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U.O.D Ematologia
Prof.ssa L. Annino
IL RISCHIO TROMBOEMBOLICO IN LAPAROSCOPIA
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NUOVA TEORIA DELLA COAGULAZIONE
IX IXa
TISSUE FACTOR (Tromboplastina)VII/VIIa
Ca
VIIIaPLCA
protrombina trombina
X XaVaPLCA
VIA INTRINSECA
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TFTF TFTF TF TF TF TFTFTF TFTF TF TFTF TF
ATTIVAZIONE DELLA TROMBINA
X+V
IX+VIII TF+VIIa
TROMBINA
TF
TF TF
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TF PAR TMPC PCa MONONUCLEATO
PAR
IIaTFPAR
FIBRINOGENO FIBRINA
V IXa
VIII XaPIASTRINA
CELL. ENDOTELIALE
V
IXIXaVIIa
V
VIII
IX
IXa
VIIa
Xa
ATTIVAZIONE DELLA TROMBINA
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PAR 2 PAR 1 PAR 3 PAR 4
TF
VIIa
TF
VIIaXa
ANGIOGENESI
VEGFPROTEINASI
VEGFPGFHIF-1
AGGREGAZIONEPIASTRINICA EMOSTASI
PROTROMBINA TROMBINA EMOSTASI
ATTIVAZIONE DELLA TROMBINA
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Predictors of thromboembolic risk
in medical and surgical patients
Clinical setting Patient risk factors
Clinical Molecular Inherited Acquired
Type/duration of surgery
Type of anaesthesia Stroke MI
Congestive heart failure
Chest infection Intensive care Spinal cord injury Multiple trauma
Previous VTE Varicose veins Malignancy Age > 70 Obesity Prolonged bed rest Level of hydration Severe medical
illness Infection/sepsis Pregnancy/ puerperium
Combined oral contraceptive
Factor V Leiden Prothrombin 20210A mutation Deficiencies: Antithrombin III Protein C Protein S
Lupus anticoagulant
Anticardiolipin antibodies Myeloproliferativedisease
Hyperhomocystei-naemia
Hyperhomocystei-naemia
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Classification of level of VTE risk in
surgical patients(6th ACCP Consensus Conference on Antithrombotic Therapy)
Low risk Moderate risk High risk Highest risk
Minor surgery Major surgery Major surgery Major surgery in patientsin patients in patients in patients >40 years plus:<40 years, no risk <40 years, >40 years, Previous VTEfactors no other additional risk Malignancy
risk factors factors or MI Hip or knee surgery Stroke or spinal cord
Minor surgery Non-major injuryand risk surgery in Hip fracturefactors patients Major trauma
>60 years, Hypercoagulable stateNon-major or withsurgery additionalin patients risk factorsaged40-60 years
Geerts et al. Chest 2001
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Markers for specific risk classifications
High-risk markers thrombophilia; age >60 years; history of
DVT/PE (certain patients) Moderate-risk markers
age 40–60 years (certain patients) Low-risk markers
age <40 years (in absence of other risk factors)
Nicolaides et al. Int Angiol 1997
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Definition of thromboembolicrisk categories
Category Calf-vein Proximal Fatal PE (%) thrombosis (%) vein thrombosis (%)
High risk 40-80 10-30 > 1
Moderate risk 10-40 1-10 0.1-1
Low risk < 10 < 1 < 0.1
Modified from Salzman and Hirsh. In: Colman RW et al, eds. Hemostasis and thrombosis; basic principles and clinical practice. New York: Lippincott, 1982
Nicolaides AN et al. Int Angiol 1997
PE, pulmonary emobolism
Frequency of VTE without prophylaxis
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Surgical risk-assessment model from the Paris public assistance hospitals
Chapuis et al. Sang Thromb Vaiss 1995
General/digestive surgery Structure of risk-assessment model
Risk associated Risk Risk associatedwith surgery level with patient
Less than 45 min, 1 No risk factorsno dissection
Moderate dissection, 2 Age >40 years less than 45 min confined to bed >4 days Complicated appendectomy Varicose veins, obesity Inflammatory GI disease
Neoplastic surgery 3 Actual/developing cancer
Previous thromboembolismThrombophilia
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Paris public assistance hospitals’recommendations for general surgery
