- 12月 02 週五 202200:24
總髂動脈瘤破裂 Common iliac artery aneurysm
- 4月 01 週四 202119:12
Aortic intramural hematoma (IMH)
- 1月 29 週五 202119:19
Aortic dissection 主動脈剝離
- 1月 15 週五 202120:30
Acute Limb Ischemia - 1
Most frequently diseased arteries leading to limb ischemia :
Femoropopliteal, tibial, aortoiliac, and brachiocephalic vessels
- 12月 10 週四 202019:51
Actue limbs ischemia (ed_notes_)
- 11月 26 週一 201809:40
Acute Limb Ischemia - 2
- 12月 08 週四 201618:49
DVT 治療 - 吳宜馨
Anticoagulant ( if no contraindication)
最重要治療，預防 further thrombosis 和併發症 ( 不要再發 !! )
Indication :
Contraindication
Initial anticoagulation 盡早開始吃 !!!
Duration of anticoagulation
Special condition
最重要治療，預防 further thrombosis 和併發症 ( 不要再發 !! )
- Major early complications :
further clot extension, acute pulmonary embolus (PE)
major bleeding (from anticoagulation), and death.
- Late complications :
recurrent clot, post-thrombotic (post phlebitic) syndrome,
and chronic thromboembolic pulmonary hypertension.
Indication :
- 膝蓋以上Proximal DVT 必吃 (popliteal vein和其上)，不論有沒有症狀
- 只有膝以下 Isolated distal DVT : 有症狀必吃
沒有症狀( CT意外發現 ) 但符合以下情況也吃
- Patients with documented DVT
extension into or toward the proximal veins during surveillance
- 有可能extend到proximal vein者:- Unprovoked DVT
- D-dimer >500 mg/ml
- Extensive thrombosis involving multiple veins (eg, >5 cm in length, >7 mm in diameter)
- Thrombosis close to the proximal veins
- Persistent/irreversible risk factors such as active cancer
- Prior DVT or PE
- Prolonged immobility
- Inpatient status
- 沒症狀又不符合以上的只要密集監測,用超音波看有沒有形成更多的thrombus
建議觀察兩周
-血栓溶解-->不用吃抗凝血
-血栓往近端延伸--> 吃抗凝血
-血栓stable但也沒溶解-->可能需要繼續觀察
- 第一次DVT 處理流程
Contraindication
- Absolute contraindications
-Active bleeding
-Severe bleeding diathesis
-Platelet count <50,000/microL
-Recent, planned, or emergent high bleeding-risk surgery/procedure
-Major trauma
-History of intracranial hemorrhage (ICH) particularly recent ICH
- Relative contraindications
-Recurrent bleeding from multiple gastrointestinal telangiectasias
-Intracranial or spinal tumors
-Platelet count <150,000/microL
-Large abdominal aortic aneurysm with concurrent severe hypertension
-Stable aortic dissection
Recent, planned, or emergent low bleeding-risk surgery/procedure
Initial anticoagulation 盡早開始吃 !!!
- warfarin 口服 + LMWH/heparin/pentasaccharide 直到 INR>2
-一開始不能單獨使用warfarin-->因為作用比較慢(要等4~5天體內的vit K 相關凝血因子用完)
-起始劑量嬌小的病人~3mg/day,年輕/大隻的病人~10mg
-目標INR 2.5 (有裝人工瓣膜2.5-3.5)
-和amiodarone, 抗生素(如rifampin, sulfamethoxazole) 有交互作用
- 口服 direct Xa inhibitors (rivaroxaban, apixaban) NOACs
-起始效果更快,半衰期更短
-可以單獨使用不用搭配heparin
-難監測,沒有解毒劑
- UFH (皮下orIV)
-間接抑制Xa and thrombin-->aPTT延長
-效果只能持續幾小時,且有解毒劑(魚精蛋白protamine sulfate)-->適合出血風險較高的病人
-不需依腎功能調整
-預防DVT 每8-12小時皮下注射5000U
- LMWH (IV或皮下)
-對Xa更具專一性-->不太影響aPTT
-懷孕,肥胖和腎功能不好的人要監測Xa
-經腎臟代謝 CrCL<10 絕對禁忌 - fondaparinux (人工合成 )
- Outpatient therapy,
自己在家皮下注射LMWH+口服warfarin/ dabigatran or edoxaban,
or 單獨口服Xa inhibitor,須符合以下條件
-出血和復發機率低
-心肺功能足夠
-給予足夠的指導且病人了解可以配合,須定期門診追蹤
-交通和求援的便利性
Duration of anticoagulation
- 至少都要吃三個月
- 第一次+transient risk factor (手術,外傷)--> 3個月
- 第一次+找不到原因-->3-6個月
- 沒有危險因子但發生PE-->至少6個月
- 反覆不明原因, 癌症,有遺傳性高凝固血態--> 吃終身
Special condition
- 癌症病人建議長期使用(直到腫瘤痊癒或是出現嚴重complication)
抗凝血劑,單獨使用皮下 LMWH是比較好的選擇(不論是initial or maintain therapy)
- 懷孕婦女 Adjusted-dose subcutaneous LMW heparin 會比warfarin安全
-Warfarin freely crosses the placental barrier
and can produce an embryopathy
when given between the sixth and ninth weeks of pregnancy
- 2月 16 週二 201623:50
Off pump V.S. On pump
Off pump V.S. On pump
No aortic cannulation -> less risk of dissection, embolism
No atrial cannulation -> less atrial injury, arrhythmias
No cross-clamping -> less risk of plaque embolism, CVA, MI
No activation of coagulation, kallikrein, inflammation caused by tubing
-> less coagulopathy, less bleeding, less transfusion
No cardioplegia -> no K+ load, fluid load, coronary air embolism
No risk of bypass machine failure -> air embolism
Less cost
Less equipment
Less staff
- 不用 CPB 少了 SIRS
減少輸血, Coagulopathy
- 不用去動到 aorta 減少 stroke, dissection
- 不用 cardioplegia 心臟不會停
減少 kidney, brain injury
- 12月 31 週四 201520:40
Aucte Aortic syndrome
- Consider the diagnosis in all patients
with chest, abdominal or back pain, syncope or stroke symptoms
- 12月 25 週五 201522:08
Cardiac tamponade 心包膜填塞
CV (7)