围麻醉期急性肺栓塞的诊治课件

1、Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee围麻醉期急性肺栓塞的防治重庆医科大学附属第一医院麻醉科闵苏Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee概念肺栓塞（肺动脉栓塞，pulmonaryembolism，PE）为内源性或外源性的栓子堵塞肺动脉或其分支，引起肺循环障碍的临床病理生理综合征。肺血栓栓塞（PTE）90%深静脉血栓形成（deepvenousthrombosis，DVT）静脉血栓栓塞性疾病（venousthromboembolism，VTE）Thisyear,mytownconstructionworki。

2、nthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee深静脉血栓的流行病学高发病率:高漏诊率:高死亡率:65～70万人/年，仅次于冠心病和高血压病国外漏诊率67％，国内漏诊率79％不经治疗者死亡率20~30%，治疗者2%~8%Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee深静脉血栓的发病机制1856年法国Virchow三角理论血流缓慢血管壁损伤血液成分改变Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,t。

3、heTownpartycommittee深静脉血栓形成及高危因素静脉淤血血管壁损伤血液高凝状态卧床、术后、妊娠产后、肥胖创伤、烧伤下肢手术败血症VirchowDVT发病机制术后、避孕药、肿瘤Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee高危手术骨科大手术癌症根治术心胸外科手术长时间手术高危因素高龄40y感染创伤肥胖妊娠期静脉曲张口服避孕药Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee相关高危因素——手术创伤——下肢挤压伤、脊髓损伤（50-100%）骨科——膝关节手术、髋关节手术(50%)腹部大手术(15－30%)大面积烧伤。

4、Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommitteeDVT的高危手术手术名称DVT发病率%大型胸部手术26～65大型腹部手术5～42髋关节手术37～74前列腺手术28～50腹部妇科手术11～29Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee相关高危因素——病人遗传因素（如缺乏抗凝血酶纤溶酶）高龄肥胖内科伴发疾病（如卒中、心衰）妊娠及产褥期病人恶性肿瘤制动（卧床＞4日、经济舱综合征）遗传性（特发性）VTE：抗纤维蛋白酶缺乏、蛋白C缺乏、蛋白S缺乏、高半胱氨酸血症Thisyear,mytownconstructionworkint。

5、hecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee左髂静脉腘静脉胫骨后静脉腘静脉（含腘静脉）以上下肢深静脉血栓形成远端DVT腘静脉（不含腘静脉）以下近端DVTThisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee相关高危因素——其它止血带Darmanis报道两例：膝关节、踝关节术中用驱血带后引起致命性PE右髂动脉85~95%的PE来自下肢深静脉和盆腔静脉血栓以左股静脉多见VAThisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipands。

6、upport,theTownpartycommittee不同麻醉术后DVT发生率作者手术椎管内麻醉全麻DavisMckenzieJorgensen股骨手术膝成形术胫骨手术46%48%18%12%76%76%50%45%Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee年龄40岁全麻+胸部或腹部手术时间30minDVT——Hull分级危险发生远端DVT的机率＜10%发展成近侧DVT的机率＜1%致命性肺栓塞的机率＜0.01%1．低危组病人Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee年龄40岁全麻+胸部或腹部手术时间30min恶性。

7、肿瘤、肥胖、静脉曲张瘫痪、长期卧床、心衰没有预防措施时：发生远端DVT的机率为10～40%发展成近侧DVT的机率为2～10%致命性肺栓塞的机率0.1～0.7%2．中危组病人Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee有DVT或肺栓塞病史严重外伤史恶性肿瘤需行腹部及盆腔较广泛手术下肢骨科较大手术（如髋关节手术，股骨颈手术等）没有预防措施时：发生小腿DVT的机率为40～80%发展成近侧DVT的机率为10～20%致命性肺栓塞的机率为1～5%3．高危组病人Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee肺栓塞中华医学会呼吸病学分会。

8、定义肺栓塞（pulmonaryembolism,PE)是以各种栓子阻塞肺动脉系统为其发病原因的一组疾病或临床综合症的统称，包括肺血栓栓塞、脂肪栓塞、羊水栓塞以及空气栓塞等。Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee肺血栓栓塞症（pulmonarythromboembolism,PTE)由于静脉系统或右心的血栓阻塞肺动脉或其分支所致疾病，以肺循环和呼吸功能障碍为其主要临床和病理生理特征。PTE为PE的最常见类型，占PE中的绝大多数，通常所称PE及指PTE。引起PTE的血栓主要来源于深静脉血栓形成。Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownp。

9、artycommittee流行病学肺栓塞发病率在心血管疾病中仅次于冠心病与高血压。年龄越大发病率越高，发病率随人群老化而增加。致残致死率高，美国肺栓塞的死亡率占死亡病因第三位，仅次于肿瘤和心肌梗死。不经治疗的肺栓塞死亡率为20%~30%，经明确诊断并经治疗者死亡率降至2%~8%。Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee肺梗塞（pulmonaryinfarction,PI)肺动脉发生栓塞后，若其支配区的肺组织因血流受阻或中断而发生坏死，称为肺梗塞。肺栓塞发展为肺梗塞只有10%。（肺动脉和支气管动脉双重供血）Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport。

10、,theTownpartycommittee肺动脉主干栓塞：急性肺心病、肺动脉高压、休克、肺血液灌流及换气功能障碍，最终导致死亡。疾病的三个过程：周围静脉血栓形成——肺动脉栓塞——肺梗塞下肢深静脉血栓形成的患者并发肺栓塞可有30％～50%，致命性肺栓塞占0.5%～2.0％。Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee肺动脉主干栓塞，可立即引起四种反射1．全肺血管强烈反射——急性右心衰2．肺-体循环反射——休克3．肺-冠状动脉反射——心肌急性缺血4．肺-肾动脉反射——急性肾衰Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommit。