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Deep vein thrombosis

Lower limb venous reflux disorders

Deep vein Thrombosis refers to abnormal coagulation of blood in deep veins, belonging to Lower limb veins Reflux disorders. Thrombosis Most occur in braking state (especially in orthopaedics Major operation ）。 Pathogenic factors include slow blood flow Venous wall Damage and High solidification state Three factors. Thrombosis After that, most of them will spread to the deep vein trunk of the whole limb, except for a few that can be self ablated or limited to the site of occurrence. If they cannot be diagnosed and treated in time, most of them will evolve into thrombosis sequela , which affects patients for a long time Quality of life ； Some patients may have complications pulmonary embolism , causing extremely serious consequences.

Chinese name: Deep vein thrombosis
Foreign name: DVT
Interpretation: Abnormal coagulation of blood in deep veins

Discipline: a Vascular surgery /a
Type of disease: Lower limb venous reflux disorders
Pathogenic factors: Slow blood flow Venous wall Damage, etc
Consequences: Thrombosis, etc

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Main impacts

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Some orthopedic patients had a successful operation, but suddenly died when they got out of bed a few days after the operation. It turned out that the patient had deep vein thrombosis after orthopedic surgery, which was caused by thrombus shedding pulmonary embolism And died. Once it happens, there is no specific treatment.

Causes

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Clinically, only 10%~17% of DVT patients have obvious symptoms. Including lower limb swelling, local deep tenderness and Instep Flexural pain. The most serious clinical features and signs of DVT development are pulmonary embolism ， mortality As high as 9%~50%, the vast majority of deaths occur within minutes to hours. DVT with symptoms and signs is more common after surgery, trauma, and late stage cancer , coma and long-term bedridden patients. Prevention is the key to DVT. All patients with major lower limb surgery should Primary prevention . For acute Venous thrombosis of lower limb The preventive measures include: avoiding putting pillows under the calves after surgery, which will affect the depth of the calves Venous reflux ； Encourage the patient's feet and toes to move actively, and ask them to take deep breath and cough more frequently; Let the patient get out of bed as soon as possible and wear clothes if necessary Medical elastic socks 。 For the elderly or heart disease Patients should pay more attention.

clinical manifestation

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Manifestations and symptoms of deep vein thrombosis of lower limbs

so-called Deep vein thrombosis of lower limbs , English name is DVT (deep venous thrombosis), which refers to the formation of blood clots in the venous lumen due to various reasons. Deep vein thrombosis of lower limbs The typical clinical manifestation of the lower limb is often swelling and pain in one side of the lower limb (commonly seen in the left lower limb). However, there may be no obvious symptoms in the early stage of thrombosis, which is one of the reasons why venous thrombosis is easy to be ignored

diagnostic method

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Deep venous thrombotic early diagnosis And importance

Lower limb deep vein thrombosis is called DVT in European and American countries, and it has attracted attention since the 1960s. Many ordinary people also know some knowledge about DVT. China really pays attention to DVT. Shanghai is the best place in China for standardized treatment of deep vein thrombosis Tongji University Affiliated Oriental Hospital, their Vascular surgery The leader, Dr. Smile (Zhang Qiang), was one of the first experts to pay attention to this disease. In the past, due to information blockage and some misconceptions in the medical community, the rate of missed diagnosis and misdiagnosis of lower limb deep vein thrombosis was very high. Different medical institutions have different levels of understanding and concepts of lower limb deep vein thrombosis, resulting in different treatment plans.

The first is the judgment of the onset time. Because the venous system has a large number of Collateral circulation , early Thrombosis Will not hinder veinal blood Smooth return. Only when the thrombus spreads to a certain length and blocks the proximal and distal openings of collateral circulation, can the lower limbs become swollen clinically. Therefore, in general, patients with lower limb swelling can only be diagnosed clinically, and the onset time is often more than a few days.

The guiding significance of judging the onset time to the treatment plan

Venous thrombus is like cement, which can be washed away as soon as possible, but once it forms a clot, it cannot be dissolved. Although this analogy is not very appropriate, it is a fact that venous thrombosis begins to be partially organized decades after its formation. It is difficult to solve organized venous thrombosis by thrombolysis. Surgical thrombectomy is also not suitable. As the organized thrombus sticks tightly to the wall of the vein, forced thrombectomy will lead to Venous wall Damage causes more extensive Thrombosis 。 Therefore, early diagnosis is very important.

How to diagnose lower limb deep vein thrombosis early

Although early deep Venous thrombosis There are no obvious symptoms, but for experienced doctors, some clues can be found through careful physical examination. For example, deep pain when squeezing the calf belly often indicates the calf Venous thrombosis (It is called Homan sign in medicine). that is because Venous thrombosis Surrounding tissue Aseptic inflammation For the same reason, the root of thigh tenderness It often indicates femoral vein thrombosis. Of course, if you suspect deep vein thrombosis, you should test the blood as soon as possible D2 polymer B ultrasound was used to detect deep veins to make a definite diagnosis. In this way, most cases of deep vein thrombosis can be diagnosed early.

therapeutic method

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thrombolysis

about thrombolysis There has been a controversy in the medical field. In China, many people have high expectations when they hear the seductive word "thrombolysis". In fact, the word "thrombolysis" refers more to the mechanism of drugs than necessarily Treatment results 。 The latest international ACCP guidelines for the treatment of thrombosis do not recommend thrombolysis as the first choice for the treatment of deep venous thrombosis of the lower limbs. There are three reasons: first, the clinical manifestations of venous thrombosis are lagging behind, and thrombolytic drugs are ineffective for organized thrombosis; Second, there is a high risk of bleeding from thrombolytic drugs, especially in elderly patients cerebral haemorrhage ； Third, a large number of comparative studies show that the therapeutic effect of thrombolysis is not better than Anticoagulant therapy 。 Of course, with Interventional technology The development of thrombolysis and whether it can be reduced complication To improve the therapeutic effect is still in the process of further experience accumulation. The clinical results are optimistic. But we must strictly grasp the evidence.

Anticoagulation

As long as the patient doesn't Bleeding tendency or Coagulation function Anticoagulant therapy is generally the first choice for the problems in this regard. The function of anticoagulant therapy is to prevent the spread of thrombus or the formation of new thrombus Collateral circulation Open to alleviate symptoms and strive for conditions.

Operation method

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There is no complete cure in medicine Sequela of deep vein thrombosis of lower limbs Means. Drug thrombolysis and interventional therapy yes Sequela of deep vein thrombosis of lower limbs meaningless. Interventional stent therapy has poor effect and low patency rate. The effect of surgical bridging or bypass is also poor, and there are surgical risks. Traditional Chinese medicine treatment is still lacking Evidence based medicine Support.

Therefore, the main purpose of treatment is to control or relieve Venous thrombosis of lower limb sequela Symptoms, promotion Deep vein Re open the lumen.

Lower limb deep vein thrombosis Is it possible to connect after surgical treatment

If B-mode ultrasonography Review findings Deep veins of lower limbs It has been completely reconnected, and it must be done at this time CT understand Iliac vein Unobstructed condition. If the iliac vein is also excluded from occlusion and stenosis, the patient has Calf ulcer Can be used as a lower limb Superficial vein And disconnection of communication. There is only edema or pigmentation of lower limbs, which is generally used Conservative treatment 。

Lower limb deep vein thrombosis How to treat if there is no recanalization after the occurrence

If B-ultrasound or CT scan of the deep vein of the lower limb indicates that there is still obstruction of the deep vein, conservative treatment should be considered first. Conservative treatment methods include: (1) stress treatment; (2) Medication. The effect of stress treatment is better than drug treatment.

Stress treatment Yes Sequela of deep vein thrombosis of lower limbs What is the therapeutic significance of

Deep veins of lower limbs Pressure gradient The change is gradually increasing from top to bottom, and stress treatment is to achieve the purpose of treatment by eliminating this pressure. Common stress treatment methods are divided into: (1) Intermittent Air pump Compression therapy; (2) Pressure gradient Elastic socks 。 The effect of intermittent air pump compression treatment is better than that of elastic stockings.

Drugs for treatment of sequelae of deep vein thrombosis of lower limbs

Strictly speaking, there is no medical treatment for deep vein thrombosis sequela Effective drugs. However, in addition to pressure treatment, some drugs can increase the effect of treatment.

technical requirement

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Standard treatment of deep vein thrombosis

Anticoagulant therapy is the first choice for deep vein thrombosis of lower limbs, and different application skills will also cause

The results are different. Standardized anticoagulation treatment has the following points:

（1） Low molecular weight heparin subcutaneous injection Take orally before warfarin. warfarin It takes effect slowly and can be induced at the early stage Thrombosis 。 Therefore, low molecular weight heparin must be used as the starting anticoagulation program.

(2) When warfarin takes effect and is relatively stable, stop subcutaneous injection of low molecular weight heparin.

(3) Adjust the dose of warfarin with reference INR Metrics to TNR It is best to maintain 2.0~3.0.

(4) The duration of anticoagulant treatment is 3-6 months.

(5) The INR was rechecked on the third day after each adjustment of warfarin dose. Dose adjustment It is better to take 1/4 tablet each time to avoid large decrease and increase.

(6) There are many factors affecting warfarin, individual difference Large, try to check INR at least every two weeks.

(7) The brand of warfarin should not be changed easily. Because the efficacy of each product is different.

(8) Using heparin Check later platelet , prevent heparin induced Thrombocytopenia (also known as HIT).

matters needing attention

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Irregular treatment often includes the following aspects:

1、 Assisted medication Alternative anticoagulants. This situation is easy to lead to the formation of fresh thrombus, pulmonary embolism The probability of is greatly increased.

