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 [email protected], [email protected] 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

4

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 appleapple. fi Ав. АУ fi АУ appleapple 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 appleapple fiав (evidence-based medicine) apple apple fi apple. Аяapple - fi fi apple fi apple. B. fiав apple appleapple [email protected]

8

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

10

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

12

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

16

17 MEPO A Ас АУ fi apple

18

19 MEPO A fi 19 1 fi АК apple Ав, apple АвАв apple Авfi applefi, apple fi. АК Ав, fiapple АУ appleау appleapple, 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.

22

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 applefi 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 appleapple 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 applefi 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:

43 MEPO A apple Westrich GH, Sculco TP. Prophylaxis against deep venous thrombosis after total knee arthroplasty: pneumatic planter compression and aspirin compared with aspirin alone. J Bone Joint Surg Am 1996; 78: Gent M, Hirsh J, Ginsberg JS, Powers PJ, Levine MN, Geerts WH, Jay RM, Leclerc J, Neemeh JA, Turpie AG. Low-molecular-weight heparinoid orgaran is more effective than aspirin in the prevention of venous thromboembolism after surgery for hip fracture. Circulation 1996; 93:80-84.

44 44 MEPO A apple АядцАяАсдлдц дцак д длдцаядлак Ам 1, 2 А AАУ B Ам (Аяд Ам) apple Ав apple appleав Ам АмАК 2. Аяfi appleау apple apple Ам applefi apple АУ appleау Ав, applefi Ам apple apple (apple, apple VII, IX X). Ав apple Аяд Ам fi (acenocoumarol Sintrom, NOVARTIS). fi, Аяд Ам Ав (warfarin Panwarfin, ABBOTT). дц Ав АУ Авfi fi - (8-11 fi АУ 2,5 - ). А Аяд Ам applefi fi apple АУ Авfi apple applefi fi. АК applefi - АвАУ apple applefi. Ам АУ Авfi apple Ав АвАУ applefi, - fi Авfi applefi fi АУ fi apple (PT), apple apple- appleав. АК appleау fiapple apple apple apple apple Аяд Ам АУ АВfi (International Normalized Ratio INR). Ам apple А appleав -, apple INR 2 3, fi 2,5. Ам apple fi fi, applefi АУ apple INR appleappleав 2, fi apple apple applefi. АК apple Ав Аяд Ам apple apple applefi Ав,, apple apple fi.

45 MEPO A apple 45 АУ apple Ав АУ applefi Ам apple apple applefi. Ая Авfi, АУ apple applefi Ав АУ apple АУ. appleapple Ав, appleауapple apple. АУ Авfi 5 mg apple INR apple 2 appleapple АУ АУ appleау АУ. АК apple АКд Авfiapple fi INR fi apple Ав АУ. АУ INR АУ apple АУ 2 АУ 3. Ая, apple Ав АУ АУ АвАв applefi АУ Ав АвАв АУ fi fi, fi apple INR. INR appleау fi, АУ apple fi - Ав АУ АвАв. apple appleapple Авfi, fi АУ INR apple АУ apple АУ apple applefi. АК apple АУ appleау Аяд Ам. АК fi - appleав applefi fi 2% АУ, fi apple Ав apple, АУ 4-5% АУ, apple. - appleapple Аяд Ам АУ АвАУ (warfarin necrosis) apple АУ fi Ав Ав appleав. дцapple fiав АУ applefi АУ, fi appleappleав apple C S АУ appleappleав applefi apple fi. АК apple Ав apple Ам, appleapple, apple.

46 46 MEPO A apple д длд АВдлА АсАядлАя 1. Hirsh J, Dalen JE, Anderson DR, Poller L, Bussey H, Ansell J, Deykin D and Brandt JT. Oral Anticoagulants: Mechanism of Action, Clinical Effectiveness, and Optimal Therapeutic Range. Chest 1998;114:445S-469S. 2. длама дцаяаса АВА АсдлА 2007: Аяapple applefi fi, ( Ая 2009).

47 MEPO A apple 47 АК-АмАВАяАядцА А длакак (АмАВАядлАмАК) АКАядлАК 1, 2 АК apple АУ АУ appleав Авo- Ав apple Ав. Ая А appleауа apple (UFH, unfractionated heparin) appleapplefi Ав applefi 5000 АУ apple applefi Dalton (АУ fi Dalton). АК apple appleавау АУ Ав appleав appleapple apple applefi apple. - АвАУ apple apple apple, apple applefiapple АвАУ АУ Авfi apple apple- Ав -АУ appleау, fiapple applefi (fi appleав fi fi) apple applefi apple (HIT) ( fi appleау apple apple). АК apple Ав apple applefi fi appleауapple apple (АвАУ, bolus АУ, appleавfi). АК apple Ав apple apple- АУ apple. д длд АВдлА АсАядлАя 1. Hirsh J, Bauer KA, Donati MB, Gould M, Samama MM and Weitz JI. Parenteral Anticoagulants: 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:

48 48 MEPO A apple АКАядл длама А длаяама д АяА 1, 2 А Happle M M B (АКд ) (Low Molecular Weight Heparin - LMWH) appleау applefi -appleау apple Авapple. АУ, 2000 АУ 9000 Dalton АУ fi 4000 АУ 5000 Dalton. дц Ав АКд apple Ав fiapple Ав- apple АвАУ, apple fi, АУ appleау Авfi, -. АК Авapple apple appleау apple АУ fi appleавfi apple. АК fi- АвАУ АКд apple. АУ appleау Авfi - apple appleау Авfi apple. applefi-ау АКд applefi appleау apple fi apple. А fi АУ (appleappleав -) Ав apple. АвАУ fi apple. apple Ав АКд. АК apple - АвАУ apple VII АУ apple - appleapple 3. А АКд АУ Ав apple applefi fi, Ав fi apple applefi apple. apple, Ав АКд АУ apple appleау АвАУ АУ Авfi, АУ fi applefi apple АУ fi Ав - appleapple ( fi HIT АУ fi- ). А АКд apple Ав АУ apple- Авfi АУ apple apple. АК АУ, fi apple apple applefi apple apple длдл, fiapple apple АУ. А АКд apple Ав : Dalteparin sodium

49 MEPO A apple 49 (Fragmin, Pfizer), Enoxaparin (Clexane, Sanofi Aventis), Nadroparin (Fraxiparine, Glaxo Smith Kline), Tinzaparin sodium (Innohep, Leo) Bemiparin sodium (Ivor, д длая) ( 2). дц fi АКд apple- АУ fi, fiapple applefi apple Аяapple (дл 2009), applefi 2,5 АУ 3 е. apple АУ АКд fi applefi. Ая д д дгдед д дидгдцдгда д»д д»дфд»дбдедфда д дхдддгдад да (дндлд д длд д ) д»дгд»дгдад деда д дфдцд дад дгдад д»д Dalteparin (Fragmin ) Enoxaparin (Clexane ) д д длд дк д д д дкд длд дод д длд дндлд д д дн дмд д длд дн длдлд дод д длд дндлд д д дн: 5000 IU дмд д длд дн д д дм дмд дод д длд дндлд д д : 5000 IU 2 длд длдлд - д д д 4 8 длд д д дмд д дод д длдкдмд д : 2500 IU 4-8 длд д д дмд д дод д длдкдмд д : 2500 IU длд длдлд д д дод д длдкдмд д 40 mg 12 А 3 длд д д дмд д дод д длдкдмд д 30 mg дадл дмдкд длдлдмдк д д дмд д дод д длдкдмд д дкд длд 5000 IU длд д дкд д длдкдмдп 5000 IU длд д дкд д длдкдмдп 5000 IU длд д дкд д длдкдмдп 40 mg длд д дкд д длдкдмдп 30 mg д д дкд д длдкдмдп Nadroparin (Fraxiparine ) 12 длд длдлд - д д д 12 длд д д дмд д дод д длдкдмд д : (<50 kg: 0,2 ml, kg: 0,3 ml, >70kg: 0,4ml) < 50 kg kg > 70 kg дгдодлд дмдкд 3дК дкд длд 0,2 ml 0,3 ml 0,4 ml дгд дм дмдкд 3дК дкд длд 0,3 ml 0,4 ml 0,6 ml Tinzaparin (Innohep ) Bemiparin (Ivor ) 2-12 длд длдлд д д дод д длдкдмд д 4500 IU 2-12 длд длдлд д д дод д длдкдмд д 50 IU/kg 2 длд длдлд д д дод д длдкдмд д 3500 IU 6 длд д д дмд д дод д длдкдмд д 3500 IU 4500 IU 50 IU/kg 3500 IU 3500 IU 2. Ав АКд apple

50 50 MEPO A apple fi Ав apple fi АКд. apple apple Ав, appleауapple apple АУАв Ав apple apple. appleapple fiapple Ав apple applefi apple АвАвАУ4,5. д длд АВдлА АсАядлАя 1. Hirsh J, Bauer KA, Donati MB, Gould M, Samama MM and Weitz JI. Parenteral Anticoagulants: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008;133; Prevention and treatment of venous thromboembolism International Consensus Statement (Guidelines according to scientific evidence). Int Angiol 2006;25: Crowther MA and Warkentin TE. Bleeding risk and the management of bleeding complications in patients undergoing anticoagulant therapy: focus on new anticoagulant agents. Blood : Fareed J, Jeske W, Fareed D, Clark M, Wahi R, Adiguzel C, Hoppensteadt D. Are all low molecular weight heparins equivalent in the management of venous thromboembolism? Clin Appl Thromb Hemost Oct;14(4): Adiguzel C, Jeske WP, Hoppensteadt D, Walenga JM, Bansal V, Fareed J. Structural and Functional Characterization of Low-molecular-weight Heparins: Impact on the Development of Guidelines for Generic Products. Clin Appl Thromb Hemost Apr;15(2):

51 MEPO A apple 51 А д А АмдцА длая АяА АКАядлАК apple Ав АУ apple applefi apple (heparin induced thrombocytopenia, HIT): apple-дл II. АК apple apple дл apple ( apple). АК apple АУ АУ АУ. А apple АУ. АУ Ав Ав Ав Авapple apple1. АК apple applefi apple apple II (HIT-II) appleауapple АУ applefi АУ appleapple2. АК Авfi- applefi apple apple apple ( - АКд fi HIT АУ fi АУ apple), Авfi Авfi 3. АК Ав apple apple apple apple 4. appleappleау fi, Ав АУ appleав, apple apple apple 50% АУ - АУ 5. Авapple apple, fi apple- appleау appleappleав 6 appleау АУ apple АУ. apple fi apple 1-5% apple apple 7. А fi appleappleау Авfi, apple applefi АУ 30% applefi АУ АУ. ( apple АУ ) fi, apple appleapple 8. fi АУ fi, АУ Ав. fi Ав fi fi apple-. АК fi applefi 15 АУ 30% 3,6. apple apple длдл appleapple fi - Ав fi. А fi apple apple II apple apple applefi, apple Ав (fi

52 52 MEPO A apple fi). дц fi АУ apple apple apple apple 4 (PF4) apple АУ fiав. А АУ Ав Ая Ам fi (ACCP 2008) apple АУ 9: appleав apple apple АКд АУ apple Ав АУ АУ, applefi 4 АУ 14 АУ АУ. АУ appleapple apple 50% fi АУ Авapple apple АУ apple fi applefiав, Ав - fi Ав, fi АУ Авapple apple appleapple applefi appleау apple apple II, Авapple apple, -appleавау applefi ( apple Ав) applefi АУ Ав, fi Ав apple АУАв fi. АК apple apple apple II appleауapple fi. д длд АВдлА АсАядлАя 1. Lilikakis AK, Papapolychroniou T, Macheras G, Michelinakis E. Thrombocytopenia and Intra-cerebral Complications Associated with Low-Molecular-Weight Heparin Treatment in Patients Undergoing Total Hip Replacement. A Report of Two Cases. J Bone Joint Surg Am 2006; 88: Warkentin TE, Kelton JG. Delayed-onset heparin-induced thrombocytopenia and thrombosis. Ann Intern Med. 2001;135: Boshkov LK, Warkentin TE, Hayward CP, Andrew M, Kelton JG. Heparin-induced thrombocytopenia and thrombosis: clinical and laboratory studies. Br J Haematol. 1993;84:

53 MEPO A apple Gerhard-Herman M. Heparin-induced thrombocytopenia. Curr Treat Options Cardiovasc Med. 2001;3: Warkentin TE, Roberts RS, Hirsh J, Kelton JG. An improved definition of immune heparininduced thrombocytopenia in postoperative orthopedic patients. Arch Intern Med. 2003;163: Chong BH. Heparin-induced thrombocytopenia. Br J Haematol. 1995;89: Warkentin TE, Kelton JG. Heparin-induced thrombocytopenia. Prog Hemost Thromb. 1991;10: Warkentin TE, Chong BH, Greinacher A. Heparin-induced thrombocytopenia: towards consensus. Thromb Haemost. 1998;79: Warkentin TE, Greinacher A, Koster A, and Lincoff AM. Treatment and Prevention of Heparin-Induced Thrombocytopenia American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). CHEST 2008; 133:340S-380S.

