出凝血异常普通外科病人围手术期静脉血栓栓塞症防治策略

Venous thromboembolism prevention and control strategy in the perioperative period of general surgery in patients with acquired or inherited coagulation disorders

易栓症是外科围手术期静脉血栓栓塞症(VTE)的防治重点。对于接受手术的止凝血障碍病人,需要谨慎评估VTE的个体风险,同时兼顾手术和麻醉的性质、出血障碍类型和严重程度、年龄、体重指数(BMI)、血栓形成史、恶性肿瘤和其他高危共患病。VTE风险应与已知出血障碍病人使用抗凝相关的出血风险平衡。实验室检查有助于发现和判断血栓与出血的病因,对病人的止凝血代偿能力作出评估,并对抗凝药物的合理使用提供依据。对上述病人,建议术后不常规使用药物预防血栓,尤其是血友病病人,但围手术期因子替代和止血药物的过度应用仍存在导致血栓的风险。使用低分子肝素(LMWH)和直接口服抗凝剂前应评估肾小球滤过率。当血小板计数<50×109/L,LMWH短期减量应用可能相对安全,监测抗Хa水平可用于调整中重度血小板减少症病人LMWH的剂量。主要消化道出血停止和重新使用华法林应至少相隔7 d。对于高血栓栓塞风险和术后高出血风险病人,术后当晚和术后第1天减量应用直接口服抗凝剂是一种可取的做法。

Thrombophilia is the focus of the prevention and treatment of venous thromboembolism during surgery.For patients with clotting disorders undergoing surgery,the individual risk of venous thrombosis needs to be carefully assessed.Surgeons should take into account the property of surgery and anesthesia,the type and severity of bleeding disorders,age,BMI,history of thrombosis,malignant tumors and other high-risk co-diseases.The risk of venous thromboembolism should be balanced with the hemorrhage risk associated with the use of anticoagulant in patients with known bleeding disorders.Laboratory examination helps to identify and determine the cause of thrombosis and hemorrhage,evaluates the patient's ability to stop clotting compensation,and provides a basis for the reasonable use of anticoagulant drugs.For those patients,it is not recommended to use routine postoperative use of pharmacological thromboprophylaxis,especially for patients with haemophilia.However,there is still a risk of thrombosis in the use of perioperative factor substitution and excessive application of hemorrhagic drugs.The glomerular filtration rate should be evaluated before using low-molecular heparin and direct oral anticoagulants.When the platelet count is less than 50×109/L,short-term reduction of low molecular heparin may be relatively safe.Monitoring anti-Ⅹa levels can be used to adjust the dose of low molecular weight heparin in patients with moderate and severe thrombocytopenia.Cessation of major gastrointestinal bleeding and re-use of warfarin should be at least 7 days apart.For patients with high thromboembolism risk and postoperative high hemorrhage risk,it believes that in the night after surgery and the day after surgery,the application of direct oral anticoagulants is a good practice.