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Уровень убедительности рекомендаций I (уровень достоверности доказательств – B)




Уровень убедительности рекомендаций I (уровень достоверности доказательств – B)

· Рекомендуется применение мультимодальной послеоперационной анальгезии [101-104].

Уровень убедительности рекомендаций IIa (уровень достоверности доказательств – B)

Комментарий: Рекомендуется после обширных операций путем сочетания опиатов (фентанил) с нестероидными противовоспалительными препаратами и/или парацетамолом [1]. Парацетамол возможно применять только при отсутствии у пациента явлений печеночной дисфункции. Дозы: парацетамол (Перфалган*) 4—5 г/сут 4—5 дней, кеторолак 90 мг/сут (в/м) (или лорноксикам 32 мг/сут) 3—4 дня [105].

· Для послеоперационного обезболивания рекомендуется применение продленных регионарных и нейроаксиальных блокад [106-113].

Уровень убедительности рекомендаций I (уровень достоверности доказательств – B)

· Рекомендуется проведение послеоперационной тромбопрофилактики [114-119].

Уровень убедительности рекомендаций I (уровень достоверности доказательств – B)

Комментарии: вероятность тромбоза глубоких вен и тромбоэмболии легочной артерии у пациентов с ожирением значительно увеличивается.

С появлением новых пероральных антикоагулянтов (ривароксабан, дабигатрана этексилат и т. д. ) при условии применения этих препаратов перед операцией к их приему следует вернуться как можно раньше, т. е. когда риск послеоперационного кровотечения представляется хирургу минимальным.

Профилактика тромбозов в ранний послеоперационный период [1]:

■ ранняя послеоперационная активизация;

■ применение низкомолекулярных гепаринов (рассчитывается на общую массу тела);

■ эластичная компрессия нижних конечностей чулками

Однако в настоящее время нет достаточных доказательств о преимуществе какого-либо препарата или схемы его применения [105]. В то же время подчеркивается риск развития послеоперационных кровотечений на фоне терапии гепаринами. С равной степенью эффективности применяются нефракционированный гепарин по 5000—7500 Ед подкожно каждые 8 ч, внутривенная инфузия гепарина 400 ЕД/ч, подкожное введение надропарина кальция 0, 3—0, 6 через 12 ч, эноксапарина натрия 30—40 мг 1—2 раза в сутки [120]. Следует начать терапию гепаринами как можно раньше после операции (приложение Г5).


Критерии оценки качества медицинской помощи

Критерии качества Уровень достоверности доказательств Уровень убедительности рекомендаций

Этап постановки диагноза

Определен индекс массы тела I A
  Оценен риск трудных дыхательных путей I B

Этап лечения

Произведена тромбопрофилактика I B

 

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