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Профилактика тромбоэмболий. Рациональный подход к ведению пациенток в послеопера
Профилактика тромбоэмболий. Рациональный подход к ведению пациенток в послеопера
Пестрикова Т.Ю., Юрасова Е.А., Юрасов И.В. и др. Профилактика тромбоэмболий. Рациональный подход к ведению пациенток в послеоперационном периоде (обзор литературы). Consilium Medicum. 2018; 20 (6): 53–56. DOI: 10.26442/2075-1753_2018.6.53-56
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Аннотация
Проблемы профилактики и лечения тромбозов и тромбоэмболий являются актуальной клинической ситуацией. По данным ряда исследователей, наиболее часто тромбоз возникает после оперативных вмешательств. Тромбоэмболия легочной артерии (ТЭЛА) – одна из наиболее частых причин материнской смертности. В определенной степени этому способствует увеличение количества операций кесарева сечения, после которых риск тромбоэмболических осложнений в 10–15 раз выше. После гинекологических операций тромбоэмболические осложнения возникают у 19% прооперированных женщин, а массивная тромбоэмболия диагностируется в ходе аутопсии у 11,2% умерших в гинекологических стационарах. Венозные тромбоэмболии следует рассматривать как предотвратимую причину госпитальной летальности пациентов. При проведении тромбопрофилактики с помощью низкомолекулярных гепаринов показатели частоты тромбоэмболий многократно снижаются. Среди всех низкомолекулярных гепаринов, используемых для лечения и профилактики венозных тромбоэмболий и ТЭЛА, обращает на себя внимание бемипарин. Особенность бемипарина в том, что на сегодняшний день это единственный низкомолекулярный гепарин, который может быть использован для тромбопрофилактики как в до-, так и послеоперационном периоде. Рутинное использование низкомолекулярных гепаринов при ежедневных оперативных вмешательствах в гинекологической и акушерской практике позволит не только снизить летальность в стационарах у гинекологических больных, но и устранить случаи материнской смертности и случаи near miss от таких осложнений, как тромбоэмболии и ТЭЛА.
Ключевые слова: тромбоэмболии, тромбоэмболия легочной артерии, низкомолекулярные гепарины, бемипарин.
Ключевые слова: тромбоэмболии, тромбоэмболия легочной артерии, низкомолекулярные гепарины, бемипарин.
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Problems of prevention and treatment of thromboses and thromboembolism are a relevant clinical situation. According to a number of researchers, most often thrombosis arises after surgeries. thromboembolism of a pulmonary artery (TEPA) – is one of the most frequent reasons of maternal mortality. To some extent it is promoted by increase the number of operations of Cesarean – section after which a risk of specific complications is 10–15 times higher. After gynecologic operations complications after TEPA arise at 19% of the operated women, and the massive thromboembolism is diagnosed during autopsy – for 11.2% of the dead in gynecologic hospitals. TEPA should consider as the preventable reason of hospital mortality of patients. When carrying out the prevention of TEPA, by means of low-molecular heparins, indicators of frequency of thromboembolism multiply decrease. Among all low-molecular heparins used for treatment and prevention of venous thromboembolism and TEPA attracts attention Bemiparin. The feature of a bemiparin is the only low-molecular heparin which can be used for the prevention of TEPA, both in to- and in the postoperative period. Usual use of low-molecular heparins at daily operations in obstetrics and gynecology will allow not only to reduce mortality in hospitals at gynecological patients, but also to eliminate cases of maternal mortality and cases of near – miss from such complications as thromboembolism and TEPA.
Key words: thromboembolism, thromboembolism of a pulmonary artery, low-molecular heparins, bemiparin.
Key words: thromboembolism, thromboembolism of a pulmonary artery, low-molecular heparins, bemiparin.