2、 Insufficient dosage and time of anticoagulant drugs, resulting in poor effect or leftover Venous thrombosis of lower limb sequela.

3、 Excessive dosage of anticoagulant drugs or excessive use of thrombolytic drugs may cause bleeding.

yes Bleeding tendency Patients can choose Treatment mode

The patient has recently History of operation 、 Cerebrovascular accident And with Coagulation function Bad patients should not use it or use it cautiously Anticoagulant therapy 。 If such patients have pulmonary embolism Risk, should be implanted into the cavity Venous filter 。

Preventive health care

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Venous thromboembolism (VTE) is a serious life threatening disease. Clinical manifestations include deep vein thrombosis and Pulmonary thromboembolism 。 Pulmonary thromboembolism Means from Venous system Or right heart thrombosis pulmonary artery Or its branches pulmonary embolism 。 They are two different stages of the same disease course. Wait in the United States the West , the incidence of VTE is Cardiovascular disease Middle ranking third. yes data display 10% of hospital deaths are caused by VTE. In Europe, more than 500000 people die from VTE every year, which is more than AIDS 、 prostatic cancer 、 mammary cancer and expressway Accidents death toll The sum of.

At the 19th Great Wall International heart disease At the academic conference, Hu Dayi Professor said that VTE is not only common in western countries, but also in China and Asia Countries are also common. A considerable number of VTE high-risk patients did not take appropriate measures preventive measure , developed into VTE after discharge, and sudden death occurred in severe cases.

In patients with VTE for the first time, 50-75% had clear Risk factors 。 Risk factors of VTE include surgery trauma , bed rest tumour Treatment (hormone chemotherapy or radiotherapy ）, old age, heart or respiratory failure Nephrotic syndrome , obesity, smoking varicosity 、 genetic or Acquirability Thrombosis Tendency, and these risk factors usually exist together.

In fact, VTE is preventable. After prevention, its incidence will be greatly reduced. Common preventive measures such as orthopedics and chest Major operation Pre routine administration of small dose Anticoagulants ； After major surgery, patients should turn over and pat their backs in time, massage their lower limbs, and patients with minor surgery should get out of bed as soon as possible. In case of sudden unilateral limb swelling, they should go to the hospital in time. In fact, to the masses and Primary medical staff universal Thrombosis The relevant knowledge of is also crucial.

Nursing methods

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one acute stage Ask the patient to stay in bed and rest, and raise the affected limb by 15 °~30 ° to help Lower limb veins Reflux, reduce edema.

2 Use the distal end of the affected limb as far as possible Superficial vein Administration To make the drug reach the thrombus site directly and increase the local drug concentration (usually the affected limb is only used as thrombolytic drug Route of administration , no other drug input).

3 Do not massage or massage the affected limbs. Keep Smooth stool , avoid forced defecation to avoid causing Abdominal pressure Sudden elevation causes thrombus shedding.

4 Avoid collision with the affected limb, and do not roll too hard.

5. Give high vitamin high protein 、 Low fat diet Avoid eating sweet and fat food to avoid increase Blood viscosity , aggravating the disease.

6. Measure the thigh circumference in each shift, and closely observe the affected limb circumference and Skin color , temperature change.

7 Prevention complication : Strengthen oral skin care, rinse more and drink more water, which can be used for those with dry stool Suppositories Glycerol Defecate, turn over regularly, change body position, prevent bedsore happen.

eight Lower limb deep vein thrombosis The most serious complications are pulmonary embolism , the mortality rate reaches 70%, and the patient should be closely observed for Chest tightness 、 Chest pain and dyspnea , suffocation cough 、 hemoptysis In case of the above situation, the doctor shall be informed immediately. 1. Pain relief. Pain is the most painful symptom of the patient ulcer 、 gangrene Or in case of concurrent infection, the pain is more severe, and appropriate analgesics can be given, but prevention is required anodyne Of Addiction 。 2. No smoking. Absolutely no smoking nicotine It can shrink blood vessels, but can drink a small amount of wine to promote Vasodilation 。 3. Protect the affected limb. Avoid cold, damp, trauma and other factors, keep the bedding clean, flat and dry, disinfect and replace it regularly, and keep the limb gangrene dry to avoid secondary bacterial infection of the wound. The ulcer surface was changed with gauze, contraindicated Irritant External medication 。 4. Exercise of affected limbs. The patient takes the horizontal position, raises the affected limb about 45 degrees, and maintains it for 2-3 minutes, then hangs the affected limb down along the bed for 3-5 minutes, and then flattens the affected limb for 2-3 minutes. At the same time, the patient conducts ankle and toe activities, and exercises several times a day, 5-6 times a time, so as to better recover the function of the affected limb.

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