АВАВАКдлАмАК дцаядлдлая дла АсдлАмАК А А AIдлАмАК АмАядл дцаяаядца АВА АсдлАя

Transcription

1 АВАВАКдлАмАК дцаядлдлая дла АсдлАмАК А А AIдлАмАК АмАядл дцаяаядца АВА АсдлАя АяАКАя 2009

2 Efi : fi applefi fi fiapple. ISBN АВАВАКдлАмАК дцаядлдлая дла АсдлАмАК А А AIдлАмАК АмАядл дцаяаядца АВА АсдлАя АУ 20, M T , Fax info@eexot.gr, eexot@otenet.gr Aapple Ав, apple,, appleapple, applefiав apple Ав appleау appleавapple fiapple, fi, fi, applefi,, apple apple Ав Авfi. fi 2121/1993 fi apple Ав.

3 АВАВАКдлАмАК дцаядлдлая дла АсдлАмАК А А AIдлАмАК АмАядл дцаяаядца АВА АсдлАя Ам А Ав fi fi А appleав Ая 2009

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5 fi Аяapplefi АУ Ав А«70 fi fi apple- appleapple fi appleавау АУ. АК apple АУ fi fi - fi fi fi apple applefi АУ apple. fi appleав АУapple fi applefi. Аяapplefi АУ Ав А«70 fi АУ АУ АУАв apple АУ apple. А АУ АУ apple appleав apple АУ Ав apple fi. АВ fi apple apple-, apple apple АУ - Ам appleау АУАв apple fi appleав. дц appleау fi apple Ав, Ав apple applefi fi. А fiав E А appleав дц- 2008,. д. apple, - apple, Ав АУ appleав apple. applefi apple fi А appleав. apple apple Ав АУ АУАв

6 apple appleapple. АК. АК apple apple- appleapple АУ АвАУ applefi apple, -... Ав. Ав apple appleау АУ Ам apple АяАв apple. АУ fi АУ apple- appleapple -, apple 10 apple Ав appleау apple- apple. fi Ав. АУ fi АУ apple- apple apple. А АУ Ав АУ Ав E А appleав дц ( fi. Ав apple- Ав applefi fi. АК Авfi Ав А appleав дц АвАУ: 1. Ам Ав applefi fi -. АК apple appleapple fi - : IАК, IАмАяА А длакдцдламак AYАяАК. 2. Ав Авfi АУ fi fi Ав. 3. apple appleapple Ав apple: apple, appleау applefi, apple..

7 4. АяАУ apple ( apple - ). 5. appleapple apple apple applefi Ав apple appleapple apple fi fiapple АУ applefi applefi. дц apple applefi applefi apple apple apple. А Ав apple- apple fiав (evidence-based medicine) apple apple fi apple. Аяapple - fi fi apple fi apple. B. fiав apple appleapple s.sourmelis@hygeia.gr

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9 длдцака дламак-yасасpaikh длдца АК fiав Аяд д Ая B. А АВАК длдцак д А А АядлдлАмАК АмАВдлдлАмАК, Ам "АсдлАя", AHNA АУ АядцдлА АяАядцАядлАяАК длама АВАяА. АкАяАсА АядлА длама АВАяА АкАяАяАяАмАК А АВА АсА -А АяАК длаядлак АяАядцАядлА АВдлАВдлАмАяАмАК АсАсдлА АяАК А А АяАяА АВА дла длавакдцак Ая' А А АядлдлАмАК АмАВдлдлАмАК, АсдлАмА А А АмА дла "АяАяАВдлАя АВдлАсАм", АяАКАя А А АядлдлАмА дла АсА, АяАКАя длавакдцак Ая' B' А А АядлдлАмАК АмАВдлдлАмАК, АсNA "Ас. АсENNHMATA", АяАКАя АяАяАВHPTH АмАяАКАсАКдцАК А А АядлдлАмАК, длдцак Ас' А А АядлдлАмАК АмАВдлдлАмАК, А А АмА дла АмАядц, АяАКАя А А АядлдлАмА дла АсА, АяАКАя АяАяАВHPTH АмАяАКАсАКдцАК А А АядлдлАмАК, Ая А А АядлдлАмАК АмАВдлдлАмАК АядлдцАКдлА АяАК, Ас "АядцдцдлАмА ", АяАКАя длдцак А А АядлдлАмАК АмАВдлдлАмАК, А А АмА дла длдц, АяАКАя