54 54 MEPO A apple YNETIKO ENTAAKXAPITH Fondaparinux (Arixtra - GlaxoSmithKline) 1, 2 дц fondaparinux АУ fi apple fi 1728 Dalton, apple apple, fi -. fi АУ Авfi, АУ АУ appleау apple АвАУ apple. АК - Ав- fi apple АУ fi applefi АКд. АВfi Ав fi apple appleау HIT - applefi. Авfi appleавfi, fi applefi АКд (17 АУ 4 ) АвАв apple appleавfi Авfi, - fi АУ apple. АяАв apple ( <30mL/min) appleapple Авfi АУ apple ( <50mL/min). дц fondaparinux Ав АУ Ав appleapple, apple АвАУ apple VIIa. АК Авfi Fondaparinux apple appleав 2,5mg apple appleавfi АУ АУ АУ ('fi АУ fi). дц fi 6,91. д длд АВдлА АсАядлАя 1. Hirsh J, Bauer KA, Donati MB, Gould M, Samama MM and Weitz JI. Parenteral Anticoagulants: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008;133; Prevention and treatment of venous thromboembolism International Consensus Statement (Guidelines according to scientific evidence). Int Angiol 2006;25:

55 MEPO A apple 55 дцая АяА дца дца АядцА АядцдлАКАмдцдлАмАя Dabigatran Etexilate (Pradaxa - Boehringer Ingelheim International GmbH) 1, 2 Ая Ав apple apple Ав АУ. Аяapple apple apple apple applefi fi Авfi 5-6%. АК applefi apple fi apple appleау applefi apple (applefi). fi, АУ АУ, Ав apple - applefi 3. АяАУ applefi АУapple applefi fi, Dabigatran, АУ АУ. АК АУ АУ Dabigatran apple apple Ав. А fi applefi дц 80% - apple applefi. Ам АУapple Ав apple. дц 2008 Ав applefi E.Me.A. (European Medicines Agency) Ав applefi дл АК Ав fi apple apple apple appleау apple fi. fi (Summary of Product Characteristics SPC) Авfi 3. H Ав АУ apple 10 АУ apple fi. дц fi apple Pradaxa applefi 1 АУ 4,5 е. дц fi fi АУ apple - fi 60 caps. дц fi applefi Авfi apple Ав fi 75 mg/caps fi 110 mg/caps.

56 56 MEPO A apple Dabigatran Etexilate (Pradaxa ) дбд д д д д д дмд д д д д д дмдод д д д дгдед д дидгдцдгд» д»д д»дфд»дбдедфд» д дхдддгда (д дл дмд дн дмдмд д дмд ) д дкд дкд длд дмдк дод д длд дндлд д д д длд д д дмдк 110 mg (1-4 длд д д дмд д дод д длдкдмд д ) дадл дмдкд 1дК д д дмд д дод д длдкдмд д дкд длд д д д д д дм 220 mg (длд д дкд д длдкдмдп) дцд д д д д д дмд д д д д д дмдод д ддд д д д >75 д дмд дгдмдлд д д д дндлд д д д д длдлд д д д (CrCl: ml/min) дфдодк д д д д д д длд дк (Angoron) 75 mg (1-4 длд д д дмд д дод д длдкдмд д ) 150 mg (длд д дкд д длдкдмдп) 3. fi apple appleау fi Dabigatran Etexilate (applefi fi). Rivaroxaban (Xarelto Bayer HealthCare AG) 1, 4 Аяapple apple Авfi apple applefiapple applefi fi АУ apple Xa. АК Авfi applefi fi 80% fi appleapple 9. Аяapple applefi - fi. дц appleау 2008 Ав applefi E.Me.A. (European Medicines Agency), Ав applefi Ав Xarelto fi appleapple apple apple fi. fi (SPC), - Авfi 10 mg rivaroxaban fi applefi fi apple -. АК Авfi appleауapple 6-10 appleау. Ав appleау АвАв apple-

57 MEPO A apple 57 Ав АвАв apple fi. apple apple Ав apple АУ АУapple ( ml/min) appleауapple apple Ав apple apple ( ml/min). АК Xarelto Ав - < 15 ml/min. дц fi apple Xarelto 4,6 е. дц fi fi АУ apple fi Ав. д длд АВдлА АсАядлАя 1. Weitz JI, Hirsh J, Samama MM; New antithrombotic drugs: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest Jun;133(6 Suppl):234S-256S. 2. Pradaxa - Summary of Product Characteristics (SPC): ( 2009). 3. Stangier J, Stahle H, Rathgen K and Fuhr R; Pharmacokinetics and Pharmacodynamics of the Direct Oral Thrombin Inhibitor Dabigatran in Healthy Elderly Subjects. Clin Pharmacokinet 2008; 47(1): Xarelto - Summary of Product Characteristics (SPC): ( 2009).

58

59 MEPO B apple OАв OappleАв /Eapple

60

61 MEPO B apple O Aapple I 61 7 apple O Aapple I А apple apple apple fi (А Аядл, А АяАс) apple АУ Ав apple д applefi appleapple 50% 1, apple д apple. дц applefi apple apple applefi 2% АУ 5% 2. дц applefi - fi apple appleapple АУ 300 АУ appleау (0,3%), appleapple apple apple apple apple3,4. дц applefi fi д fi apple apple А Аядл apple apple А АяАс. дц А АяАс fiapple apple fi д. АК - А Аядл appleapple Ав, appleау АУ fi fi Ав. АК applefi appleау АУАв applefi Ав Ав apple fi apple. Ам Ав apple fiapple apple apple apple, apple apple fi apple apple А Аядл 5.

62 62 MEPO B apple O Aapple I Ая. АяАяАмдцдлАмH А д А А АВАяАК А АКд АУ АУ - apple А Аядл. АУ appleapple 6. apple placebo apple apple А Аядл, apple fi- д apple apple 12% 4% apple placebo 42% 20% 7. АяАУ appleау fi АУ АУ АКд Аяд Ам applefi apple- АУ applefi д appleapple. appleау applefi appleау АУ АУ, apple д fi fi 13,7% 3,4% apple АКд 20,7% 4,8% apple Аяд Ам дц apple appleав АУ АУ 5,3% 3,3%. - appleау 13 АУ Ав fi АКд apple appleау appleау Аяд Ам fi applefi appleавав- АУ д fi д. apple Ав- fi Ав 14. АК (Аяд Ам) АУ appleау АУ АКд АУ apple applefi д. дц appleapplefi fi АУ АУ Ав- apple appleауapple fi appleав. А Ав fi АУ, apple INR, fi applefi apple Ав apple apple apple. apple apple д fi Ая, apple apple АКд apple apple apple.

63 MEPO B apple O Aapple I 63 appleау fi АУ АУ appleав fi fondaparinux (Arixtra ) applefi д А Аядл АУ Ав appleapple apple apple АУ. apple АУ (EPHESUS) apple fondaparinux АУ 4-8 apple 40 mg АУ 12 apple. дц apple fi д 4% 1% fondaparinux 9% 2% apple -, АвАУ АУ. АУ д Ая (PENTATHLON) 16, Ав applefi fondaparinux apple Авfi 30 mg x 2 АУ , АУ АвАУ Ав Ав. АК appleау apple Авfi ( apple, 5000 IU 8 12 ) АУ appleав - 20 appleау - fi 17 apple д applefi 46,8% 23,3% apple apple А Аядл Ав appleав fi АКд apple apple- АУ д 18 ( applefi 21,2% 13,8% applefi 4,1% 1,7% ) appleау apple Авfi apple appleау. applefi - 19 АУАв fi apple, appleapple д apple applefi. АУ (PEP TRIAL) 20 fi appleавав fi applefi apple АУ fiав, Ав АУ Ав. АК apple- АвАУ, apple, appleау fi- applefi21. АК apple АУАв fi АУАв apple А Аядл ACCP 22 Ав applefi International Angiology 23 NICE 24. Ая SIGN 25, applefi American Academy of Orthopaedic Surgeons (AAOS) 26, apple apple applefi-

64 64 MEPO B apple O Aapple I. А apple АУ apple fi А Аядл А АяАс, applefi fi д. дцappleау fi АУ АУ Ав fi Ав apple appleapplefi АКд 27 apple 28, fi Ав apple apple fi apple, apple apple (apple applefi АКapple apple длдл, HIT-II). Ас fi fi Ав appleapplefi apple - Ав. fi fi Ав АУ, applefi fi, АУ apple А Аядл А АяАс: Dabigatran (Pradaxa ) Rivaroxaban (Xarelto ). дц Dabigatran, Авfi 220 mg ( 150 mg Ав Ав АУapple 3), Авapple- АУ (R-NOVATE) А Аядл, apple Авfi 40 mg ( apple АУ) дц apple applefi fi applefi apple appleававау applefi. дц Dabigatran АУ (non-inferior) Ав Ав. apple АУ АвАУ fi. дц Rivaroxaban, Авfi 10 mg, apple Авfi 40 mg Авapple- АУ (RECORD 1) А Аядл. дц apple applefi fi applefi applefi. T Rivaroxaban АУ apple- АУ (superior), Ав apple АУ АвАУ fi applefiав. д. АКАядлАм А А дл А д А А АВАяАК А Ав АУ АУАв apple АУ А Аядл АУ fi Ав д. АК applefi fi appleавау fiав, Ав

65 MEPO B apple O Aapple I 65 applefi fi д. А Ая (IPC) apple- АУ д А Аядл (fi fi applefi fi fi) 31. АУ АУ,, - fi applefi д applefi 43,6% Ав АУ ( apple) 21% А АяАя (VFP) АУ Ав fi fi д АУ АУ35-37 fi АУ apple, appleау appleapple apple Ав. А Авfi Ам (GCS) АяАя (VFP) АУ Ав applefi fi д А Аядл А АяАс. АУ apple- Ам (GCS) АвАУ АяАя (VFP) АУ apple fi д 32% 5% 35. apple apple fi Ам (GCS) appleау А Аядл apple Ав apple apple Ав. АК fi fiав apple - apple А Аядл., fi АУ fi АвАУ, Ав apple Ав- АУ АУ apple АУ Ав apple. Ас. длаяамдлая А д А А АВАяАК apple fi apple apple Ав АУ- АвАв applefi А Аядл АУ Ав Ав АУ 38,39. appleав АУ apple apple- А Аядл АУ fi apple АУ, 76% appleав Ав АУАв applefi 40. fiapple АУ appleау, fi placebo, 41, АУАв apple fi, fi fi д appleау АКд (27-35 АУ), apple apple. дцау - АУ apple42-45 apple apple А Аядл А АяАс, -

66 66 MEPO B apple O Aapple I fi АУАв applefi apple ( Ав- : АУ), fi apple, fi. АК Ав apple appleау apple Авfi 60%, Ав 46. дц АУ apple Аяд Ам АУАв applefi, АУ apple 47. apple АУ appleау Fondaparinux А Аядл. АК appleау Ав - applefi АУ. дц Dabigatran Rivaroxaban АУ appleау Ав (АУ R-NOVATE АУ АУ RECORD АУ ) appleау АУ - appleapple.

67 MEPO B apple O Aapple I 67. дцаядл I. apple fi apple appleapple applefi apple fiав: АКд ( Ав АУ apple apple applefi -, АУapple ) [длак дцамакдлак]. Fondaparinux (2,5mg, АУ 6 ) [длак дцамакдлак]. Аяд Ам (fi: INR 2,5 - INR 2-3, АУ apple Ав АУ ) [длак дцамакдлак]. applefi fi apple: Dabigatran [дламаяа А дл- АКдцдлАмАК дцамакдлак], Rivaroxaban [дламаяа А длакдцдламак дцамакдлак] ( Ав АУ apple apple applefi, АУapple ). II. АУ Ав apple apple: Ая (IPC) АяАя (VFP) [длак дцамакдлак]. АУ Ав, apple apple - appleapple [АяАяАК дцамакдлак]. III. apple: apple applefi АвАвАУ fiав applefi applefi 10 АУ АУ 35 АУ [длак дцамакдлак]. А appleау appleау apple : АКд [длак дцамакдлак] Аяд Ам [дламаяа А длакдцдламак дцамакдлак] Dabigatran [дламаяа А длакдцдламак дцамакдлак] Rivaroxaban [дламаяа А длакдцдламак дцамакдлак] Fondaparinux [АяАяАК дцамакдлак]

68 68 MEPO B apple O Aapple I А АВдлА длдцака дламак длдца АК apple fi АУ apple- АУ apple. АУ, appleау appleapple applefi 10 АУ 42 АУ, apple fi Ав fi АУ АУ АвАв (28-42 ). АК apple appleapple apple АУ apple apple АвАвАУ - apple 28 АУ 42 АУ (АУ АУ АУ АвАв).

