Antithrombotic Therapy iu tr khng ng

Anticoagulation
The initial treatment of thromboembolism that is not life-threatening is anticoagulation with
heparin.
Khng ng
Thuyn tc huyt khi m khng e da tnh mng th iu tr u tay l khng ng bng
heparin.
Unfractionated Heparin
The standard treatment of both deep vein thrombosis and acute pulmonary embolism is
unfractionated heparin (UFH) given by continuous intravenous infusion using weight-based dosing,
as shown in Table .!. These guidelines have been derived from patients weighing less than "#$ %g
(#&). For body weights in e'cess of "#$ %g, the guidelines in Table .! can result in e'cessive
anticoagulation (#(), so it is important to monitor anticoagulation carefully in these patients.
Heparin khng phn on (t ng a thin nhin)
iu tr tiu chun ca c hai huyt khi tnh mch su v thuyn tc phi cp l Heparin
khng phn on (unfractionated heparin - UFH) truyn tnh mch lin tuc bng liu thuc dua trn
trng luong, nhu th hin trong Bng 5.6. Nhng hung dn ny uoc xut pht t cc bnh
nhn c trng luong thp hon 130 kg (37). i vi trng luong co th vuot qu 130 kg, cc hung
dn trong Bng 5.6 c th dn n trong khng ng qu mc (38), do , iu quan trng l phi
theo di khng ng cn thn nhng bnh nhn ny.
)*ng ,! +h,c -. li/u Heparin d0a tr1n tr2ng l34ng
".5hu6n b7 heparin b8ng c,ch b9m :$.$$$ ;U heparin v<o $$ m= d7ch
pha lo>ng (?$ ;U @ m=).
:. 5ho li/u bolus ban -Au ($ ;U@%g, sau -B truy/n li1n tCc "(;U@%g@giD.
(EF dCng tr2ng l34ng c9 thG th0c tH.)
#. IiGm tra +TT ! giD sau %hi bJt -Au truy/n, v< -i/u chKnh li/u heparin
theo b1n d3Li.
+TT
(giMy)
TN lO
+TT
=i/u
bolus
Truy/n tPnh mQch li1n tCc
R# R".: ($ ;U@%g TSng li/u ? ;U@%g@h
#T? ".:T". ?$ ;U@%g TSng li/u : ;U@%g@h
?!T&$ ".T:.# U U
&"TV$ :.#T#.$ U Wi*m : ;U@%g@hr
XV$ X# U Yg3ng truy/n trong vZng "h, sau -B
Wi*m li/u # ;U@%g@hr
?.IiGm tra +TT ! giD sau m[i lAn -i/u chKnh li/u l34ng. Ihi \ trong
phQm vi mong mu]n (?!-&$ giMy), theo d^i h<ng ng<y.
o!"#olecular"$eight Heparin
=ow-molecular-weight heparin (=_`H) is an effective alternative to UFH for treatment of
deep vein thrombosis and acute pulmonary embolism. The therapeutic dose of a standard =_`H
preparation isa bno'aparin, " mg@%g by subcutaneous incection every ":h
ds mentioned earlier, =_`H is cleared by the %idneys, and dose adcustments are necessary
in patients with renal impairment (see 5hapter "& for these dose adcustments). ;n patients with renal
failure and thromboembolism who reeuire heparin, UFH is recommended over =_`H.
=_`H offers several advantages over UFH, including simplified dosing, no need to monitor
anticoagulant activity (see below), and the ability to treat outpatients (which could help to reduce
hospital admissions for deep vein thrombosis). For these reasons, =_`H is slowly replacing UFH
for the initial management of thromboembolism.
Heparin trng lng phn t thp
Heparin trng luong phn t thp (LMWH) l mt thay th hiu qu cho UFH iu tr
huyt khi tnh mch su v thuyn tc phi cp. Liu iu tr ca mt LMWH tiu chun l:
enoxaparin, 1 mg / kg tim dui da mi 12 gi
Nhu cp truc , LMWH uoc thi bi thn, v iu chinh liu l cn thit nhng
bnh nhn suy thn (xem Chuong 17 cho nhng iu chinh liu). nhng bn b suy thn v
thuyn tc huyt khi yu cu heparin, UFH uoc khuyn khch hon LMWH.
LMWH c nhiu loi th hon UFH, bao gm dng thuc on gin, khng cn theo di hot
ng chng ng mu (xem bn dui), v c kh nng iu tr bnh nhn ngoi tr (gip gim
nhp vin do huyt khi tnh mch su). i vi nhng l do ny, LMWH uoc dn dn thay th
UFH cho vic iu tr ban u ca thuyn tc huyt khi.
#onitoring Anticoagulation
ds mentioned earlier in the chapter, the anticoagulation produced by a given dose of UFH
can vary, primarily because of the variable sife of the heparin molecules in UFH. ds a result,
laboratory tests of anticoagulant activity must be monitored to determine the anticoagulant response
to UFH. The activated partial thromboplastin time (a+TT) can be used for this purpose because it is
a reflection of coagulation factor ;;a activity, and one of the prominent effects of UFH is inhibition of
factor ;;a (antithrombin effect). The a+TT cannot be used to monitor anticoagulation with =_`H
because =_`H acts primarily to inhibit factor ga, and the a+TT is not a reflection of factor ga
activity. Eince =_`H produces a more predictable level of anticoagulation than heparin, monitoring
laboratory tests of anticoagulation is usually not necessary with =_`H. ;f needed, the anticoagulant
response to =_`H can be assessed by measuring factor ga activity.
Theo di xt nghi!" #hng ng
Nhu cp truc trong chuong ny, thuc khng ng uoc sn xut theo liu luong
UFH c th khc nhau, ch yu l do kch thuc khc nhau ca cc phn t heparin trong UFH.
Kt qu l, cc xt nghim v khng ng phi uoc theo di xc nh phn ng chng ng
mu ca UFH. Xt nghim Thi gian kch hot ca mt phn thromboplastin (APTT) c th uoc
s dung cho muc ch ny bi v n phn nh hot ng ca yu t ng mu IIa, v mt trong cc
tc dung ni bt ca UFH l c ch yu t IIa (antithrombin c hiu luc). APTT khng th dng
theo di vi khng ng LMWH v LMWH hot ng ch yu c ch yu t Xa, v APTT khng
phn nh hot ng ca yu t Xa. K t khi c LMWH to ra mc du on khng ng nhiu hon
heparin, xt nghim theo di thuc chng ng thung khng cn thit vi LMWH. Nu cn thit,
p ng chng ng mu LMWH c th uoc nh gi bng cch o yu t Xa hot ng.
$arfarin Anticoagulation
For patients with a reversible cause of venous thromboembolism (e.g., macor surgery),
oral anticoagulation with warfarin (5oumadin) can be started on the first day of heparin therapy.
`hen the prothrombin time reaches an international normalifed ratio (;Yh) of : to #, the heparin
can be discontinued. (Eee reference #V for a description of the ;Yh.) iral anticoagulation with
coumadin is continued for at least # months. +atients with cancer-related or recurrent jTb reeuire
longer periods of anticoagulation (see reference & for more information on long-term anticoagulant
therapy).
%hng ng !arfarin
k]i vLi c,c bn b7 thuy1n tJc huyHt %h]i tPnh mQch do hlu eu* cma mnt -i/u tr7 %h,c (vo dC,
phpu thult lLn), u]ng thu]c ch]ng -qng vLi warfarin (5oumadin) cB thG -34c bJt -Au v<o ng<y
-Au ti1n cma liOu ph,p heparin. Ihi thDi gian prothrombin -Qt -Hn mnt tN lO chu6n hBa eu]c tH (;Yh)
tr : -Hn #, cB thG ng3ng heparin. (gem tham %h*o #V cho chK -7nh ;Yh) U]ng thu]c ch]ng -qng
vLi coumadin li1n tCc trong ot nhst # th,ng. )n b7 thuy1n tJc huyHt %h]i tPnh mQch cB li1n euan -Hn
ung th3 hotc t,i ph,t -Zi hui thDi gian dvng %h,ng -qng d<i h9n ('em t<i liOu tham %h*o & -G biHt
th1m thqng tin v/ -i/u tr7 ch]ng -qng d<i hQn).
Thrombolytic Therapy
Thrombolytic therapy is usually reserved for life-threatening cases of pulmonary embolism
accompanied by hemodynamic instability.
