graduated compression stockings Dotaz Zobrazit nápovědu
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. SUMMARY: 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.
- MeSH
- antikoagulancia terapeutické užití MeSH
- bariatrická chirurgie MeSH
- enoxaparin terapeutické užití MeSH
- kompresivní punčochy MeSH
- lidé MeSH
- nádory chirurgie MeSH
- perioperační péče MeSH
- směrnice jako téma MeSH
- výsledek terapie MeSH
- warfarin terapeutické užití MeSH
- žilní trombóza prevence a kontrola MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- přehledy MeSH
In trauma patients, pulmonary embolism occurs in up to 4% of cases and carries a mortality of 20-50%. The incidence of deep vein thrombosis (DVT) varies from 5 to 63% depending on patients' risk factors, modality of prophylaxis, and methods of detection. For these reasons, trauma patients require adequate DVT prophylaxis. RECENT FINDINGS: Spinal fracture or cord injury patients are at particular risk. Increasing injury severity, head injury, older age, lower limb injuries, and obesity are other risk factors. The current standard of care for DVT prophylaxis is enoxaparin (a low molecular weight heparin) as long as anticoagulation is not contraindicated. Unfractionated heparin alone does not provide sufficient protection against DVT. Selective factor Xa inhibitors such as fondaparinux are showing promising results. Other strategies for pulmonary embolism prevention include: graduated compression stockings, sequential compression devices, continuous passive motion, and prophylactic inferior vena cava filter. There is lack of consensus regarding the optimal DVT prophylaxis in trauma patients and few level I recommendations exist. SUMMARY: Best practice in thromboprophylaxis for trauma patients will remain on the basis of recommendations until definitive risk-benefit ratios are determined to justify the use of various mechanical and pharmacological measures, in combination or alone.
- MeSH
- antikoagulancia terapeutické užití MeSH
- časové faktory MeSH
- enoxaparin terapeutické užití MeSH
- faktor Xa MeSH
- incidence MeSH
- inhibitory faktoru Xa MeSH
- kritický stav MeSH
- lidé MeSH
- plicní embolie epidemiologie etiologie prevence a kontrola MeSH
- polysacharidy terapeutické užití MeSH
- rány a poranění komplikace MeSH
- rizikové faktory MeSH
- žilní trombóza epidemiologie etiologie prevence a kontrola MeSH
- Check Tag
- lidé MeSH
BACKGROUND: Deep vein thrombosis (DVT) is a serious but preventable complication of critical illness with a reported incidence from 4 to 17%. Anti-Xa activity in critically ill patients achieved with standard dosing of low-molecular-weight heparins (LMWH) is often below the target of 0.2-0.5 IU/mL. However, the clinical significance of this finding is unclear. The quality of thromboprophylaxis also strongly impacts the incidence of DVT. We performed a prospective observational study to evaluate the incidence of DVT in a mixed medical-surgical-trauma intensive care unit (ICU) using a thromboprophylaxis protocol with a fixed dose of enoxaparin. We also explored the relation between DVT incidence and anti-Xa activity. METHOD: All consecutive patients with expected ICU stay ≥72 hours and without evidence of DVT upon admission were included. They underwent ultrasound screening for DVT twice a week until ICU discharge, death, DVT or pulmonary embolism. Peak anti-Xa activity was measured twice a week. Patients received 40 mg of enoxaparin subcutaneously (60 mg in obese, 20 mg in case of renal failure). Graduated compression stockings were used in case of LMWH or another anticoagulant contraindication. RESULTS: A total of 219 patients were enrolled. We observed six cases of DVT (incidence of 2.7%). The agreement between expected and delivered DVT prophylaxis was 94%. Mean peak anti-Xa activity level was 0.24 (SD, 0.13) IU/mL. There was no significant difference in anti-Xa activity in DVT and non-DVT group. CONCLUSION: A low incidence of DVT was achieved with meticulous adherence to the standard prophylactic protocol. The low incidence of DVT was observed despite low levels of anti-Xa activity. Our findings suggest that enoxaparin dose adjustment based on regular monitoring of anti-Xa activity is unlikely to result in further reduction of DVT incidence in a mixed ICU population. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03286985.