Chapuis et al. Sang Thromb Vaiss 1995
Low
High
Moderate
1
2
3
2
1
3
Surgical risk + Patient risk = Thromboembolic Recommended factors factors risk therapeutic regimen
No treatment
LMWH, UFHor graduated compression stockings (GCS)
LMWH + GCS orUFH + GCS
1
2
3
1
2
3
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Laparoscopic surgery and thrombosis
Pneumoperitoneum haemodynamic changes:
Increase in the venous pressure distal to the obstacle Decrease in the blood flow Decrease in the blood venous return in lower limbs
Duration of surgery
Reverse Trendelenburg position
THROMBOSIS
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Laparoscopic surgery and thrombosis
Catheline JM, Int. Surg. Investig. 2000; 2(1):41-47
Thromboembolism prophylaxis and incidence of thromboembolic complications of laparoscopic surgery
Non-oncologic surgery: 2384 pts
8 DVT (0.33%)0 PE
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Laparoscopic surgery and thrombosis
Catheline JM, Int. Surg. Investig. 2000; 2(1):41-47
Thromboembolism prophylaxis and incidence of thromboembolic complications of laparoscopic surgery
8 DVT
6 Trendelenburg > 1h
Trendelenburg > 3h2
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Laparoscopic surgery and thrombosis
Catheline JM, Int. Surg. Investig. 2000; 2(1):41-47
Thromboembolism prophylaxis and incidence of thromboembolic complications of laparoscopic surgery
In 6/8 cases the DVT occurs:
after cessation of LWMH delivery after discharge at home before post-operative day 10
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Cellula tumorale
Tissue FactorProcoagulant protein
Attività fibrinoliticaT-PA,u-PA,,u-ParTf, PAI-1, PAI-2
Molecole diadesione
Effetto diretto
IL 1, TNF, VEGF
Effetto indiretto
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TF PAR TMPC PCa MONONUCLEATO
PAR
IIaTF
FIBRINOGENO FIBRINA
PAR
V IXa
VIII XaPIASTRINA
CELL. ENDOTELIALE
V
IXIXaVIIa
V
VIII
IX
IXa
VIIa
Xa
TF
PC
VIIa
IFNIL 1
CELL. NEOPLASTICA
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Complex Relation Between Cancer and VTE
VTE occult cancer Cancer increased risk of VTE
- peri-operatively - in non-surgical patients
Cancer resistance to prophylaxis and treatment
Cancer central catheter thrombosis
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Thrombopathogenetic Factorsin Cancer Patients
Hypercoagulability TF expression Endothelial damage tumour invasion,
chemotherapy, radiation, catheters, host response
Platelet dysfunction activation, thrombocytosis
Venous stasis venous obstruction,immobility, increasedblood viscosity
TF, tissue factor
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Embolia Polmonare e Mortalità
2a causa di morte nel paziente oncologico
20% delle TVP Paziente con TVP e tumore:
Mortalità a 6 mesi elevata, 3 Mortalità a 6 mesi elevata, 3 volte maggiore di quelli senza volte maggiore di quelli senza tumore e non sempre correlata tumore e non sempre correlata alla gravità del cancroalla gravità del cancro
Hillen HFP: Ann Oncol 2000Hillen HFP: Ann Oncol 2000Levitan et al, Medicine 1999Levitan et al, Medicine 1999Shen & Pollock South Med J 1980Shen & Pollock South Med J 1980
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Tasso di trombosi in pazienti neoplastici
Correlazioni
Levitan et al 1999Levitan et al 1999
98
81 7661
110117120
0
20
40
60
80
100
120
140
Ovaio Encefalo Pancreas LinfomaLeucemiaColonPolmone
Tasso di tromboembolismo in base alla localizzazione del tumore
Tasso/10.000 pazienti
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Cancer and Post-operative VTE
More extensive surgery Venous trauma Prothrombotic haemostasis Chemotherapy Radiation Indwelling vascular lines Prolonged immobilization
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Flordal PA et al. Eur J Surg 1996;162:783–9.