Eome also recommend thrombolytic therapy for hemodynamically stable patients with right
ventricular dysfunction and for cardiac arrest, although the benefits of lytic therapy in these
situations is unclear. The macor problem with thrombolytic therapy is bleedinga there is a ":w
incidence of macor hemorrhage and a "w incidence of intracranial hemorrhage. dlthough the
presence of ris% factors for bleeding is usually a contraindication to thrombolytic therapy, in the
setting of a life-threatening condition, the ris% of withholding lytic therapy (i.e., death) can sometimes
outweigh the ris% of bleeding.
$i%& tr' ti& (i h&)*t
iu tr tiu soi huyt thung uoc dnh cho trung hop e da tnh mng ca thuyn tc
phi c ri lon huyt ng hc.
Mt s tc gi khuyn nn iu tr tiu soi huyt cho c bn huyt ng n nh vi ri lon
chc nng tm tht phi v ngng tim, mc d loi ch ca liu php tan mu trong nhng tnh
hung khng r rng . Vn chnh vi iu tr tan huyt khi l xut huyt : t l 12% xut
huyt nng v 1% xut huyt ni s. Khi c cc yu t nguy co chy mu th chng chi nh iu tr
tan huyt khi; nhung trong bi cnh ca mt tnh trng e da tnh mng, th nguy co tr hon tiu
soi huyt (tc l, ci cht) i khi c th ln hon nhng nguy co chy mu.
dll thrombolytic agents are considered eeually effective, and systemic drug administration is
favored over local infusion into the pulmonary arteries because of bleeding at the catheter insertion
site. The two drug regimens shown below are designed to achieve rapid clot lysis.
dlteplasea $.! mg@%g over " minutes.
heteplasea "$ Units by bolus incection, and repeat in #$ minutes.
The usual alteplase dose is "$$ mg infused over : hours, but the alteplase regimen shown
here achieves the same degree of clot lysis in a shorter period of time (?#). heteplase is not
currently approved for treatment of thromboembolism in this country, but the bolus administration of
this drug is well-suited for rapid clot dissolution. For more information on the use of thrombolytic
agents, see 5hapter "&.
Tt c cc thuc tan huyt khi uoc coi l hiu qu nhu nhau, v thuc tc dung ton thn
uoc ua chung hon ti ch vo cc ng mch phi v chy mu ti ch t catheter. Hai phc
thuc uoc hin th dui y uoc thit k t uoc ly gii cuc mu ng nhanh chng.
Alteplase: 0,6 mg / kg trong 15 pht.
Reteplase: 10 on v tim bolus, v lp li trong 30 pht.
Liu alteplase thng thung l 100 mg truyn hon 2 gi, nhung phc alteplase y t
uoc cng mt mc ly gii cuc mu ng trong mt khong thi gian ngn hon. Reteplase hin
khng uoc chp thun iu tr thuyn tc huyt khi t nuc ny, nhung tim bolus loi
thuc ny l rt ph hop cho cuc mu ng tan nhanh chng. bit thm thng tin v vic s
dung cc thuc tan huyt khi, xem Chuong 17.
&nferior 'ena (a)a *ilter+
_eshli%e filter devices can be placed in the inferior vena cava to trap thrombi that brea%
loose from leg veins and prevent them from traveling to the lungs. These devices can be used in
any of the conditions listed below.
,- l.c t/nh m0ch ch1 d23i
Thit b lc Meshlike c th t trong tnh mch ch dui by cuc huyt khi v ph v n
t tnh mch chn v ngn cn n i ln phi. Cc thit b ny c th uoc s dung trong bt ky
iu kin no uoc lit k dui y.
;ndications
d. +atient has pro'imal deep vein thrombosis in the legs and has one of the following
conditionsa
". d contraindication to anticoagulation
:. +ulmonary embolifation during full anticoagulation
#. d free-floating thrombus (i.e., the leading edge of the thrombus is not adherent
to the vessel wall).
?. +oor cardiopulmonary reserve and unli%ely to tolerate a pulmonary embolus.
). +atient does YiT have pro'imal deep vein thrombosis in the legs but has one of
the following conditionsa
". heeuires long-term prophyla'is of pulmonary embolism (e.g., patients with a history
of recurrent pulmonary embolism)
:. Has a high ris% of thromboembolism and a high ris% of hemorrhage from
anticoagulant drugs (e.g., trauma victims).
