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Уровень убедительности рекомендаций I (уровень достоверности доказательств – B)
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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
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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 |
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Этап постановки диагноза | |||
| Определен индекс массы тела | I | A | |
| Оценен риск трудных дыхательных путей | I | B | |
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Этап лечения | |||
| Произведена тромбопрофилактика | I | B | |
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