Independent Risk Factors for Major Post-operative Thromboembolism
2,070 patients undergoing elective abdominal surgery
Risk factor OR P Prevalence(%)
Malignant disease 1.7 <0.05 66Duration of surgery >150 min 1.4 <0.05 35Pre-op hospital stay 6 days 1.6 <0.02 24Previous major orthopaedic
event 1.7 <0.02 12Pre-op transfusion >1 unit 2.0 <0.01 7Previous thromboembolism 1.7 <0.04 6Leg ulcer 4.2 <0.001 0.5
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Br J Surg 1997;84:1099–103.
ENOXACAN Study
Efficacy and safety of enoxaparin versus unfractionated heparin for
prevention of deep vein thrombosis in elective cancer surgery: a double-blind randomized multicentre trial
with venographic assessment
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Br J Surg 1997;84:1099–103.
ENOXACAN Study Prophylaxis of VTE in Abdominal
and Pelvic Cancer Surgery
631 evaluable patients
UFH Enoxaparin(n=319) (n=312)
Overall 58 (18.2%) 46 (14.7%)DVT only 56 45PE + DVT 2 0Death 0 1
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ENOXACAN Study Blood Loss and Haemorrhagic
Complications 1,115 patients
UFH Enoxaparin(n=560) (n=555)
Intra-op bleeding (ml), median (range) 500 (11–9,670) 500 (22–7,000)
Post-op bleeding (ml), median (range) 434 (2–11,250) 385 (2–6,520)
Major bleeding, n (%) 16 (2.9) 23 (4.1)Discontinued prophylaxis,
n (%) 12 (2.1) 18 (3.2)Injection-site haematoma,
n (%) 11 (2.0) 6 (1.1)
Br J Surg 1997;84:1099–103.
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Duration of Thromboprophylaxis
1 weekor
1 monthor?
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Ris
k o
f V
TE
Surgery Discharge
Time
?
Risk of VTE over Time
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Reasons for Prolonged Prophylaxis
Late DVT Late fatal PE Impaired haemodynamics Proximal-vein injury Poor post-discharge mobilization Change in clinical routines Commercial interests
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ENOXACAN II
Duration of prophylaxis against venous thromboembolism with
enoxaparin after surgery for cancer
Bergqvist D et al. N Engl J Med 2002;346(13):975–80.
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Inclusion Criteria
Age 40 years Life expectancy 6 months Open, elective, curative
surgery Abdominal/pelvic cancer Duration of surgery 45 min General anaesthesia
Bergqvist D et al. N Engl J Med 2002;346(13):975–80.
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Primary Endpoint
Venographically confirmed DVT at Day 28±3
All objectively verified VTE before Day 28±3
Bergqvist D et al. N Engl J Med 2002;346(13):975–80.
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Risk Factors at Baseline
Intent-to-treat for efficacy population, n (%) Placebo
Enoxaparin (n=167) (n=165)
History of VTE 4 (2.4) 5 (3.0)Varicose veins 24 (14.4) 17 (10.3)Obesity 23 (13.8) 22 (13.3)Chronic heart failure 6 (3.6) 7 (4.2)Chronic lung disease 4 (2.4) 10 (6.1)Hormone replacement 4 (2.4) 4 (2.4)
Bergqvist D et al. N Engl J Med 2002;346(13):975–80.
