Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_885_Библиотеки_им_академика_М_И_Перельмана.pdf
438 E. Gonzalez and E. E. Moore
Table 6. Heparin induced thrombocytopenia 4T pre-test probability.
21 0
Thrombocytopenia >50% fall and nadir
9
Timing of platelet
count decrease
(1st day of heparin
exposure = day 0)
≥20 × 10
days 5–10
(or ≤ day 1 if prior
heparin exposure
within last 30 days)
30–50% fall
or nadir
10–19 × 10
> day 10, or
timing unclear
(or > day 1 if
prior heparin
<30% fall or nadir
<10 × 10
9
< day 5 (no prior hepa-
rin exposure within
last 100 days)
9
exposure within
30–100 days)
Thrombosis new thrombosis
(arterial or venous),
adrenal hemorrhage, skin
necrosis, or acute
suspected
thrombosis, or
recurrence
of previous
thrombosis
none
systemic reaction
after heparin bolus
Other causes of
Thrombocytopenia
none evident possible definite (e.g., hemodi-
lution, other
medications, sepsis)
Pre-test probability of HIT: ≥6 points = HIGH, 4–5 points = INTERMEDIATE, ≤3 points = LOW.
Prevention and Management of Venous Thromboembolism 439
Fig. 1. Deep vein thrombosis diagnostic and therapeutic algorithm.
440 E. Gonzalez and E. E. Moore
Fig. 2. Pulmonary embolism.
Review of Current Literature with References
• American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines 2012 9th Ed. Guidelines. Antithrombotic therapy and prevention of
thrombosis. Chest 2012; 141:e227S–e277S.
• In a Cochrane review, data from two trials involving 331 major trauma
patients demonstrated that LMWH (enoxaparin 30 mg q12h) appeared to
reduce the risk of DVT compared to low-dose UFH (5000 units bid) (RR
0.68; 95%CI 0.50–0.94). Routine DVT screening was performed on all studied patients. There was no statistically significant difference in risk of
incidence of PE, bleeding complications, and in mortality when comparing
LMWH vs. UFH. People who received both mechanical and pharmacological
prophylaxis had the lowest risk of DVT (RR 0.34; 95% CI 0.19 to 0.60).
Cochrane Database Syst Rev. 2013; 28:CD008303.
• A multicenter, randomized, blinded, placebo-controlled trial compared an
additional three weeks of pharmacologic VTE with a LMWH (bemiparin) to
Prevention and Management of Venous Thromboembolism 441
no additional prophylaxis in 626 patients who underwent abdominal or pelvic
surgery for cancer, all of whom initially received 1 week of prophylaxis with
once-daily LMWH. Surveillance venography was performed after three
weeks, and patients were followed clinically for three months. The primary
outcome was a composite of any DVT (including asymptomatic and distal
DVT), PE, and death from any cause. Although the risk of the composite
outcome was 24% lower and the risk of proximal DVT was 88% lower in the
extended prophylaxis group, there were no differences in symptomatic or
fatal VTE events. J Thromb Hemostasis. 2010;1223–1229.
• Jamjoon et al. performed a systematic review of the literature reporting on the
timing of pharmacologic prophylaxis in TBI patients. The authors dichotomized the timing of prophylaxis to early and late at 72 h post-injury. A total
of five retrospective cohort studies were included in the review with a total of
1,624 patients, of which 713 received early prophylaxis and 911 received late
prophylaxis. There was a VTE risk reduction of 0.52 (95%CI 0.37–0.73) for
those receiving early prophylaxis. Assessing safety, the relative risk of ICH
progression in the early vs. the late group was 0.64 (95%CI 0.35–1.14). Based
on the available literature, the authors conclude that prophylaxis by 72 hours
reduces the risk of VTE without affecting progression of ICH. The retrospective nature of the studies included in this review and the variability in the
measurement of ICH progression (some studies described it as progression on
head CT obtained for clinical suspicion or need for craniotomy, another study
described it as progression on head CT routinely obtained after prophylaxis
initiation) limit the interpretation of the data. Other studies have reported
progression of ICH when prophylaxis is started before 48 hours. No randomized controlled studies on timing of prophylaxis exist to date.
J Neurotrauma. 2013; 30: 503–511.
• Consensus guidelines for VTE prophylaxis in pediatric trauma patients are
lacking. Overall, the incidence of post-injury VTE in pediatric patients is
lower than that of adults. However, the age cut-off at which this difference is
no longer significant has not been studied. In an evidence-based review of the
literature Streck et al. identified that the mean age of patients with a VTE was
16.6 years vs. 12.1 years (p < 0.01) in those who did not develop VTE, inde-
pendent of other risk factors. By multivariate logistic regression those <14
years of age had a decreased risk of VTE (OR 0.2, 95%CI 0.1–0.9). With the
limitations of the data available, this is the first study that identifies an age
cut-off (≥14 y.o.) at which VTE prophylaxis in pediatric trauma patients could
be beneficial. J Pediatr Surg 2013;1413–1421.
