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