Они утверждают крамольные вещи. Эффективность периоперационного назначения НМГ для профилактики ТГВ и ТЭЛА у пациентов групп повышенного риска было убедительно доказано в масштабных исследованиях и рекомендации по их назначению были помечены, как имеющие высокий уровень доказательной обоснованности (
http://www.guideline.gov/summary/sum...=9266&nbr=4960 ).
Другое дело, что все известные мне гайды ограничивают назначение антикоагулянтов у нейрохирургических больных, в связи с высоким риском внутричерепного кровоизлияния.
Нейрохирургическим пациентам в периоперационном периоде не противопоказана только пневмокомпрессия.
Приведу без сокращения еще небольшой текстовый блок по сабжу из The Clinical Practice of Critical Care Neurology 2nd Ed, 2003
Цитата:
Indications for Prophylactic Anticoagulation
The actual occurrence of venous thrombosis and pulmonary emboli is probably more frequent than the neurologic literature suggests and is, for the most part, preventable. Although the efficacy of heparin in the prevention of deep venous thrombosis is undisputed, in the intensive care unit, the overall risk of deep venous thrombosis with subcutaneous administration of low-dose heparin is 5% to 15% in the first week.5 The risk of deep venous thrombosis can be substantial in patients with a brief stay in the NICU who did not receive prophylaxis. The risk of deep venous thrombosis may also be determined by the patient mix in the NICU (trauma or nontrauma). Deep venous thrombosis often develops in a paralyzed leg (or legs in Guillain-Barr syndrome or acute spinal cord disorder). Subcutaneous heparin substantially reduces the risk of deep venous thrombosis and pulmonary embolism when given to patients with ischemic stroke.59 Intracerebral hematomas do not necessarily preclude use of subcutaneous heparin. A study of subcutaneous heparin in patients with intracerebral hematoma found that pulmonary embolism was significantly reduced without increased risk of hemorrhagic complications (deep venous thrombosis was monitored with phleboscintigraphy of erythrocytes labeled in vitro, and pulmonary perfusion scans were done in instances of clinical suspicion).13
However, pneumatic compression devices have similarly significantly reduced the incidence of venous thrombosis postoperatively17,19 but have not been rigorously tested in the NICU population with the exception of elective neurosurgical patients.101 Pneumatic compression devices compress the calves and markedly increase venous flow velocity.
The reduction in deep venous thrombosis and pulmonary embolus with intermittent pneumatic compression devices is similar to that with low-dose heparin and may be a safer alternative in patients with spontaneous or traumatic hematoma. One study comparing historical controls with stroke patients suggested that these devices should be used in combination with a heparin regimen; with this approach, deep venous thrombosis occurred in 0.2% of 432 patients and there were no pulmonary emboli.57
Generally, venous thromboembolism is most effectively prevented with low doses of unfractionated heparin (5000 units subcutaneously every 12 hours) until the patient is ambulatory. Patients with a history of recurrent venous thrombosis should receive the low-molecular-weight heparin enoxaparin, 30 mg subcutaneously every 12 hours. Aspirin, although appealing, or a low dose of warfarin (1 mg) cannot be recommended yet and awaits further evaluation of safety and efficacy.
In most of our patients, however, we have been using pneumatic compression devices to prevent deep venous thrombosis. These devices provide more comfort than twice-daily subcutaneous injections, but they have to remain in place much of the day. (They are disconnected during transport and procedures.) Pneumatic compression devices are generally well tolerated. These devices are probably not sufficient in preventive action in patients with a high risk of venous thromboembolism (previous deep venous thrombosis, underlying malignant disease, or expectation of major surgery, e.g., orthopedic surgery for fractures in patients with multitrauma) or thrombophilia. (Patients with a genetic predisposition to thrombosis usually have the first thrombotic event before age 45.94) Subcutaneous heparin is warranted.
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