This page intentionally left blankThis page intentionally left blank
10. Infectious Disease
This page intentionally left blankThis page intentionally left blank
Chapter 10-(i)
Evaluation of Fever
Robert T. Stovall, MD*
*Assistant Professor of Surgery, University of Colorado School of Medicine
Take Home Points
• Fever is a sign of inflammation, not necessarily infection.
• A thorough history and physical exam will usually identify the likely source
of infection.
• Routine “knee jerk” batteries of tests to workup a fever are often not warranted.
• Imaging, labs or cultures should be obtained based on risk factors identified
in the history and physical exam.
Background
• Fever is common after a surgical procedure, occurring in 50% of patients.
• Up to 90% of critically ill patients with severe sepsis will experience fever
during their stay in the intensive care unit.
• Significant cost can be accrued in the workup of the febrile ICU patient.
• Fever is a natural response to inflammation and may not itself be pathological
depending on the setting.
Contact information: Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver,
CO 80204. Email: robert.stovall@dhha.org
445
446 R. T. Stovall
Main Body
• Source of fever
{ Inflammation (both infectious and non-infectious).
{ Medications (common culprits).
• Definition of a fever
{ Normal temperature varies based on age, time of day, and method of
measurement.
{ Temperature can be affected by various environmental factors and drugs
in the ICU.
{ Fever is defined differently by different groups and is somewhat arbitrary
and depends on patient characteristics and setting (e.g. immunosuppressed,
post operatively).
{ A broadly defined generalization by the ACCM and IDSA suggests >38.3
deserves attention in an ICU setting.
{ If you want a more sensitive screen, use a lower workup threshold.
{ Our Surgical ICU uses 38.5 but this can vary based on clinical suspicion.
Many post trauma/surgery patients have a large inflammatory burden
which may cause fever of non-infectious origin.
• Non-infectious sources of fever
{ Up to 50% of fevers in the ICU are not related to infection.
{ Potential non-infectious fevers (any cause of inflammation)
Pancreatitis, thromboembolism, drugs, alcohol withdrawal myocar-
dial infarction, pneumonitis, pericarditis, cancer, surgery, autoimmune
disease, adrenal insufficiency, ischemia, blood product transfusions,
iatrogenic, transfusions, many others.
• Common ICU sources of infectious fever
{ All usual infections are present while the incidence of each type may vary
based on ICU.
{ It is commonly reported that surgical site, respiratory, bloodstream, and
urinary tract make up the vast majority of infectious sources of fever in
the SICU.
Surgical sites of any kind both superficial and deep.
Respiratory — Pneumonia (ventilator associated and otherwise),
empyema.
Urinary tract infection (upper and lower), especially if instrumented.
Bloodstream infections, especially with indwelling devices.
Evaluation of Fever 447
Abdominal infections – abscesses, perforations, colitis, toxic mega-
colon, C. diff, cholangitis, cholecysitis (calculus and acalculus),
spontaneous bacterial peritonitis.
Central nervous system (risk is higher with instrumentation or
trauma).
Sinusitis.
• Workup of the febrile ICU patient
{ Start with thorough history and physical examination.
Key points are past history as well as recent history/events.
Recent procedures/surgeries/trauma.
Any indwelling hardware or foreign bodies.
Recent infections.
Search for reasons for potential immunosuppression.
Physical examination emphasis on surgical sites and foreign bodies.
Evaluated front and back.
{ Use adjunctive studies (imaging, labs, and cultures) to help confirm or
refute suspicious sources found on history and physical exam. Routine
sets of labs, culture or imaging are less likely to be cost-effective in finding an infectious source of fever.
{ Cultures:
Respiratory cultures
Ö Multiple methods of obtaining cultures are debated.
Ö Broncho-alveolar lavage (BAL) or mini BAL felt to be appropriate.
Ö Clinical scores exist to help stratify the risk/benefit of obtaining
respiratory cultures in ventilated febrile ICU patients, but no clear
consensus exists as to optimal method.
Ö Clinic suspicion is increased for respiratory source of infection
when there has been worsening of respiratory parameters [e.g.
hypoxia (decreased p/f ratio), increasing vent settings, new findings on CXR, long duration of intubation, etc.].
Urinary Tract Cultures
Ö Instrumentation of the urinary tract is believed to increase the risk
of infection similar to other body systems.
Ö Urinalysis (UA) has been proposed as a rapid screen of infection;
however the utility of this test as a screen for infection is patient
and setting dependent. Conflicting literature exists as to its use in
the ICU.