Analysis:
Most pulmonary embolism can be treated. Its treatment varies according to different clinical types. In recent years, the research on the treatment of pulmonary embolism has made rapid progress and the treatment has become more standardized. The mortality rate of patients receiving treatment is 5%-8%, and the mortality rate of patients without treatment is 25%-30%.
(A) the treatment of acute pulmonary embolism
1. therapeutic purpose
(1) found the critical period; (2) reduce or eliminate thrombosis; (3) Relieve the cardiopulmonary dysfunction caused by embolism; (4) prevent recurrence.
2. Special treatment
(1) Generally, closely monitor the changes of respiration, heart rate, blood pressure, electrocardiogram and blood gas. Keep the patient quiet and stay in bed absolutely. A 3 weeks), oxygen inhalation, severe chest pain can be given painkillers, keep defecation unobstructed, defecation is not hard, use antibiotics to control femoral thrombophlebitis and prevent pulmonary embolism complicated with infection.
(2) The first aid measures for complicated shock are to give dopa gum 5- 10 week /kg/min, dopa gum 3.5- 10.0μg/kg/min or norepinephrine. -2-2.0 weeks /kg/min, and quickly correct arrhythmia that causes hypotension, such as atrial flutter and atrial fibrillation. Maintain average arterial blood pressure >: 10.7kPa(80mmHg), cardiac index >: 2.50min/m2, urine output >; 50m 14(6). At the same time, actively carry out Ficus microcarpa suppository and anticoagulant therapy, and strive for rapid relief of the disease. It should be pointed out that 80% patients with acute pulmonary embolism died within 2 hours after onset, so they should be treated and rescued quickly.
(3) Thrombolytic therapy (7) can quickly dissolve thrombus, restore lung tissue reperfusion, reverse right heart failure, improve pulmonary capillary volume and reduce mortality and recurrence rate. The effective rate is above 80%. Thrombolysis is mainly used for fresh thromboembolism within 2 weeks, and the earlier the better. Indications: 1) massive pulmonary embolism; 2) Pulmonary embolism with shock; 3) Patients with circulatory failure caused by primary cardiopulmonary disease and massive pulmonary embolism. The specific scheme of thrombolytic therapy was approved by the US Food and Drug Administration: ① The dosage of streptokinase was 250 000IUAOmin, followed by 100 000ILIA 1, and intravenous drip was maintained for 24 hours; ② The dosage of urokinase was 2000 iu/1b (lb)/10 min, followed by 2000ILIAbA. The commonly used adult thrombolysis methods in our hospital are: ① intravenous infusion of urokinase 20000 iu/kgAh；; ②rt-PA50- 10OmgAh, intravenous drip, with satisfactory effect and safety. Because thrombolytic therapy for pulmonary embolism does not use heparin at the same time, it is generally not necessary to do hemagglutination test. At present, medication is usually given at a fixed dose, and dose judgment is not needed. After thrombolytic therapy, heparin and warfarin were routinely used. The bleeding rate of thrombolytic therapy is 5-7%, and the mortality rate is about 65438 0%. The absolute contraindications for the treatment of latent thrombosis are active gastrointestinal bleeding, intracranial hemorrhage within two months and craniospinal surgery. The main relative contraindications are surgery and delivery in colleges and universities at home and abroad for 65,438+00 days. Recently, there are severe gastrointestinal bleeding, liver and kidney failure, severe trauma and hypertension with systolic blood pressure of 26.7KPa(200mmHg) and diastolic blood pressure of 222.65,438+04.7 kPa (65,438+065,438+00 mmHg). The secondary diseases are cardiopulmonary resuscitation, left atrial thrombosis, infective endocarditis, liver and kidney diseases, hemorrhagic diseases, polio and diabetic hemorrhagic retinitis.
See the attached table for the comparison between the old and new schemes of banyan suppository.
Comparison of timetable between old and new thrombolytic schemes
Past and recent projects
Time window ≤5 days ≤ 14 days
Diagnostic pulmonary angiography lung scan/echocardiography/enhanced CT
The descent time is getting shorter and shorter.
Transpulmonary vein
There are many laboratory tests.
General ward of intensive care unit (ICU)
(4) Anticoagulation therapy (9) can prevent the development and recurrence of embolism and make fibrinolysis mechanism dissolve the existing thrombus. However, the curative effect and long-term results of anticoagulation alone are far less than those of thrombolysis combined with anticoagulation. After anticoagulant therapy 1-4 weeks, pulmonary artery thrombosis was completely dissolved by 25%, and after 4 months, it was 50%. Commonly used anticoagulants are heparin and warfarin. Heparin is usually given by continuous intravenous drip with a loading dose of 2000-3000IU/h, followed by 750- 1000IU/h or 15-20IU/kg/h, and the dosage is adjusted according to the activation time (PTT) of partial thromboplastin. Low molecular weight heparin can also be used. Heparin is generally used when the clinical situation is stable, usually 7- 10 days. After 48 hours of heparin application, oral anticoagulants were added and overlapped for at least 4 days. The initial dose of warfarin for adults is about 4.0 tons. After adjusting the dose, the prothrombin time is prolonged to 1.5-2.5 times of normal (about 1.6-20 seconds), and the prothrombin activity is reduced to 30%-40%. The international normalization rate is 2. O the course of oral anticoagulants is 3-6 months, and the course of treatment for patients with pulmonary hypertension and cor pulmonale is prolonged. J Subacute infective endocarditis, malignant hypertension, cerebrovascular diseases, recent surgery and potential hemorrhagic diseases are contraindications.
(5) Surgical treatment
1) pulmonary thrombotomy: used for massive pulmonary embolism with shock, systolic blood pressure lower than 13.3kPa( 100mmHg), central venous pressure increased, renal failure, medical treatment failed or inappropriate. The operative mortality rate is high.
2) Huge pulmonary embolism was crushed by pig tail rotating catheter and local thrombolysis was used (10). After 48 hours, the average pulmonary pulse pressure decreased significantly, with an effective rate of 60% and a mortality rate of 20%. It is mostly used for patients who are contraindicated by banyan suppository and anticoagulant therapy.
(6) Treatment of deep vein thrombosis About 70%-90% of emboli in acute pulmonary embolism come from deep vein thrombosis, especially deep veins of lower limbs. Therefore, in the treatment of patients with acute pulmonary embolism, we must never ignore the examination and treatment of deep venous thrombosis to prevent the recurrence of pulmonary embolism. The treatment principles of DVT are bed rest, limb elevation, anticoagulation (heparin and warfarin), Banyan suppository (individualization), anti-inflammatory and anti-platelet aggregation drugs. These have been considered in the treatment of acute pulmonary embolism, but the specific usage is still different. In order to prevent the recurrence of thromboembolism, a filter can be installed in the inferior vena cava, such as patients who are contraindicated by anticoagulant therapy or have complications or thromboembolism recurrence, or have high-risk proximal venous thrombosis or pulmonary embolism, or have chronic recurrent embolism and pulmonary embolism with pulmonary hypertension (1 1).
(II) Treatment of chronic embolic pulmonary hypertension
1. Endometriectomy for pulmonary thromboembolism has a good effect, and the operative mortality has been reduced to below 10% (12). A few hospitals in China have developed 13. Surgical indications are: (1) pulmonary vascular resistance is greater than 30 odyn s-m-5; (2) Embolization of the larger pulmonary artery accessible by surgery; (3) e-concave level of cardiac function; (4) No obvious complications.
2. Warfarin is commonly used in anticoagulant therapy, and the course of treatment is more than 6 months or lifelong anticoagulation.