Полный текст
Список литературы
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1. Neotlozhnye sostoyaniya v akusherstve. Ruk-vo dlya vrachej. Pod red. V.N.Serova, G.T.Suhih, I.I.Baranova i dr. M.: GEOTAR-Media, 2011. [in Russian]
2. Akusherstvo. Nacionalnoe ruk-vo. Pod red. G.M.Savelevoj, G.T.Suhih, V.N.Serova, V.E.Radzinskogo. Izd. 2-e, pererab. i dop. M.: GEOTAR-Media, 2015. [in Russian]
3. Prichiny i rezervy snizheniya materinskoj smertnosti na sovremennom etape. Ruk-vo dlya vrachej. Izd. 2-e, dop. Pod red. A.P.Milovanova, I.O.Bushtyrevoj. M.: MDV, 2014. [in Russian]
4. Pestrikova T.Yu. Monitorirovanie osnovnyh pokazatelej raboty akushersko-ginekologicheskoj sluzhby Dalnevostochnogo Federalnogo okruga v 2017 g. Sb.: Novye tehnologii v akusherstve i ginekologii. Habarovsk: Izd-vo DGMU, 2018; с. 10–52. [in Russian]
5. Ragimova R.I. Kompleksnaya profilaktika rannih tromboembolicheskih oslozhnenij s ispolzovaniem perftoruglerodnyh soedinenij u bolnyh posle ginekologicheskih operacij. Sovr. problemy nauki i obrazovaniya. 2016; 2: 165. [in Russian]
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7. Chapman NH, Brighton T, Harris MF et al. Venous thromboembolism – management in general practice. Aust Fam Physician 2009; 38 (1–2): 36–40.
8. Cohen AT, Agnelli G, Anderson FA et al. Venous thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality. Thromb Haemost 2007; 98 (4): 756–64.
9. Cohen AT, Tapson VF, Bergmann JF et al. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet 2008; 371 (9610): 387–94.
10. Geerts WH, Bergqvist D, Pineo GF et al. Prevention of Venous Thromboembolism. American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Ed.). Chest 2008; 133: 381–453.
11. Kearon C, Akl EA, Comerota AJ et al. Antithrombotic therapy for venous thromboembolic disease: antithrombotic therapy and prevention of thrombosis. American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (9th Ed.). Chest 2012; 141: 419–94.
12. Makacariya A.D., Bicadze V.O., Akinshina S.V. Trombozy i tromboembolii v akushersko-ginekologicheskoj praktike. Molekulyarno-geneticheskie mehanizmy i strategiya profilaktiki tromboembolicheskih oslozhnenij: Ruk-vo dlya vrachej. M.: Medicinskoe informacionnoe agentstvo, 2007. [in Russian]
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17. Abad JI, Gomez-Outes A, Martinez-Gonzalez J, Rocha E. A prospective observational study on the effectiveness and safety of bemiparin, first dose administered 6 h after knee or hip replacement surgery. Arch Orthop Trauma Surg 2007; 127 (8): 665–70.
18. Vavken P, Lunzer A, Grohs JG. A prospective cohort study on the effectiveness of 3500 IU versus 5000 IU bemiparin in the prophylaxis of postoperative thrombotic events in obese patients undergoing orthopedic surgery. Wien Klin Wochenschr 2009; 121 (13–14): 454–8.
19. Rodriguez-Manas L, Gomez-Huelgas R, Veiga-Fernandez F et al. Thromboprophylaxis with the low-molecular-weight heparin bemiparin sodium in elderly medical patients in usual clinical practice: the ANCIANOS study. Clin Drug Investig 2010; 30 (5): 337–45.
20. Planes A. Review on bemiparin sodium – a new second generation low-molecular-weight heparin and its applications in venous thromboembolism. Expert Opin Pharmacother 2003; 4: 1551–61.
21. Abad Rico JI, Lozano Sánchez FS, Rocha E. Clinical experience with bemiparin. Drugs 2010; 70 (Suppl. 2): 25–33.
22. Gómez-Outes A, Rocha E, Martínez-González J, Kakkar W. Cost effectiveness of bemiparin sodium versus unfractionated heparin and oral anticoagulants in the acute and long-term treatment of deep vein thrombosis. Pharmacoeconomics 2006; 24 (1): 81–92.
23. Kahn SR, Panju A, Geerts W et al. Multicenter evaluation of the use of venous thromboembolism prophylaxis in acutely ill medical patients in Canada. Thromb Res 2007; 119 (2): 145–55.
24. Abad JI, Gómez-Outes A, Martínez-González J, Rocha E. A prospective observational study on the effectiveness and safety of bemiparin, first dose administered 6h after knee or hip replacement surgery. Arch Orthop Trauma Surg 2007; 127 (8): 665–70.
25. Kakkar W, Balibrea JL, Martínez-González J, Prandoni P. Extended prophylaxis with bemiparin for the prevention of venous thromboembolism after abdominal or pelvic surgery for cancer: the CANBE-SURE randomized study. J Thromb Haemost 2010; 8 (6): 1223–9.
26. Constans M, Santamaria A, Mateo J et al. Low-molecular-weight heparin as bridging therapy during interruption of oral anticoagulation in patients undergoing colonoscopy or gastroscopy. Int J Clin Pract 2007; 61: 212–7.
27. Lecumberri R, Rosario E, Pacho J, Rocha E. Fixed-dose low-molecular-weight heparin, bemiparin, in the long-term treatment of venous thromboembolism in patients with transient risk factors in standard clinical practice: the FLEBUS study. J Thromb Haemost 2006; 4: 2504–8.
28. Amin A, Stemkowski S, Lin J, Yang G. Thromboprophylaxis rates in US medical centers: success or failure? J Thromb Haemost 2007; 5 (8): 1610–6.
29. Cohen AT, Tapson VF, Bergmann JF et al. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet 2008; 371 (9610): 387–94.
30. Instrukciya po primeneniyu preparata Cybor. http://medside.ru/tsibor [in Russian]
2. Akusherstvo. Nacionalnoe ruk-vo. Pod red. G.M.Savelevoj, G.T.Suhih, V.N.Serova, V.E.Radzinskogo. Izd. 2-e, pererab. i dop. M.: GEOTAR-Media, 2015. [in Russian]
3. Prichiny i rezervy snizheniya materinskoj smertnosti na sovremennom etape. Ruk-vo dlya vrachej. Izd. 2-e, dop. Pod red. A.P.Milovanova, I.O.Bushtyrevoj. M.: MDV, 2014. [in Russian]
4. Pestrikova T.Yu. Monitorirovanie osnovnyh pokazatelej raboty akushersko-ginekologicheskoj sluzhby Dalnevostochnogo Federalnogo okruga v 2017 g. Sb.: Novye tehnologii v akusherstve i ginekologii. Habarovsk: Izd-vo DGMU, 2018; с. 10–52. [in Russian]
5. Ragimova R.I. Kompleksnaya profilaktika rannih tromboembolicheskih oslozhnenij s ispolzovaniem perftoruglerodnyh soedinenij u bolnyh posle ginekologicheskih operacij. Sovr. problemy nauki i obrazovaniya. 2016; 2: 165. [in Russian]
6. Guidelines on the diagnosis and management of acute pulmonary embolism. The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology. Eur Heart J 2008; 29: 2276–315.
7. Chapman NH, Brighton T, Harris MF et al. Venous thromboembolism – management in general practice. Aust Fam Physician 2009; 38 (1–2): 36–40.
8. Cohen AT, Agnelli G, Anderson FA et al. Venous thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality. Thromb Haemost 2007; 98 (4): 756–64.
9. Cohen AT, Tapson VF, Bergmann JF et al. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet 2008; 371 (9610): 387–94.
10. Geerts WH, Bergqvist D, Pineo GF et al. Prevention of Venous Thromboembolism. American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Ed.). Chest 2008; 133: 381–453.
