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1、围术期大面积肺梗塞 Perioperative Massive Pulmonary Embolism (PMPE) 从 处理 到 预防,麻 醉 科 朱斌 黄宇光,Why 麻醉科 ？,Perioperative medicine -describes the consultation, care, or co-management of a patient undergoing surgery that is provided by an anesthesiologist, an internal medicine generalist or hospitalist.,Why 麻醉科 ？,瓶颈科
2、室,平台科室,麻醉医生是手术室的 “内科医生”,Confidential Enquiry into Perioperative Deaths (CEPOD) -reported in 1987 Unique to this study was the establishment of “crown privilege” by the government to allow total confidentiality The data or information sent to the Confidential Enquiry into Perioperative Deaths is ther
3、efore protected from subpoena ,Deaths occurring within 30 days after surgery were included in the study. There were 4034 deaths in an estimated 485,850 operations,Why me ？,面临的问题惨痛的事件,北大医院事件与风波?!,男性，56岁，11-9因车祸致骨盆、耻骨骨折、多发肋骨骨折、肩胛骨骨折、腰椎压缩性骨折。11-17全麻下行骨盆骨折内固定术。术前PaO2 56,PaCO2 33。入室血压120/80，HR 102，SpO2 9
4、4。全麻顺利，手术开始10min后Bp骤降至65/35， PETCO2 33迅速降至193mmHg，即刻给予升压药，Bp继续降至3424mmHg，HR 107bpm, ECG示室早、室速，启动CPR并动员全院力量抢救。抢救时间1小时50分钟后放弃。,男性，30岁，一月前多处刀扎伤失血性休克、多科协作行急诊手术。手术全程约12小时，由于缺乏血液供应，术中较长时间血压维持在5070/3040。待输血后生命体征逐渐好转，术毕送返ICU。患者在ICU治疗两天后转回泌尿外科病房，因为病情术后一直卧床，术后第5天突发呼吸心跳骤停，经抢救无效死亡。尸检证实为肺栓塞。,面临的问题沉重的数据,在美国，肺栓塞每年
5、发病约63万70万例 在美国或欧洲每年约有10-30万死于PE 临床死因第三位: 肿瘤、心肌梗死、肺栓塞 79%PE病人有DVT证据(二者共属于VTE, 是同一疾病的两个不同阶段。) 11%PE死于发病1h以内，89%存活至少1h以上； Heart 2008;94;795-802 N Engl J Med 2008;358:1037-52 N Engl J Med 2008;359:2804-13.,国内PE死亡人数？ 全国肺栓塞协作组40家医院19952006年统计的PE病例数从90 年 200 余例增加到2006 年的1859 例，增加近十倍（死亡率1015%） 中国介入放射学 2008;
6、 7:276-277 骨科大手术后DVT发生率： 41%-60% 2009年中国骨科大手术静脉血栓栓塞症预防指南,面临的问题沉痛的教训,肺栓塞不应被视为少见病、罕见病 不应受到公众和医务人员的冷落与忽视 病因：血栓、心脏病、肿瘤、分娩、多发骨折,肺栓塞是三高一低： 发病率高、死亡率高、漏诊率高、知晓率低,从DVT到PE,N Engl J Med 2008;358 （March）:1037-52,PMPE,51-71%DVT患者可能发生PE,DVT高危因素,深静脉血栓形成的诊断和治疗指南 （2007）中华医学会外科学分会血管外科学组,2009年中国骨科大手术静脉血栓栓塞症预防指南,DVT诊断的临
7、床评分,深静脉血栓形成的诊断和治疗指南 （2007年版） 中华医学会外科学分会血管外科学组,DVT诊断流程,深静脉血栓形成的诊断和治疗指南 （2007年版） 中华医学会外科学分会血管外科学组,PE诊断流程-1,N Engl J Med 2008;359（12）:2804-13,无 低血压 和 休克,PE诊断流程-2,N Engl J Med 2008;359（12）:2804-13,有 低血压 和 休克,紧 急！,PE诊断流程-3 Perioperative Massive-PE,PE中高危病人（评分2） 气管插管病人PETCO2突然剧降 循环突然崩溃 需要立即CPR CPR成功者才可能有机会
8、确诊,2/3病人在出现循环崩溃后1小时内死于PMPE 由于情况紧急,要求利用一切可能的手段快速有效地纠正病人MAP!,临床鉴别诊断,PE风险分级及处理,N Engl J Med 2008;359（12）:2804-13,PE预防与处理,如前所述，强调PMPE的处理不如强调术前加强对DVT和PE高危病人的筛查 PMPE可能只有紧急的外科取栓和ECMO才可能有机会成功救治病人。,PE预防,强调DVT的术前筛查 梯度加压弹力袜 强调术后早期活动 强调DVT和PE高风险病人围术期的抗凝治疗 DVT明确的病人术前应有血管科会诊，以决定血栓的处理及是否需要在术前植入下腔静脉滤器,PUMCH 深静脉血栓/肺
9、栓塞（DVT/PE）风险预警及预防流程草案 - 适应症,Assessment of risk and prophylaxis for deep vein thrombosis and pulmonary embolism in medically ill patients during their early days of hospital stay at a tertiary care center in a developing country. Vascular Health and Risk Management. 4 August 2009,PUMCH 深静脉血栓/肺栓塞（DVT/
10、PE）风险预警及预防流程草案 - 禁忌症,如存在上述问题，请相关专业科室会诊（呼吸 or 血液 or 血管）,As noted earlier, about half of those who develop DVT/PE have two things in common. First, they have one or more identifiable risk factors for the disease. Second, they experience some sort of triggering event, such as hospitalization, trauma, s
11、urgery, or a prolonged period of immobilization. The other half of those who get the disease have “unprovoked DVT/PE”that is, the reasons for the events are unknown. The search was conducted at www.guideline.gov on June 27, 2006, and more than 100 guidelines related to PE and DVT were found. The ini
12、tial search on the term “pulmonary embolism” produced 111 guidelines. While searching on the term “deep vein thrombosis” 88 guidelines were produced The National Quality Forum (NQF) now recommends that all hospitalized patients be evaluated upon admission and regularly thereafter, and that those fou
13、nd to be at risk be given prophylaxis for VTE,A call to action is a science-based document to stimulate action nationwide to solve a major public health problem. Over the years, the Surgeon General has issued several calls to action. The first and most important document was the Report on Smoking an
14、d Health issued in 1964.2 This warning about the health risks of cigarettes was issued by the Surgeon General at a time when smoking was common and fashionable. It caught the attention of the general public and set the groundwork for the subsequent 40 years of research and awareness that resulted in
15、 the lowest smoking rates in history. Now, 44 years later, the alarm has been sounded on another equally disabling and deadly disease, deep vein thrombosis (DVT) and pulmonary embolism, collectively known as venous thromboembolism (VTE),Circulation. 2009; 119:e480-e482.,We care what we do;,We do make the difference,