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Characteristics of Surgical Procedures
Intent-to-treat for efficacy population, n (%) Placebo Enoxaparin
(n=167) (n=165)Location of surgery
Gastrointestinal 137 (82) 141 (86)Gynaecological 11 (7) 17 (10)Urological 17 (10) 11 (7)Others 3 (2) 2 (1)2 sites 11 (7) 9 (6)
Palliative surgery 6 (3.6) 16 (9.7)*Bleeding complications 8 (5) 10 (6)Duration of surgery, h:min 3:05 3:13
median (range) (0:45–11:00) (0:23–9:35)
*P=0.024
Bergqvist D et al. N Engl J Med 2002;346(13):975–80.
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Incidence of VTE
Intent-to-treat for efficacy population, n (%)
Placebo Enoxaparin RRR (%) P (n=167) (n=165) (95% CI)In double-blind period
All DVT 20 (12.0) 8 (4.8) 60 (10–82) 0.02Proximal DVT 3 (1.8) 1 (0.6)Distal DVT 17 (10.2) 7 (4.2)PE 1 0
At 3 monthsAll DVT 23 (13.8) 9 (5.5) 60 (17–81) 0.02Proximal DVT 4 (2.4) 2 (1.2)Distal DVT 17 (10.2) 7 (4.2)PE 2* 0
*One fatal
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Incidence of Haemorrhage
Placebo Enoxaparin (n=248) (n=253) n (%)
In double-blind period Minor 9 (3.6) 12 (4.7)Major 0 1 (0.4)Total 9 (3.6) 13 (5.1)
At 3 monthsMajor 1 (0.4) 2 (0.8)
Cumulative incidence at 3 monthsMajor 1 (0.4) 3 (1.2)Total 11 (4.4) 18 (7.1)*
*P=0.2
Bergqvist D et al. N Engl J Med 2002;346(13):975–80.
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Mortality
Placebo Enoxaparin
(n=167) (n=165)
In double-blind period 0 0At follow-up 6 (3.6%) 3 (1.8%)
Bergqvist D et al. N Engl J Med 2002;346(13):975–80.
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EPARINA NON FRAZIONATA
AT III
PROTEINE PLASMATICHE
EPARINA
•SOLO UN TERZO SI LEGA ALL’AT III
•EFFETTO ANTICOAGULANTE NON PREVEDIBILE•TERAPIA CON DOSI PERSONALIZZATE•NECESSARI FREQUENTI ESAMI DI LABORATORIO
PESO MOLECOLARE MEDIO: 15.000 d
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EPARINA A BASSO PESO MOLECOLARE
AT III
PROTEINE PLASMATICHE
EPARINA
•ALTA ATTIVITA’ ANTI Xa/BASSA ATTIVITA’ ANTI IIa•MIGLIORE BIODISPONIBILITA’•EMIVITA PIU LUNGA•ATTIVITA’ ANTICOAGULANTE PREVEDIBILE
PESO MOLECOLARE MEDIO: 4.000-5.000 d
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PROFILASSI TVP E/O EP
5000 U/ s.c. X 2 o 3 volte/die
EPARINA CALCICA
EPARINE A BASSO PESO MOLECOLARE
ENOXAPARINA 2000-4000 U s.c./dieDALTEPARINA 2500 U s.c./dieNADROPARINA 3000 U s.c./die
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•CHIR. NEOPLASTICA•CHIR. ADDOMINALE•CHIR. ORTOPEDICA•SPLENECTOMIA
•APPENDIC. COMPLICATA•CHIR. MALATTIE INFIAMM.COLON /TENUE
•APPENDICECTOMIA•ERNIA INGUINALE•COLECISTECTOMIA
ETA’ < 40aa
ETA’> 40aaALLETTATOOBESITA’POST –PARTUM
CANCROPRECEDENTETVPTROMBOFILIA
PROFILASSI CON:EPARINA NON FRAZIONATAEPARINE A BASSO PESO MOLECOLARE
PROFILASSI PAZIENTI CHIRURGICI
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PROFILASSI PAZIENTI NON CHIRURGICI
•ICTUS +PARESI• BPCO CON RESP. MECCANICA
•INFARTO•SCOMPENSO CARDIACO•SEPSI•IMMOBILIZZAZIONE
•CATETERE VENOSO (?)•MALATTIA INFETTIVA
•NO RISCHIO
NO RISCHIO
•V.VARICOSE•TVPFAMILIARE•OBESITA’•PILLOLA
•>65 aa• GRAVIDANZA• S. NEFROSICA
•TROMBOFILIA•TVP PRECED.•CANCRO
PROFILASSI CON:EPARINA NON FRAZIONATAEPARINE A BASSO PESO MOLECOLARE
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TERAPIA CON EPARINA SODICA e.v.
TERAPIA TVPTERAPIA EP
TERAPIA DELL’IMA
VANTAGGI:• PER e.v. EFFETTO ANTICOAGULANTE IMMEDIATO• POSSIBILITA’ DI MONITORARE L’EFFETTO ANTICOAGULANTE• BREVE EMIVITA• ESISTENZA DELL’ANTIDOTO
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TERAPIA CON EPARINA NON FRAZIONATA
MONITORAGGIO DELL’EFFETTOANTICOAGULANTE
PTT
RANGE TERAPEUTICO:
PTT in secondi paziente
PTT in secondi pool normale=1.5- 2.5
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NORMOGRAMMA DI RASCHKE
BOLO DI 5000 U DI EPARINA SODICA EV
IN PAZ A BASSO RISCHIO EMORRAGICO:
1680 U/h (40.000/24 ore)
IN PAZ AD ALTO RISCHIO EMORRAGICO:
1240 U/h (30.000/24 ore)
PRIMO PTT DOPO 6 ORE POI CONTROLLI OGNI 6 ORE
paz. ad alto rischio emorragico:•soggetti > 60 anni•pazienti con gravi patologie intercorrenti di altra natura•pazienti reduci da interventi e/o traumi•alcoolisti•pazienti con storia di emorragia gastrica/ulcera peptica•pazienti con predisposizione emorragica•pazienti con piastrine <150.000/mm3
TERAPIA CON EPARINA NON FRAZIONATA
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PTT BOLOEPARINA
SOSPENSIONE VARIAZIONEDOSE EPARINA
<1.2 80 U/Kg + 4 U/kg/h
1.2 - 1.5 40 U/Kg + 2 U/kg/h
1.5 - 2.3
2.3 - 3.0 - 2 U/kg/h
>3 - 3 U/kg/h 1 ora
CONTROLLO DEL PTT OGNI 6 ORE
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EPARINA A BASSO PESO MOLECOLARE (LWMH)
INDICAZIONI TERAPEUTICHE
NADROPARINADALTEPARINAENOXAPARINA
TRATTAMENTO DELLA TVP ACUTA
PROFILASSI DELLA COAGULAZIONE IN EMODIALISI
TRATTAMENTO DELL’ANGINA INSTABILE E DELL’IMA NON Q
PROFILASSI DELLA TVP IN CHIRURGIA GENERALE E IN CHIRURGIA ORTOPEDICA
PROFILASSI DELLA TVP IN PAZIENTI NON CHIRURGICI
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EPARINA A BASSO PESO MOLECOLARE (LWMH)
•NADROPARINA
•ENOXAPARINA
•DALTEPARINA
•ARDEPARINA
•TINZAPARINA
•REVIPARINA
DOSI TERAPEUTICHE NELLA TVP/EP
90U /Kg/ 12 ORE180U /Kg/ 24 ORE
100U /Kg/ 12 ORE
200U /Kg/ 24 ORE
130U /Kg/ 12 ORE
175U /Kg/ 24 ORE
100U /Kg/ 12 ORE
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EPARINA A BASSO PESO MOLECOLARE (LWMH)
Confronto LWMH /EPARINASTANDARD nella terapia
della TVP e/o EP
• RIDUZIONE RECIDIVE TROMBOEMBOLICHE: 2.7% vs 7%
• RIDUZIONE EVENTI EMORRAGICI MAGGIORI: 0.9% vs 3.2%
• RIDUZIONE MORTALITA’ A LUNGO TERMINE: 4.3% vs 8.1%
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INATTIVA:
• 100% EPARINA NON FRAZIONATA(1 mg per 100 U di Eparina)
• 30% ENOXAPARINA• 40% DALTEPARINA• 60% TINZAPARINA
TRATTAMENTODELL’IPERDOSAGGIO DA EPARINA
SOLFATO DI PROTAMINA
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PROFILASSI TVP IN PAZIENTI CHIRURGICI
emocromoLWMHLWMH
giornigiorni
-1 1-1 1 2 2 33 4 5 6 4 5 6
INTERVENTO DIMISSIONE
ENOXAPARINA 4000 U s.c./dieDALTEPARINA 2500 U s.c./dieNADROPARINA 3000 U s.c./die
emocromoLWMHLWMH
??
