减少入院患者静脉

Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital减少入院患者静脉血栓栓塞（深静脉和肺栓塞）的风险,This guideline updates NICE clinical guideline 46 and replaces it（NICE clinical guideline 92 ）该指南更新于NICE指南46，并取代它（NICE临床指南92）,广东省中医院芳村医院肾内科,撰写机构 NICE clinical guideline 92 Developed by the National Collaborating Centre for Acute and Chronic Conditions,NICE临床指南92是由英国国家急慢性病合作中心撰写,Contents 内容,Introduction 简介,The House of Commons Health Committee reported in 2005 that an estimated 25,000 people in the UK die from preventable hospital-acquired venous thromboembolism (VTE) every year. This includes patients admitted to hospital for medical care and surgery. 下议院卫生委员会在2005年已经发表报告，该报告评估了约2500人，他们选自每年死于可以预防的医院获得性静脉血栓栓塞患者。这些患者是来自于内科和外科的住院患者。,Introduction 简介,The inconsistent use of for VTE in hospital patients has been widely reported. 对住院的静脉血栓栓塞患者采取不合理的防范措施已经被广泛的报道。A UK survey suggested that 71% of patients assessed to be at medium or high risk of developing deep vein thrombosis did not receive any form of mechanical or pharmacological VTE prophylaxis.一项英国调查发现71%的患者存在发生中重度深静脉血栓的风险，但是他们没有接收任何形式的机械的或者药理学的静脉血栓栓塞的预防方法。,Introduction简介,VTE is an important cause of death in hospital patients, and treatment of non-fatal symptomatic VTE and related long-term morbidities is associated with considerable cost to the health service.静脉血栓栓塞是住院患者的一个重要死亡原因，治疗非致命的、有症状的静脉血栓栓塞及相关的长期并发症，花费了健康医疗的相当大的开销。,Key priorities for implementation 重点实施,Assessing the risks of VTE and bleeding 重点评估VTE和出血风险Reducing the risk of VTE 减少VTE的风险Using VTE prophylaxis 使用VTE预防方法Anti-embolism stockings抗栓袜,all patients,Assessing the risks of VTE 重点评估VTE风险,medical patients,had or are expected to have significantly reduced mobility for 3 days or more or are expected to have ongoing reduced mobility relative to their normal state.已经或预期3天或以上有显著减少的血流，或预计较相对正常状态血流持续减少的流动。,Assess all patients on admission to identify those who are at increased risk of VTE.对所有入院患者进行评估，辨别发生VTE的高危人群,surgical patients and patients with trauma,1.surgical procedure with a total anaesthetic and surgical time of more than 90 minutes, or 60 minutes if the surgery involves the pelvis or lower limb .1.外科手术总的麻醉时间超过90min，或骨盆、下肢手术总的麻醉时间超过60min。2. acute surgical admission with inflammatory or intra-abdominal condition .2.有炎症或腹腔内急诊手术。3.expected significant reduction in mobility .3.预计有明显血流减少的情况。,VTE危险因素,BOX1 VTE危险因素1.活动的癌症或癌症治疗者2.年龄大于60岁3.新收的危重护理病人4.脱水5.已知的血栓形成倾向6.肥胖（BMI30kg/m2）7. 1个或以上明显的内科并发症，如心脏病；代谢的、内分泌、呼吸的病理疾病；急性传染性疾病；炎症等。8. VTE个人史或直系亲属9.使用激素替代治疗10.使用含雌二醇的避孕疗法11.静脉曲张静脉炎12.孕妇在分娩前6周,Assessing the risks of bleeding重点评估出血风险,Assess all patients for risk of bleeding before offering pharmacological VTE prophylaxis.在为患者提供VTE药物预防方法前评估出血风险。 Do not offer pharmacological VTE prophylaxis to patients with any of the risk factors for bleeding shown in box 2。不要为存在出血风险的患者提供VTE药物预防方法。unless the risk of VTE outweighs the risk of bleeding. 除非VTE的风险比出血风险严重。,Box2 Risk factors for bleeding 出血的危险因素,出血风险因素1.活动出血2.获得性出血性疾病（如急性肝衰竭）3.已知同时使用抗凝剂会增加出血风险（如国际标准比值INR高于2时使用华法林）4.腰椎穿刺或硬膜外脊髓麻醉后12小时内5.腰椎穿刺或硬膜外脊髓麻醉前4小时内6.急性中风7.血小板减少症（血小板低于75109L）8.不受控制的收缩性高血压（230120mmHg以上）9.未治疗的遗传性出血疾病（如血友病和血管性血友病）,Assessing the risks of VTE and bleeding 重点评估VTE和出血风险,患者入院24小时内或者临床表现改变时再评估出血和VTE风险。目的是确保VTE药物预防方法使用合适；使用正确及辨别药物预防方法所导致的不良事件。,Reducing the risk of VTE 减少VTE的风险,1.