抗血栓药物在内镜操作时的管理.docx
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抗血栓药物在内镜操作时的管理.docx
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抗血栓药物在内镜操作时的管理
Management【管理】ofantithrombotic【抗血栓形成的】agents【药剂】forendoscopic【内窥镜检查的】procedures【程序、操作、步骤、过程】
ThisisoneofaseriesofstatementsdiscussingtheuseofGIendoscopy【胃肠内镜检查】incommonclinicalsituations.TheStandards【标准】ofPracticeCommitteeoftheAmericanSocietyforGastrointestinalEndoscopy(ASGE)【美国胃肠镜协会】preparedthistext.Thisguideline【指导原则】combinesandupdates2previously【以前】issuedguidelines,‘‘Guidelineonthemanagementofantithromboticandantiplatelettherapy【抗血小板治疗】forendoscopicprocedures’’1and‘‘ASGEguideline:
themanagementoflow-molecular-weightheparin【低分子肝素】andnonaspirin【非阿司匹林】antiplateletagentsforendoscopicprocedures.’’2Topreparethisguideline,asearchofthemedicalliteraturewasperformedusingPubMed【免费搜索引擎,提供生物医学方面的论文搜索以及摘要】.Studiesorreportsthatdescribedfewerthan【少于】10patientswereexcludedfromanalysisifmultipleserieswithmorethan10patientsaddressingthesameissuewereavailable.Additional【额外的】references【参考】wereobtained【获得】fromthebibliographies【文献】oftheidentified【确认】articlesandfromrecommendations【推荐、建议】ofexpertconsultants【专家顾问】.Guidelinesforappropriate【合适的】useofendoscopyarebasedonacriticalreview【批评性审查】oftheavailabledataandexpertconsensus【一致同意】atthetimetheguidelinesaredrafted【制定、起草】.Furthercontrolledclinicalstudiesmaybeneededtoclarify【使清楚,澄清】aspects【方面】ofthisguideline.Thisguidelinemayberevised【修订、修正】asnecessarytoaccountforchangesintechnology,newdata,orotheraspectsofclinicalpractice.Therecommendations【推荐、建议】arebasedonreviewedstudies【综述研究】andweregradedon【被分级】thestrengthofthesupportingevidence(Table1).3Thestrengthofindividual【个人的、独特的】recommendationsisbasedonboththeaggregate【总数的、总计的】evidencequalityandanassessment【评估、评价】oftheanticipated【预先的、预期的】benefitsandharms.Weaker【微弱的、无说服力的】recommendationsareindicatedbyphrasessuchas“wesuggest”whereasstrongerrecommendationsaretypicallystatedas“werecommend.”
TABLE1.GRADEsystemforratingthequalityofevidenceforguidelines
Qualityofevidence
Definition【定义】
Symbol
Highquality
Furtherresearchisveryunlikelytochangeourconfidenceintheestimateofeffect
++++
Moderatequality
Furtherresearchislikelyto
haveanimportantimpacton
ourconfidenceintheestimate
ofeffectandmaychangethe
estimate
+++-
Lowquality
Furtherresearchisverylikely
tohaveanimportantimpact
onourconfidenceintheestimate
ofeffectandislikelytochange
theestimate
++--
Verylowquality
Anyestimateofeffectisvery
uncertain
+---
Weakerrecommendationsareindicatedbyphrasessuchas‘‘wesuggest,’’whereasstrongerrecommendationsaretypicallystatedas‘‘werecommend.’’AdaptedfromGuyattetal.3
Thisguidelineisintendedtobeaneducationaldevicetoprovideinformationthatmayassistendoscopistsinprovidingcaretopatients.Thisguidelineisnotaruleandshouldnotbeconstruedasestablishingalegalstandardofcareorasencouraging,advocating,requiring,ordiscouraginganyparticulartreatment.Clinicaldecisionsinanyparticularcaseinvolveacomplexanalysisofthepatient’sconditionandavailablecoursesofaction.Therefore,clinicalconsiderationsmayleadanendoscopisttotakeacourseofactionthatvariesfromthisguideline.