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11 д А АВдцдлАмАК длдца АК АмАядцАК д АядцдлдлАК АяАяАсдлдцАК АКАяАмА А АВА АядлдцдлАК д. АкА А АсАсдлА АмАядцАяА EOIАВO KAPAXAАВIO АКАКдцдлА. АмА АмдцАядцдлА АяАВдлАкА длаяак АяАК АсАсдлА АяАядлАя длаяак дла АяАВАяА E. АК д АядлАВдлА длдца АК АКАВдлАя АяАяАсдлдцА А АВА дламавак АяАяА А АВА АсEPАсIO ETATH АяАяАсдлдцАК. А АмАяАмА длаяак А АК АяАядцАядлА длдца А АВА длаяак длдца А длак длама А АмАяАКАсАКдцАК А А АядлдлАмАК АядлдцАКдлА АяАВдлАя, Ас АВАядлАя, АВАядлАя АмАяАКАсАКдцАК А А АядлдлАмАК, длдцак А А АядлдлАмАК АмАВдлдлАмАК АядлдцАКдлА Аядц, Ас Аядц, АядцАя АяАяАВHPTH АмАяАКАсАКдцАК А А АядлдлАмАК, длдцак АяА А АядлдлАмАК АмАВдлдлАмАК АядлдцАКдлА АяАК, Ас "АядцдцдлАмА ", AHNA АмАяАКАсАКдцАК А А АядлдлАмАК, длдцак АсА А АядлдлАмАК АмАВдлдлАмАК АядлдцА дцавдла АядлдцАКдлА АяАВА дламак, Ас "АяАяАсАсдлА ", EAАВONIKH АяАяАВHPTH АмАяАКАсАКдцАК А А АядлдлАмАК АядлдцАКдлА АяАВдлАя, Ас АВАядлАя, АВАядлАя АмАяАКАсАКдцАК А А АядлдлАмАК, длдцак АсА А АядлдлАмАК АмАВдлдлАмАК АядлдцАКдлА АяАК, А А АмА дла АмАядц, АяАКАя АмАяАКАсАКдцАК А А АядлдлАмАК, длдцак А А АядлдлАмАК АмАВдлдлАмАК АядлдцАКдлА АяАВдлАя, Ас АВАядлАя, АВАядлАя длдцак А А АядлдлАмАК АмАВдлдлАмАК, А А АмА дла "АмА АсдлАяАВдлА -АяАмдлА "..., АяАКАя длдцак ' А А АядлдлАмАК АмАВдлдлАмАК, А А АмА дла АмАядц, АяАКАя длдцак ' А А АядлдлАмАК АмАВдлдлАмАК, А А АмА дла АяАмАВАКдлдлА д А АВАя, АяАКАя АмАяАКАсАКдцАК А А АядлдлАмАК АядлдцАКдлА длаядл, Ас длаядл, длаядлая А А АядлдлАмА дла АсА, длаядцдлама АмдцА АяАК, АяАКАя АмАяАКАсАКдцАК А А АядлдлАмАК АядлдцАКдлА Аядц, Ас Аядц, АядцАя АВАмдцА Ая А А АядлдлАмАК Ая, АяА А АядлдлАмАК АмАВдлдлАмАК, Ас АяАВА дламак "Ас. АяАядлАмА АВАяА ", АяАВА дламак АмАяАКАсАКдцАК А А АядлдлАмАК АядлдцА дцавдла АядлдцАКдлА АяАВА дламак, Ас АяАВА дламак "Ас. АяАядлАмА АВАяА ", АяАВА дламак А А дцдла АмАяАКАсАКдцАК А А АядлдлАмАК, АяАКАя длдцак АК' А А АядлдлАмАК АмАВдлдлАмАК, А А АмА дла АяАмАВАКдлдлА д А АВАя, АяАКАя АмАяАКАсАКдцАК А А АядлдлАмАК АядлдцА дцавдла АядлдцАКдлА АяАВА дламак, длдцак АяА А АядлдлАмАК АмАВдлдлАмАК Ас АяАВА дламак "Ас. АяАядлАмА АВАяА ", АяАВА дламак АмАяАКАсАКдцАК А А АядлдлАмАК АядлдцА дцавдла АядлдцАКдлА АяАВА дламак, длдцак д А А АядлдлАмАК АмАВдлдлАмАК, Ас АяАВА дламак "Ас. АсАКАядцАя", АяАВА дламак

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13 apple Аяд Ам АяАУ д Ам АяАя Ая apple Авfi д д fi 1 АКд АКapple д Ам Ам АУ apple А АяАс А Аяapple Асfi А Аядл А Аяapple дл Ая apple apple АяАУ - 2 AAOS American Academy of Orthopaedic Surgeons ACCP American College of Chest Physicians DVT Deep Vein Thrombosis EMEA European Medicines Agency GCS Graduated Compression Stockings HIT Heparin-Induced Thrombocytopenia INR International Normalized Ratio IPC Intermittent Pneumatic Compression LDUH Low Dose Unfractionated Heparin LIT Limited Incision Techniques LMWH Low Molecular Weight Heparin MIS Minimally Invasive Surgery NICE National Institute for Health and Clinical Excellence PE Pulmonary Embolism SIGN Scottish Intercollegiate Guidelines Network SPC Summary of Product Characteristics UFH Unfractionated Heparin VKA Vitamin K Antagonist VFP Venous Foot Pump 3 VTE Venous ThromboEmbolism 1 АК д Ав fi (fi fi АУ) - fi (fi АУ apple ). 2 А fi fi apple fi apple fi apple д. 3 FIT: Foot Impulse Technology.