除非临床指征需要，否者不要让病人处于脱水状态。 2.尽可能的鼓励患者走动。 3.不要认为阿司匹林或其他抗血小板药物足以预防VTE的发生。 4.对于VTE高风险的患者，如以前的VTE事件或一个活跃的恶性肿瘤患者）和对机械和药物预防静脉血栓栓塞都有禁忌的患者，应考虑提供临时下腔静脉过滤器。,下腔静脉过滤器,下腔静脉滤器置入的方法：1.先行患肢的静脉造影检查，以确定深静脉血栓形成的诊断。2.根据深静脉血栓累及的范围选择适当的腔静脉滤器置入部位。3.患者置于有荧光屏监测的DSA室，4.滤器最常用的置入途径是健侧股静脉，当下腔静脉出现血栓时，可选用颈内静脉。其他可供选择的途径有肱静脉和颈外静脉。,机械预防法,药物预防法,Using VTE prophylaxis 使用VTE预防方法,1.anti-embolism stockings (thigh or knee length) 抗栓袜（大腿或膝盖的长度）2.foot impulse devices 脚脉冲装置3.intermittent pneumatic compression devices (thigh or knee length).间歇充气加压装置（大腿或膝盖的长度）。,Base the choice of pharmacological VTE agents on local policies and individual patient factors, including clinical condition (such as renal failure) and patient preferences.VTE药物的基本选择要参考当地的政策和病人的个体差异，包括临床表现（如肾衰竭）和病人的喜好。,Anti-embolism stockings抗栓袜,抗栓袜使用禁忌症,1.可疑或已证明的外周动脉疾病；2.外周动脉旁路移植术3.周围神经病变或其他原因引起的感觉障碍4.在现存的条件下，袜子可能造成损害，如脆弱的面巾纸样的皮肤，皮炎，坏疽或最近有皮肤移植者。5.对材料过敏6.心力衰竭7.小腿严重水肿，或充血性心力衰竭引起的肺水肿8. 腿的大小或形状与以往不同9.主要肢体畸形时使用预防装置来正确安装10.有静脉曲张或皮肤损伤者要正确小心使用。,Do not offer anti-embolism stockings to patients who have: suspected or proven peripheral arterial disease peripheral arterial bypass grafting peripheral neuropathy or other causes of sensory impairment any local conditions in which stockings may cause damage, for example fragile tissue paper skin, dermatitis, gangrene or recent skin graft known allergy to material of manufacture cardiac failure severe leg oedema or pulmonary oedema from congestive heart failure unusual leg size or shape major limb deformity preventing correct fit. Use caution and clinical judgement when applying anti-embolism stockings over venous ulcers or wounds.,抗栓袜使用注意事项,1. 确保那些需要抗栓袜患者已经测量过腿围，并为患者提供正确的尺寸。抗栓袜应正确佩戴，专业人员应指导患者如何正确使用抗栓袜。2.当患者出现水肿或术后肢体肿胀时应确保重测量腿围，并重新佩戴抗栓袜。3.如果怀疑有动脉疾病，在佩戴抗栓袜前征询专家的意见。4.使用抗栓袜后，应保证患肢受压均匀，使小腿产生14-15毫米汞柱压力。5.鼓励病人全天都穿抗栓袜，直到他们不再有显著性的血流减慢。,1.Ensure that patients who need anti-embolism stockings have their legs measured and that the correct size of stocking is provided. Anti-embolism stockings should be fitted and patients shown how to use them by staff trained in their use. 2.Ensure that patients who develop oedema or postoperative swelling have their legs re-measured and anti-embolism stockings refitted. 3.If arterial disease is suspected, seek expert opinion before fitting anti-embolism stockings. 4.Use anti-embolism stockings that provide graduated compression and produce a calf pressure of 1415 mmHg. 5.Encourage patients to wear their anti-embolism stockings day and night until they no longer have significantly reduced mobility.,抗栓袜使用注意事项,6. 每天取下抗栓袜进行患者的卫生保健和检查皮肤状况。当患者的血流显着减少，皮肤完整性差或感觉丧失时，每天应检查肢体皮肤两次或三次，尤其是在脚骨突起处。7.如果抗栓袜使用到期；皮肤起泡或变色，特别是在脚跟和骨突出；患者经历疼痛或不适。如果条件可以，提供脚脉冲装置或间歇充气加压装置作为替代治疗。8.告诉患者如何正确使用抗栓袜，并确保他们明白这将减少患静脉血栓栓塞的风险。9.监测抗栓袜的使用情况，当患者没有被正确佩戴时，提供帮助。10.不要为知道自己对材料过敏的患者提供脚脉冲装置或间歇充气加压装置。11.鼓励病房使用脚脉冲装置或间歇充气加压装置的患者尽可能多的运用装置，不管是躺在床上，还是坐在凳子上。,6.Remove anti-embolism stockings daily for hygiene purposes and to inspect skin condition. In patients with a significant reduction in mobility, poor skin integrity or any sensory loss, inspect the skin two or three times per day, particularly over the heels and bony prominences. 7.Discontinue the use of anti-embolism stockings if there is marking, blistering or discolouration of the skin, particularly over the heels and bony prominences, or if the patient experience