부인과수술을하는 high-risk* patients 을위한혈전예방을위해서는, especially for malignancy, 아래의예방책중에서선택을한다 : 수술전 Pneumatic compression devices 을사용하고퇴원할때까지계속사용한다. 미분획헤파린 (5,

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Guideline Title DVT 와 PE 예방. Bibliographic Source(s) American College of Obstetricians and Gynecologists (ACOG). Prevention of deep vein thrombosis and pulmonary embolism.

이가이드라인은이전 version 을갱신한것이다 : American College of Obstetricians and Gynecologists (ACOG). Prevention of deep vein thrombosis and pulmonary embolism.

1 Guideline Title DVT 와 PE 예방. Bibliographic Source(s) American College of Obstetricians and Gynecologists (ACOG). Prevention of deep vein thrombosis and pulmonary embolism. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2007 Aug. 12 p. (ACOG practice bulletin; no. 84). [75 references] Guideline Status 이것은최신판가이드라인입니다. 이가이드라인은이전 version 을갱신한것이다 : American College of Obstetricians and Gynecologists (ACOG). Prevention of deep vein thrombosis and pulmonary embolism. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2000 Oct. 10 p. (ACOG practice bulletin; no. 21). The American College of Obstetricians and Gynecologists (ACOG) 은 2012 년에이가이드라인의통용을재차단언하였다. Recommendations Major Recommendations The grades of evidence (I-III) 와 levels of recommendations (A-C) 은 "Major Recommendations." 의말미에정의가되어있다 아래의 recommendations 은일관된과학적근거에바탕을두고있다 (Level A): 부인과수술을하는 moderate-risk* patients 들을위한혈전예방을하기위해서는아래의예방책중에서선택을한다 : 수술시작전 Graduated compression stockings 을신기고환자들이완벽하게걸을수있을때까지신고있도록한다. 수술시작전 Pneumatic compression devices 을사용하고환자들이완벽하게걸을수있을때까지계속사용한다. 미분획헤파린 (5,000 units) 을수술 2 시간전에피하로주사하고수술후퇴원할때까지 12 hours 마다피하주사를한다 저분자헤파린 (dalteparin, 2,500 antifactor-xa units, or enoxaparin, 40 mg) 을수술 12 시간전에피하주사를하고수술후부터퇴원할때까지하루에한번피하주사를한다.

2 부인과수술을하는 high-risk* patients 을위한혈전예방을위해서는, especially for malignancy, 아래의예방책중에서선택을한다 : 수술전 Pneumatic compression devices 을사용하고퇴원할때까지계속사용한다. 미분획헤파린 (5,000 units) 을수술 2 시간전에피하로주사하고수술후 8 시간마다피하주사하고퇴원할때까지계속피하주사한다 저분자헤파린 (dalteparin 5,000 antifactor-xa units or enoxaparin 40 mg) 을수술 12 시간전에피하주사하고수술후퇴원할때까지하루에한번피하주사한다 다음의 recommendations 은제한적인과학적근거에바탕을두고있다. (Level C): highest-risk 환자들을위한예방을위해서는다음예방책중에서선택을한다 : 압박기기와저용량미분획헤파린과병행사용, 또는압박기기와저분자헤파린병행예방 수술후 28 일까지외래환자로써계속적인저분자헤파린예방을고려. 만일수술 12 시간전에저분자헤파린주사를하지못하면, 최초의처방을수술후 6~12 에시작하여야한다. 부인과수술을받고있는 low-risk patients 는조기보행을시키는것외의특별한예방이필요치않다. 좀더많은근거들이쌓일때까지는, laparoscopic surgery 을받는환자들은 laparotomy 을받는환자들처럼예방책이필요한위험군으로분류되어야한다. * 부인과수술환자들중에서혈전색전증의위험도분류, 아래의표를보세요 : Venous Thromboembolism Risk Factors 수술 외상 (major or lower extremity) 기동성부재, 부전마비 (paresis) 악성종양 (Malignancy) 암치료 (hormonal, chemotherapy, or radiotherapy) 정맥혈전색전증의병력 나이 (Increasing age) 임신중, 그리고출산후 (postpartum period) Estrogen 이포함되어있는구강피임약또는호르몬치료 선택성에스트로겐수용체조절인자 (selective estrogen receptor modulators) Acute medical illness 심부전또는호흡부전 염증성장질환 골수증식성질환 (Myeloproliferative disorders) 발작성야간혈색뇨증 (Paroxysmal nocturnal hemoglobinuria) 신증후군 (Nephrotic syndrome) 비만 흡연 하지정맥류 Central venous catheterization 선천적또는후천적혈전이상증 (thrombophilia) Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126(suppl):338S 400S.