14 fi MEPO A Ас АУ fi apple fi appleав АУ...23 АК apple А appleав KАв д fi OАв apple АУ MfiАв apple...37 Ам Ам АУ apple...41 Аяapple...41 АяАУ д Ам...44 M-KappleАУ (K) АКapple...47 АКapple д...48 apple applefi apple...51 fi...53 applefi fi apple...55

15 MEPO B apple OАв OappleАв /Eapple apple O Aapple I apple O Aapple Асfi apple K I apple M T apple O K N M apple X appleав (fi ) apple Aapple X Асfi apple MАУ K K Асfi apple X MEPO Ас EАв АУ apple Аяapple: АК Аяfi apple A Ая apple E АУ Eapplefi apple A apple A Eapplefi

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17 MEPO A Ас АУ fi apple

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19 MEPO A fi 19 1 fi АК apple Ав, apple АвАв apple Авfi applefi, apple fi. АК Ав, fiapple АУ appleау apple- apple, apple Ав Ав Ав, Ав (дл) (длдл) ( 1). дл. АК apple apple apple Ав Авfi apple apple длдл apple apple длдлa, fi АУ apple АУ apple apple, fiapple fi, apple - applefi АУ Ав. АУ apple АвАв apple дл, дл, apple apple a. длдл. АК Авfi apple apple, fi apple (Tissue Factor - TF), apple apple Авfi. АК Авfi apple fi - fiapple. apple Авapple АУ Ав, fi apple Ав apple apple, apple VII, apple apple apple VIIa, apple apple a. appleappleау, apple apple дл, АУ - Ав Авfi.

20 20 MEPO A fi apple apple apple apple длдл, Ав appleау apple - apple VIIa. А Ав Ав apple, apple appleау a, apple apple, apple fiapple apple Авfi Ав. А fi fi АУ, Ав apple - apple. apple - Ав apple fi fi fi. А apple applefi fi apple apple apple, АУ Ав apple (Tissue Factor Pathway Inhibitor -TFPI), apple fi applefi Ав. АК Ав appleау apple - apple VIIa - АУ fi apple Ав apple a. А Ав applefi fi Ав applefi. АК АвАУ АУ appleавау Ав apple АУ - appleapple (thrombomodulin). H Ав apple Ав apple apple, apple C, apple Авfi fi apple apple, apple S, Авapple apple- VIIIa Va. А applefi fi apple apple, длдлдл, apple Авapple apple apple-.

21 MEPO A fi А apple. дц fi apple АвАв- apple applefi apple, applefi apple длдл (Ав Авfi) apple VII ( Авfi) Ав (дл). А АУ apple Ав apple-, АвАУ АУ applefi Ав apple applefi apple.

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23 MEPO A 23 2 appleав АУ АК () АУ applefi Авfi apple Ав Ав Ав Ав. applefi АУ 1 applefi Ав VITAE (Venous Thromboembolism Impact Assessment Group in Europe), fi АУ appleавfi АУ, apple appleapple apple. дц appleау apple АУ fi apple applefi E B fi (д ), apple applefi - () applefi fi Ав. apple, applefi fi fi fi apple АУ , fi appleавapple АУ fi - apple apple AIDS (5860 ), (86831 ), apple (63636 ) Ав (53599 ). дц 93% apple appleау Ав Ав- АУ д. fi 7% apple Ав. дц 63% appleав apple Ав apple apple apple. дц appleав - applefi АУ АКАя 2,3. АУ ENDORSE (Epidemiologic International Day for the

24 24 MEPO A Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting), applefi , 52% АУ fi Ав fi fi applefi (58,5% - 39,5% apple ) apple apple4. Аяapplefi АвАвАУ appleapple fi Ав АУ АУ Ав apple apple. fi АУ АУapple apple fi. fi fi applefi, АУ АУapple apple д apple fi apple apple 5 : дц fi fi Ав 25% - apple д. АК apple appleау. А АУ Ав д АУ. АвАУ apple applefiав д appleapple АУ apple Ав fi. дц fi Ав. А Ав applefi apple дц fi apple. дц fi АКАя fi АУ - Ав applefi fi fi fi applefi- Ав, apple fi apple applefi apple. applefi fi Ав fi fi Ав apple fi appleау applefi apple apple appleау Virchow 19 :, Ав appleapplefi ( 2). А applefi applefi fi apple appleау applefi. fi, - fi fi fi apple fi-, Ав apple Ав,

