Læknablaðið - 15.09.1994, Blaðsíða 13

LÆKNABLAÐIÐ 1994; 80
289
Fragmin
5000 U/d
Org 10172 Antithrombin
750 anti Xa U 3 and low
x2/d Warfarin dose heparin
15/97
3/41
19/62
11/53 13/65 2/41
22/103 15/97 24/118 2/41
21.4 15.5 20.3 4.9
Table IV. Suggested surgical thromboprophylaxis:*
1. Surgical patients at moderate or high risk of post-operative venous thromboembolism should receive pharma-
cological thromboprophylaxis, in general starting pre-operatively and lasting at least 7-10 days post-operatively
or until discharge.
2. To achieve optimal thromboprophylactic practice it is suggested that a standard admission order form be
designed in which it is made mandatory to prescribe thromboprophylactic agents unless contraindications exist.
Contraindications should be documented.
3. Acceptable prophylactic options in moderate and high risk patients include:
Moderate risk: Low dose standard unfractionated heparin (i.e. 5000 IU x 2-3 s.c.).
Low dose low molecular weight heparin (LMWH) once daily, e.g. logiparin, enoxaparin or
fragmin in doses as recommended by manufacturers.
High risk: Low dose standard heparin (i.e. 5000 IU x 3 s.c.).
Low dose low molecular weight heparin (LMWH) once daily, e.g. logiparin, enoxaparin or
fragmin in doses as recommended by manufacturers.
Two-step warfarin
4. Platelet counts should be obtained on days 4, 8 and 12 if heparins are prescribed to avoid potential complications
from heparin induced thrombocytopenia and thrombosis**. If platelets decrease to <80-90.000/^1 heparins
should be discontinued and a hematology consultation obtained.
5. Graded elastic compression stockings and early ambulation are advocated as adjunctive therapy although they
are of unproven benefit. Such measures cannot replace the above pharmacological measures.
6. LMWH prophylaxis has been shown to be effective and safe in brain surgery and spinal anesthesia. However, in
the absence of further studies and since there is a slightly increased risk of wound hemorrhages with their use, it
may be safer to use them only as post-operative prophylaxis. Intermittent sequential pneumatic compression is a
prophylaxis alternative in these patients.
* Modified from the recommendations ofthe committee on surgical thromboprophylaxis at Landspítalinn 1993: Dr’s P.T. önundarson, Th. S. Stefánsson,
H. Jónsson Jr, H Jóhannsson and R. Gunnarsdóttir Cand. Pharm.
** For review see reference 47.
gerðar/áverka (tafla I). Segamyndunin getur
komið fram sem skyndidauði, lungnaeinkenni,
og bráð eða þrálát einkenni frá fæti. Áhætta er
veruleg í sjúklingum skilgreindum með meðal-
eða hærri áhættu og því ber að beita fyrirbyggj-
andi meðferð í öllum slíkum tilvikum þar sem
frábendingar vega ekki þyngra. Tafla IV er
byggð á tillögum segavarnanefndar handlækn-
ingadeildar Landspítalans haustið 1993, en til-
lögurnar byggja á þeirri úttekt, sem hér er birt.
Unnt er að minnka tíðni djúpra bláæðasega
úr um það bil 25% í 5% í meðal-áhættu sjúk-
lingum með notkun heparíns eða smáheparína
(tafla II) og þar með draga verulega úr dauðs-
föllum (um það bil 70% áhættuminnkun) og
öðrum afleiðingum. Smáheparínin eru alla-
vega jafnvirk lágskammta heparíni. Alvarleg
blæðingarhætta er ekki fyrir hendi við notkun
smáheparína í ráðlögðum fyrirbyggjandi
skömmtum.
í hærri-áhættu sjúklingum er unnt að
minnka bláæðasegamyndun úr 50% í 25% eða