醫學筆記匯整 ED Notes

1. 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.
      
2. 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 

     

      

     
      
   •  

      
3. 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
      
4.  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
     
      
5. 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
      
6. 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

1. Indication:
   • Massive proximal lower extremity or iliofemoral thrombosis
   • phlegmasia cerulea dolens (PCD)
     -acute massive venous thrombosis that causes an obstruction of the venous drainage of an extremity (upper or lower) and is associated with a high degree of morbidity. Patients usually present with sudden severe pain, swelling, cyanosis, edema, venous gangrene, and compartment syndrome that together impair arterial supply, 
   • 症狀<14 days (新鮮的血塊軟軟的才能被溶解)
   • 相對適應症: 服用抗凝血劑仍然復發
     
     
      
2. 血栓溶解劑 (systemic and catheter-directed) v.s 抗凝血劑
   -血栓溶的比較快比較多
   -得到併發症 post-thrombotic syndrome (PTS)的機率較低
   -之後得到PE的機率和死亡率沒有降低
   -出血機率較高
    
3. systemic thrombolysis  v.s catheter-directed thrombolysis (CDT)
   - CDT 局部打--> 效果較好且劑量較低,比較不會出血
    
4. thrombolitic agent
   • r-tPA  100 mg IV over two hours
   • Streptokinase – Administer 250,000 units intravenously over the initial 30 minutes, then 100,000 units/hour for 24 to 72 hours
   • Urokinase – Administer 4400 units/kg intravenously over the initial 10 minutes, then 2200 units/kg per hour for 12 hours.
      

1. Acute proximal DVT 且 無法服用抗凝血劑
   (eg, recent surgery, hemorrhagic stroke, active bleeding)
    
2. 服用抗凝血劑仍然復發
3. 相對適應症 : 慢性PE合併肺高壓, 無法容忍下一次PE

https://www.evernote.com/shard/s680/sh/1629af31-60f3-4369-a4cf-571ef7530ee8/62dfb0afda4dbb9f