1 mese ?1 mese ?
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emocromo
11 22 33 44 55 66 3 a 63 a 6mesimesigiornigiorni
TERAPIA ANTICOAGULANTE DELLA TVP
emocromoemocromo
eparinaeparina
Anticoagulante oraleAnticoagulante orale
INR > 2INR > 2
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Terapia/profilassi con anticoagulanti orali nel paziente
neoplastico
Gravata da un maggior numero di
fallimenti:
maggior rischio di recidive
maggior rischio di emorragie
monitoraggio più frequente
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AO nei pazienti oncologici
Dieta Farmaci (Interazione) Assorbimento intestinale (vomito) Funzionalità epatica
Causano imprevedibili cambiamenti della dose/risposta
Causano impreviste fluttuazioni dell’ INR con necessità di frequenti monitoraggi e frequenti
sospensioni
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Sanguinamento degli AO
Gitter 1995 Neoplastici 10.6% Non neoplastici 5.3%Prandoni 1996 Neoplastici 8.6% (3.4% mag) Non neoplastici 5.3% (3.0% mag)Palareti 2000 Neoplastici 21.6% Non neoplastici 4.5%
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EBPM: alternativa agli AO
Vantaggi: non necessita monitoraggio assenza d’ interazione con le piastrine risposta anticoagulante costante (non
interferenza con fattori dietetici o con farmaci concomitanti)
rapidità del meccanismo d’azione più maneggevoli per le interruzioni/ripristino
della terapia anticoagulante (piastrinopenia, manovre invasive)
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Laparoscopic surgery and thrombosis
Catheline JM, Int. Surg. Investig. 2000; 2(1):41-47
… all patients will undergo laparoscopy surgery
must be prophylaxed with LWMH…
….continued prophylaxis after discharge should be
considered in individual patients….
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Laparoscopic surgery and thrombosis
ROUTINE ADMINISTRATION OF PHARMACOLOGICAL ANTI DVT
PROPHILAXIS
HEPARIN IS CONTINUED AL LEAST UNTIL THE PATIENT IS FULLY
AMBULANT
AVOIDANCE OF PROLONGED REVERSE TRENDELENBURG POSITION
AVOIDANCE OF HIGH INSUFFLATION PRESSURE
INTERMITTENT RELEASE OF PNEUMOPERITONEUM ESPECIALLY
IN LENGTHY PROCEDURE
EARLY POSTOPERATIVE MOBILIZATION OR DISCHARGE
RECOMMENDATIONS
Meshinkhes 2003
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Conclusions
Cancer surgery is a high-risk situation for post-operative thromboembolism
Cancer surgery may be a situation where prolonged thromboprophylaxis is indicated
LWMH for 1 month is significantly better than for 1 week in reducing phlebographically confirmed thrombosis
The benefit is maintained at 3 months The optimal duration is not known The optimal pharmacological substance is
not known