Chi nh
A. Bn c huyt khi tnh mch su gn hng v c mt trong nhng iu kin sau y:
1. Chng chi nh vi thuc khng ng
2. Thuyn tc phi khi liu khng ng
3. Mt huyt khi tri ni tu do (tc l, hng u l cc huyt khi khng dnh thnh mch).
4. Du tr tim phi km v khng chu ung uoc mt thuyn tc phi.
B. Bn khng c huyt khi tnh mch su gn hng nhung c mt trong
cc iu kin sau y:
1. Yu cu du phng di hn ca thuyn tc phi (v du, bnh nhn c tin s thuyn tc
phi ti pht)
2. C mt nguy co cao thuyn tc huyt khi v c nguy co cao xut huyt t thuc chng
ng mu (v du, cc nn nhn chn thuong).
Hnh 5.5 Cc b lc Greenfield. Hnh dng thun di cho php lc by huyt khi m khng
nh hung n din tch mt ct ca TM ch dui.
dbout ($w of inferior vena cava (;j5) filters are placed in patients who have deep vein
thrombosis in the legs combined with one of the conditions listed in section d (?).
Khong 80% b lc tnh mch ch dui (IVC) uoc t nhng bnh nhn c huyt khi
tnh mch su chn kt hop vi mt trong cc iu kin uoc lit k trong phn A (45).
The 4reenfield *ilter
The most widely used ;j5 filter in the United Etates is the Wreenfield filter ()oston Ecientific,
Wlen dllen, jd), shown in Figure .. The macor advantage of this filter is its elongated, conical
shape, which allows the bas%et to fill with thrombi to &w of its capacity without compromising the
cross-sectional area of the vena cava. This limits the ris% for vena cava obstruction and
troublesome leg edema, which plagued earlier models of ;j5 filters.
+, l- .reen/ield
B lc tnh mch ch dui (IVC) uoc s dung rng ri nht Hoa Ky l b lc Greenfield
(Boston Scientific, Glen Allen, VA), th hin trong hnh 5.5. Uu im chnh ca b lc ny l hnh
nn thun di ca n, cho php cc ti cha y huyt khi n 75% kh nng ca mnh m khng
lm nh hung n din tch mt ct ngang ca TM ch dui. iu ny hn ch nguy co tc nghn
tnh mch ch v phin toi do ph n chn, so vi m hnh truc ca b lc IVC.
&n+ertion
;j5 filters are inserted percutaneously, usually through the internal cugular vein or femoral
vein, and are placed below the renal veins, if possible. Euprarenal placement is occasionally
necessary when the thrombus e'tends to the level of the renal veins, but this does not impair
venous drainage from the %idneys. dlthough usually inserted in the radiology department, ;j5 filters
can be placed at the bedside, thereby eliminating the ris%s and manpower involved in patient
transport .
0h1n
B lc IVC uoc chn vo dui da, thung l xuyn qua cc tnh mch cnh trong hoc tnh
mch i, v uoc t dui tnh mch thn, nu c th. V tr trn thn i khi cn thit khi huyt
khi ko di n mc tnh mch thn, nhung iu ny khng lm gim thot nuc tnh mch t
thn. Mc d thung uoc chn vo trong khoa X-quang, b lc IVC c th uoc t ti giung
bnh, do loi b ri ro v ngun nhn luc lin quan n vn ti bn.
;j5 filters have proven both safe and effective, which e'plains why their use has increased
:-fold over the last two decades. The incidence of post-insertion pulmonary embolism is about w,
and macor complications (e.g., migration of the filter) are reported in less than "w of patients.
xespite their intravascular location, ;j5 filters rarely become infected in the face of septicemia (for
unclear reasons).
B lc IVC uoc chng minh an ton v hiu qu, iu ny gii thch l do ti sao n
uoc s dung tng 25 ln so vi hai thp k qua. T l ca chn thuyn tc phi l khong 5% , v
cc bin chng ln (v du, di lch cc b lc) uoc bo co t hon 1% s bnh nhn. D b lc IVC
him khi b nhim trng ti ch nhung phi i mt vi nhim trng huyt (vi nhng nguyn nhn
chua r).