侵入性治療用藥安全

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侵侵侵侵侵侵侵侵侵 侵侵侵 侵侵侵侵侵侵侵 侵侵侵侵侵侵 2011.7.30

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侵入性治療用藥安全. 徐永偉 麻醉科主治醫師 馬偕紀念醫院 2011.7.30. 侵入性治療. 侵入性治療 的 知情同意 “ An ounce of informed consent is worth a pound of malpractice defense." “ 事前一盎司告知勝過在法院一磅解釋”. 大綱. 侵入性治療用藥安全 抗凝血劑 抗血小板藥物 預防性抗生素 鎮靜止痛藥物. 抗凝血劑的用藥安全. 侵入性治療前停用抗凝血劑 ?. 栓塞. 出血. 凝血機轉 ( Hemostasis). - PowerPoint PPT Presentation

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  • 2011.7.30

  • An ounce of informed consent is worth a pound of malpractice defense."

  • ?

  • (Hemostasis)3 Major systems involved (Vessel wall) (Platelets) (Coagulation factors)

  • FibrinogenFibrinThrombinProthrombinXaVaVIIaTFIXaVIIIaXIaXIIaXIIIaSoft clotFibrinHard clotVVIII

  • Enhances the action of Antithrombin III Factors IIa, IXa, Xa, XIa and XIIaActivated Partial Thromboplastin Time (APTT) Vitamin K antagonistFactors II, VII, IX and XProthrombin Time (PT)INRHeparinWarfarin

  • Warfarin: Vit KVit KII, VII, IX, XPT( Prothrombin time;) 2- 2.5warfarin

  • warfarinGenotype variants of CYP2C9 and VKORC1

  • Warfarin ~ 174199920074

    2011, Vol .54, No.3

  • Warfarin ~ 2712001200944INRinternational normalized ratio1.0 2011, Vol .54, No.3

  • Warfarin ~ 373200620094INR2.0INR1.42 2011, Vol .54, No.3

  • (Warfarin)45INR12~24warfarinwarfarin(bridging anticoagulant) heparin low molecular weight heparin Antithrombotic and Thrombolytic Therapy 8TH ED: ACCP Guidelines

  • (warfarin) INR=2~4collagen sponges 5 tranexamic acid qid 2 Guideline for the management of patients on oral anticoagulants requiring dental surgery. (UK)

  • ~ 752001Panaldin (Ticlopidine)2002(TUR-B) 2500 cc Bleeding Time (>5 )

  • Aspirin 100mg / qd: TX A2: : Ticlopidine: C-AMP: aspirin:

  • clopidogrel( Plavix):ADP75mg/ qdbioavailability

  • ?5~10 AspirinPlavix, clopidogrel 24 612

  • ~ 10741.1%137.0%35.3%47.2%36 2002;12:215-25

  • WHO Prevalence SurveyMayon-White et al. J Hosp Infect 198847 hospitals in 14 countries during 1983-85

    Wound Class

    Prevalence

    x 100 post-op patients

    Clean

    13.3

    Clean-contaminated

    16.4

    Contaminated

    28.9

    All

    16.6

    (range 4.6-34.4)

  • % (hour)14/3695/6995/1,0092/1801/611/411/4715/441012343>2>1012345Classen DC et al. N Engl J Med. 1992;326:281286.

  • Guidelines for the use of prophylactic antibiotics in surgery in Taiwan ()2004 http://www.cdc.gov.tw/

  • (single dose)3

  • 30

  • RISKBENEFITHypoventilation Apnea Airway obstruction Laryngospasm Cardiac depressionMinimize pain Control movementMinimize anxietyMaximize amnesia benefits, risks

  • No matter the level of sedation you intend to produce, you should be able to rescue patients one level of sedation deeper than that which was intended. JCAHO

  • Unfractionated (5000-30000 Da) - Low molecular weight (LMWH) (1000-10000 Da)Unfractionated (5000-30000 Da) - Low molecular weight (LMWH) (1000-10000 Da)

    INR (the INR achieved with a stable warfarin dose), the target INR (the desired INR), the useof concomitant medications (grouped according to those that increase and those that decrease theINR), and the presence of genotype variants of CYP2C9 (*1, *2 and *3) and VKORC1 (at least one ofseven single nucleotide polymorphisms [SNPs] in linkage disequilibrium11),*2011 MarchPLAVIX 2.1. Antiplatelet agents 2.1.7 clopidogrel (Plavix 75mg) plavixclopidogrel headache(7.6%) dizziness(6.2%),depression(3.6%),fatigue(3.3%)

    1. (1) acetylsalicylic acid (Aspirin) (2) acetylsalicylic acid (Aspirin) (3) (4) XXacetylsalicylic acidx() 2. 3acetylsalicylic acid (aspirin) 3. ST(Q) acetylsalicylic acid (aspirin) 9 In patients with a bare metal coronary stent who require surgery within 6 weeks of stent placement, werecommend continuing aspirin and clopidogrel in the perioperative period (Grade 1C); in patients with adrug-eluting coronary stent who require surgery within 12 months of stent placement, we recommend continuingaspirin and clopidogrel in the perioperative period[4,5]Older ageObesity Malnutrition Diabetes mellitus Immunocompromising diseases or therapies Presence of other infections Skin diseases

    Preoperative Factors Prolonged pre-op stay Shaving the skin Inadequate antibiotic prophylaxis

    Surgical Factors Inadequate skin antisepsis Emergency procedure Prosthetic implants Prolonged procedure Use of drains Poor technique Unexpected contamination

    Environmental Factors Staph. or Strep. carrier Excessive activity in OR Contaminated antiseptics Inadequate ventilation Inadequately sterilized equipment

    Older ageObesity Malnutrition Diabetes mellitus Immunocompromising diseases or therapies Presence of other infections Skin diseases

    Preoperative Factors Prolonged pre-op stay Shaving the skin Inadequate antibiotic prophylaxis

    Surgical Factors Inadequate skin antisepsis Emergency procedure Prosthetic implants Prolonged procedure Use of drains Poor technique Unexpected contamination

    Environmental Factors Staph. or Strep. carrier Excessive activity in OR Contaminated antiseptics Inadequate ventilation Inadequately sterilized equipment

    Older ageObesity Malnutrition Diabetes mellitus Immunocompromising diseases or therapies Presence of other infections Skin diseases

    Preoperative Factors Prolonged pre-op stay Shaving the skin Inadequate antibiotic prophylaxis

    Surgical Factors Inadequate skin antisepsis Emergency procedure Prosthetic implants Prolonged procedure Use of drains Poor technique Unexpected contamination

    Environmental Factors Staph. or Strep. carrier Excessive activity in OR Contaminated antiseptics Inadequate ventilation Inadequately sterilized equipment

    Classen and colleagues also investigated the rates of surgical infections compared with the timing of antibiotic administration relative to the time of incision. Patients who received prophylactic antibiotics within 2 hours of the start of surgery experienced the lowest infection rate. The pattern of higher infection rates with each hour of delayed administration postsurgical incision was statistically significant (Wilcoxon test P