25 MEPO A 25 дфд д д д дмдмд дмд дмд дхд д д д д дмдмдмдк дад д д дкдмд длд дкдмдк д д д дн дмдод д д д длд длд д дмдк дбд д дк д д д д д дкд д дн д д длд дмд дмд д д дк д д додк д дмдод дн д д д дмд д дмд д д дмд д длд длдлдкд дмд д дмдкдмд дцд д д д днд д д д дод д длд дмд д д длд д д 2. АК Ав Virchow А appleав АвАУ Авfi АУ applefi apple- АУapple appleау fi appleapple apple fi Ав- fi АУ. А fi fi apple appleау apple, fi applefi apple, apple- АУ apple д, Ав АУ 6. Ав, appleав apple apple apple- : 7 АК apple appleау АУ АУ Ав appleау8, fi appleау Ав- appleау fi. Ам Ав apple fi АУ, fi apple apple Ав appleау applefi. apple fi, apple applefi appleав applefi АУ fi Ав appleау apple. АК Ав apple apple applefi АУ - АУ Ав appleау.

26 26 MEPO A дл apple apple apple apple Ав appleау apple- АУ. appleapplefi apple Ав appleау, apple АУ appleау appleappleауав длдлдл Ав. АК apple А appleав А apple apple appleавау apple (АУ appleау fi, apple ) appleapple Ав Ав Ав д. apple, appleapple АвappleАУ д, applefi appleав appleау, 40-60% fi д 10-30% 5,6,9. АК apple. apple д apple Ав- apple appleав apple Авapple apple,. АУ fi apple appleав apple. Ав АУАв applefi - appleав. АУ apple apple apple, 20% fi АУАвfi, АУapple д АУ applefi АвАв10. Ам Ав apple fiapple appleав apple apple 11, apple fi apple apple appleавау apple. appleау АвАУ appleау - 5,6 :. АК apple apple applefi д fi д.. АК apple apple applefi apple

27 MEPO A 27 д apple АУ Ав fi apple applefi fi.. АК applefi д apple. Ав. АК apple appleававау apple. fi Ав appleapple applefi apple, applefi АвappleАУ АУ АУ, АУ Ав Ав apple apple Авfi Happle M M B (АКд ), A B Ам (Аяд Ам) apple АУ Авfi. fi apple appleау АУ appleав fi apple apple АУ appleав АУ- apple Ав5,6. д длд АВдлА АсАядлАя 1. Cohen AT, Agnelli G, Anderson FA, Arcelus JI, Bergqvist D, Brecht JG, Greer IA, Heit JA, Hutchinson JL, Kakkar AK, Mottier D, Oger E, Samama MM, Spannagl M; VTE Impact Assessment Group in Europe (VITAE). Venous thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality. Thromb Haemost. 2007;98: Anderson FA Jr Wheeler HB, Goldberg RJ, Hosmer DW, Patwardahan NA, Jovanovic B, Forcieer A, Dalen JE. A population-based perspective of the hospital incidence and casefatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT Study. Arch Intern Med 1991;151: Silverstein MD, Heit JA, Mohr DN, Petterson TM, O'Fallon WM, Melton LJ 3rd. Trends in the incidence of deep vein thrombosis and pulmonary embolism: A 25-year populationbased study. Arch Intern Med Mar 23;158(6): Cohen AT, Tapson VF, Bergmann JF, Goldhaber SZ, Kakkar AK, Deslandes B, Huang W, Zayaruzny M, Emery L, Anderson FA Jr; ENDORSE Investigators. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet. 2008;371: Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, Ray JG. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126:338S-400S.

28 28 MEPO A 6. Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell CW; American College of Chest Physicians. Prevention of venous thromboembolism: Evidence- Based Clinical Practice Guidelines (8th Edition). Chest Jun;133(6 Suppl):381S- 453S. 7. Lieberman JR, Hsu WK. Prevention of venous thromboembolic disease after total hip and knee arthroplasty. J Bone Joint Surg Am 2005;87: Planееs A, Vochelle N, Fagola M. Total hip replacement and deep vein thrombosis. A venographic and necropsy study. J Bone Joint Surg Br Jan;72(1): Cordell-Smith JA, Williams SC, Harper WM, Gregg PJ. Lower limb arthroplasty complicated by deep venous thrombosis: prevalence and subjective outcome. J Bone Joint Surg Br 2004; 86: Planes A, Vochelle N, Darmon JY, Fagola M, Bellaud M, Huet Y. Risk of deep-venous thrombosis after hospital discharge in patients having undergone total hip replacement: double-blind randomised comparison of enoxaparin versus placebo. Lancet 1996;348: Beksac B, Della Valle AG, Salvati EA. Thromboembolic disease after total hip arthroplasty: who is at risk? Clin Orthop 2006; 453:

