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膝关节镜后的血栓预防
Thromboprophylaxis after Knee Arthroscopy


Rebecca E. Berger ... 其他 • 2017.02.09

本互动栏目讨论一个临床问题的解决方法。文中先提供一份病例摘要,后面是具体的治疗选项,其中任何一个选项都没有绝对的对错。之后,该领域的专家将撰写短文论证每个选项。读者可参与其中,形成群体意见,他们可以选择一个选项,如果愿意,还可以说明理由。

 

病例摘要

一名考虑在膝关节镜手术后进行血栓预防的女性

Rebecca E. Berger, M.D.

 

Benson女士是一名60岁的女性,她来到您的办公室讨论即将进行的膝关节镜手术。她最近被诊断为右外侧半月板撕裂,并计划进行关节镜下半月板切除术。她听说膝关节手术会增加血块的产生危险,并想知道是否应该在术后使用抗凝剂以降低危险。需要关注的Benson女士的病史包括高血压和2型糖尿病,她正在服用赖诺普利和二甲双胍进行治疗。她既往有吸烟史,曾连续30年每天抽一包烟,直到10年前戒烟。患者无静脉血栓栓塞疾病个人史,也无出血体质。她的姊妹曾在一次妊娠后发生肺栓塞。当日在办公室,Benson女士的血压为125/75 mmHg,体质指数(体重[kg]除以身高[m]的平方)为31。体检结果中需要关注的是麦氏试验结果阳性,右膝施轻度外翻力后有疼痛。她计划在术后疼痛减轻后继续接受物理治疗。Benson女士向您询问如何在术后预防血块形成。您的建议如何?

 

治疗选项

您会向该患者推荐以下哪一个选项?

1. 接受术后血栓预防。

2. 不接受术后血栓预防。

为帮助您做出决策,其中每种方法均由该领域的一名专家撰写短文提供支持。根据您对于该患者的了解以及专家提出的观点,您会选择哪一个选项?请做出选择,在NEJM.org投票并留言。





作者信息

Rebecca E. Berger, M.D., Menaka Pai, M.D., and Anita Rajasekhar, M.D.
From the Division of Hematology and Thromboembolism, McMaster University, Hamilton, ON, Canada.

 

参考文献

1. Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141Suppl:e278S-325S

2. Krych AJ, Sousa PL, Morgan JA, Levy BA, Stuart MJ, Dahm DL. Incidence and risk factor analysis of symptomatic venous thromboembolism after knee arthroscopy. Arthroscopy 2015;31:2112-2118

3. van Adrichem RA, Nelissen RG, Schipper IB, Rosendaal FR, Cannegieter SC. Risk of venous thrombosis after arthroscopy of the knee: results from a large population-based case-control study. J Thromb Haemost 2015;13:1441-1448

4. Camporese G, Bernardi E, Noventa F, et al. Efficacy of Rivaroxaban for thromboprophylaxis after Knee Arthroscopy (ERIKA): a phase II, multicentre, double-blind, placebo-controlled randomised study. Thromb Haemost 2016;116:349-355

5. Ramos J, Perrotta C, Badariotti G, Berenstein G. Interventions for preventing venous thromboembolism in adults undergoing knee arthroscopy. Cochrane Database Syst Rev 2008:CD005259-CD005259

6. van Adrichem RA, Nemeth B, Algra A, et al. Thromboprophylaxis after knee arthroscopy and lower-leg casting. N Engl J Med 2017;376:515-525

7. Cushman M. Epidemiology and risk factors for venous thrombosis. Semin Hematol 2007;44:62-69

8. Couturaud F, Leroyer C, Tromeur C, et al. Factors that predict thrombosis in relatives of patients with venous thromboembolism. Blood 2014;124:2124-2130

9. Pannucci CJ, Shanks A, Moote MJ, et al. Identifying patients at high risk for venous thromboembolism requiring treatment after outpatient surgery. Ann Surg 2012;255:1093-1099

10. Mauck KF, Froehling DA, Daniels PR, et al. Incidence of venous thromboembolism after elective knee arthroscopic surgery: a historical cohort study. J Thromb Haemost 2013;11:1279-1286

11. Camporese G, Bernardi E, Prandoni P, et al. Low-molecular-weight heparin versus compression stockings for thromboprophylaxis after knee arthroscopy: a randomized trial. Ann Intern Med 2008;149:73-82 

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