子肝素皮下注射或磺达肝癸钠 如选华法林长期用药 应有至少5 7天过渡期 联用抗凝药 如 普通肝素 低分子肝素或磺达肝癸钠 直至INR 2 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 预防性抗凝治疗 Aspirin 81 325mg d 仅适用于低危的多发性骨髓瘤患者 只有1个的高危因素 Warfarin INR 2 3 适用于高危的多发性骨髓瘤患者 有较2个或以上的高危因素 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 依诺肝素 达肝素及fondaparinux Xa因子抑制剂 预防VTE Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial VTE的治疗 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial VTE的治疗 即刻治疗 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial VTE的治疗 急性期治疗 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial VTE的治疗 慢性期治疗 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial p进展性下肢远端DVT p近段DVT或PE但有抗凝治疗禁忌证 p因DVT接受标准抗凝治疗时发生的PE p因PE接受标准抗凝治疗时新发的PE p患者拒绝抗凝治疗 p患者基础肺功能差而使任何PE将会致命 放置下腔静脉滤网 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial VTE的预防 p无禁忌证 预防性抗凝治疗 LWFH或UFH p有禁忌证 机械性抗凝 VTE的治疗 p无禁忌证 即刻治疗 LWFH或UFH 维持治 疗 LWFH或华法令 p有禁忌证 下腔静脉滤网 总结 4 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 谢 谢 大 家
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