69 MEPO B apple O Aapple I 69 д длд АВдлА АсАядлАя 1. Hirsch J. Prevention of venous thrombosis in patients undergoing major orthopaedic surgical procedures. Acta Chir Scand Suppl 1990;556: Dahl OE, Gudmunsen TE, Bjornara BT, Solheim DM. Risk of clinical pulmonary embolism after joint surgery in patients receiving low-molecular-weight heparin prophylaxis in hospital: a 10-year prospective register of 3954 patients. Acta Orthop Scand 2003;74: Warwick D, Williams MH, Bannister GC. Death and thromboembolic disease after total hip replacement: a series of 1162 cases with no routine chemical prophylaxis. J Bone Joint Surg Br 1995; 77: Wroblewski BM, Siney PD, Fleming PA. Fatal pulmonary embolism after total hip arthroplasty: diurnal variations. Orthopedics 1998; 21: National Institutes of Health Consensus Conference. Prevention of venous thrombosis and pulmonary embolism. JAMA 1986; 256: 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. 7. Turpie AG, Levine MN, Hirsh J, Carter CJ, Jay RM, Powers PJ, Andrew M, Hull RD, Gent M. A randomized controlled trial of a low-molecular-weight heparin (enoxaparin) to prevent deep-vein thrombosis in patients undergoing elective hip surgery. N Engl J Med Oct 9;315(15):925-9]. 8. RD Heparin Arthroplasty Group. RD heparin compared with warfarin for prevention of venous thromboembolic disease following total hip or knee arthroplasty. J Bone Joint Surg Am 1994; 76: Francis CW, Pellegrini VD, Totterman S, Boyd AD Jr, Marder VJ, Liebert KM, Stulberg BN, Ayers DC, Rosenberg A, Kessler C, Johanson NA. Prevention of deep-vein thrombosis after total hip arthroplasty: comparison of warfarin and dalteparin. J Bone Joint Surg Am 1997; 79: Hull R, Raskob G, Pineo G, Rosenbloom D, Evans W, Mallory T, Anquist K, Smith F, Hughes G, Green D, Elliott CG, Panju A, and Brant R. A comparison of subcutaneous low-molecular-weight heparin with warfarin sodium for prophylaxis against deep-vein thrombosis after hip or knee implantation. N Engl J Med 1993; 329: Hamulyak K, Lensing AW, van der Meer J, Smid WM, van Ooy A, Hoek JA. Subcutaneous low-molecular weight heparin or oral anticoagulants for the prevention of deep-vein thrombosis in elective hip and knee replacement? Thromb Haemost 1995; 74: Hull RD, Pineo GF, Francis C, Bergqvist D, Fellenius C, Soderberg K, Holmqvist A, Mant M, Dear R, Baylis B, Mah A, Brant R. Low-molecular-weight heparin prophylaxis using dalteparin in close proximity to surgery vs. warfarin in hip arthroplasty patients: a doubleblind, randomized comparison. Arch Intern Med 2000; 160:

70 70 MEPO B apple O Aapple I 13. Mismetti P, Laporte S, Zufferey P, Epinat M, Decousus H, Cucherat M. Prevention of venous thromboembolism in orthopedic surgery with vitamin K antagonists: a meta-analysis. J Thromb Haemost 2004; 2: OА»Donnell M, Julian J, Kearon C. Risk of bleeding with vitamin K antagonists compared with low-molecular-weight heparin after orthopedic surgery: a rebuttal. J Thromb Haemost 2005; 3: Lassen MR, Bauer KA, Eriksson BI, Turpie AG; European Pentasaccharide Elective Surgery Study (EPHESUS) Steering Committee. Postoperative fondaparinux versus preoperative enoxaparin for prevention of venous thromboembolism in elective hip-replacement surgery: a randomised double-blind comparison. Lancet 2002; 359: Turpie AG, Bauer KA, Eriksson BI, Lassen MR; PENTATHLON 2000 Study Steering Committee. Postoperative fondaparinux versus postoperative enoxaparin for prevention of venous thromboembolism after elective hip-replacement surgery: a randomised double-blind trial. Lancet 2002; 359: Collins R, Scrimgeour A, Yusuf S, Peto R. Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of subcutaneous heparin. Overview of results of randomised trials in general, orthopedic and urologic surgery. N Eng J Med 1988;318: Koch A, Ziegler S, Breitschwerdt H, Victor N. Low loecular weight heparin and unfractionated heparin n thrombosis prophylaxis: meta-analysis based on original patient data. Thromb Res 2001;102: 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: Pulmonary Embolism Prevention (PEP) Trial Collaborative Group. Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin. Lancet 2000; 355: Eikelboom JW, Karthikeyan G, Fagel N, Hirsh J. American association of orthopedic surgeons and american college of chest physicians guidelines for venous thromboembolism prevention in hip and knee arthroplasty differ: what are the implications for clinicians and patients? Chest Feb;135(2): Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell CW. Prevention of venous thromboembolism: American College of Chest Physicians Evidence- Based Clinical Practice Guidelines (8th edition). Chest 2008;133: Prevention and treatment of venous thromboembolism International Consensus Sttement (Guidelines according to scientific evidence). Int Angiol 2006;25: Venous thromboembolism: reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing surgery. ( АУ 2008).

71 MEPO B apple O Aapple I Prophylaxis of Venous Thromboembolism SIGN Publication No. 62 Published October ( АУ 2008). 26. American Academy of Orthopaedic Surgeons Clinical Guideline on Prevention of Pulmonary Embolism in Patients Undergoing Total Hip or Knee Arthroplasty Adopted by the American Academy of Orthopaedic Surgeons Board of Directors May ( I 2009). 27. Eriksson BI, Wille-Jrgensen P, Klebo P, Mouret P, Rosencher N, Bsch P, Baur M, Ekman S, Bach D, Lindbratt S, Close P. A comparison of recombinant hirudin with a lowmolecular-weight heparin to prevent thromboembolic complications after total hip replacement. N Engl J Med Nov 6;337(19): Eriksson BI, Ekman S, Lindbratt S, Baur M, Bach D, Torholm C, Klebo P, Close P. Prevention of thromboembolism with use of recombinant hirudin. Results of a double-blind, multicenter trial comparing the efficacy of desirudin (Revasc) with that of unfractionated heparin in patients having a total hip replacement. J Bone Joint Surg Am Mar;79(3): Eriksson BI, Dahl OE, Rosencher N, Kurth AA, van Dijk CN, Frostick SP, Prins MH, Hettiarachchi R, Hantel S, Schnee J, Bе ller HR; RE-NOVATE Study Group. Dabigatran etexilate versus enoxaparin for prevention of venous thromboembolism after total hip replacement: a randomised, double-blind, non inferiority trial. Lancet. 2007;370(9591): Eriksson BI, Borris LC, Friedman RJ, Haas S, Huisman MV, Kakkar AK, Bandel TJ, Beckmann H, Muehlhofer E, Misselwitz F, Geerts W; RECORD1 Study Group. Rivaroxaban versus enoxaparin for thromboprophylaxis after hip arthroplasty. N Engl J Med. 2008;358(26): 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: Gallus A, Raman K, Darby T. Venous thrombosis after elective hip replacement: the influence of preventive intermittent calf compression and of surgical technique. Br J Surg 1983;70: Hull RD, Raskob GE, Gent M, McLoughlin D, Julian D, Smith FC, Dale NI, Reed-Davis R, Lofthouse RN, Anderson Cl. Effectiveness of intermittent pneumatic leg compression for preventing deep vein thrombosis after total hip replacement. JAMA 1990;263: Hartman JT, Pugh JL, Smith RD, Robertson WW Jr, Yost RP, Janssen HF. Cyclic sequential compression of the lower limb in prevention of deep venous thrombosis. J Bone Joint Surg Am 1982;64:

72 72 MEPO B apple O Aapple I 35. Fordyce MJ, Ling RS. A venous foot pump reduces thrombosis after total hip replacement. J Bone Joint Surg Br 1992; 74: Warwick D, Harrison J, Glew D, Mitchelmore A, Peters TJ, Donovan J. Comparison of the use of a foot pump with the use of low-molecular-weight heparin for the prevention of deep-vein thrombosis after total hip replacement. J Bone Joint Surg Am 1998; 80: Pitto RP, Hamer H, Heiss-Dunlop W, Kuehle J. Mechanical prophylaxis of deep-vein thrombosis after total hip replacement a randomised clinical trial. J Bone Joint Surg Br 2004; 86: Dahl OE, Aspelin T, Arnesen H, Seljeflot I, Kierulf P, Ruyter R, Lyberg T. Increased activation of coagulation and formation of late deep venous thrombosis following discontinuation of thromboprophylaxis after hip replacement surgery. Thromb Res 1995; 80: Sikorski JM, Hampson WG, Staddon GE. The natural history and aetiology of deep vein thrombosis after total hip replacement. J Bone Joint Surg Br 1981; 63: White RH, Romano PS, Zhou H, Rodrigo J, Bargar W. Incidence and time course of thromboembolic outcomes following total hip or knee arthroplasty. Arch Intern Med 1998; 158: Hull RD, Pineo GF, Stein PD, Mah AF, MacIsaac SM, Dahl OE, Butcher M, Brant RF, Ghali WA, Bergqvist D, Raskob GE. Extended out-of-hospital low-molecular-weight heparin prophylaxis against deep venous thrombosis in patients after elective hip arthroplasty: a systematic review. Ann Intern Med 2001; 135: Eikelboom JW, Quinlan DJ, Douketis JD. Extended duration prophylaxis against venous thromboembolism after total hip or knee replacement: a meta-analysis of the randomised trials. Lancet 2001; 358: Cohen AT, Bailey CS, Alikhan R, Cooper DJ. Extended thromboprophylaxis with low molecular weight heparin reduces symptomatic venous thromboembolism following lower limb arthroplasty: a meta-analysis. Thromb Haemost 2001; 85: Skedgel C, Goeree R, Pleasance S, Thompson K, O'Brien B, Anderson D. The cost-effectiveness of extended-duration antithrombotic prophylaxis after total hip arthroplasty. J Bone Joint Surg Am 2007; 89: Douketis JD, Eikelboom JW, Quinlan DJ, Willan AR, Crowther MA. Short duration prophylaxis against venous thromboembolism after total hip or knee replacement: a metaanalysis of prospective studies investigating symptomatic outcomes. Arch Intern Med 2002; 162: O'Donnell M, Linkins LA, Kearon C, Julian J, Hirsh J. Reduction of out-of-hospital symptomatic venous thromboembolism by extended thromboprophylaxis with low-molecularweight heparin following elective hip arthroplasty: a systematic review. Arch Intern Med 2003; 163:

73 MEPO B apple O Aapple I Prandoni P, Bruchi O, Sabbion P, Tanduo C, Scudeller A, Sardella C, Errigo G, Pietrobelli F, Maso G, Girolami A. Prolonged thromboprophylaxis with oral anticoagulants after total hip arthroplasty: a prospective controlled randomized study. Arch Intern Med 2002; 162:

74

75 MEPO B apple O Aapple Асfi 75 8 apple O Aapple Асfi дц АвАвАУ applefi apple apple (А Аядл) Ав appleауapple apple apple fi (А АяАс). А Ав д А АяАс applefi А Аядл 1. fi, Ав fi д А АяАс АУ appleав АУ Ав АУАв applefi 2. Ая. АяАяАмдцдлАмH А д А А АВАяАК appleау fi АУ appleауав fi АКд apple apple- АУ applefi placebo 3, appleававау д applefi 65% 19%. АУ АУ appleауав fi АКд apple appleау applefi apple АУ Авfi4,5. Ая appleау АУ appleау, apple apple АКд Аяд Ам applefi А АяАс, fi apple- д АКд 33% fi д 7,1% Ая Аяд Ам 48% 10,4%. А Ав fi fi АКд (4,5% АУ 2,7%). - 12,13 apple fi АКд АУ fi -

76 76 MEPO B apple O Aapple Асfi apple АУ Авfi, fi, fi Ав Ав. АК (Аяд Ам) АУ appleау appleау АУ АУ А АяАс., fi applefi д apple Ав fi (25-50%), applefi apple fi. Ая apple apple АУАв apple А АяАс, fi apple applefi АКд fondaparinux. АУ 1049 А АяАс, fondaparinux ( Авfi 2,5mg -, АУ АУ ) apple (30mg Ав, АУ ) 14. дц apple д fi fondaparinux 12,5% 2,5% apple 27,8% 5,4%. А АУ appleappleау apple АУ Ав fondaparinux (2,1% АУ 0,2%). apple АУ apple apple, apple АУ Авfi appleapple applefi apple fiав, АКд, Ав. АК apple АУ Ав apple АУ apple А АяАс 15 Ая 16 fi apple applefi fiав apple17,18 Ав apple apple Ав. дц, applefi fi (Dabigatran-Pradaxa Rivaroxaban-Xarelto ), АУ apple А АяАс. To Dabigatran, Авfi 220 mg ( 150 mg Ав Ав АУapple 3), Ав АУ А АяАс apple - 12 (apple, RE-MА DEL 19 apple 40mg АУ apple 2076, Ав, RE-MOBI- LIZE 20 apple 30mg Ав АУ 2615 ). дц apple applefi - fi applefi apple appleававау applefi. дц Dabigatran АУ (non-inferior)

77 MEPO B apple O Aapple Асfi 77 apple АУ RE-MODEL. Ая RE-MOBILIZE Ав АУ (non-inferior) apple. apple АУ Ав- АУ Ав fi Ав АУ. дц Rivaroxaban apple, Ав apple- 12, Ав АУ А АяАс (apple, RECORD mg apple apple АУ 2531 Ав-, RECORD 4 22 apple 30mg Ав АУ ). дц apple applefi fi applefi applefi. Ам Ав - АУ Rivaroxaban АУ appleау (superior) apple, Ав applefiав. д. АКАядлАм А А дл А д А А АВАяАК дц appleау appleау АУАв fi Ая (IPC) appleау apple apple applefi А АяАс 16, АяАУ АУ appleауapple fi Ав apple apple, АУ apple apple. А АУ, fi, apple АУ apple АКд - apple 25 АУ applefi applefi АУ Ая (IPC). appleappleау, apple Ая (IPC) Ав АУ АвАУ apple Ая (IPC) apple, appleау Ая/IPC - apple. АК АяАя (VFP) АУ Ав apple А АяАс Ав АУ АУ АУ27,28 fi apple АКд Ав 29,30. apple apple- Ам (GCS) А АяАс apple Ав appleapple Ав. А АяАс, fiapple А Аядл, Ав fiав apple fi, apple apple. -, Ав, Ав apple АвАвАУ

78 78 MEPO B apple O Aapple Асfi АвАУ АУ, apple apple apple, АУapple apple АУ Ав. Ас. длаяамдлая А д А А АВАяАК дцак А АВдлАмАК АяА - АВАядцдлАмАК дца АсА АядцА А АяАс, appleау apple АКд АУ 28 АУ Ав applefi (17,5%) 7-10 (20,8%) 31. appleapplefi fiapple АУАв fi applefi appleау apple (30-42 АУ) АКд fi А АяАс applefi fi А Аядл 32. АК apple- АУ Аяд Ам apple applefiав fi apple А АяАс 2. apple apple АУ appleау appleау 12 Fondaparinux applefi fi А АяАс, apple appleау.