29 MEPO A KАв 29 3 KАв дц fi АУ appleapple applefiав АУ apple apple fi. АК apple applefiав fi, Ав Ав applefi fi, - apple apple apple Ав (apple.. АУ apple,,..) 1. appleав appleауapple АУ fi Ав appleав apple apple apple, apple applefi apple- fi Ав. А apple Ав - д 1. fi fi АУ АУ apple Ав, 40 % АУ 3 applefi. д д длд д д дмд дфд д д д д дн дцд днд д дмдк дцдбдхде ддд д д д д д додндмд длд д дгд дкд д д длд д д дхд д длд дндлд д д дцдлд д д дмдк дгд дмдкд д д дад д д дмд дкдмд дад д д дкдмд длд дкдмдк дедмдмд длд д д д д д дкдлд дпд д дк дхдедц дфд д д д д д д д д д дед длд длд д дфд д д д д д д дфдкдмдк д д д дфд дод д д»длд д д д д дед длд длд д (длдо д д дмд дмднд д дкдлдмд д ) дцдлд дмдкдмдк дфд дкдлд д д д д д дедлд д д д днд д д дедлд д д дпдмд д д д д дмд д -дфд дмд дмдмдмд д дфд д дмдлд д дхд д д д д дфд д д дмдлд дхд д д д д дад д длдлд д д д дфдмдп д длдпд 1.

30 30 MEPO A KАв Ая apple applefi Ав 1: АК: АК appleapple 1/10000 fi 40, 1/ fi applefi 1/ : А Ав fi АУ, fi Ав (Body Mass Index - BMI) дц - appleау - : АУ apple, apple,, appleау - Ав fi 10 АУ2. Ая: АК АУ Ав АУ Ав applefi appleав / appleав 2,8. Аяapple: АК appleау appleау appleавау Ав. АК apple- apple Ав 10 АУ2. длfi дцау fi: дц applefi appleapple 5% appleау, fi appleapple apple - appleау 2,9. Ам: АК apple apple (apple, - apple) Ав fi apple АУ2. Ам АВ: АК Ав fi АУ2,10. А АУ apple: А АУ apple (fiapple apple, - apple apple) Ав 3-6 АУ2. apple Ам : fiapple АУ apple C S, - appleау apple C, АУ длдлдл, apple V (Leiden), appleавfi Ав, apple, appleав.. 11,12 АУ Ам - : fiapple Ав apple - АУ, Ав apple, apple apple, appleау -, appleapple Ав, fi Ав 2.

31 MEPO A KАв 31 Амfi fi Ам: АК apple - Ав АУ АУ АУ (fiapple appleapple - apple, apple appleау Авfi) 13. Аяapple K : А Ав 1,5, fi appleapple appleавау apple, apple fi apple АУ apple 2,7. АК АУ Ав appleауapple - appleау, apple applefi Ав14 : АмАв: Ая fi 40, apple apple appleау, appleappleау apple Ав АмАв: Ая appleавapple, apple apple - appleау АУ appleappleау apple Ав Ая 40-60, apple apple АУ - appleау appleappleау apple Ав АмАв: Ая 60, apple apple АУ appleау Ая 40-60, apple apple appleау АУ appleappleау apple Ав АмАв: Ая appleавapple, apple apple appleау АУ appleapple apple Ав Аяapple Аяapple fi Ам дцfi

32 32 MEPO A KАв А АВдлА длдцака дламак длдца АК: appleав, Ав apple fi, АУ - apple. Ая, International Consensus Statement , applefiapple АУ Авfi, apple apple Ав fi 45 apple apple fi АвАУ apple- fi АУ Ав 45 apple. д длд АВдлА АсАядлАя 1. Kearon C. Natural History of Venous Thromboembolism. Circulation 2003;107: Scottish Intercollegiate Guidelines Network: Prophylaxis of Venous Thromboembolism. A National Clinical Guideline. А Ая АУ Heit JA, Silverstein MD, Mohr DN, Petterson TM, Lohse CM, O'Fallon WM, Melton LJ 3rd. The epidemiology of venous thromboembolism in the community. Thromb Haemost 2001; 86: Anderson FA Jr, Wheeler HB, Goldberg RJ, Hosmer DW, Patwardhan NA, Jovanovic B, Forcier A, Dalen JE. A population based perspective of the hospital incidence and case fatality rates of deep vein thrombosis and pulmonary embolism. The Worchester DVT Study. Arch Intern Med 1991; 151: Nordstrm M, Lindblad B, Bergqvist D, Kjellstrm T. A prospective study of the incidence of deep vein thrombosis within a defined urban population. J Intern Med 1992; 232: Kniffin WD Jr, Baron JA, Barrett J, Birkmeyer JD, Anderson FA Jr. The epidemiology of diagnosed pulmonary embolism and deep vein thrombosis in the elderly. Arch Intern Med 1994; 154: Lowe GD, Haverkate F, Thompson SG, Turner RM, Bertina RM, Turpie AG, Mannucci PM. Prediction of deep vein thrombosis after elective hip replacement surgery by preoperative clinical and haemostatic variables: the ECAT DVT Study. European Concerted Action on Thrombosis. Thromb Haemost 1999; 81: Rodgers A, Walker N, Schug S, McKee A, Kehlet H, van Zundert A, Sage D, Futter M, Saville G, Clark T, MacMahon S. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomized trials. BMJ ;321(7275):1493.