3 표 : 예방을하지않고수술을받는환자들에게정맥혈전색전증을위한위험분류 (Risk Classification) Level of Risk Low Moderate Definition 추가위험인자없는 40 세이하환자가수술시간이 30 분이내일때추가위험인자없는 40 세이하의환자가수술시간이 30 분이내일때 ; 추가위험인자가없는 40~60 세의환자가수술시간이 30 분이내일때 ; 추가위험인자가없는 40 세이하의환자의 major surgery 시 High 60 세이상의환자가수술시간이 30 분이내일때또는추가위험인자가있고 ; 40 세이상 환자가 major surgery 시또는추가위험인자가있을시 Highest 60 세이상의환자가 Major surgery 시 plus 정맥혈전증병력, 암, 또는 응고항진상태 ( hypercoagulable state) Modified from Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126(suppl):338S 400S. Definitions: Grades of Evidence I 최소한 1 개의알맞게계획된무작위대조연구로부터획득한증거 II-1 무작위추출방식이아닌잘계획된대조연구로부터획득한증거 II-2 잘계획된 cohort or case-control 분석연구, 1 곳이상의센터나연구집단으로부터획득한증거. II-3 다양한시계열분석 (time series) 으로획득한증거 (with or without the intervention). Dramatic results in uncontrolled experiments also could be regarded as this type of evidence. III 신임이있는연구기관, 임상경험의근거, 기술연구 or 전문위원회의논문들의의견 Level A Recommendations 은일관성이있는과학적근거에바탕을두고있다. Level B - Recommendations 은제한적이거나또는일관성이없는과학적근거에바탕을두고있다. Level C - Recommendations 은최우선적으로전문가의동의와의견에바탕을두고있다. Clinical Algorithm(s) None provided Scope Disease/Condition(s) DVT 와 PE 를포함한 VTE Guideline Category 예방 위험평가

4 Clinical Specialty Family Practice Internal Medicine Obstetrics and Gynecology Pulmonary Medicine Surgery Intended Users Physicians Guideline Objective(s) 적절한산부인과치료에대한결정을하는 practitioners 를돕기위함 부인과환자들에게혈전예방의이용에대한최신논문을재검토하도록하기위해서, 그리고임상적결정을 가이드하기위한 evidence-based recommendations 을제공하기위해서 Target Population gynecologic surgery 하는여성 주의를기울여야할 Interventions 그리고 Practices 1. 정맥혈전색전증위험인자에의한외과의사의예방책 (surgical prophylaxis) Graduated 압박스타킹 간헐적공기압박기기 (IPC) 저용량미분획헤파린 (Low-dose unfractured heparin) 저분자헤파린 (LMWH)(dalTEPARIN, ENOXAPARIN) Combination 예방 ( 공기압박기기와헤파린의병행예방 ) 수술뒤 28 일까지항응고제예방지속 2. 혈액응고이상증테스트 3. 헤파린유도성혈소판기능이상증 (platelet counts) 주의를기울여야할주요결과 (Major Outcomes) 정맥혈전색전증예방을위한혈전예방책의효과 예방과연관된사망률