- MeSH
- antikoagulancia terapeutické užití MeSH
- enoxaparin * terapeutické užití MeSH
- heparin nízkomolekulární MeSH
- jednotky intenzivní péče MeSH
- kritický stav terapie MeSH
- lidé MeSH
- prospektivní studie MeSH
- žilní tromboembolie * farmakoterapie etiologie prevence a kontrola MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- pozorovací studie MeSH
Tromboembolická nemoc (TEN) je významný společensko-zdravotní problém. Je zřejmé, že východiskem je profylaxe TEN v klinických oborech, nikoli léčba sama. Lze usuzovat, že efektivní profylaxe ve svém důsledku snižuje náklady na následnou léčbu. Smrtící plicní embolie (PE) může představovat první a konečnou klinickou prezentaci u nemocných s asymptomatickou hlubokou žilní trombózou. Z těchto důvodů je nutná systematická prevence žilní tromboembolie u nemocných se zvýšeným rizikem. Bohužel farmakologická prevence se užívá méně, než by bylo třeba. Nedílnou součástí profylaxe TEN jsou fyzikální metody. Farmakologické možnosti profylaxe tromboembolické nemoci se v posledních 10 letech výrazně rozšířily. Pro profylaxi TEN po totální náhradě (TEP) kyčelního a kolenního kloubu je třeba dodržovat tyto zásady: profylaxe TEN by měla být prováděna LMWH, fondaparinuxem, dabigatranem, rivaroxabanem nebo apixabanem po dobu 28–35 dnů u kyčelního kloubu a nejméně po dobu 14 dní od operace kolenního kloubu. Použití ASA, dextranu a UFH jako tromboprofylaxe po TEP kyčelního kloubu a kolenního kloubu nemá v rámci ČR opodstatnění. Fyzikální prostředky (kompresní punčochy s graduovaným tlakem nebo IPC) je možno použít jako doplněk doporučené farmakologické léčby, neměly by být používány samostatně kromě případů, kdy je farmakologická tromboprofylaxe kontraindikována.
Thromboembolic disease (TED) is a considerable social and health problem. The solution evidently consists in the prevention of TED in clinical fields, not in the treatment itself. We can assume that effective prevention consequently reduces the cost of the following treatment. A lethal pulmonary embolism (PE) can be the first and the final clinical manifestation in patients with an asymptomatic deep venous thrombosis. This makes the systematic prevention of venous thromboembolism in higher risk patients necessary. Unfortunately, pharmacological prevention has been used less than would be needed. Inseparable from the TED prevention are physical methods. Pharmacological possibilities of the thromboembolic disease prevention were significantly extended within the past decade. To ensure the TED prevention after the total replacement (TEP) of hip and knee joints the following rules need to be observed: the TED prevention should be effected with LMWH, fondaparinux, dabigatran, rivaroxaban or apixaban for a period of 28-35 days after the hip joint replacement surgery and for 14 days after the knee joint replacement. The use of ASA, dextran and UFH as a thromboprophylaxis after the hip and knee joint TEP is not justified within the Czech Republic. Physical means (graduated compression stockings or IPC) can be used to support the recommended pharmacological treatment, they should not be used individually except in cases where pharmacological thromboprophylaxis is contraindicated.
- Klíčová slova
- apixaban,
- MeSH
- antikoagulancia * aplikace a dávkování farmakologie terapeutické užití MeSH
- benzimidazoly aplikace a dávkování farmakokinetika farmakologie terapeutické užití MeSH
- dabigatran MeSH
- heparin nízkomolekulární aplikace a dávkování MeSH
- lidé MeSH
- morfoliny aplikace a dávkování farmakokinetika farmakologie terapeutické užití MeSH
- náhrada kyčelního kloubu * MeSH
- pooperační péče MeSH
- pyrazoly aplikace a dávkování farmakokinetika farmakologie terapeutické užití MeSH
- pyridiny aplikace a dávkování farmakokinetika farmakologie terapeutické užití MeSH
- pyridony aplikace a dávkování farmakokinetika farmakologie terapeutické užití MeSH
- rivaroxaban MeSH
- thiofeny aplikace a dávkování farmakokinetika farmakologie terapeutické užití MeSH
- totální endoprotéza kolene * MeSH
- tromboembolie * prevence a kontrola MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- práce podpořená grantem MeSH
- přehledy MeSH