11. Kearon C, Akl EA, Comerota AJ et al. Antithrombotic therapy for venous thromboembolic disease: antithrombotic therapy and prevention of thrombosis. American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (9th Ed.). Chest 2012; 141: 419–94.
12. Makacariya A.D., Bicadze V.O., Akinshina S.V. Trombozy i tromboembolii v akushersko-ginekologicheskoj praktike. Molekulyarno-geneticheskie mehanizmy i strategiya profilaktiki tromboembolicheskih oslozhnenij: Ruk-vo dlya vrachej. M.: Medicinskoe informacionnoe agentstvo, 2007. [in Russian]
13. Heit JA. The epidemiology of venous thromboembolism in the community: implications for prevention and management. J Thrombos Thrombol 2006; 21: 23–9.
14. Serov V.N., Pasman N.M., Sturov V.G., Drobinskaya A.N. Nasledstvennye i priobretennye trombofilicheskie sostoyaniya v akushersko-ginekologicheskoj praktike. Klinicheskie aspekty, diagnostika, taktika vedeniya, podhody k terapii. Ruk-vo dlya vrachej. Novosibirsk: Sova, 2011. [in Russian]
15. Ryazhenov V.V., Gorohova S.G. Kliniko-ekonomicheskij analiz primeneniya nizkomolekulyarnyh geparinov v rutinnoj klinicheskoj praktike. Trudnyj pacient. 2012; 10 (6): 12–5. [in Russian]
16. Scottish Intercollegiate Guidelines Netword (SIGN), Prevention and Management of Venous Thromboembolism, A National Clinical Guideline, 2010.
17. Abad JI, Gomez-Outes A, Martinez-Gonzalez J, Rocha E. A prospective observational study on the effectiveness and safety of bemiparin, first dose administered 6 h after knee or hip replacement surgery. Arch Orthop Trauma Surg 2007; 127 (8): 665–70.
18. Vavken P, Lunzer A, Grohs JG. A prospective cohort study on the effectiveness of 3500 IU versus 5000 IU bemiparin in the prophylaxis of postoperative thrombotic events in obese patients undergoing orthopedic surgery. Wien Klin Wochenschr 2009; 121 (13–14): 454–8.
19. Rodriguez-Manas L, Gomez-Huelgas R, Veiga-Fernandez F et al. Thromboprophylaxis with the low-molecular-weight heparin bemiparin sodium in elderly medical patients in usual clinical practice: the ANCIANOS study. Clin Drug Investig 2010; 30 (5): 337–45.
20. Planes A. Review on bemiparin sodium – a new second generation low-molecular-weight heparin and its applications in venous thromboembolism. Expert Opin Pharmacother 2003; 4: 1551–61.
21. Abad Rico JI, Lozano Sánchez FS, Rocha E. Clinical experience with bemiparin. Drugs 2010; 70 (Suppl. 2): 25–33.
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Авторы
Т.Ю.Пестрикова*, Е.А.Юрасова, И.В.Юрасов, Т.П.Князева, В.А.Ткаченко
ФГБОУ ВО «Дальневосточный государственный медицинский университет» Минздрава России. 680000, Россия, Хабаровск, ул. Муравьева- Амурского, д. 35
*typ50@rambler.ru
ФГБОУ ВО «Дальневосточный государственный медицинский университет» Минздрава России. 680000, Россия, Хабаровск, ул. Муравьева- Амурского, д. 35
*typ50@rambler.ru
________________________________________________
T.Yu.Pestrikova*, E.A.Yurasova, I.V.Yurasov, T.P.Knyazeva, V.A.Tkachenko
Far Eastern State Medical University of the Ministry of Health of the Russian Federation. 680000, Russian Federation, Khabarovsk, ul. Murav'eva-Amurskogo, d. 35
*typ50@rambler.ru
Far Eastern State Medical University of the Ministry of Health of the Russian Federation. 680000, Russian Federation, Khabarovsk, ul. Murav'eva-Amurskogo, d. 35
*typ50@rambler.ru
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