5 Methodology Description of Methods Used to Collect/Select the Evidence 2012 Reaffirmation 2007 년 ~2012 년에발표된논문들을 Medline/Pubmed/Cochrane databases 에서조사하였다. Number of Source Documents Not stated Methods Used to Assess the Quality and Strength of the Evidence Weighting According to a Rating Scheme (Scheme Given) Rating Scheme for the Strength of the Evidence 연구들이재검토되었고 U.S. Preventive Services Task Force 에의해강조된방법에따라 quality 가평가되었다 I 최소한 1 개의알맞게계획된무작위대조연구로부터획득한증거 II-1 무작위추출방식이아닌잘계획된대조연구로부터획득한증거 II-2 잘계획된 cohort or case-control 분석연구, 1 곳이상의센터나연구집단으로부터획득한증거. II-3 다양한시계열분석 (time series) 으로획득한증거 (with or without the intervention). Dramatic results in uncontrolled experiments also could be regarded as this type of evidence. III 신임이있는연구기관, 임상경험의근거, 기술연구 or 전문위원회의논문들의의견위원회의위원은서류그리고주제에관한연구의새로운논문을재검토하였다. 위원회에서그서류를재검토하였고그서류가새로이사용할수있고정확하다고인정하였다. Rating Scheme for the Strength of the Recommendations Data 에있는가장높은증거수준 (highest level of evidence) 에바탕을두었고, recommendations 은다음의분류에따라서등급이매겨졌다 : Level A Recommendations 은일관성이있는과학적근거에바탕을두고있다. Level B - Recommendations 은제한적이거나또는일관성이없는과학적근거에바탕을두고있다. Level C - Recommendations 은최우선적으로전문가의동의와의견에바탕을두고있다. Cost Analysis 두비용효과분석이부인과수술을했던환자들에게시행하였었다. pneumatic compression 이가장비용효과가좋은것으로분석되었다. 또다른연구에서는 high-risk gynecologic cancer 환자들에게공기압박기기와헤파린병행의비용효과가우수한것으로밝혀졌다. 저자는저분자헤파린과공기압박기기를함께병행해서사용하는것이 high-risk group 에게비용효과 (cost-effective) 가크다고결론을내렸다. Description of Method of Guideline Validation Practice Bulletins 은 practicing obstetricians-gynecologists generalists 와 sub-specialists 로구성된 two internal clinical review panels 에의해정당성을검증받았다.

6 American College of Obstetricians and Gynecologists (ACOG) 집행위원회가최종가이드라인을재검토해서승인을하였다. Benefits/Harms of Implementing the Guideline Recommendations Potential Benefits Overall Benefits Appropriate use of prophylaxis to prevent venous thromboembolism in gynecologic patients Benefits of Specific Interventions Graduated compression stockings prevent pooling of blood in the calves. A Cochrane review of randomized, controlled trials reported a 50% reduction in deep vein thrombosis (DVT) formation with graduated compression stockings, and they were more effective when combined with a second prophylactic method. Low cost and simplicity are the main advantages of using graduated compression stockings. Knee-length stockings are as effective as thigh-length stockings and should be preferentially used. 압박기기 : 규칙적으로종아리를마사지해줌으로서종아리의정체된혈액을감소시켜주는기기. major gynecologic surgery 전, 중, 후에사용하면, 압박기기는심부정맥혈전증발생감소율이저용량헤파린과 저분자헤파린의효과와같다. Low-dose unfractionated heparin: Two large meta-analyses of randomized clinical trials of patients who had undergone general surgery showed a two-thirds reduction in fatal pulmonary embolism with the use of low-dose unfractionated heparin every 8 hours compared with placebo or no prophylaxis. Advantages of low-dose unfractionated heparin include well-studied efficacy and low cost. Low-molecular-weight heparin: Advantages of low molecular weight heparin include greater bioavailability and a once-daily dosage. These benefits result from a longer half-life, more predictable pharmacokinetics, and equivalent efficacy when compared with prophylactic use of low-dose unfractionated heparin. Low molecular weight heparin has more antifactor-xa and less antithrombin activity than low-dose unfractionated heparin, which may decrease medical bleeding and wound hematoma formation. However, low molecular weight heparin is more expensive than low-dose unfractionated heparin. Heparin-induced thrombocytopenia is rarely observed with low molecular weight heparin, and screening for this is not recommended. 이중예방책 : 수술. 압박기기와헤파린을병행사용하여정맥혈전색전증을예방하면 highest-risk patients 에게 아주효과적이며헤파린과압박기기의 combination 예방을 American College of Chest Physicians Consensus Conference. 잠재적위험성 (Potential Harms) 잘맞지않는압박스타킹은혈관을압박할수있어정맥정체 ( 정맥울혈 ) 를더증가시킨다. 수술중혈액의손실이저용량미분획헤파린의수술전사용으로인해증가하지않는다고생각할수도있지만, 수술후출혈을증가시킨다는것에주목해야한다, 특히 in wound hematoma formation. 게다가, 4 days 이상사용하는것은꼭 platelet counts 를모니터링하여야한다. 왜냐하면환자중 6% 에게서헤파린유도성혈소판감소증 (heparin induced thrombocytopenia) 이나타나기때문이다.

황지웅

황지웅 Comparison of Laparoscopy and Exploration in the Distal Pancreatectomy BACKGROUND: To determine the benefits of laparoscopic surgery compared with exploration, the clinical outcomes of open and laparoscopic