79 MEPO B apple O Aapple Асfi 79. дцаядл I. apple fi apple appleapple fi applefi apple- fiав: АКд ( Ав АУ apple apple applefi -, АУapple ) [длак дцамакдлак]. Fondaparinux (2,5mg, АУ 6 ) [дламаяа А длакдцдламак дцамакдлак]. Аяд Ам (fi: INR 2,5 - INR 2-3, АУ apple Ав АУ ) [длак дцамакдлак]. applefi fi apple: Dabigatran [дламаяа А дл- АКдцдлАмАК дцамакдлак], Rivaroxaban [дламаяа А длакдцдламак дцамакдлак] ( Ав АУ apple apple applefi -, АУapple ). АУ apple apple Ам АяАУ [Ая (IPC)] [дламаяа А длакдцдламак дцамакдлак]. II. АУ Ав apple apple Ая (IPC), [длак дцамакдлак] АяАя (VFP), [дламаяа А длакдцдламак дцамакдлак]. АУ Ав, apple apple apple [дламаяа А длакдцдламак дцамакдлак]. III. apple: apple apple applefi АвАвАУ fiав 10 АУ [длак дцамакдлак]. appleау apple АУ 35 АУ [АяАяАК дцамакдлак].

80 80 MEPO B apple O Aapple Асfi А АВдлА длдцака дламак длдца АК АК Ав appleау apple apple- АУ apple А АяАс. Аяfi - fi АУ (fiapple АУ appleapple А Аядл),, appleappleау, fi appleавfi ( applefi fi А Аядл). appleappleау Авfi apple А АяАс, apple АУ apple - appleapple, apple АвАв АУ Ав applefi АУ appleappleау fi appleау apple А АяАс, А Аядл. АК appleapple fi applefi fi АУ д applefi А АяАс, fiapple А Аядл, appleау 12 - applefi Ав. appleау, apple appleapple apple- АУ Ав apple АУ АУ appleау АвАв (28-35 АУ).

81 MEPO B apple O Aapple Асfi 81 д длд АВдлА АсАядлАя 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: Pellegrini VD Jr, Donaldson CT, Farber DC, Lehman EB, Evarts CM. The Mark Coventry Award: prevention of readmission for venous thromboembolism after total knee arthroplasty. Clin Orthop 2006; 452: Leclerc JR, Geerts WH, Desjardins L, Jobin F, Laroche F, Delorme F, Haviernick S, Atkinson S, Bourgouin J. Prevention of deep vein thrombosis after major knee surgery a randomised, double-blind trial comparing a low molecular weight heparin fragment (enoxaparin) to placebo. Thromb Haemost 1992;67: Colwell CW Jr, Spiro TE, Trowbridge AA, Stephens JW, Gardiner GA Jr, Ritter MA. Efficacy and safety of enoxaparin versus unfractionated heparin for prevention of deep venous thrombosis after elective knee arthroplasty. Clin Orthop 1995; 321: Faun P, Suomalainen O, Rehnberg V, Hansen TB, Krner K, Soimakallio S, Nielsen E. Prophylaxis for the prevention of venous thromboembolism after total knee arthroplasty: a comparison between unfractionated and lowmolecular- weight heparin. J Bone Joint Surg Am 1994; 76: RD Heparin Arthroplasty Group. RD heparin compared with warfarin for prevention of venous thromboembolic disease following total hip or knee arthroplasty. J Bone Joint Surg Am 1994; 76: Hull R, Raskob G, Pineo G, Rosenbloom D, Evans W, Mallory T, Anquist K, Smith F, Hughes G, Green D, Elliott CG, Panju A, and Brant R. A comparison of subcutaneous low-molecular-weight heparin with warfarin sodium for prophylaxis against deep-vein thrombosis after hip or knee implantation. N Engl J Med 1993; 329: Hamulyak K, Lensing AW, van der Meer J, Smid WM, van Ooy A, Hoek JA. Subcutaneous low-molecular weight heparin or oral anticoagulants for the prevention of deep-vein thrombosis in elective hip and knee replacement? Thromb Haemost 1995; 74: Leclerc JR, Geerts WH, Desjardins L, Laflamme GH, L'Espедrance B, Demers C, Kassis J, Cruickshank M, Whitman L, Delorme F. Prevention of venous thromboembolism after knee arthroplasty: a randomized, double-blind trial comparing enoxaparin with warfarin. Ann Intern Med 1996; 124: Heit JA, Berkowitz SD, Bona R, Cabanas V, Corson JD, Elliott CG, Lyons R. Efficacy and safety of low molecular weight heparin (ardeparin sodium) compared to warfarin for the prevention of venous thromboembolism after total knee replacement surgery: a doubeblind, doseranging study. Thromb Haemost 1997; 77: Fitzgerald RH Jr, Spiro TE, Trowbridge AA, Gardiner GA Jr, Whitsett TL, O'Connell MB, Ohar JA, Young TR; Enoxaparin Clinical Trial Group. Prevention of venous thromboembolic

82 82 MEPO B apple O Aapple Асfi disease following primary total knee arthroplasty: a randomized, multicenter, open-label, parallel-group comparison of enoxaparin and warfarin. J Bone Joint Surg Am 2001; 83: Howard AW, Aaron SD. Low molecular weight heparin decreases proximal and distal deep venous thrombosis following total knee arthroplasty: a meta-analysis of randomized trials. Thromb Haemost 1998; 79: Brookenthal KR, Freedman KB, Lotke PA, Fitzgerald RH, Lonner JH. A meta-analysis of thromboembolic prophylaxis in total knee arthroplasty. J Arthroplasty 2001; 16: Bauer KA, Eriksson BI, Lassen MR, Turpie AG; Steering Committee of the Pentasaccharide in Major Knee Surgery Study. Fondaparinux compared with enoxaparin for the prevention of venous thromboembolism after elective major knee surgery. N Engl J Med 2001; 345: Lotke PA, Palevsky H, Keenan AM, Meranze S, Steinberg ME, Ecker ML, Kelley MA. Aspirin and warfarin for thromboembolic disease after total joint arthroplasty. Clin Orthop 1996; 324: 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: Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell CW. Prevention of venous thromboembolism: American College of Chest Physicians Evidence- Based Clinical Practice Guidelines (8th edition). Chest 2008;133: Prevention and treatment of venous thromboembolism International Consensus Sttement (Guidelines according to scientific evidence). Int Angiol 2006;25: Eriksson BI, Dahl OE, Rosencher N, Kurth AA, van Dijk CN, Frostick SP, Klebo P, Christiansen AV, Hantel S, Hettiarachchi R, Schnee J, Bе ller HR; RE-MODEL Study Group. Oral dabigatran etexilate vs. subcutaneous enoxaparin for the prevention of venous thromboembolism after total knee replacement: the REMODEL randomized trial. J Thromb Haemost. 2007;5(11): RE-MOBILIZE Writing Committee, Ginsberg JS, Davidson BL, Comp PC, Francis CW, Friedman RJ, Huo MH, Lieberman JR, Muntz JE, Raskob GE, Clements ML, Hantel S, Schnee JM, Caprini JA. The oral thrombin inhibitor dabigatran etexilate vs the North- American enoxaparin regimen for the prevention of venous thromboembolism after knee arthroplasty surgery. J Arthroplasty Jan;24(1): Lassen MR, Ageno W, Borris LC, Lieberman JR, Rosencher N, Bandel TJ, Misselwitz F, Turpie AG; RECORD 3 Investigators. Rivaroxaban versus enoxaparin for thromboprophylaxis after total knee arthroplasty. N Engl J Med. 2008;358(26): Turpie AG, Lassen MR, Davidson BL, Bauer KA, Gent M, Kwong LM, Cushner FD, Lotke

83 MEPO B apple O Aapple Асfi 83 PA, Berkowitz SD, Bandel TJ, Benson A, Misselwitz F, Fisher WD; RECORD 4 Investigators. Rivaroxaban versus enoxaparin for thromboprophylaxis after total knee arthroplasty (RECORD4): a randomised trial. Lancet. 2009;373(9676): Hull R, Delmore TJ, Hirsh J, Gent M, Armstrong P, Lofthouse R, MacMillan A, Blackstone I, Reed-Davis R, Detwiler RC. Effectiveness of intermittent pulsatile elastic stockings for the prevention of calf and thigh vein thrombosis in patients undergoing elective knee surgery. Thromb Res 1979; 16: Haas SB, Insall JN, Scuderi GR, Windsor RE, Ghelman B. Pneumatic sequential compression boots compared with aspirin prophylaxis of deep-vein thrombosis after total knee arthroplasty. J Bone Joint Surg Am 1990; 72: Kaempffe FA, Lifeso RM, Meinking C. Intermittent pneumatic compression versus Coumadin: prevention of deep vein thrombosis in low-extremity total joint arthroplasty. Clin Orthop 1991;269: 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: Westrich GH, Sculco TP. Prophylaxis against deep venous thrombosis after total knee arthroplasty: pneumatic planter compression and aspirin compared with aspirin alone. J Bone Joint Surg Am 1996; 78: Wilson NV, Das SK, Kakkar VV, Maurice HD, Smibert JG, Thomas EM, Nixon JE. Thrombo-embolic prophylaxis in total knee replacement: evaluation of the A-V Impulse System. J Bone Joint Surg Br 1992; 74: Norgren L, Toksvig-Larsen S, Magyar G, Lindstrand A, Albrechtsson U. Prevention of deep vein thrombosis in knee arthroplasty: preliminary results from a randomized controlled study of low molecular weight heparin vs foot pump compression. Int Angiol 1998; 17: 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: Comp PC, Spiro TE, Friedman RJ, Whitsett TL, Johnson GJ, Gardiner GA Jr, Landon GC, Jovед M; Enoxaparin Clinical Trial Group. Prolonged enoxaparin therapy to prevent venous thromboembolism after primary hip or knee replacement. J Bone Joint Surg Am 2001; 83: Eikelboom JW, Quinlan DJ, Douketis JD. Extended-duration prophylaxis against venous thromboembolism after total hip or knee replacement: a meta-analysis of the randomised trials. Lancet 2001;358:9-15.

84

85 MEPO B apple K I 85 9 apple K I А apple Ав fi - Ав. apple apple д АУ 46-60% 1,2, fi Ав АУ applefi 0,4-7,5% 3-7. дц apple apple fi applefi apple appleapplefi appleау fi. apple apple- appleау Ав, apple appleау АУ apple. -, applefi, apple apple АУ Авfi apple apple apple АУ 48, АУАв fi applefi д 62% fi д 14% 8. fi, АУ apple apple fi АУ apple appleау fi. Ая. АяАяАмдцдлАмH А д А А АВАяАК АУ АУ appleав apple apple Аяд Ам ( - fi). дц appleау applefi appleау 9-11 АУАв fi Аяд Ам Ав Ав fi д 61% 66% АУ apple.

86 86 MEPO B apple K I АК apple АУ Авfi (5000 U/ 8), АУ fi appleау АУ apple fi fi 12. АК АУ АУАв apple apple АУ АКд dalteparin, applefi АвappleАУ д. Ая apple applefi ACCP fi fi (1B), - Ав Ав apple appleау fi АУ - apple. Ас fi fi Ав АУ apple apple Ав. Ав АУ apple HMMB placebo, Авapple д 12% apple АУ apple, АУ 21% apple АУ placebo 13. fiapple Cochrane apple apple- 31 АУ, fi apple АУ Авfi fi АКд АУ appleау applefi д apple 14. АК fondaparinux Ав, apple applefi appleау АУ 1711 (PENTHIFRA) 15. АК АУ АУАв fi apple 11 АУ fondaparinux appleау fi apple fi д, apple apple Ав fi Ав. дцау, fi apple, fi applefi Авapple - АУ PEP trial 16, fi applefi 10 appleау 17, fi applefi applefi apple АУ АУ fiав. appleappleау, АУ apple appleapple. д. АКАядлАм А А дл А д А А АВАяАК АК applefi fiав apple Ав Ав apple АУ. Ав Ав-

87 MEPO B apple K I 87 АУ Авapple АУ 18, Ая (IPC) Ав. fi, АУ fi fi, Ав Ав apple apple-. Ас. длаяамдлая А д А А АВАяАК АК Ав Ав apple Ав АУ apple. АК АУ PENTHIFRA Plus 19 apple - АвАУ АУ АУ АУ , АУ apple fondaparinux apple АУ, Ав Ав: apple Ав АУ - fondaparinux fi АвАв, Ав Ав placebo Ав Ав. дц applefi АвappleАУ д АУ АвАв 1,4% Ав apple - АУ fondaparinux, АУ 35% Ав placebo. apple-, appleау АУ apple Ав Ав АвАв АУ АУ АвАв АКд (certoparin) 20. АК АУ apple 360 apple fi apple А Аядл А АяАс. АК appleау - apple appleау fi fi fi, АвАУ apple, apple д fi apple. АмАУ applefi Ав. apple Ав apple applefi АУ appleау, fi fi АКд fi Аяд Ам apple appleау apple.