Antithromboticagentsincludeanticoagulants【抗凝剂】(eg,warfarin,heparin,andlowmolecularweightheparin)andantiplatelet【抗血小板的】agents(eg,aspirin,nonsteroidalanti-inflammatorydrugs(NSAIDs),thienopyridines【噻吩并吡啶】(eg,clopidrogrel【氯吡格雷】andticlopidine【噻氯吡啶】),andglycoproteinIIb/IIIareceptorinhibitors【糖蛋白IIb/IIIa受体抑制剂】).Antithrombotictherapy【治疗】isusedtoreducetheriskofthromboembolicevents【血栓栓塞事件】inpatientswithcertain【某一,必然的】cardiovascular【心血管的】conditions(eg,atrialfibrillation【心房纤颤】andacutecoronarysyndrome【ACS急性冠脉综合征】),deepvenousthrombosis(DVT)【深部静脉血栓形成】,hypercoagulablestates【高凝状态】,andendoprostheses【内镜置管术】.Themostcommonsiteofsignificantbleedinginpatientsreceivingoralanticoagulationtherapy【口服抗凝治疗】istheGItract【胃肠道】.4Theantithromboticdrugclasseswith【把...与...归入一类】durationofactionandroutesforreversal【逆转】aredescribedinTable2.
TABLE2.Antithromboticdrugs:
durationofactionandroutesforreversal
Routesforreversal
Drugclass
Specificagent(s)
Duration【持续的时间,持续】ofaction
Elective【可选择的】
Urgent【极力主张的,急迫的】
Antiplatelet
agents
Aspirin
10days
NA
Transfuseplatelets【血小板输注】
NSAIDs
Varies【相应变化】
NA
Transfuseplatelets
Dipyridamole
【双嘧达莫】
2-3days
Hold
Transfuseplatelets
Thienopyridines(clopidrogrel,【氯吡格雷】ticlopidine【】噻氯吡啶)
3-7days
NA
Transfuseplatelets±desmopressin【去氨加压素】ifoverdose
GPIIb/IIIainhibitors(tirofiban,abciximab,eptifibatide)
Varies
NA
Transfuseplatelets;incaseofoverdose,someagentscanberemovedwithdialysis【透析】
Anticoagulants
Warfarin
3-5days
Hold
FFP±vitaminK,considerprotaminesulfate*
Unfractionatedheparin【未分离肝素】
4-6h
Hold
Holdorconsiderprotaminesulfate*
LMWH【低分子肝素】
12-24h
Hold
Holdorconsiderprotaminesulfate【硫酸鱼精蛋白】*
NA,Notapplicable;NSAID,nonsteroidalanti-inflammatorydrug;GP,glycoprotein;FFP,freshfrozenplasma;LMWH,lowmolecularweightheparin.
*Caution:
Cancauseseverehypotensionandanaphylaxis.
Beforeperforming(【执行】endoscopic【内镜检查】proceduresonpatientstakingantithromboticmedications,oneshouldconsidertheurgency【紧迫,紧要】oftheprocedureandtherisksof
(1)bleedingrelatedsolely【唯一地,仅仅】toantithrombotictherapy,
(2)bleedingrelatedtoanendoscopicinterventionperformedinthesettingofantithromboticmedicationuse,and(3)athromboemboliceventrelatedtointerruptionofantithrombotictherapy.Alternative【备选的,替代的,其他的】diagnostic【诊断的】studiesforpatientevaluation【诊断(医学);估价】(eg,videocapsuleendoscopy【胶囊内镜】orradiologicstudies【放射检查】)shouldalsobeconsideredaswellastheuseofresourcesforhospitalization【住院治疗】,parenteral【胃肠外的】antithrombotictherapy,andlaboratorytests【实验室检查】usedtomonitor【监测,记录】antithrombotictherapy.Furthermore,potential【潜在的】thromboemboliceventsthatmayoccurwithwithdrawal【撤回,撤退】ofmedicationcanbedevastating【可怕的,毁灭性的】,whereas【鉴于】bleedingafterhigh-riskprocedures,althoughincreasedinfrequency【频繁性】,israrely【罕有的】associatedwithanysignificantmorbidity【发病率,病态】ormortality【死亡率,死亡数】.Discussionwiththepatientandhisorherprescribingphysician【处方医生】beforetheprocedureisinvaluable【无法估计】tohelpdeterminewhetherantithromboticagentsshouldbestoppedoradjusted【调整】inanyparticularpatient.ThisguidelineisanupdateoftwopreviousASGEguidelines1,2andaddressesthemanagementofpatientsundergoing【经历,承受】endoscopicprocedureswhoarereceivingantithrombotictherapy,providingrecommendationsandmanagement【管理】algorithms【运算法则】.
