日本肺栓塞及深静脉血栓指南2011版流行病学•发病率逐渐升高•美国500/百万，日本62/百万2006年，围手术期4.41-2.79，女性发病率增高较快，好发年龄60-70岁。危险因素•Interruptedbloodflow–长期卧床–肥胖–怀孕–心肺疾病(如充血性心力衰竭、慢性肺心病等)–全麻–下肢麻醉–下肢制动–下肢静脉曲张•Endothelialdysfunction–手术–外伤、骨折–中心静脉置管–导管介入检查或治疗–血管炎–抗磷脂综合症–Hyperhomocysteinemia（高同型半胱氨酸血症，遗传或获得性）•Hypercoagulability–恶性肿瘤–怀孕–手术、创伤、骨折–烧伤–药物(如口服避孕药、雌激素等)–感染–肾病综合征–炎性肠病–骨髓增生性疾病，红细胞增多症–阵发性睡眠型血红蛋白尿–抗磷脂综合症–脱水–抗凝酶缺乏–蛋白C缺乏–蛋白S缺乏–纤溶酶原异常–纤维蛋白原异常–组织纤溶酶原活化抑制因子增多–血栓调节素异常–蛋白C活化抵抗–凝血酶原基因变异(G20210A)*症状、体征•缺乏特异性•呼吸困难、胸痛•典型者是起床活动、排便排尿或体位改变时出现严重程度的判别血流动力学心脏超声检查右心负荷增重心脏骤停、休克心脏骤停、休克有大面积不稳定、低血压或休克（收缩压低于90或较基础血压下降大于等于40）有次大面积稳定有非大面积稳定无急性肺栓塞诊断步骤Startheparintherapywhenpulmonaryembolismissuspected.Examinefordeepveinthrombosisatonce.*1ScreenthepatientwithchestX-ray,ECG,arterialbloodgasanalysis,transthoracicechocardiography,andbloodchemistry.*2WhenPCPSisnotavailable,maintaincirculationwithcardiaccompressionandvasopressors.CT,computedtomography;PCPS,percutaneouscardiopulmonarysupport.AdaptedfromTherapeuticResearch2009;30:744–747.处理程序*1Whenriskofbleedingishigh.*2Treatcomplicationsappropriatelywithavailablemethods.*3Unstablehemodynamicsconsistentwithshockorprolongedhypotension.*4Conditionrequiringcardiopulmonaryresuscitationorprolongedsevereshock.*5ConsiderPCPSaccordingtohospitalequipmentsandpatientcondition.*6Selectappropriatetreatmentaccordingtohospitalequipmentsandpatientcondition.*7Evaluatebasedonrightventricularenlargementonechocardiographyandseverityofpulmonaryhypertension.*8Presence/absenceofDVTwhichmayhaveseriouseffectsifitreleasesembolicausingrecurrentembolism.Theabovealgorithmisanexample.Eachinstitutionshouldselectappropriatemethodsaccordingtoitshealthcareresources.DVT,deepveinthrombosis;PCPS,percutaneouscardiopulmonarysupport;IVC,inferiorvenacava.肝素抗凝剂量调整及监测•普通肝素首剂5,000units静滴,继以1,400units/hr的速度持续维持.首剂后6hr监测APTT，按照上表调整剂量•*1UsethistableforAPTTreagentswithatherapeuticrangeof1.9to2.7timesthecontrol.•*2Whenunfractionatedheparinisadministeredataconcentration40units/mL.•APTT,activatedpartialthromboplastintime;Bolus,bolusdoseforrepeatedadministration;Hold,durationofsuspensionofcontinuousinfusion;Ratechange,changeininfusionrateduringcontinuousinfusion;Dosechange,changeindoseduringcontinuousinfusion.药物治疗•肝素治疗应在拟诊阶段，首剂80u/kg或5000u，继以18u/kg/hr或1300u/hr维持。同时给予华法林3-5mg/日口服，3-5天后停肝素。•Rt-PA，（蒙替普酶Monteplase）13,750-27,500u/kg2分钟内静注。•药物治疗的标准•(1)抗凝治疗适合于血压正常、无右心功能障碍的急性肺栓塞患者.•(2)血压正常而右心功能不全的患者需要权衡溶栓治疗的出血风险•(3)溶栓治疗适应于持续低血压及休克的患者华法林抗凝治疗的期限华法林（2011版英国指南）VTE初发VTEshouldbetreatedwithanINRtargetof2.5必须同时使用unfractionatedheparin,lowmolecularweightheparinorfondaparinuxatleast5danduntiltheINRis≥2foratleast24h复发VTEtheINRtargetto3.5.Antiphospholipidsyndrome(APS)INRshouldbe25...