88 88 MEPO B apple K I. дцаядл I. fi apple apple АУ applefi fi - : Fondaparinux (2,5mg, АУ 6 ) [длак дцамакдлак], АКд ( Ав АУ apple apple applefi -, АУapple ) [дламаяа А дл- АКдцдлАмАК дцамакдлак], Аяд Ам (fi: INR 2,5 - INR 2-3, АУ apple Ав АУ ) [дламаяа А длакдцдламак дцамакдлак]. II. apple appleауapple apple АУ apple apple АУ apple- АКд [Ая- АяАК дцамакдлак]. III. fiав apple fi: apple АУАв fiав [дламаяа - А длакдцдламак дцамакдлак] fi apple АУ Ав [дламаяа А длакдцдламак дцамакдлак]. АУ Ав apple applefi АУ fiав apple fiав Ав - fi АУ [АяАяАК дцамакдлак]. IV. apple: appleapplefi applefi 10 АУ АУ 35 АУ [длак дцамакдлак].

89 MEPO B apple K I 89 А appleау appleау Ав apple- : Fondaparinux [длак дцамакдлак] АКд [АяАяАК дцамакдлак] Аяд Ам [АяАяАК дцамакдлак]. А АВдлАя длдцака дламак длдца АК АК appleау apple. АУ Ав - АУ. АК apple appleapple АУ apple apple АУ АУ АУ АвАв (28-42 АУ). АК АКд appleау apple apple apple, fi Ав. АК apple appleapple apple. АК АУ Ав apple Авfi fi АУ appleау, apple АвАУ fi apple. А apple appleауapple - apple apple fiав Ав appleapple Ав АУ appleав АУ/apple Ав.

90 90 MEPO B apple K I д длд АВдлА АсАядлАя 1. Snook GA, Chrisman OD, Wilson TC. Thromboembolism after surgical treatment of hip fractures. Clin Orthop Relat Res Mar-Apr;(155): Morris GK, Mitchell JR. Warfarin sodium in prevention of deep venous thrombosis and pulmonary embolism in patients with fractured neck of femur. Lancet Oct 23;2(7991): Dahl OE, Caprini JA, Colwell CW, Frostick SP, Haas S, Hull RD, Laporte S, Stein PD. Fatal vascular outcomes following major orthopaedic surgery. Thromb Haemost 2005; 93: Bjornara BT, Gudmundsen TE, Dahl OE. Frequency and timing of clinical venous thromboembolism after major joint surgery. J Bone Joint Surg Br 2006; 88: Hitos K, Fletcher JP. Venous thromboembolism and fractured neck of femur. Thromb Haemost 2005; 94: Rosencher N, Vielpeau C, Emmerich J, Fagnani F, Samama CM; ESCORTE group. Venous thromboembolism and mortality after hip fracture surgery: the ESCORTE study. J Thromb Haemost 2005; 3: Haake DA, Berkman SA. Venous thromboembolic disease after hip surgery: risk factors, prophylaxis, and diagnosis. Clin Orthop 1989; 242: Zahn HR, Skinner JA, Porteous MJ. The preoperative prevalence of deep vein thrombosis in patients with femoral neck fractures and delayed operation. Injury 1999; 30: 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: Borgstrom S, Greitz T, van der Linden W, Molin J, Rudics I. Anticoagulant prophylaxis of venous thrombosis in patients with fractured neck of the femur: a controlled clinical trial using venous phlebography. Acta Chir Scand 1965; 129: Hamilton HW, Crawford JS, Gardiner JH, Wiley AM. Venous thrombosis in patients with fracture of the upper end of the femur: a phlebographic study of the effect of prophylactic anticoagulation. J Bone Joint Surg 1970; 52-B: Monreal M, Lafoz E, Navarro A, Granero X, Caja V, Caceres E, Salvador R, Ruiz J. A prospective double-blind trial of a low molecular weight heparin once daily compared with conventional low-dose heparin three times daily to prevent pulmonary embolism and venous thrombosis in patients with hip fracture. J Trauma 1989;29: Jrgensen PS, Strandberg C, Willie-Jrgensen P, Torholm C, Neergaard K, Paaske BP, Rasmussen SW, Christensen SW, Mantoni M, Thamsen H. Early preoperative thromboprophylaxis with Klexane in hip fracture surgery: a placebo-controlled study. Clin Appl Thromb Haemost 1998; 4:

91 MEPO B apple K I Handoll HH, Farrar MJ, McBirnie J, Tytherleigh-Strong G, Milne AA, Gillespie WJ. Heparin, low molecular weight heparin and physical methods for preventing deep vein thrombosis and pulmonary embolism following surgery for hip fractures. Cochrane Database Syst Rev 2002, issue 4: article No. CD Eriksson BI, Bauer KA, Lassen MR, Turpie AG; Steering Committee of the Pentasaccharide in Hip-Fracture Surgery Study. Fondaparinux compared with enoxaparin for the prevention of venous thromboembolism after hip-fracture surgery. N Engl J Med 2001; 345: 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: Collins R, Baigent C, Sandercock P, Peto R. Antiplatelet therapy for thromboprophylaxis: the need for careful consideration of the evidence from randomized trials. Antiplatelet TrialistsА» Collaboration. BMJ. 1994;309: Fisher CG, Blachut PA, Salvian AJ, Meek RN, O'Brien PJ. Effectiveness of pneumatic leg compression devices for the prevention of thromboembolic disease in orthopaedic trauma patients: a prospective, randomized study of compression alone versus no prophylaxis. J Orthop Trauma 1995;9: Eriksson BI, Lassen MR, PENTasaccharide in HIp-FRActure Surgery Plus Investigators (PENTHIFRA Plus). Duration of prophylaxis against venous thromboembolism with fondaparinux after hip fracture surgery: a multicenter, randomized, placebo-controlled, double-blind study. Arch Intern Med 2003; 163: Kolb G, Bodamer I, Galster H, Seidlmayer C, Grambach K, Koudela K, Eisele RR, Becker C, Paal V, Spannagel U, Brom J, Weidinger G; Long-term Thromboprophylaxis Study Group. Reduction of venous thromboembolism following prolonged prophylaxis with the low molecular weight heparin Certoparin after endoprothetic joint replacement or osteosynthesis of the lower limb in elderly patients. Thromb Haemost 2003; 90:

92

93 MEPO B apple M T apple M T Аяapplefi fi appleав, apple АУ Ав. apple, appleapple АУ Ав д 50% 1-4. АК fi appleapple apple apple АУ fi 2,5,6. - Ав АУ,. АК fi apple, fi АУ, АУ, appleау appleау apple apple appleappleау apple apple1-4,7-9. А fi appleау Ав apple- АУ. А АУ АУ - applefi applefi АУ apple Ав 1,3. Ая. АяАяАмдцдлАмH POMBOPOYАВAH АК АКд Ав АУ apple fi АУ 36 fi apple apple applefi apple apple 1,3,10. АяАв АУ АКд apple apple Ав-, fi

94 94 MEPO B apple M T Авfi. АК apple,, - (fiapple applefi, applefi, apple, ), appleapple- applefi, apple Ав Ав apple АУАв АУ apple АКд, appleapplefi fi Ав apple fi АмАУ АУ appleав fi АКд apple appleау applefi АУ Авfi apple14 applefi АУ - apple [Ая (IPC)] 15, apple АУ АвАУ АУ АвАУ. д. АКАядлАмE OOI POMBOPOYАВAH А» fi АУ apple apple АУ, apple apple АУ apple applefi АУ apple H applefi fi Ав - apple fi АУ АК fi Ав apple apple apple fi АУ apple fi АУ applefi apple АУ apple АУ АУ АУ. Ая АвАУ АУ apple apple Ав, Ав АУ. АК apple appleау АУ apple АУ АУ apple Ав АК Ав Ав applefi АУ28 АвАУ- applefi applefi appleappleау29-33.

95 MEPO B apple M T 95 Ас. длаяамдлая А д А А АВАяАК АК АУ АУ apple apple applefi apple 1. АК Ав Ав apple Ав, appleауapple fi АУ АУАв applefi. дц АУ apple appleауapple apple Ав fi Авfi appleауapple apple fi fi appleapplefi21,22. Ав (appleау fi apple) apple Ав Ав АвАв, apple Ав fi, fi appleауapple - АКд Аяд Ам applefi fi. АК Аяд Ам Ав АУ apple applefi АУ apple Ав Ав. АК apple Ав appleау fi АУ., apple АУ - apple АУ appleау - fi34 apple apple apple apple appleapple.

96 96 MEPO B apple M T. дцаядл I. apple fi apple. [длак дцамакдлак]. II. apple apple Ав, apple АУ apple АКд fi Авfi [длак дцамакдлак]. apple apple Авfi АКд АУ apple- [дламаяа А длакдцдламак дцамакдлак]. III., apple АКд - Ав fi apple, apple АУ apple- [Ая (IPC) Ам (GCS)] [дламаяа А длакдцдламак дцамакдлак]. Ав appleау, fi apple - apple АУ apple applefi АУ [АяАяАК дцамакдлак]. IV. apple, Ав АУ АУ apple [АяАяАК дцамакдлак]. V. apple, АУ apple АУ АУАвfi applefi - [АяАяАК дцамакдлак]. АУ - fi apple АУ apple, apple АУ apple АКд Аяд Ам (fi: INR 2,5 - INR 2-3) [АяАяАК дцамакдлак].

97 MEPO B apple M T 97 А АВдлА длдцака дламак длдца АК apple АУ Авfi apple apple. АК apple- appleapple apple apple Авfi Ав - apple apple А Аядл А АяАс (АУapple ).

98 98 MEPO B apple M T 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: Geerts WH, Code KI, Jay RM, Chen E, Szalai JP. A prospective study of venous thromboembolism after major trauma. N Engl J Med 1994; 331: Rogers FB, Cipolle MD, Velmahos G, Rozycki G, Luchette FA. Practice management guidelines for the prevention of venous thromboembolism in trauma patients: the EAST Practice Management Guidelines Work Group. J Trauma 2002; 53: Nathens AB, McMurray MK, Cuschieri J, Durr EA, Moore EE, Bankey PE, Freeman B, Harbrecht BG, Johnson JL, Minei JP, McKinley BA, Moore FA, Shapiro MB, West MA, Tompkins RG, Maier RV. The practice of venous thromboembolism prophylaxis in the major trauma patient. J Trauma 2007; 62: OА»Malley KF, Ross SE. Pulmonary embolism in major trauma patients. J Trauma 1990;30: Rogers FB, Shackford SR, Wilson J, Ricci MA, Morris CS. Prophylactic vena cava filter insertion in severely injured trauma patients: indications and preliminary results. J Trauma 1993;35: ; discussion Velmahos GC, Kern J, Chan LS, Oder D, Murray JA, Shekelle P. Prevention of venous thromboembolism after injury: an evidence-based report; part II. Analysis of risk factors and evaluation of the role of vena caval filters. J Trauma 2000; 49: Meissner MH, Chandler WL, Elliott JS. Venous thromboembolism in trauma: a local manifestation of systemic hypercoagulability? J Trauma 2003; 54: Knudson MM, Ikossi DG, Khaw L, Morabito D, Speetzen LS. Thromboembolism after trauma: an analysis of 1602 episodes from the American College of Surgeons National Trauma Data Bank. Ann Surg 2004; 240: Cothren CC, Smith WR, Moore EE, Morgan SJ. Utility of once-daily dose of low-molecular-weight heparin to prevent venous thromboembolism in multisystem trauma patients. World J Surg 2007; 31: Norwood SH, McAuley CE, Berne JD, Vallina VL, Kerns DB, Grahm TW, McLarty JW. A potentially expanded role for enoxaparin in preventing venous thromboembolism in high risk blunt trauma patients. J Am Coll Surg 2001; 192: Norwood SH, McAuley CE, Berne JD, Vallina VL, Kerns DB, Grahm TW, Short K, McLarty JW. Prospective evaluation of the safety of enoxaparin prophylaxis for venous thromboembolism in patients with intracranial hemorrhagic injuries. Arch Surg 2002; 137: Alejandro KV, Acosta JA, Rodriguez PA. Bleeding manifestations after early use of low-

99 MEPO B apple M T 99 molecular-weight heparins in blunt splenic injuries. Am Surg 2003; 69: : Geerts WH, Jay RM, Code KI, Chen E, Szalai JP, Saibil EA, Hamilton PA. A comparison of low-dose heparin with low-molecular-weight heparin as prophylaxis against venous thromboembolism after major trauma. N Engl J Med 1996; 335: Ginzburg E, Cohn SM, Lopez J, Jackowski J, Brown M, Hameed SM; Miami Deep Vein Thrombosis Study Group. Randomized clinical trial of intermittent pneumatic compression and low molecular weight heparin in trauma. Br J Surg 2003; 90: Velmahos GC, Kern J, Chan LS, Oder D, Murray JA, Shekelle P. Prevention of venous thromboembolism after injury: an evidence-based report; part I. Analysis of risk factors and evaluation of the role of vena caval filters. J Trauma 2000; 49: Lacut K, Bressollette L, Le Gal G, Etienne E, De Tinteniac A, Renault A, Rouhart F, Besson G, Garcia JF, Mottier D, Oger E; VICTORIAh (Venous Intermittent Compression and Thrombosis Occurrence Related to Intra-cerebral Acute hemorrhage) Investigators. Prevention of venous thrombosis in patients with acute intracerebral hemorrhage. Neurology 2005; 65: Knudson MM, Morabito D, Paiement GD, Shackleford S. Use of low molecular weight heparin in preventing thromboembolism in trauma patients. J Trauma 1996; 41: Elliott CG, Dudney TM, Egger M, Orme JF, Clemmer TP, Horn SD, Weaver L, Handrahan D, Thomas F, Merrell S, Kitterman N, Yeates S. Calf-thigh sequential pneumatic compression compared with plantar venous pneumatic compression to prevent deep-vein thrombosis after non-lower extremity trauma. J Trauma 1999; 47: Knudson MM, Lewis FR, Clinton A, Atkinson K, Megerman J. Prevention of venous thromboembolism in trauma patients. J Trauma 1994; 37: Comerota AJ, Katz ML, White JV. Why does prophylaxis with external pneumatic compression for deep vein thrombosis fail? Am J Surg 1992; 164: Cornwell EE 3rd, Chang D, Velmahos G, Jindal A, Baker D, Phillips J, Bonar J, Campbell K. Compliance with sequential compression device prophylaxis in at-risk trauma patients: a prospective analysis. Am Surg 2002; 68: Murakami M, McDill TL, Cindrick-Pounds L, Loran DB, Woodside KJ, Mileski WJ, Hunter GC, Killewich LA. Deep venous thrombosis prophylaxis in trauma: improved compliance with a novel miniaturized pneumatic compression device. J Vasc Surg 2003; 38: Rogers FB, Shackford SR, Ricci MA, Wilson JT, Parsons S. Routine prophylactic vena cava filter insertion in severely injured trauma patients decreases the incidence of pulmonary embolism. J Am Coll Surg 1995; 180: Rodriguez JL, Lopez JM, Proctor MC, Conley JL, Gerndt SJ, Marx MV, Taheri PA, Greenfield LJ. Early placement of prophylactic vena caval filters in injured patients at high risk for pulmonary embolism. J Trauma 1996; 40:

100 100 MEPO B apple M T 26. Carlin AM, Tyburski JG, Wilson RF, Steffes C. Prophylactic and therapeutic inferior vena cava filters to prevent pulmonary emboli in trauma patients. Arch Surg 2002; 137: Giannoudis PV, Pountos I, Pape HC, Patel JV. Safety and efficacy of vena cava filters in trauma patients. Injury 2007; 38: Girard TD, Philbrick JT, Fritz Angle J, Becker DM. Prophylactic vena cava filters for trauma patients: a systematic review of the literature. Thromb Res 2003; 112: McMurtry AL, Owings JT, Anderson JT, Battistella FD, Gosselin R. Increased use of prophylactic vena cava filters in trauma patients failed to decrease overall incidence of pulmonary embolism. J Am Coll Surg 1999; 189: Patton JH Jr, Fabian TC, Croce MA, Minard G, Pritchard FE, Kudsk KA. Prophylactic Greenfield filters: acute complications and long-term follow-up. J Trauma 1996; 41: Decousus H, Leizorovicz A, Parent F, Page Y, Tardy B, Girard P, Laporte S, Faivre R, Charbonnier B, Barral FG, Huet Y, Simonneau G. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. N Engl J Med 1998; 338: Blebea J, Wilson R, Waybill P, Neumyer MM, Blebea JS, Anderson KM, Atnip RG. Deep venous thrombosis after percutaneous insertion of vena caval filters. J Vasc Surg 1999; 30: 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: Bridges GG, Lee MD, Jenkins JK, Stephens MA, Croce MA, Fabian TC. Expedited discharge in trauma patients requiring anticoagulation for deep venous thrombosis prophylaxis: the LEAP Program. J Trauma 2003; 54:

101 MEPO B apple O K N M apple O K N M А АУ applefi- д АУ fi fi 1-3. АК д % 1,4, apple А» 5,6. apple apple д apple apple- АУ, appleapple АУ apple, fi (apple АУ Ав), fi apple -, apple АУ АУ apple1,7,8. АК fi applefi Ав applefi apple fi appleapple appleapple Ав apple. А Ав д Ав apple fi, appleав apple apple apple д 10% 3% 9. Ая. АяАяАмдцдлАмH POMBOPOYАВAH АК apple appleау fi. А АвАУ appleау АУ АУ apple appleау fi

102 102 MEPO B apple O K N M АКд АУ1,10-13 Авfi АКд Авfi - apple Ая (IPC) apple appleау appleау1. -, apple Ав appleау apple apple fi apple АУ10,11,14,15. Ая apple applefi ACCP ( Авfi АУ) 1, Ав Ав - apple appleау fi АУ apple. Ас fi fi Ав АУ apple apple Ав. д. АКАядлАмE OOI POMBOPOYАВAH Аяapple appleapplefi АУ apple apple fi. Ая apple Ав, appleауapple - apple АУ apple applefi apple fi Ав АУ. дц АУ apple- Ав apple apple АУ, Ав appleау apple apple 16. АК АУ - apple АУ АУ17,18, Ав fi applefi АУ appleappleау apple apple АУ fiав apple- 1,19. Ас. длаяамдлая дцак А д А А АВАяАК appleау, apple appleауapple Ав АКд appleapple Аяд Ам appleав АУ appleау apple1,3,20. o, apple Ав apple- Ав, АУ АКд appleауapple АУ АУ1., apple Аяд Ам appleауapple apple АвАв fi apple apple1.

103 MEPO B apple O K N M 103. дцаядл I. fi, appleapple apple [длак дцамакдлак]. II. apple АКд АУ fi АУ applefi [дламаяа А длакдцдламак дцамакдлак]. - apple Ая (IPC) Авfi АКд [АяАяАК дцамакдлак]. III. appleapple apple apple Ав fi Ав, apple Ая (IPC) / Ам (GCS) [длак дцамакдлак]. Ав, apple - apple Ав АУ apple [АяАяАК дцамакдлак]. IV. apple - appleав, apple АУ apple apple АУ [АяАяАК дцам- АКдлАК]. V. apple АУ [АяАяАК дцамакдлак]. VI. apple applefi apple - Ав, apple АУ АКд АУ apple Аяд Ам (fi: INR 2,5 - INR 2-3) appleав АУ appleау apple [АяАяАК дцамакдлак].

104 104 MEPO B apple O K N M А АВдлA длдцака дламак длдца АК А АУ apple apple Ав appleауapple Авapple АУ. А applefi АУ Ав Ав АУ (ACCP 1 International Consensus Stetement 21 ). АК applefi apple apple appleауapple applefi apple appleapplefi Ав, apple apple fi apple Ав. apple АУ Авfi apple. АК apple appleapple apple apple Авfi Ав apple apple А Аядл А АяАс (АУapple ).

105 MEPO B apple O K N M 105 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: Rogers FB, Cipolle MD, Velmahos G, Rozycki G, Luchette FA. Practice management guidelines for the prevention of venous thromboembolism in trauma patients: the EAST Practice Management Guidelines Work Group. J Trauma 2002; 53: Consortium for Spinal Cord Medicine. Prevention of thromboembolism in spinal cord injury. J Spinal Cord Med 1997; 20: Spinal Cord Injury Thromboprophylaxis Investigators. Prevention of venous thromboembolism in the acute treatment phase after spinal cord injury: a randomized multicenter trial comparing low dose heparin plus intermittent pneumatic compression with enoxaparin. J Trauma 2003; 54: Waring WP, Karunas RS. Acute spinal cord injuries and the incidence of clinically occurring thromboembolic disease. Paraplegia 1991;29: DeVivo MJ, Krause JS, Lammertse DP. Recent trends in mortality and causes of death among persons with spinal cord injury. Arch Phys Med Rehabil 1999; 80: Green D, Hartwig D, Chen D, Soltysik RC, Yarnold PR. Spinal cord injury risk assessment for thromboembolism (SPIRATE study). Am J Phys Med Rehabil 2003; 82: Jones T, Ugalde v, Franks P, Zhou H, White RH. Venous thromboembolism after spinal cord injury: incidence, time course, and associated risk factors in adults and children. Arch Phys Med Rehabil 2005; 86: Chen D, Apple DF, Hudson LM, Bode R. Medical complications during the acute rehabilitation following spinal cord injury: current experience of the Model Systems. Arch Phys Med Rehabil 1999; 80: Geerts WH, Jay RM, Code KI, Chen E, Szalai JP, Saibil EA, Hamilton PA. A comparison of low-dose heparin with low-molecular-weight heparin as prophylaxis against venous thromboembolism after major trauma. N Engl J Med 1996; 335: Green D, Lee MY, Lim AC, Chmiel JS, Vetter M, Pang T, Chen D, Fenton L, Yarkony GM, Meyer PR Jr. Prevention of thromboembolism after spinal cord injury using low-molecular-weight heparin. Ann Intern Med 1990; 113: Chiou-Tan FY, Garza H, Chan KT, Parsons KC, Donovan WH, Robertson CS, Holmes SA, Graves DE, Rintala DH. Comparison of dalteparin and enoxaparin for deep venous thrombosis prophylaxis in patients with spinal cord injury. Am J Phys Med Rehabil 2003; 82:

106 106 MEPO B apple O K N M 13. Harris S, Chen D, Green D. Enoxaparin for thromboembolism prophylaxis in spinal injury: preliminary report on experience with 105 patients. Am J Phys Med Rehabil 1996;75: Green D, Lee MY, Ito VY, Cohn T, Press J, Filbrandt PR, VandenBerg WC, Yarkony GM, Meyer PR Jr. Fixed- vs adjusted-dose heparin in the prophylaxis of thromboembolism in spinal cord injury. JAMA 1988; 260: Merli GJ, Herbison GJ, Ditunno JF, Weitz HH, Henzes JH, Park CH, Jaweed MM. Deep vein thrombosis: prophylaxis in acute spinal cord injured patients. Arch Phys Med Rehabil 1988; 69: Green D, Rossi EC, Yao JS, Flinn WR, Spies SM. Deep vein thrombosis in spinal cord injury: effect of prophylaxis with calf compression, aspirin, and dipyridamole. Paraplegia 1982; 20: Hadley MN. Deep venous thrombosis and thromboembolism in patients with cervical spinal cord injuries. Neurosurgery 2002; 50(suppl):S73-S Johns JS, Nguyen C, Sing RF. Vena cava filters in spinal cord injuries: evolving technology. J Spinal Cord Med 2006; 29: Maxwell RA, Chavarria-Aguilar M, Cockerham WT, Lewis PL, Barker DE, Durham RM, Ciraulo DL, Richart CM. Routine prophylactic vena cava filtration is not indicated after acute spinal cord injury. J Trauma 2002; 52: Spinal Cord Injury Thromboprophylaxis Investigators. Prevention of venous thromboembolism in the rehabilitation phase after spinal cord injury: prophylaxis with low-dose heparin or enoxaparin. J Trauma 2003; 54: Prevention and treatment of venous thromboembolism. International Consensus Stetement (Guidelines according to scientific evidence). Int Angiol 2006;25:

107 MEPO B apple X appleав (fi ) apple X appleав (fi ) дц АвАУ АвАвАУ fi applefi appleау apple apple appleав. дц applefi д apple АУ 18% 1. АК fi fi applefi apple, fi, apple apple- Ав2. Ав apple apple- АУ, applefi applefiав, apple, Ав appleау, АУ apple - fi2, applefi АвАУ applefi apple - appleappleау 3, АУ fiapple1. Ая. АяАяАмдцдлАмH POMBOPOYАВAH АУ appleау АУ apple АУ fi АКд apple Ав д 4,5. fi АУ appleау fi АУ Авfi Аяд Ам Ав appleау АУ АУ Ав applefi applefi appleapple 6. Аяapple appleapplefi АУ apple apple fi apple apple.

108 108 MEPO B apple X appleав (fi ) д. АКАядлАмE OOI POMBOPOYАВAH appleау АУ АУ fi АУ apple [Ая (IPC) Ам (GCS)] Ав д 6. apple, Ав АУ 1954 АУАв fi Авfi АКд Ам (GCS) apple applefi fiapple -apple7. дц АУ apple Ав appleapple - АУ Ав. Ас. длаяамдлая А д А А АВАяАК apple АУ АУ apple Ав - apple apple apple appleав. appleау apple apple- appleауapple Ав АУ apple А» fi Ав 8.

109 MEPO B apple X appleав (fi ) 109. дцаядл I. apple apple appleав (fi ) Ав АУ apple Ав, Ав appleapple, apple apple [АяАяАК дцамакдлак]. II. apple Ав apple АКд [дламаяа А длакдцдламак дцамакдлак] Ая (IPC) [АяАяАК дцамакдлак]. apple Ав- АУ АКд apple АУ apple- [Ая (IPC) / Ам (GCS)] [АяАяАК дцамакдлак]. А АВдлАя длдцака дламак длдца АК А АУ apple apple apple apple- appleав (fi ) Ав appleауapple Авapple АУ. А applefi АУ Ав Ав АУ- (ACCP 2 International Consensus Stetement 7 ). apple АУ Авfi apple apple apple appleав- (fi ). АК apple appleapple apple - apple Авfi Ав apple apple А Аядл А АяАс (АУapple - ).

110 110 MEPO B apple X appleав (fi ) д длд АВдлА АсАядлАя 1. Oda T, Fuji T, Kato Y, Fujita S, Kanemitsu N. Deep venous thrombosis after posterior spinal surgery. Spine 2000;25: 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: Heck CA, Brown CR, Richardson WJ. Venous thromboembolism in spine surgery. J Am Acad Orthop Surg 2008;16: Gallus AS, Hirsh J, O'Brien SE, McBride JA, Tuttle RJ, Gent M. Prevention of venous thrombosis with small subcutaneous doses of heparin. JAMA 1976;235: Voth D, Schwarz M, Hahn K, Dei-Anang K, al Butmeh S, Wolf H: Prevention of deep vein thrombosis in neurosurgical patients: A prospective double-blind comparison of two prophylactic regimen. Neurosurg Rev1992;15: Rokito SE, Schwartz MC, Neuwirth MG. Deep vein thrombosis after major reconstructive spinal surgery. Spine 1996; 21: Gerlach R, Raabe A, Beck J, Woszczyk A, Seifert V. Postoperative nadroparin administration for prophylaxis of thromboembolic events is not associated with an increased risk of hemorrhage after spinal surgery. Eur Spine I 2004;13: Prevention and treatment of venous thromboembolism. International Consensus Stetement (Guidelines according to scientific evidence). Int Angiol 2006;25:

111 MEPO B apple Aapple X Асfi apple Aapple X Асfi АК fiapple fi apple applefi fi appleавау АУ apple apple fi Ав АУ appleapple - АУ АУ applefi fi applefi. appleау АУ, apple apple fiapple fi - apple АУАв fi applefi д 5-9% applefi д fi 0,7-3% 1-3. АК applefi д - appleау appleа» fi, АвАУ apple fi appleapplefi Ав appleау4,5, apple apple3, appleау ( ) appleав4,5. АК applefi apple appleауapple - applefi Ав appleауapple - apple fi Авfi. Ая. АяАяАмдцдлАмH POMBOPOYАВAH А АУ apple, apple appleapple fi appleау fi АКд applefi apple д, Ав 6-8. АУ АУ apple - Ав.

112 112 MEPO B apple Aapple X Асfi д. АКАядлАмE OOI POMBOPOYАВAH apple АУ АУ АУ, apple АУ applefi АУ apple apple apple fiapple fi. АК Ав АвАУ АУ Ам (GCS) АКд fi Ав apple, - appleау fi АКд apple Ам (GCS) 8. Ас. длаяамдлая А д А А АВАяАК apple АУ АУ АУ, apple Ав apple apple apple oapple - fi. АК Ав АвАУ АУ appleау- fi appleау apple (АКд 20 АУ АУАв applefi ) apple apple apple Авapple apple АвАУ applefi д 9. Асfi, appleау - apple apple, appleауapple Ав АУ apple apple.

113 MEPO B apple Aapple X Асfi 113. дцаядл I. apple apple apple fi- Ав АУ apple Ав, Ав apple - apple, apple apple [АяАяАК дцамакдлак]. II. apple Ав fi appleapple apple appleау, АКд [дламая- А А длакдцдламак дцамакдлак], АУ appleapple АУАв АКд [АяАяАК дцамакдлак] АУ - apple. А АВдлАя длдцака дламак длдца АК А АУ apple apple apple appleapple fi Ав appleауapple Авapple АУ. А applefi АУ Ав Ав АУ (ACCP 1 International Consensus Stetement 10 ). apple АУ Авfi apple apple apple apple - fi. АК apple appleapple apple apple Авfi Ав apple apple А Аядл А АяАс (АУapple ).

114 114 MEPO B apple Aapple X Асfi 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: Ettema HB, Hoppener MR, Veeger NJ, Bе ller HR, van der Meer J. Low incidence of venographically detected deep vein thrombosis after knee arthroscopy without thromboprophylaxis: a prospective cohort study. J Thromb Haemost 2006; 4: Hoppener MR, Ettema HB, Henny CP, Verheyen CC, Bе ller HR. Low incidence of deep vein thrombosis after knee arthroscopy without thromboprophylaxis: a prospective cohort study of 335 patients. Acta Orthop 2006; 77: Demers C, Marcoux S, Ginsberg JS, Laroche F, Cloutier R, Poulin J. Incidence of venographically proved deep vein thrombosis after knee arthroscopy. Arch Intern Med 1998; 158: Jaureguito JW, Greenwald AE, Wilcox JF, Paulos LE, Rosenberg TD. The incidence of deep vein thrombosis after arthroscopic knee surgery. Am J Sports Med 1999;27: Wirth T, Schneider B, Misselwitz F, Lomb M, Tе ylе H, Egbring R, Griss P. Prevention of venous thromboembolism after knee arthroscopy with low molecular weight heparin (reviparin): results of a randomized controlled trial. Arthroscopy 2001; Michot M, Conen D, Holtz D, Erni D, Zumstein MD, Ruflin GB, Renner N. Prevention of deep vein thrombosis in ambulatory arthroscopic knee surgery; a randomized trial of prophylaxis with low molecular weight heparin. Arthroscopy 2002; 18; Camporese G, Bernardi E, Prandoni P, Noventa F, Verlato F, Simioni P, Ntita K, Salmistraro G, Frangos C, Rossi F, Cordova R, Franz F, Zucchetta P, Kontothanassis D, Andreozzi GM; KANT (Knee Arthroscopy Nadroparin Thromboprophylaxis) Study Group. Low-molecular-weight heparin versus compression stockings for thromboprophylaxis after knee arthroscopy: a randomized trial Ann Intern Med Jul 15; 149(2): Marlovits S, Striessnig G, Schuster R, Stocker R, Luxl M, Trattnig S, Vедcsei V. Extendedduration thromboprophylaxis with enoxaparin after arthroscopic surgery of the anterior cruciate ligament: a prospective, randomized, placebo-controlled study. Arthroscopy Jul;23(7): Prevention and treatment of venous thromboembolism. International Consensus Stetement (Guidelines according to scientific evidence). Int Angiol 2006;25:

115 MEPO B apple MАУ K K Асfi apple MАУ K K Асfi АК АУ apple apple, fiapple -, АвАУ, fiав fi. АК - fi д АУ fi applefi 10% АУ 45% applefi apple fi 1. А Ав 0,4% АУ 2,1% 2. appleapple apple appleау, apple - АУ, apple, appleав, АУ apple fi appleау- apple. А fi АУ Ав applefi applefi, АвАв Ав АУ Ав applefi fi Ав applefi appleав3. АК АУ, apple, АУ - Ав д 4-6. А»fi apple apple apple apple АУ АУ appleау 7, Ав applefi АУ АУ АУ appleауapple apple applefi Ав.

116 116 MEPO B apple MАУ K K Асfi Ая. АяАяАмдцдлАмH POMBOPOYАВAH АУ fi, Ав АУ, appleау fi fi д АКд. А АУ АУ fi apple Ав apple Ав appleауapple Авapple - АУ 4-6,8,9. д. АКАядлАмE OOI POMBOPOYАВAH АК АУ apple Ав apple АУ fi, fi - АвАУ. Ас. длаяамдлая А д А А АВАяАК apple АУ АУ АУ apple Ав apple АУ fi.

117 MEPO B apple MАУ K K Асfi 117. дцаядл I. АУ fi apple Ав АУ apple Ав, Ав apple apple, apple - apple [АяАяАК дцамакдлак]. II. apple Ав apple АКд [АяАяАК дцамакдлак] АУ apple. А АВдлАя длдцака дламак длдца АК А АУ apple apple - АУ fi Ав appleауapple Авapple АУ. А applefi - АУ Ав Ав АУ (ACCP 1 International Consensus Stetement 10 ). АК Ав apple apple Авfi Ав. АК applefi apple appleауapple АУ apple applefi Ав. appleappleау, АУ- fiapple fi АУ Ав -, appleау apple АКд apple АУ apple. apple АУ Авfi apple АУ fi-. АК apple appleapple apple apple Авfi Ав- apple apple А Аядл А АяАс (АУapple ).

118 118 MEPO B apple MАУ K K Асfi 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: Barrett JA, Baron JA, Beach ML. Mortality and pulmonary embolism after fracture in the elderly. Osteoporos Int 2003; 14: Abelseth G, Buckley RE, Pineo GE, Hull R, Rose MS. Incidence of deep vein thrombosis in patients with fractures of the lower extremity distal to the hip. J Orthop Trauma 1996; 10: Lassen MR, Borris LC, Nakov RL. Use of the low molecular weight reviparin to prevent deep vein thrombosis after leg injury requiring immobilization. N Engl J MED 2002; 347: Jrgensen PS, Warming T, Hansen K, Paltved C, Vibeke Berg H, Jensen R, Kirchhoff- Jensen R, Kjaer L, Kerbouche N, Leth-Espensen P, Narvestad E, Rasmussen SW, Sloth C, Trholm C, Wille-Jrgensen P. Low molecular weight heparin (Innohep) as thromboprophylaxis in outpatients with a plaster cast: a venografic controlled study. Thromb Res 2002; 105: Lapidus LJ, Rosfors S, Ponzer S, Levander C, Elvin A, Lrfars G, de Bri E. Prolonged thromboprophylaxis with dalteparin after surgical treatment of achilles tendon rupture: a randomized, placebo-controlled study. J Orthop Trauma 2007; 21: Ageno W, Dentali F, Imberti D. A survey of thrombosis prophylaxis use in patients with lower limb fractures. Thromb Haemost 2004; 92: Kujath P, Spannagel U, Habscheid W. Incidence and prophylaxis of deep vein thrombosis in outpatients with injury of the lower limb. Haemostasis 1993; 23(suppl 1): Kock HJ, Schmit-Neuerburg KP, Hanke J, Rudofsky G, Hirche H. Thromboprophylaxis with low molecular weight heparin in outpatients with plaster cast immobilization of the leg. Lancet 1995; 346: Prevention and treatment of venous thromboembolism. International Consensus Stetement (Guidelines according to scientific evidence). Int Angiol 2006;25:

119 MEPO B apple X apple X АК fi Ав Ав fi АУ 1. Аяapple 4-10% fi appleав. АК АУ RIETE apple appleау АУАв fi 38% АУapple applefi 45% - fi fi 2. АК appleapple fi Ав Ав, fi Ав АУ apple 3. H Ав: Ая) appleapple apple apple Авapple, Ав fiав Ав apple (Ав Paget-Schrotner) apple 30% fi. д ) Авapple apple apple Ав (apple. - fi fi,, АвАУ apple). АК appleapple 72% 4. АК apple appleapple appleав apple. А АУ АУ АУ appleapple apple appleавау apple apple fi 5,6. apple АУ apple Ав- appleав apple 5. АК appleав

120 120 MEPO B apple X apple apple appleауapple - applefi Ав7. д длд АВдлА АсАядлАя 1. Watson HG. Upper extremity deep vein thrombosis-not the same disease at a different site. J Thromb Haemost Aug;6(8): Muoz FJ, Mismetti P, Poggio R, Valle R, Barrе«n M, Guil M, Monreal M; RIETE Investigators. Clinical outcome of patients with upper-extremity deep vein thrombosis: results from the RIETE Registry. Chest Jan;133(1): Flinterman LE, Van der Meer FJ, Rosendaal FR, Doggen CJ. Current perspective of venous thrombosis in the upper extremity. J Thromb Haemost Aug;6(8): Shah MK, Burke DT, Shah SH. Upper-extremity deep vein thrombosis. South Med J Jul;96(7): Spaniolas K, Velmahos GC, Wicky S, Nussbaumer K, Petrovick L, Gervasini A, De Moya M, Alam HB. Is upper extremity deep venous thrombosis underdiagnosed in trauma patients? Am. Surg. 2008;74(2): Saleem A, Markel DC. Fatal pulmonary embolus after shoulder arthroplasty. J. Arthroplasty 2001:16(3), Lyman S, Sherman S, Carter TI, Bach PB, Mandl LA, Marx RG. Prevalence and risk factors for symptomatic thromboembolic events after shoulder arthroplasty. Clin Orthop Relat Res Jul;448:152-6.

121 MEPO Ас EАв АУ apple

122

123 MEPO Ас Aapple: H Afi apple Аяapple: АК Afi apple АК apple apple fi applefi fi-. АК apple apple fi applefi apple apple appleapple appleау fi apple АвАУ appleapple 1. дц appleау apple applefi apple applefi fi. дц Ав applefi fi - АУ fi apple applefi apple Ав fiapple Авfi. appleappleау Ав apple Ав Ав apple apple apple applefi mg 2,4-8. дц 1994 АяPTc (Antiplatelet trial collaboration) 2 fi apple- АУ apple apple applefi. АУ apple Ав - fiapple apple placebo apple apple apple apple. appleавapple - apple fi Авfi apple appleау Ав д 39% apple 64%. apple АУ АУ fi appleау appleав fi apple appleауapple apple-

124 124 MEPO Ас Aapple: H Afi apple АУАв apple. АК - АвАУ 3. fi applefi apple Авfi apple АУ apple Ав АУ Ав apple. applefi АвАУ АУ apple appleав fi apple apple Ав АУ. дц Ав appleав Ав 56 fiapple apple apple apple Ав apple9. АК АУ appleау applefi APTc. - АУ fi apple fi apple - fi fi Ав д ( fi) fi АКд Ав. дц 2000 Ав appleау apple АУ PEP (Pulmonary Embolism Prevention trial) 7 apple apple apple / fi. Ав apple apple 160 mg Ав АУ placebo. дцfi, appleapplefi apple Ав apple appleappleау АКд АУ apple fi apple fiав applefi АУ. А appleapple д АУappleapple apple apple apple /. - appleapple АвАУ apple apple fiapple Ав apple 1,6% Ав АУ 2,5% (p=0,0003). АУ appleау appleapple Ав apple fi Ав fi. Ам apple fiapple, Ав apple, fi fi fi Ав appleав. А applefi apple apple apple Ав. дц appleау - АУ apple Ав applefi.

125 MEPO Ас Aapple: H Afi apple 125 дц Ав fi AAOS Ав Ав Ав applefi apple apple - А Аядл А АяАс 10,11. АУ apple Ав apple-. А АУ fi apple Ав - Ав Ав apple fiapple appleавfi fiapple apple apple АУ Ав 12. АК AAOS АУ д, АУ apple АУ appleав appleау АУ12. АК д applefi fi Ав apple apple applefi АУ appleapple appleappleау (АУapple - appleав- АУ) А» АУ АК..Ая 13. А» fi fi AAOS Ав apple- д fi applefi apple А Аядл А АяАс. appleappleау АУ Ав AAOS apple apple Авfi 325 mg Ав applefi apple А Аядл А АяАс. длав applefi apple Ав apple - АУ Ав apple АУ АУ Ав fi. appleappleау, Авapple fi Ав АУ apple applefi АУ 12. АУ apple appleapple fi apple Ав АУ АУАв applefi.

