使用抗凝剂患者实施椎管内麻醉处理原则.pptVIP

低分子肝素伊诺肝素（克塞）：40mg那曲肝素（速必宁）：4100u达肝素（法安明）：5000u平均分子量4500，分子量分布略有不同低分子肝素椎管内穿刺应在首次、再次应用LMWH后10~12hr或大剂量（30mgbid.）使用LMWH后24hr术中LMWH的应用最好在麻醉穿刺置管操作后至少2hr穿刺过程发现硬膜外穿刺针有血染，手术后LMWH应推迟应用华法林（Warfarin）抑制VitK环氧化物还原酶，导致VitK缺乏，抑制II，VII，IX，X因子的活化和C蛋白，S蛋白的羧化（治疗剂量华法林使其减少30~50%）华法林的抗凝效应主要通过PT和INR判定FFP（5~8ml/kg）、rFVIIa和凝血酶原复合物可迅速拮抗华法林的作用，静注VitK12.5~25mg可在6hr后拮抗华法林华法林（Warfarin）PTINR降至1.5时手术安全，通常须停药4天术前一天必须复查凝血功能，如果INR1.8，皮下注射VitK110mg致畸，孕妇禁用，适当的替代疗法6~12周华法林治疗1~4周妊娠试验阳性13~38周替代治疗123456***WarfarininhibitsthesynthesisofvitaminK-dependentcoagulationfactorsII,VII,IX,andXandanticoagulantproteinsCandS.Specifically,warfarininterfereswiththecyclicinterconversionofvitaminKandits2,3epoxide(vitaminKepoxide).VitaminKisacofactorforthecarboxylationofglutamateresiduestogamma-carboxyglutamatesontheN-terminalregionsofvitaminK-dependentproteins.Carboxylationallowsthecoagulationproteinstoundergoaconformationalchangewhichisnecessaryfortheiractivation.WarfarinexertsitsanticoagulanteffectbyinhibitingvitaminKepoxidereductaseandpossiblyvitaminKreductase.ThisresultsindepletionofthereducedformofvitaminK(vitaminKH2)andlimitsthegamma-carboxylationofthevitaminK-dependentcoagulantproteins.ThedegreeofeffectonthevitaminK-dependentproteinsisdependentuponthedoseofwarfarin.Theanticoagulanteffectsofwarfarinarestereoselective;theS-isomerofwarfarinis3—5timesmorepotentthantheR-isomer.TherapeuticdosesofwarfarindecreasethetotalamountofactivevitaminK-dependentclottingfactorsproducedbytheliverby30—50%.*Phytonadione,orvitaminK1,isasyntheticcompoundthatischemicallyindistinguishablefromnaturallyoccurringvitaminK1.VitaminKisfoundinbothplantandanimalsources,andisalsoproducedbyintestinalbacteria;however,vitaminKfromthesedifferentsourcesisnotidentical.isfound