{"id":2768,"date":"2023-02-10T10:26:33","date_gmt":"2023-02-10T10:26:33","guid":{"rendered":"https:\/\/www.karotidnahirurgija.com\/?page_id=2768"},"modified":"2023-02-24T12:31:55","modified_gmt":"2023-02-24T12:31:55","slug":"7-4-postoperativno-medikamentozno-lecenje","status":"publish","type":"page","link":"https:\/\/www.karotidnahirurgija.com\/?page_id=2768","title":{"rendered":"7.4. POSTOPERATIVNO MEDIKAMENTOZNO LE\u010cENJE"},"content":{"rendered":"

\"\"<\/a><\/p>\n

<\/p>\n

MEDIKAMENTOZNA TERAPIJA KAROTIDNE BOLESTI<\/h1>\n

<\/a><\/h1>\n

\n

\n

7.4. MEDIKAMENTOZNO LE\u010cENJE<\/p>\n

<\/h3>\n<\/div>\n
\n

POSTOPERATIVNO<\/b><\/span> <\/b><\/span>MEDIKAMENTOZNO<\/b><\/span> <\/b><\/span>LE\u010cENJE<\/b><\/span><\/p>\n

\u201cCochraneova<\/i><\/span>\u201d<\/span> <\/span>analiza<\/span> <\/span>dokazuje<\/span> <\/span>antitrombocitni<\/b><\/span> <\/b><\/span>lekovi<\/b><\/span> <\/b><\/span>smanjuju<\/span> <\/span>stopu<\/span> <\/span>mo\u017edanog<\/span> <\/span>udara<\/span> <\/span>nakon<\/span> <\/span>karotidne<\/span> <\/span>endarterektomije.<\/span> <\/span><\/sup>U<\/span> <\/span>dvostruko-slepoj<\/span> <\/span>placebo<\/span> <\/span>kontrolisanoj<\/span> <\/span>studiji,<\/span> <\/span>niska<\/span> <\/span>doza<\/span> <\/span>acetil-salicilne<\/span> <\/span>kiseline<\/span> <\/span>od<\/span> <\/span>75 mg<\/span> <\/span>dnevno,<\/span> <\/span>smanjuje<\/span> <\/span>incidencu<\/span> <\/span>postoperativnog<\/span> <\/span>mo\u017edanog<\/span> <\/span>udara.<\/span><\/p>\n

Klopidogrel<\/b><\/span> <\/b><\/span>u<\/span> <\/span>kombinaciji<\/span> <\/span>sa<\/span> <\/span>acetil-salicilnom<\/span> <\/span>kiselinom<\/span> <\/span>je<\/span> <\/span>koristan<\/span> <\/span>u<\/span> <\/span>redukciji<\/span> <\/span>cerebralne<\/span> <\/span>embolizacije<\/span> <\/span>prilikom<\/span> <\/span>karotidne<\/span> <\/span>endarterektomjie.<\/span> <\/span><\/sup>Broj<\/span> <\/span>embolizacija,<\/span> <\/span>dijagnostikovan<\/span> <\/span>transkranijalnim<\/span> <\/span>doplerom,<\/span> <\/span>u<\/span> <\/span>prva<\/span> <\/span>tri<\/span> <\/span>sata<\/span> <\/span>nakon<\/span> <\/span>operacije,<\/span> <\/span>bio<\/span> <\/span>je<\/span> <\/span>\u010dak<\/span> <\/span>deset<\/span> <\/span>puta<\/span> <\/span>ni\u017ei<\/span> <\/span>u<\/span> <\/span>pacijenata<\/span> <\/span>kojima<\/span> <\/span>je<\/span> <\/span>ordiniran<\/span> <\/span>klopidogrel<\/span> <\/span>u<\/span> <\/span>pore\u0111enju<\/span> <\/span>sa<\/span> <\/span>placebo<\/span> <\/span>grupom.<\/span> <\/span>Medjutim,<\/span> u <\/span>pacijenata<\/span> <\/span>kojima<\/span> je <\/span>ordiniran<\/span> <\/span>klopidogrel,<\/span> <\/span>vreme<\/span> <\/span>od<\/span> <\/span>uspostavlljanja<\/span> <\/span>cerebralne<\/span> <\/span>cirkulacije<\/span> <\/span>do<\/span> <\/span>rekonstrukcije<\/span> <\/span>ko\u017ee<\/span> <\/span>(indirektan<\/span> <\/span>znak<\/span> <\/span>vremena<\/span> <\/span>hemostaze)<\/span> <\/span>bilo<\/span> <\/span>je<\/span> <\/span>zna\u010dajno<\/span> <\/span>du\u017ee,<\/span> <\/span>premda<\/span> <\/span>nisu<\/span> <\/span>registrovani<\/span> <\/span>hematomi<\/span> <\/span>i<\/span> <\/span>nije<\/span> <\/span>bilo<\/span> <\/span>potrebe<\/span> <\/span>za<\/span> <\/span>primenom<\/span> <\/span>transfuzije<\/span> <\/span>krvi.<\/span><\/p>\n

\u201cBridging\u201d,<\/span> <\/span>odnosno<\/span> <\/span>premo\u0161tavaju\u0107a<\/span> <\/span>antikoagulantna<\/span> <\/span>terapija<\/span> <\/span>perioperatvnom<\/span> <\/span>administracijom<\/span> <\/span>nisko-molekularnog<\/span> <\/span>heparina,<\/span> <\/span>neophodna<\/span> <\/span>je <\/span>u<\/span> <\/span>pacijenata<\/span> <\/span>na<\/span> <\/span>hroni\u010dnoj<\/span> <\/span>oralnoj<\/span> <\/span>antikoagulantnoj<\/span> <\/span>terapiji.<\/span> <\/span>Upotreba<\/span> <\/span>warfarina<\/span> <\/span>se<\/span> <\/span>mora<\/span> <\/span>prekinuti<\/span> <\/span>nekoliko<\/span> <\/span>dana<\/span> <\/span>pre<\/span> <\/span>planirane<\/span> <\/span>operacije.<\/span> <\/span>U<\/span> <\/span>pacijenta<\/span> <\/span>koji<\/span> <\/span>prima<\/span> <\/span>warfarin<\/span> <\/span>sa<\/span> <\/span>ciljnim<\/span> <\/span>vrednostima<\/span> <\/span>INR-a<\/span> <\/span>2.0\u20133.0<\/span> <\/span>ili<\/span> <\/span>2.5-3.5,<\/span> <\/span>prekid<\/span> <\/span>upotrebe<\/span> <\/span>warfarina<\/span> <\/span>5<\/span> <\/span>ili<\/span> <\/span>6<\/span> <\/span>dana<\/span> <\/span>pre<\/span> <\/span>operacije<\/span> <\/span>trebalo<\/span> <\/span>bi<\/span> <\/span>da<\/span> <\/span><\/span>normalizuje<\/span> <\/span>vrednosti<\/span> <\/span>INR-a<\/span> <\/span>u<\/span> <\/span>vreme operacije.<\/p>\n

\"\"<\/b><\/p>\n

\n

Intimalni flap zaostao tehni\u010dkom gre\u0161kom na distalnom kraju karotidne endarterektomije.
<\/em>Neophodno je medikamentozno prevenirati restenozu
<\/em>B mod<\/em><\/p>\n

Preoperativna <\/b>terapija <\/b>statinima <\/b>u pacijenata kojima predstoji endarterektomija, ispitivana je u 1566 pacijenata tokom desetogodi\u0161njeg pra\u0107enja. Upotreba statina dovela je do redukcije stope perioperativnog mo\u017edanog udara (1.2% vs<\/i> <\/i>4.5%), smrtnog ishoda i trajanja hospitalizacije. (prose\u010dno 2 dana). Stopa mo\u017edanog udara ostajala je ni\u017ea tokom celog perioda postoperativnog pra\u0107enja. 31<\/span><\/sup> <\/span><\/sup>Pacijenti kojima predstoji karotidna endarterektomjia ili druga velika vaskularna operacija su randomizovani na grupu pacijenata koja je primala 20 mg<\/p>\n

atorvastatina i placebo grupu. Terapija je primenjivana 45 dana, nevezano za vrednosti serumskog holesterola. Vaskularna operacija u\u010dinjena je prose\u010dno 30-og dana od po\u010detka randomizacije i pacijenti su prospektivno pra\u0107eni. Pacijenti koji su uzimali statine su imali tri puta manji kombinovani rizik od kardiovaskularnih doga\u0111aja, uklju\u010duju\u0107i akutni infarkt miokarda, ishemi\u010dni mo\u017edani udar, nestabilnu anginu pektoris ili smrtni ishod unutar 6 meseci. (8% prema 26%).<\/p>\n

Statini ordinirani 40 dana pre elektivne vaskularne procedure, uz postoperativni nastavak terapije \u010dim su pacijenti sposobni za oralnu terapiju, sni\u017eavali su stopu perioperativniog mortaliteta i morbiditeta (8. 8% v<\/i> <\/i>14. 7%). <\/span><\/sup>Statine treba uklju\u010diti \u0161to ranije jer svojim pleiotropnim efektima, a ne samo regulisanjem lipidnih frakcija, pozitivno uti\u010du na rane i udaljene rezultate vaskularnih operacija.<\/p>\n

Perioperatvno medikamentozno le\u010denje<\/h3>\n
    \n
  • Acetilsalicilnu kiselinu u dozi od 75mg bi trebalo ordinirati pre, tokom i nakon karotidne endarterektomjie.<\/li>\n
  • Cerebralna embolizacija perioperativno je re\u0111a u pacijenata kojima je preop- erativno ordiniran klopidogrel.<\/li>\n
  • Ima indicija da bi klopidogrel trebalo primenjivati kao dodatni antitrombocitni lek u svih pacijenata sa povi\u0161enim rizikom.<\/li>\n
  • Kod pacijenata koji primaju warfarin sa ciljnim vrednostima INR-a 2.0 \u20133.0 ili 2.5-3.5, prekid upotrebe warfarina 5 ili 6 dana pre operacije trebalo bi da nor- malizuje vrednosti INR-a u vreme operacije, uz primenu niskomolekularnog heparina kao terapije za premo\u0161\u0107enje.<\/li>\n
  • Statin treba uklju\u010diti \u0161to ranije pre planirane vaskularne rekonstrukcije, a naj- manje 45 dana.<\/li>\n<\/ul>\n<\/div>\n


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