126 126 MEPO Ас Aapple: H Afi apple д длд АВдлА АсАядлАя 1. Hovens MM, Snoep JD, Tamsma JT, Huisman MV. Aspirin in the prevention and treatment of venous thromboembolism. J Thromb Haemst 2006 Jul;4(7): Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. Antithrombotic TrialistsА» Collaboration. BMJ 2002 Jan 12;324(7329): Cohen AT, Skinner JA, Kakkar VV. Antiplatelet treatment for thromboprophylaxis: a step forward? BMJ 1994; 309: Gent M, Hirsh J, Ginsberg JS, Powers PJ, Levine MN, Geerts WH, Jay RM, Leclerc J, Neemeh JA, Turpie AG. Low-molecular-weight heparinoid orgaran is more effective than aspirin in the prevention of venous thromboembolism after surgery for hip fracture. Circulation 1996 Jan 1;93(1): Lotke PA, Palevsky H, Keenan AM, Meranze S, Steinberg ME, Ecker ML, Kelley MA. Aspirin and warfarin for thromboembolic disease after joint arthroplasty. Clin Orthop Relat Res Mar;(324): Gehling H, Giannadakis K, Lefering R, Hessmann M, Achenbach S, Gotzen L. Prospective randomized pilot study of ambulatory prevention of thromboembolism. 2 times 500 mg aspirin (ASS) vs. clivarin 1750 (NMH). Unfallchirurg Jan;101(1): Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) trial. Lancet Apr 15;355(9212): Cusick LA, Beverland DE. The incidence of fatal pulmonary embolism after primary hip and knee replacement in a consecutive series of 4253 patients. J Bone Joint Surg Br May;91(5): Imperiale TF, Speroff T. A meta-analysis of methods to prevent venous thromboembolism following total hip replacement. JAMA Jun 8;271(22): Parvizi J, Azzam K, Rothman RH. Deep venous thrombosis prophylaxis for total joint arthroplasty: American Academy of Orthopaedic Surgeons guidelines. J Arthroplasty 2008 Oct;23(7 Suppl): American Academy of Orthopaedic Surgeons. Clinical Guidelines on prevention of symptomatic pulmonary embolism in patients undergoing total hip or knee arthroplasty. ( дл 2009). 12. Eikelboom JW, Karthikeyan G, Fagel N, Hirsh J. American Association of Orthopedic Surgeons and American College of Chest Physicians guidelines for venous thromboembolism prevention in hip and knee arthroplasty differ: what are the implications for clinicians and patients? Chest 2009 Feb;135(2): U.S. Department of Health and Human Services. The Surgeon GeneralА»s call to action to prevent deep vein thrombosis and pulmonary embolism ( дл- 2009).

127 MEPO Ас A A A A АК apple appleау apple appleау apple. А - АУ apple apple ( appleав - appleав ) АУ appleав fi apple apple Ав apple, fi. АУ АУ apple АУ applefi apple 1,2. АК appleау, apple apple- АУ appleapple. АК fi - АУ appleapple apple apple apple apple. АК Ая Ая (ASRA) apple fiapple длapple (SEPAR) Ас (DGAI) Ая (OGARI) д (BARA) АУ Ав Ав apple apple -. А Ав applefi АУ АвАУ 1,3. Ая, applefi Ав ACCP (2008) apple АУ appleappleау apple 2.

128 128 MEPO Ас A A АсдлАм АмАядцдцАКдл А АКАсдл: АК apple appleауapple apple, - Ав apple. АК, appleауapple appleау -. АК appleав appleауapple apple apple fi appleappleав applefi fi. АК fi appleав - appleappleау fi fi appleауapple apple apple apple apple. apple apple Авfi applefi АУ apple appleауapple appleapple Ав fi apple. Ам apple apple appleав appleауapple applefi apple appleapple fiapple АУ. длдлам АмАядцдцАКдл А АКАсдл: apple Ав АК apple Ав Ав Ав Ав apple- Ав Ав apple Авapple appleау apple apple 1,3. apple А apple Clopidogrel (Plavix, Iscover ) appleауapple Авfiapple apple АУ apple apple 1,3. HMMB АК apple appleавау apple apple АКд apple АвАвАвАУ apple. appleappleау HMMB fi fi apple apple

129 MEPO Ас A A 129, applefiав Ав.. АК fi - apple АУ 13 appleapple - apple АУ fi Авfi apple applefi АУ 12 apple-. Ая Ая fiapple Авfi fi, fiapple apple (30mg x 2), Ав Ав. дц FDA Авfi 60 appleapple 1998 АУ fi 13 appleapple АУ Medwatch Ав- АУ appleapple 1. АК appleау apple apple apple HMMB appleауapple 12 Авfi. appleapple apple apple- HMMB appleауapple 6 appleау. АК appleав appleауapple - Ав 4-6 apple applefi Авfi1,2. Fondaparinux (Arixtra ) АК АУ Expert 4 appleау fi Fondaparinux apple - fi Ав. АК appleав appleауapple appleapple 36 apple Авfi applefi АК Авapple apple Ав appleау applefi. Аяд Ам Ая apple Аяд Ам apple apple apple fi INR fi 1,5. applefi apple fi apple Аяд Ам applefi, АУapple HMMB apple АУ. Ая appleapple appleау- appleapple applefi HMMB Аяд Ам 1,2. applefi fi apple (Dabigatran- Pradaxa & Rivaroxaban-Xarelto ) apple АУ apple -

130 130 MEPO Ас A A fi Dabigatran Rivaroxaban. АК fi - applefi fi apple appleауapple apple fi appleapple applefi apple. SPC Ав 5,6 Ав Авfi fi apple appleав -. SPC Dabigatran apple - Ав. SPC Rivaroxaban apple fi Ав appleауapple applefi 18 Авfi applefi Ав appleауapple - applefi АУ applefi. АК applefi Ав Ав apple - Ав appleapple- АУ. Ам appleapple apple apple АУ appleapple, applefi АУ apple.

131 MEPO Ас A A 131 д длд АВдлА АсАядлАя 1. Horlocker TT, Wedel DJ, Benzon H, Brown DL, Enneking FK, Heit JA, Mulroy MF, Rosenquist RW, Rowlingson J, Tryba M, Yuan CS. Regional anesthesia in the anticoagulated patient: defining the risks (the second ASRA consensus on neuraxial anesthesia and anticoagulation) Reg Anesth Pain Med May-Jun;28(3): 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: Llau JV, De Andrедs J, Gomar C, Gfimez-Luque A, Hidalgo F, Torres LM. Anticlotting drugs and regional anaesthetic and analgesic techniques: comparative update of the safety recommendations. Eur J Anaesthesiol May;24(5): Singelyn FJ, Verheyen CC, Piovella F, Van Aken HK, Rosencher N; EXPERT Study Investigators. The safety and efficacy of extended thromboprophylaxis with fondaparinux after major orthopedic surgery of the lower limb with or without a neuraxial or deep peripheral nerve catheter: the EXPERT Study. Anesth Analg Dec;105(6): Pradaxa - Summary of Product Characteristics (SPC): ( 2009). 6. Xarelto - Summary of Product Characteristics (SPC): ( 2009).

132

133 MEPO Ас apple E АУ Eapplefi apple E АУ Eapplefi А appleау applefi А appleав fi АУ АУАв. А АУ apple apple fi, - Ав, apple,.. АУ apple fi apple apple - appleау applefi Ав apple. А appleау applefi АУ apple АУ fi apple- АУ fi. АК appleау appleав Ав fiapple. А fi - apple fi apple АУ applefi appleapple fi apple fi. Ас fi apple- Ав apple apple appleау applefi (MIS LIT) АУ - (apple apple Ajay Kakkar ).

134

135 MEPO Ас apple A apple A А apple АУ Ав apple applefiав apple Ав appleapple appleау1. fiapple apple- Ав fi АУ fi appleав apple. fi fi fi АУ apple Ав appleapple fiав apple. appleapple apple apple- applefiав apple, applefi - АУ АУ appleауapple (д АУapple АУ АУАв apple - Ам Ам АУ). apple apple Авfi apple2. д длд АВдлА АсАядлАя 1. 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: Kakkar Ajay - apple apple, 2009.

136

137 MEPO Ас E apple apple 1 Ам Ав Ав 2-5 АУ. А АУ Ав Ав apple, АУ Авfi fi АУ. дц 2/3 fi appleав apple applefi. АК appleав АУ fi Ав. дц apple АУ apple- appleав apple АКд Ав. appleapple apple apple АУ apple- Ав apple Ав, fi appleау fiapple apple АКд. д длд АВдлА АсАядлАя 1. Chulinal SD and Bates SM. Venous thromboembolism in pregnancy: diagnosis, management and prevention. Thromb Haemost 2009;101:

138

139 A Eapplefi 139 A applefi А Ав applefi fi Ав apple- АУ fi appleapple apple apple fi fi appleау applefi apple Авfi Ав. apple apple apple appleавfi oapple fi: 1. Ая apple apple fi ( Ав apple) - apple Аяд Ам (apple.. Sintrom ) applefi apple appleав appleау Авapple Аяд Ам apple appleав. АвАвАУ Ав apple, Ав apple АУ- (bridging therapy); 2. A apple apple (apple.. Plavix ) applefi fi appleауapple Авfi appleapple АвАв apple appleау apple. АУ apple fi, applefi АУ apple appleау; 3. Ая applefi applefiав apple applefi apple apple apple. apple apple apple appleapple; дц АУ apple apple applefi АУ - Ав. А fi АУ appleapple -

140 140 A Eapplefi apple АУ appleав Ав-. O Авfi fi АУ apple- Ав Ав АУ apple : Douketis JD, Berger PB, Dunn AS, Jaffer AK, Spyropoulos AC, Becker RC, Ansell J, American College of Chest Physicians. The perioperative management of antithrombotic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008 Jun;133(6 Suppl):299S-339S Patrono C, Baigent C, Hirsh J, Roth G. Antiplatelet Drugs. American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) Chest 2008; 133:199S-233S. 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:

141 141

142 142 apple apple д д дгдед д дидгдцдгда д»д д»дфд»дбдедфда д дхдддгдад да (дндлд д длд д ) д»дгд»дгдад деда д дфдцд дад дгдад д»д Dalteparin (Fragmin ) Enoxaparin (Clexane ) д д длд дк д д д дкд длд дод д длд дндлд д д дн дмд д длд дн длдлд дод д длд дндлд д д дн: 5000 IU дмд д длд дн д д дм дмд дод д длд дндлд д д : 5000 IU 2 длд длдлд - д д д 4 8 длд д д дмд д дод д длдкдмд д : 2500 IU 4-8 длд д д дмд д дод д длдкдмд д : 2500 IU длд длдлд д д дод д длдкдмд д 40 mg 12 А 3 длд д д дмд д дод д длдкдмд д 30 mg дадл дмдкд длдлдмдк д д дмд д дод д длдкдмд д дкд длд 5000 IU длд д дкд д длдкдмдп 5000 IU длд д дкд д длдкдмдп 5000 IU длд д дкд д длдкдмдп 40 mg длд д дкд д длдкдмдп 30 mg д д дкд д длдкдмдп Nadroparin (Fraxiparine ) 12 длд длдлд - д д д 12 длд д д дмд д дод д длдкдмд д : (<50 kg: 0,2 ml, kg: 0,3 ml, >70kg: 0,4ml) < 50 kg kg > 70 kg дгдодлд дмдкд 3дК дкд длд 0,2 ml 0,3 ml 0,4 ml дгд дм дмдкд 3дК дкд длд 0,3 ml 0,4 ml 0,6 ml Tinzaparin (Innohep ) Bemiparin (Ivor ) Fondaparinux (Arixtra ) 2-12 длд длдлд д д дод д длдкдмд д 4500 IU 2-12 длд длдлд д д дод д длдкдмд д 50 IU/kg 2 длд длдлд д д дод д длдкдмд д 3500 IU 6 длд д д дмд д дод д длдкдмд д 3500 IU 6 длд д д дмд д дод д длдкдмд д 2,5mg 4500 IU 50 IU/kg 3500 IU 3500 IU 2,5mg

143 143 д д дгдед д дидгдцдгда д»д д»дфд»дбдедфда д дхдддгдад да (д дл дмд дн дмдмд д дмд ) д»дгд»дгдад деда д дфдцд дад дгдад д»д д д длд дк д д д дкд длд дод д длд дндлд д д дн дадл дмдкд длдлдмдк д д дмд д дод д длдкдмд д дкд длд Dabigatran Etexilate (Pradaxa ) дбд д д д д дмд д д д д д д дод д 110 mg (1-4 длд д д дмд д дод д длдкдмд д ) 220 mg длд д дкд д длдкдмдп дцд д д д д дмд д д д д д д дод д ддд д д д >75 д дмд дгдмдлд д д д дндлд д д д д длдлд д д д (CrCl: ml/min) дфдодк д д д д д д длд дк (Angoron ) 75 mg (1-4 длд д д дмд д дод д длдкдмд д ) 150 mg длд д дкд д длдкдмдп Rivaroxaban (Xarelto ) 6-10 длд д д дмд д дод д длдкдмд д 10mg 10 mg длд д дкд д длдкдмдп

144 дцавдламак АяАядцАКАКАК А -АУ apple appleapple, АУ appleapple А appleав дц- Ав fi АУ apple fiав apple applefi Ав АУ, apple apple, apple apple fi apple appleау applefi. apple apple apple appleавapple / АУ applefi ( ), АУ - Ав.

145 ISBN