33 MEPO A KАв Prandoni P, Lensing AW, Cogo A, Cuppini S, Villalta S, Carta M, Cattelan AM, Polistena P, Bernardi E, Prins MH. The long term clinical course of acute deep vein thrombosis. Ann Intern Med 1996; 125: Chulinal SD and Bates SM. Venous thromboembolism in pregnancy: diagnosis, management and prevention. Thromb Haemost 2009;101: Lane DA, Mannucci PM, Bauer KA, Bertina RM, Bochkov NP, Boulyjenkov V, Chandy M, Dahlbck B, Ginter EK, Miletich JP, Rosendaal FR, Seligsohn U. Inherited thrombophilia: Part 2. Thromb Haemost 1996;76: Greaves M and Baglin T. Laboratory testing for heritable thrombophilia: impact on clinical management of thrombotic disease (annotation). Br J Haematol 2000; 109: Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell CW; American College of Chest Physicians. Prevention of Venous Thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008;133: Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, Ray JG. Prevention of Venous Thromboembolism. The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126:338S-400S. 15. Prevention of venous thromboembolism. International Consensus Statement (guidelines according to scientific evidence). Int Angiol Mar;16(1):3-38.

34

35 MEPO A д fi OАв apple 35 4 д fi OАв apple Авfi appleapple АУАв Ав apple - apple apple fi Ав 1-5. А fiapple fi apple : 1. appleappleав (level of evidence) apple apple АУ Ав, 2. fiapple АУ Ав/fi (benefit-risk/cost balance) apple apple apple - 3. Авfi АУ apple-. appleау apple АУ applefi fiapple fi apple appleappleав, apple fi АУapple fi apple. apple appleау apple - fi apple appleав apple АУ-, : 1. длак дцамакдлак,,, 2. дламаяа А длакдцдламак дцамакдлак 3. АяАяАК дцамакдлак.

36 36 MEPO A д fi OАв apple АК appleау АУ : длак дцамакдлак: appleау applefi appleappleау, appleау fi АУ (prospective, randomised, controlled trials) appleау, АвАУ - (meta-analyses) АУ apple (systematic reviews). дламаяа А длакдцдламак дцамакдлак: appleappleау, appleау fi АУ fi appleау / apple Ав apple. АяАяАК дцамакдлак: АвАУ АУ apple- (observational studies), appleау АУ - Ав apple, АУ apple applefi АУ. АК apple fi applefi АУ II III АУ- АУ applefi Ав. д длд АВдлА АсАядлАя 1. Guyatt GH, Cook DJ, Jaeschke R, Pauker SG and Schе nemann HJ. Grades of Recommendations for Antithrombotic Agents: American College of Chest Physicians Evidence- Based Clinical Practice Guidelines (8th Edition). Chest 2008;133; Prevention and treatment of venous thromboembolism International Consensus Stetement (Guidelines according to scientific evidence). Int Angiol 2006;25: National Institute for Health and Clinical Excellence. Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing surgery. NICE clinical guideline No. 46: Аяapple Guidance/CG46 ( АУ 2008). 4. Scottish Intercollegiate Guidelines Network: Prophylaxis of Venous Thromboembolism. A National Clinical Guideline. А ( АУ 2008). 5. American Academy of Orthopaedic Surgeons Clinical Guideline on Prevention of Pulmonary Embolism in Patients Undergoing Total Hip or Knee Arthroplasty. ( 2009).

