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TOPIC: THROMBOSIS AND EMBOLIA OF MAGISTRAL VESSELS. PTPhS.


(for the 5-th year students of the faculty of general medicine) The chair of hospital surgery of Volgograd State Medical University Zaporoshenko A.V. Plan of the lecture:
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Definition of the concepts. Motivation of the problem; Classification of ischemic lesion of extremities; Classification of postthrombophlebitic syndrome PTPhS; Factors and risk stages of the thrombosis of profound veins/pulmonary embolism development.; Risk factors of the arterial thrombosis; Clinical features of embolism and thrombosis; Pulmonary embolism; Diagnostics of thrombosis and embolia; Preventive measures and treatment:

2. 3. 4. 5. 6.
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Phramacotherapy; Surgical therapy; Conclusion; Recommended literature.

10. 11.

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Classification of the ischemic lesion of extremities (Saveliev V.S., Zatevakhin I.I., 1970): I feeling of numbness, coldness, paresthesia. I b the same symptoms and pain. II disturbances of perceptibility and active movements in joints II b plegia of the extremity. III subfascial edema of the extremity. III contraction.

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3 Risk factors of the profound veins thrombosis/pulmonary embolism: Pulmonary embolism/profound veins thrombosis in anamnesis, Varicose veins

Oncological diseases, Postoperative complications, General anesthesia, Age over 40, Obesity, Diabetes, Dehydratation/polycythemia, Infection/sepsis, Treatment with estrogens, Blood circulation insufficiency, Respiratory insufficiency,

Character and duration of the surgery,


Bed regime (for more then 4-6 days), Immobilization,

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Trauma, Postoperative period. Risk of postoperative venous thromboembolic complications (C.Samama and M.Samama, 1999, modificated):
Risk Risk factors from: Surgery Patients comditions Low(I ) I. Uncomplicated . no interferences, lasting no more then 45 min (appendectomy, hernia section, delivery, abortion, transurethral adenectomy etc.) Moderate (I, I, II. Larger . Over 40, varicose II, II interferences(cholecyst veins, prescription of ectomy, stomach estrogens, blood resection, complicated circulation appendectomy, insufficiency, bed Cesarean section, regime longer then 4 uterus amputation etc) days, 40 ,infection, obesity, postpartum period (6 weeks) High II, III, III. Expanded . Oncological III, III surgeries(gastrectomy, diseases, profound pancreatectomy, veins thrombosis, colectomy, uterus pulmonary embolism in extirpation etc) anamnesis, paralysis of lower extremities, thrombophilia

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5 Risk factors for arterial thrombosis:


Thrombophilia, Obesity, Emotional stress, Smoking, Atherosclerosis, Hyperlipidemyia, Hypercholesterolemia, Increase of blood pressure, Increase of blood viscosity, Age, Oral contraceptives, Disturbance of nutrition regime,

Diabetes,

Coronary vessels diseases in anamnesis.

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Classic triad of profound veins thrombosis of the lower extremities:

Pain. Edema.

Increased skin temperature of the extremity.

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Classification of the antithrombotic medications:


1.

antiaggregants (antithrombotic drugs): Acetylsalicylic acid (aspirin). Dipiridamol (Curantyl). Indobuphen (Ibustrin). Tiklopdin (Ticlid). Clopidogrel (Plavinix). Inhibitors of glycoprotein receptors (GP) II

b/III a:

Abximab (Rheo-pro-). Lamifiban. Integrilin.

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8 Classification of antithrombotic medications:


2. anticoagulants: Direct:

heparin . Low-molecular heparins: Dalteparin (fragmin). Nadroparin (fraksiparin) Parnoparin (fluxum). Reviparin (Clivarin). Enoxaparin (Cleksan). Sulodeksid (Vessel due F) Indirect inhibitors of prothrombine: Girudin (Lepirudin). Indirect: Acenocoumarol (syncumar). Caumarin (Varfarin). Phenindione (Phenilin).

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Classification of the antithrombotic medications:

3. Thrombolytic medications:

Streptokinase (Cabikinase, streptase).

Streptodekase. Urokinase. Anisoisolated plasminogen-streptokinase activated complex (anistreplase)

Tissue plasminogen activator (alteplase, TPA).

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10 Preventive measures against venous thromboembolism complications:


Risk stages Low Preventive measures Early exercising of patients Elastic compression of low extremities (Clexan 20 ) * once a day subcutaneously or 5000 Units * 2-3 times a day subcutaneously or Prolonged interrupted compression of extremities (clexan 20 ) * once a day subcutaneously or 5000-7500 units * 3-4 times a day subcutaneously + methods of acceleration of venous circulation

Moderate

High

Special cases

Medical doses of or + Partial occlusion of inferior vena cava (implantation of filter, plication)

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Indication for prescription of heparin:


Treatment of acute arterial thrombosis.

Treatment of acute thrombosis and superficial veins. patients, which are in shock (nonhemorrhagical).

Prevention and treatment of acute thrombosis in Prevention of reocclusion after angioplasty Prevention of thrombosis and embolism during valves prosthesis in cardio-vascular surgery. Decrease of the risk of thrombosis of profound veins and pulmonary embolism after surgeries, during prolonged immobilization or other risk factors. Prevention of reocclusion in patients receiving Thrombolytic therapy with the help of tissue-type plasminogen activator.

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Positive moments of heparin prescription:

accessibility. (substitution therapy).

Treatment with heparin is physiological Effectiveness studies). Successive clinical use of heparin. and relative safety of

heparin (proved by multiple randomized

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Disadvantages of ungraded heparin in prevention and treatment of thrombosis:

Relatively low bioavailability. Multiple introduction of heparin. (up to 10%).

Rapid elimination from the organism

Significant number of hemorrhagic complications Necessity of thorough laboratory monitoring of the system of coagulation. No reliable direct correlation between the quantity and effect expression. No clinically valuable effect on thrombin, connected with thrombi.

Increased sensitivity reaction, where heparin is an allergen.

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Model of heparin indication due to the initial time of blood coagulation:

Time of blood coagulation, min (Lee-White) Less then 5 5-10 11-18 19-25 More then 25

Heparin dose, Units 20 000 15 000 10 000 500 Injection isnt prescribed

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Indirect anticoagulants:
Neodicumarin 0,1 (N. 30). 1pill 2-3 times a day, controlling prothrombin time (PT). Tab. Phepromaron 0,01 (N. 20). Tab. Nitropharini 0,005 (N. 30). Tab. Syncumari 0,004 (N. 50) /syncoumar or acenocoumarol/ from the 2-nd day of treatment the medicine is prescribed in the supporting dose of 2 mg/daily once a day in the morning. Tab. Phenylini 0,03 (N. 30) /phenylin, or phenindione/. Tab. Omephini 0,05 (N. 30).

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Advantages of low-molecular heparins over upgraded heparin:

Prolong effect. Introduced 1-2 times a day. control.

No need for the frequent laboratory Less expressed influence on

thrombocytes. Less frequency of the side effects and complications development.

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17 Methods of embolectomy in patients with pulmonary embolism: Trendelenburgs position with extrapleural approach, cross-clamping of aorta and pulmonary artery (it is nor used nowadays).

Embolectomy through the branches of pulmonary artery (Marion P., Estanove K., 1956 . ). Embolectomy from the pulmonary artery in conditions of temporary (more then 3 min) cross-clamping of veins cava (Vosschulte K., 1959). It is advised to perform a surgery in conditions of artificial lung ventilation. It is rather well spread method of surgery.

Transvenous embolectomy is the most perspective.