DEFINITIONS【定义,规定】
Procedurerisks【操作风险】
Endoscopicproceduresvaryintheirpotentialtoproducesignificantoruncontrolledbleeding(Table3).Low-riskproceduresincludealldiagnosticproceduresincludingthosewithmucosalbiopsy【粘膜活检】5,6andERCP【内镜逆行胰胆管造影】withoutsphincterotomy【括约肌切开术】,7,8diagnosticballoon-assistedenteroscopy【气囊辅助内镜检查】,9andEUS【超声内镜】withoutFNA【细针抽吸】orTru-Cutneedlebiopsy.10
TABLE3.Procedureriskforbleeding
Higher-riskproceduresLow-riskprocedures
PolypectomyDiagnostic(EGD,colonoscopy,flexiblesigmoidoscopy)
Biliaryorpancreaticsphincterotomyincludingbiopsy
PneumaticorbougiedilationERCPwithoutsphincterotomy
EUSwithoutFNA
PEGplacementEnteroscopyanddiagnosticballoon-assistedenteroscopy
Therapeuticballoon-assistedenteroscopy
Capsuleendoscopy
Enteralstentdeployment(withoutdilation)
EUSwithFNA
Endoscopichemostasis
Tumorablationbyanytechnique
Cystogastrostomy
Treatmentofvarices
Higher-riskproceduresincludethoseassociatedwithanincreasedriskofbleeding,suchasendoscopicpolypectomy【内镜息肉切除术】,11,12therapeuticballoon-assistedenteroscopy,9,13endoscopicsphincterotomy【内镜下括约肌切开术】,14andthoseprocedureswiththepotentialtoproducebleedingthatisinaccessibleoruncontrollable【难以或无法控制的】byendoscopicmeanssuchasdilationofbenign【良性扩张】ormalignantstrictures【恶性狭窄】,15-17percutaneousendoscopicgastrostomy【经皮内镜胃造口术】,18andEUS-guidedFNA【超声内镜引导下细针穿刺活检术】.19Finally,patientsrequiringhemostasis【止血】shouldbeconsideredathigherriskofrebleedingregardlessofwhethertheirinitial【最初的】procedurewaslowrisk.
Conditionrisks【风险条件】
Theprobability【概率】ofathromboemboliccomplication【并发症】relatedtothetemporary【短暂的,临时的】interruption【中断】ofantithrombotictherapyforanendoscopicproceduredependsonthepreexisting【先前存在的】conditionthatresultedintheuseofantithrombotictherapy.Theseconditionsmaybedividedintolow-andhigherriskgroupsbasedontheirassociatedriskofthromboembolicevents(Table4).Low-riskconditionsincludeDVT【深静脉血栓形成】,chronic【慢性的】orparoxysmal【阵发性】atrial【心房的,中庭的】fibrillation【纤维颤动】notassociatedwithvalvulardisease【瓣膜病】,bioprostheticvalves【生物瓣膜】,andmechanicalvalves【机械瓣膜】intheaortic【大动脉】position.Higher-riskconditionsincludeatrialfibrillationassociatedwithvalvularheartdisease【瓣膜性心脏病】(whethersurgicallycorrectedornot),mechanicalvalvesinthemitralposition【二尖瓣位置】,andmechanicalvalvesinpatientswhohavehadaprevious【先前的、以前的】thromboembolicevent【血栓栓塞事件】.Patientswithcoronary【冠状动脉】stents【支架】(especiallythosewithadrug-elutingstent【药物释放支架】[DES])areathigherriskofstentthrombosis【血栓症】,particularlywhendualantiplatelettherapy【双联抗血小板治疗】(DAT)isdiscontinued【终止,中断】beforeminimumdurationrecommendations.Current【现在的,最近的】guidelines【指南,指导方针】fromtheAmericanHeartAssociation(AHA)【美国心脏联合会】recommendthatDATshouldideally【理论上地,完美地,理想地】becont
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