37 MEPO A АУ MfiАв apple 37 5 АУ MfiАв apple fi applefi АУ fiав apple, apple АУ apple : 1. АвАУ apple (Ам) (Graduated Compression Stockings - GCS) 2. АУ Авapple apple АУ (Ая) (Intermittent Pneumatic Compression - IPC) 3. apple appleавfi (АяАя) (Venous Foot Pumps - VFP) А АУАв АУ appleapple apple. Ав АУ applefi- АУАв appleapple apple Ав fiав apple1. АК apple applefi АУ apple appleау apple applefi - fiав 1. А АУ АУ apple appleау АУ apple- 1,3-6. apple, fi, appleау АУ, apple АУ fiав Авfi - АУ appleав fi apple 1, , Ав apple АУ АУ Авfi applefi Ав АУ apple1.

38 38 MEPO A АУ MfiАв apple appleapple, apple apple АУ apple, appleауapple Ав apple АУ, - fi Ав. apple-, АУ Ав appleауapple appleав apple 1,11. дц АУ applefi АУ apple Ав fi. Ав NICE 11, fi fiapple АвАУ- apple applefi АУ, 24 fi 30 apple АУ ( Ав apple Ав). appleapple apple Ав Ав appleауapple apple fi. А Ам (GCS) appleауapple appleау apple 18 mm Hg apple- appleав, 14 mm Hg fi 8 mm Hg fi. дц АУ apple apple apple Авfi Ам (GCS). А Ав Ам (GCS) : apple fi,, apple apple, - Ав, applefi Ав, Ав fi Ав- apple, appleау АвАУ apple, Ав Ав apple doppler (doppler pressure index) fi applefi 0.8. Ам Ам АУ дц apple АУ appleау - apple fi apple. apple - apple Ав Ав applefi applefi applefi appleappleау (appleappleау fi appleау, applefi АУ,, ) 1,12,13. АК АУ appleappleау АУ, Ав apple 1,13,14.

39 MEPO A АУ MfiАв apple 39 АК АУ Ав АУ apple, Ав apple appleау АУ - АУ apple. appleappleау, Ав АУ Ав apple appleау fiав apple1. apple АУ apple АУ fi applefi applefi, Ав Авapple applefi, apple- fi1,12. дцау, АУ Ав applefi д, АУ 12,15. apple, Ав Ав fi applefi АвАУ appleapple appleау д, apple fi Ав Ав- fiав apple1,12,15. д длд АВдлА АсАядлАя 1. Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell CW; American College of Chest Physicians. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008;133: Freedman KB, Brookenthal KR, Fitzgerald RH Jr, Williams S, Lonner JH. A meta-analysis of thromboembolic prophylaxis following elective total hip arthroplasty. J Bone Joint Surg Am 2000;82: Hull RD, Raskob GE, Gent M, McLoughlin D, Julian D, Smith FC, Dale NI, Reed-Davis R, Lofthouse RN, Anderson C. Effectiveness of intermittent pneumatic leg compression for preventing deep vein thrombosis after total hip replacement. JAMA 1990;263: Francis CW, Pellegrini VD Jr, Marder VJ, Totterman S, Harris CM, Gabriel KR, Azodo MV, Leibert KM. Comparison of warfarin and external pneumatic compression in prevention of venous thrombosis after total hip replacement. JAMA 1992; 267: Blanchard J, Meuwly JY, Leyvraz PF, Miron MJ, Bounameaux H, Hoffmeyer P, Didier D, Schneider PA. Prevention of deep-vein thrombosis after total knee replacement: randomised comparison between a low-molecular-weight heparin (nadroparin) and mechanical prophylaxis with a foot-pump system. J Bone Joint Surg Br 1999; 81: Schulz SL, Stechemesser B, Seeberger U, Meyer D, Kesselring C. Graduated compression stockings for the prevention of venous thromboembolism in surgical patients in the age of low molecular weight heparins. J Thromb Haemost 2005; 3:

40 40 MEPO A АУ MfiАв apple 7. Silbersack Y, Taute BM, Hein W, Podhaisky H. Prevention of deep-vein thrombosis after total hip and knee replacement: low-molecular-weight heparin in combination with intermittent pneumatic compression. J Bone Joint Surg Br 2004;86: Roderick P, Ferris G, Wilson K, Halls H, Jackson D, Collins R, Baigent C. Towards evidence-based guidelines for the prevention of venous thromboembolism: systematic reviews of mechanical methods, oral anticoagulation, dextran and regional anaesthesia as thromboprophylaxis. Health Technol Assess 2005; 9: Urbankova J, Quiroz R, Kucher N, Goldhaber SZ. Intermittent pneumatic compression and deep vein thrombosis prevention: a meta-analysis in postoperative patients. Thromb Haemost 2005; 94: Kalodiki EP, Hoppensteadt DA, Nicolaides AN, Fareed J, Gill K, Regan F, al-kutoubi A, Cunningham DA, Birch R, Harris N, Hunt D, Johnson J, Marx C. Deep venous thrombosis prophylaxis with low molecular weight heparin and elastic compression in patients having total hip replacement: a randomised controlled trial. Int Angiol 1996;15: National Institute for Health and Clinical Excellence. Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing surgery. NICE clinical guideline No. 46: Аяapple Guidance/CG46 ( АУ 2008). 12. W. Geerts, Oliva V, Massicotte P. Inferior Vena Cava Filters. Clinical Guides by the А The Thrombosis Interest Group of CanadaА. Available at: ( I 2009). 13. Karmy-Jones R, Jurkovich GJ, Velmahos GC, Burdick T, Spaniolas K, Todd SR, McNally M, Jacoby RC, Link D, Janczyk RJ, Ivascu FA, McCann M, Obeid F, Hoff WS, McQuay N Jr, Tieu BH, Schreiber MA, Nirula R, Brasel K, Dunn JA, Gambrell D, Huckfeldt R, Harper J, Schaffer KB, Tominaga GT, Vinces FY, Sperling D, Hoyt D, Coimbra R, Rosengart MR, Forsythe R, Cothren C, Moore EE, Haut ER, Hayanga AJ, Hird L, White C, Grossman J, Nagy K, Livaudais W, Wood R, Zengerink I, Kortbeek JB. Practice patterns and outcomes of retrievable vena cava filters in trauma patients: an AAST multicenter study. J Trauma 2007;62: Antevil JL, Sise MJ, Sack DI, Sasadeusz KJ, Swanson SM, Rivera L, Lome BR, Weingarten KE, Kaminski SS. Retrievable vena cava filters for preventing pulmonary embolism in trauma patients: a cautionary tale. J Trauma 2006;60: PREPIC Study Group. Eight-year follow-up of patients with permanent vena cava filters in the prevention of pulmonary embolism: the PREPIC (Prevention du Risque dа» Embolie Pulmonaire par Interruption Cave) randomized study. Circulation, 2005;112:

41 MEPO A apple 41 6 apple АядлдлАК дц applefi apple fi АвАУ Ав АУ Авfi fi fi. АУ applefi, apple Ав Ав, АУ apple. А fi Ав Ав - COX-1 COX-2, apple appleав-. АК apple apple applefi fi Авfi 40-50% 1. АК apple Ав Ав COX-1, applefi Ав fi Ав apple. А АУ fi apple 8-10 АУ 10-12% apple 2,3. А fi appleау fi apple applefi appleapplefi (Авappleapple,, apple Ав, appleapplefi АУ, ) applefi АУ Ав АУ. appleауapple applefi АУ G6PD, applefi 16, Авfi apple Ав Авfi Reye. АК apple А» applefi fi4, fi apple fi, АУ apple АУ

42 42 MEPO A apple applefi 5. fi, apple applefi applefi - 6. А АУ apple apple apple- АУ Ав apple7,8, appleав- fi apple Ав appleау apple apple 5,9-12. д длд АВдлА АсАядлАя 1. Pedersen A, Fitzgerald G. Dose-related kinetics of aspirin: presystemic acetylation of platelet cyclo-oxygenase. N Engl J Med 1984; 311: Cerskus A, Ali M, Davies B, McDonald JW. Possible significance of small numbers of functional platelets in a population of aspirin-treated platelets in vitro and in vivo. Thromb Res 1980; 18: OА»Brien J. Effects of salicylates on human platelets. Lancet ;1(7546): Patrono C, Coller B, Fitzgerald GA, Hirsh J, Roth G. Platelet-active drugs: the relationships among dose, effectiveness, and side effects: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126(Suppl):234S-264S. 5. Pulmonary Embolism Prevention (PEP) Trial Collaborative Group. Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) Trial. Lancet 2000; 355: Analg 2001; 93: Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell CW; American College of Chest Physicians. Prevention of Venous Thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008;133: Antiplatelet TrialistsА» Collaboration. Collaborative overview of randomised trials of antiplatelet therapy: III. Reduction in venous thrombosis and pulmonary embolism by antiplatelet prophylaxis among surgical and medical patients. BMJ 1994;308: Cohen AT, Skinner JA, Kakkar VV. Antiplatelet treatment for thromboprophylaxis: a step forward or backwards? BMJ 1994; 309: McKenna R, Galante J, Bachmann F, Wallace DL, Kaushal PS, Meredith P. Prevention of venous thromboembolism after total knee replacement by high-dose aspirin or intermittent calf and thigh compression. BMJ 1980; 280: Powers PJ, Gent M, Jay RM, Julian DH, Turpie AG, Levine M, Hirsh J. A randomized trial of less intense postoperative warfarin or aspirin therapy in the prevention of venous thromboembolism after surgery for fractured hip. Arch Intern Med 1989; 149: