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1 $PHOL\DW6RQUDVÕ7URPERHPEROLN2OD\ODUÕQ3URILODNVLYH7HGDYLVLQGH * QFHO<DNODúÕP 'U < NVHO $UÕNDQ 1 'U )HUGD 0 ùhqho 2 'U øeudklp =L\DO 3, Dr. Yavuz Akman 2 9HQ LQWLPDVÕQGD KDUDEL\HW VWD] YH NDQÕQ SÕKWÕODúPD ]HOOL LQGHNL DUWÕú DPHOL\DW YH DPHOL\DW VRQUDVÕ GHULQ YHQ WURPER]XQXQ VHEHSOHUL RODUDN J VWHULOPLúWLU <DSÕODQ odoõúpdodugd, 125 ILEULQRMHQ NXOODQÕODUDN WURPE V Q LúDUHWOHQPHVL LOH YDNDODUÕQ XQGD GHULQ YHQ WURPER]X WHVSLW HGLOPLúWLU $PHOL\DW VRQUDVÕ G QHPGH J U OHELOHQ WURPERHPEROLN ROD\ODU QHPOL PRUELGLWH YH PRUWDOLWH VHEHSOHULGLU 'HULQ YHQ WURPER]XQXQ WDQÕVÕQGD HQ QHPOL EXOJXODU úlúoln KDVVDVL\HW YH +RPDQV EHOLUWLVLGLU 7DQÕ \ QWHPOHUL DUDVÕQGD IOHERJUDIL YH 'RSSOHU XOWUDVRQRJUDIL QHPOL \HU NDSODPDNWDGÕU $PHOL\DW VRQUDVÕ EDFDN YHQOHULQGHNL SÕKWÕ ROXúXPXQX HQJHOOHPHN DPDFÕ LOH HODVWLN EDQGDM X\JXODPDVÕ JLEL ohúlwol PHNDQLN QOHPOHU \DUDUOÕGÕU +HSDULQ DPHOL\DW QFHVL SURILODNVL DPDoOÕ X\JXODPDODUGD VXEN WDQ RODUDN DPHOL\DWWDQ VDDW QFH YH VDDW VRQUD YHULOPHNWHGLU 7URPERHPEROLN ROD\ODUÕQ WHGDYLVLQGH N o N PROHN OO KHSDULQ NXOODQÕPÕ \D\JÕQODúPÕúWÕU 5HN UHQVL QOHPHN DPDFÕ\OD KHSDULQ WHGDYLVLQL WDNLEHQ D\ V UH\OH RUDO DQWLNRDJ ODQ WHGDYL JHUHNPHNWHGLU 7URPERHPEROLN ROD\ODUÕQ QOHQPHVL LoLQ ULVN IDNW UOHULQLQ EHOLUOHQLS HQ X\JXQ SURILODNVLQLQ YHULOPHVL NLOLW QRNWDODUGÕU >7XUJXW g]do 7ÕS 0HUNH]L Anahtar Kelimeler: Tromboembolik olaylar, profilaksi, heparin Damage to intima of the vein, stasis of the blood, and tendency for coagulation are the main factors in development of deep venous thrombosis, particularly after surgery. Deep venous thrombosis was identified in 30 to 60% of the cases following operations by utilizing 125 I fibrinogen labeling of the thrombus. The thromboembolic diseases occuring after surgery are the main factors for morbidity and mortality. The most common signs of deep venous thrombosis are swelling, tenderness of the foot, and the Homans sign. Phlebography and Doppler ultrasound are important diagnostic tools. Mechanical preventions such as application of elastic bandages to avoid development of thrombus are useful. Prophylactic subcutaneous heparin is administered 2 hours before and 8-12 hours after the operation. Recently the use of low-molecule heparin is becoming popular. Oral anticoagulant treatment for 6 months is necessary in order to prevent recurrences. Nevertheless, the key points to prevent occurrence of thromboembolic events are determination of the risk factors and application of the optimal prophylaxis. [Journal of Turgut Özal Medical Center 1998;5(1): ] Key Words: Thromboembolic events, prophylaxis, heparin $EDQW ø]]hw %D\VDO hqlyhuvlwhvl ' ]FH 7ÕS )DN OWHVL *HQHO &HUUDKL $QDELOLP 'DOÕ ' ]FH%ROX $EDQW ø]]hw %D\VDO hqlyhuvlwhvl ' ]FH 7ÕS )DN OWHVL hurorml $QDELOLP 'DOÕ ' ]FH%ROX $EDQW ø]]hw %D\VDO hqlyhuvlwhvl ' ]FH 7ÕS )DN OWHVL %H\LQ &HUUDKLVL $QDELOLP 'DOÕ ' ]FH %ROX Journal of Turgut Özal Medical Center 5(1):

2 $PHOL\DW VRQUDVÕ WURPERHPEROLN ROD\ODUÕQ SURILODNVL YH WHGDYLVLQGH J QFHO \DNODúÕP $UÕNDQ < et al. $PHOL\DW VRQUDVÕ G QHPGH J U OHELOHQ YHQ ] tromboz ve pulmoner tromboemboli önemli morbidite YH PRUWDOLWH VHEHSOHULGLU <DSÕODQ LON odoõúpdodugd DPHOL\DWODUGDQ VRQUD KDVWDODUÕQ XQGDQ D]ÕQGD GHULQ YHQ WURPER]X '97 VDSWDQÕUNHQ GDKD VRQUD, 125 ILEULQRMHQ NXOODQÕODUDN WURPE V Q LúDUHWOHQPHVL LOH YDNDODUÕQ XQGD '97 WHVSLW HGLOPLúWLU %XQODUÕQ \DUÕVÕQGDQ or XQGD NOLQLN EHOLUWL EXOXQPDPDNWDGÕU 6HPSWRPDWLN YDNDODUGD LVH EDFDNWD úlúoln YH NÕ]DUÕNOÕN ROPDNWDGÕU øohul \Dú úlúpdqoõn RUDO NRQWUDVHSWLY NXOODQÕPÕ NDOS KDVWDOÕNODUÕ NDQVHU WUDYPD KDUHNHWVL]OLN X]DPÕú DPHOL\DW V UHVL SHOYLN FHUUDKL JLULúLPOHU YH DOW HNVWUHPLWH\L LOJLOHQGLUHQ RUWRSHGLN FHUUDKL JLULúLPOHU WURPE V ULVNLQL DUWWÕUDQ QHPOL IDNW UOHUGLU ø\rwox ILEULQRMHQ NXOODQÕODUDN \DSÕODQ UDG\RL]RWRS odoõúpdoduõqgd HOHNWLI DPHOL\DW JHoLUHQ KDVWDODUÕQ LQGH NDOoD NÕUÕ Õ RODQ KDVWDODUÕQ QGH NDGÕQODUGD GR XP VRQUDVÕ RUDQÕQGD YH PL\RNDUG HQIDUNW V JHoLUHQ KDVWDODUÕQ XQGD EDFDNODUGD YHQ ] WURPER] WHVSLW HGLOPLúWLU Patofizyoloji ve etiyoloji 2QGRNX]XQFX \ ]\ÕOÕQ RUWDODUÕQGD YHQ LQWLPDVÕQGD KDUDEL\HW VWD] YH NDQÕQ SÕKWÕODúPD ]HOOL LQGHNL DUWÕú DPHOL\DW YH DPHOL\DW VRQUDVÕ '97 QLQ VHEHEL RODUDN J VWHULOPLúWLU 'DKD VRQUDODUÕ SÕKWÕ ROXúXPXQXQ PHNDQL]PDVÕ KDNNÕQGD GHWD\OÕ ELOJLOHU HOGH HGLOPLúWLU 9HQ ] WURPER] VWD] ROXúDQ \HUOHUGH ]HOOLNOH EDFDNWDNL N o N YHQOHUGH YH\D YHQ NDSDNODUÕQÕQ DUNDVÕQGD ROXúPD\D EDúODU &HUUDKL VWUHV YH WUDYPD\D ED OÕ KLSHUNRDJ ODELOLWH DQHVWH]L VÕUDVÕQGD EDFDN NDVODUÕQGDNL KLSRWRQL\H ED OÕ YHQ ] DNÕPGD D]DOPD YHQ ] J OOHQPH YH ORNDO YDVN OHU WUDYPDODU WURPER] ULVNLQL DUWÕUPDNWDGÕU Tromboz ilk olarak vende obstrüksiyona sebep olur ( HU HWNLOHQHQ YHQ PDM U ELU YHQ LVH YH\D ELUGHQ orn YHQ WXWXOXPX V ] NRQXVX LVH GLVWDO YHQ ] EDVÕQoWD \ NVHOPH RUWD\D oõndu 9HQ ] NDSLOOHUOHUGHNL EDVÕQo DUWÕQFD VX YH SDUWLN O HPLOLPL HQJHOOHQLU YH E \OHFH GHP RUWD\D oõndu ( HU EX EDVÕQo ORNDO DUWHU\DO EDVÕQFÕQ ]HULQH oõnduvd HNVWUHPLWHGHNL NDQ DNÕPÕ D]DOÕU YH YHQ ] JDQJUHQ J U OHELOLU 7URPE V ROXúXPXQX WDNLEHQ YHQOHUGH X]XQ G QHPGH ROXúDQ skarlar ise venöz yetmezliklere ve ülserlere yol DoPDNWDGÕU %DFDNWD ROXúDQ SÕKWÕQÕQ LON QFH VD NDOEH YH EXQX WDNLEHQ DNFL HUOHUH HPEROL]DV\RQX LVH KD\DWL bir tehlike arz eder (6). %XOJXODU YH WDQÕ 'HULQ YHQ WURPER]XQXQ WDQÕVÕQGD HQ QHPOL EXOJXODU úlúoln KDVVDVL\HW YH +RPDQV EHOLUWLVLGLU %DFDNWDNL úlúoln Oo OHUHN YH GL HU HNVWUHPLWH LOH NDUúÕODúWÕUÕODUDN EHOLUOHQPHOLGLU 7URPER]H YHQGHNL KDVVDVL\HW GDPDU WUDVHVLQLQ EDFDN NDVODUÕQÕQ SRSOLWHDO VDKDQÕQ YH NDVÕN E OJHVLQLQ SDOSDV\RQX LOH J VWHULOLU $\D ÕQ GRUVDO IOHNVL\RQX HVQDVÕQGD RUWD\D oõndq D UÕ +RPDQV EHOLUWLVLQLQ SR]LWLI ROGX XQX gösterir. Bunun sebebi gastroknemius ve soleus NDVODUÕQÕQ JHULOPHVL LOH EXUDGDNL WURPER]H YHQOHULQ LUULWDV\RQXGXU $QFDN \DSÕODQ ED]Õ odoõúpdodugd EX WHVWLQ '97 QLQ WDQÕVÕQGD VSHVLILN ROPDGÕ Õ J VWHULOPLúWLU.OLQLN EXOJXODU '97 QLQ WDQÕVÕQGD QHPOL \HU LúJDO HWPHNWHGLU 7DQÕ \ QWHPOHUL DUDVÕQGD IOHERJUDIL QHPOL ELU \HU NDSODPDNWDGÕU g]hoolnoh VHPSWRP YH EXOJXODUÕ EHOLUJLQ ROPD\DQ KDVWDODUGD ID\GDOÕ ROPDNWDGÕU $\DN YHQOHULQGHNL EDVÕQFÕ OoPHN GH '97 QLQ WHúKLVLQGH \DUGÕPFÕ RODQ GL HU ELU \ QWHPGLU 'RSSOHU ultrasonografi ve impedans pletismografi femoral E OJHGHNL E \ N YHQOHUGHNL WURPER]ODUÕQ WHúKLVLQGH EDúDUÕOÕ VRQXoODU YHUPHNWHGLU $QFDN N o N YHQOHUGH ROXúDQ WURPER]ODUÕQ WHúKLVLQGH LVH, 125 LúDUHWOL ILEULQRMHQ VLQWLJUDILVL ROGXNoD \DUDUOÕGÕU %X WHVW JHQHOOLNOH WURPER] ROXúXPXQXQ HUNHQ G QHPOHULQGH YH WDNLELQGH ID\GDOÕGÕU Gastroknemius, soleus ve plantar kaslardaki \ÕUWÕOPDODU EDFDNWD GHP KDVVDVL\HW YH SR]LWLI +RPDQV EHOLUWLVLQH \RO DoDELOLU g\n GH EDFD D \ QHOLN WUDYPDQÕQ YDUOÕ Õ D\ÕUÕFÕ WDQÕ LoLQ QHPOLGLU.OLQLN RODUDN '97 \H EHQ]H\HQ VHO OLW LVH \RO DoWÕ Õ \ NVHN DWHú EDFDNWD NÕ]DUÕNOÕN YH O NRVLWR] LOH '97 GHQ D\UÕODELOLU )OHERJUDIL YH 'RSSOHU XOWUDVRQRJUDIL LOH EX GXUXPODU '97 GHQ NROD\OÕNOD D\UÕODELOLU Profilaksi $PHOL\DW VRQUDVÕ EDFDN YHQOHULQGHNL SÕKWÕ ROXúXPXQX HQJHOOHPHN DPDFÕ LOH ohúlwol PHNDQLN QOHPOHU GHQHQPLúWLU %DFDNODUÕQ DPHOL\DW V UHVLQFH \XPXúDN SDQVXPDQ YH\D HODVWLN EDQGDM LOH VDUÕOPDVÕ DUDOÕNOÕ SQ PRWLN NRPSUHV\RQ EDFDNODUÕQ NDOS VHYL\HVLQLQ ]HULQH NDOGÕUÕOPDVÕ YH KDVWDQÕQ HUNHQ PRELOL]DV\RQX HQ VÕN NXOODQÕODQ \ QWHPOHUGLU %X \ QWHPOHU ]HOOLNOH '97 ROXúXPX LoLQ \ NVHN ULVN JUXEXQGD RODQ KDVWDODUGD E \ N ID\GD VD ODPDNWDGÕU 106 7XUJXWg]DO 7ÕS0HUNH]L'HUJLVL

3 $UÕNDQ < et al. 0HNDQLN NRUXPD QOHPOHULQLQ \DQÕVÕUD GL HU ELU LOJL RGD Õ LVH SÕKWÕODúPD\Õ HQJHOOH\HQ DMDQODUÕQ NXOODQÕPÕ ROPXúWXU 7DP DQODPÕ\OD \DSÕODQ ELU DQWLNRDJ ODV\RQ '97 ULVNLQL RUWDGDQ NDOGÕUVD ELOH DPHOL\DW VÕUDVÕQGD YH VRQUDVÕQGD NDQDPDODUD \RO açabilmektedir. Bu nedenle kanama riski az olan DQFDN WURPER] ROXúXPXQX HQJHOOH\HFHN DMDQODUÕQ JHOLúWLULOPHVL LoLQ \R XQ odoõúpdodu \DSÕOPDNWDGÕU Kanama faktörlerinden II, VII, IX ve X u, protein C ve protein S nin sentezini inhibe eden kumadin JHQHOOLNOH WURPERHPEROLN ROD\ODUÕQ X]XQ V UHOL NRUXPDVÕQGD NXOODQÕOPDNWDGÕU $PHOL\DW QFHVL EDúODQDQ NXPDGLQ LVH WHUDS WLN G ]H\OHUH JHOGL LQGH DPHOL\DW VÕUDVÕQGD FLGGL NDQDPDODUD \RO açabilmektedir. Trombosit agregasyonunu azaltan DVSLULQ QFHOHUL GHQHQPLú LVH GH EXQXQ '97 \L HQJHOOHPHNWH \HWHUVL] NDOGÕ Õ J U OP úw U :DUIDULQ VÕQÕUOÕ ELU DQWLNRDJ ODQ HWNL J VWHUPHNWHGLU YH EX QHGHQOH NXOODQÕPÕ SRS ODULWH ND]DQPDPÕúWÕU $QFDN VRQ \ÕOODUGD LODo IDUPDNRNLQHWLNOHULQGH GH LúLNOLNOHU \DSÕODUDN RUDO DQWLNRDJ ODQ DMDQODUÕQ HWNLQOL LQLQ DUWWÕUÕOPDVÕQD odoõúõopdnwdgõu. o N PROHN O D ÕUOÕNOÕ GHNVWUDQODU '97 QLQ SURILODNVLVLQGH NXOODQÕOPÕú DQFDN \RO DoWÕ Õ DOOHUMLN UHDNVL\RQODU YH NRQMHVWLI NDOS KDVWDOÕ Õ ULVNLQL DUWWÕUPDVÕ QHGHQL\OH \D\JÕQ NXOODQÕP DODQÕ EXODPDPÕúWÕU +DOHQ ELUoRN NOLQLNWH WURPERHPEROLN ROD\ODUÕQ SURILODNVLVLQGH N o N GR] KHSDULQ NXOODQÕOPDNWDGÕU +HSDULQ SRUNLQ PXNR]DGDQ HOGH HGLOHQ GH LúLN X]XQOXNWD SROLVDNNDULG ]LQFLUOHULQGHQ ROXúDQ ELU PROHN OG U 3DUHQWHUDO \RO GÕúÕQGD YHULOGL LQGH EL\R\DUDUODQÕPÕ \RN VD\ÕODFDN NDGDU D]GÕU %X QHGHQOH hemen her zaman hastanede yatan hastalarda NXOODQÕOPDNWDGÕU $PHOL\DW QFHVL SURILODNVL DPDoOÕ uygulamalarda 5000 U heparin subkütan olarak ameliyattan 2 saat önce ve 8-12 saat sonra verilmektedir. Hasta mobilize oluncaya kadar heparine devam edilmektedir. Heparin profilaksisi ölümle neticelenen pulmoner tromboemboli riskini RUDQÕQGD D]DOWPDNWDGÕU $QIUDNVL\RQH heparin, fibrinojen, faktör VIII, vitronektin ve fibronektin gibi plazma proteinlerine non-spesifik RODUDN ED ODQÕU %X ED ODQPD DQIUDNVL\RQH KHSDULQH dirençten sorumludur ve onun antikoagülan etkisini D]DOWÕU.RQYDQVL\RQHO KHSDULQLQ NXODQÕPÕ LOH WURPERHPEROLN ROD\ODU QHPOL RUDQGD D]DOPÕú ROVD GD aptt düzeylerini tahmin edilemeyen düzeylerde HWNLOHPHVL YH GR]G ]H\ LOLúNLVLQLQ J YHQLOLU ROPDPDVÕ NRQYDQVL\RQHO KHSDULQLQ NXOODQÕPÕQÕ J oohúwluphnwhglu (14). Günümüzde, konvansiyonel büyük moleküllü KHSDULQLQ \DQÕVÕUD IUDNVL\RQH KHSDULQ JLGHUHN QHP ND]DQPDNWDGÕU &LOW DOWÕ GRNXGDQ GDKD J YHQLOLU HPLOLPH YH \ NVHN EL\R\DUDUODQÕPD VDKLS RODQ fraksiyone heparin daha iyi plazma düzeyleri VD ODPDNWDGÕU 6RQ \ÕOODUGD \DSÕODQ NOLQLN odoõúpdodugd IUDNVL\RQH KHSDULQLQ NRQYDQVL\RQHO anfraksiyone heparine göre daha iyi bir DQWLNRDJ ODV\RQ VD ODGÕ ÕQÕ J VWHUPLúWLU. o N moleküllü heparinin farmakokinetik özellikleri daha NROD\ WDKPLQ HGLOHELOGL L YH EHOLUOL GR]GDNL HWNLVL VDELW ROGX X LoLQ WHGDYL VÕUDVÕQGD ODERUDWXYDU monitörizasyonuna (örn. PTT takibi) daha az gerek GX\XOPDNWDGÕU %XQD HN RODUDN N o N PROHN OO KHSDULQ NXOODQÕPÕ KDVWDQHGH NDOÕú V UHVLQL GH azaltmakta ve böylece tedavinin genel maliyetini ROGXNoD D]DOWPDNWDGÕU Derin ven trombozu ve pulmoner tromboembolinin tedavisinde ilk seçenek heparin tedavisi olsa da ciddi WURPERHPEROLN ROD\ODUÕQ ]HOOLNOH PDVLI SXOPRQHU tromboembolinin akut tedavisinde yüksek doz VWUHSWRNLQD] NXOODQÕPÕ EDúDUÕOÕ VRQXoODU YHUPLúWLU.XOODQÕODQ KHSDULQ GR]X JHQHOOLNOH 377 G ]H\LQL NDWÕQD oõndudfdn úhnlogh D\DUODQPDNWDGÕU +DVWDQÕQ Y FXW D ÕUOÕ ÕQD YH LON DOWÕ VDDWWH 377 \L NDWÕQD oõnduwdq KHSDULQ GR]XQD J UH VDELW ELU WHGDYL úhpdvõ JHOLúWLULOHELOPHNWHGLU 7URPERHPEROLN ROD\ODUGD heparin tedavisi genellikle 7 gün devam etmekte, daha VRQUD J Q LoHULVLQGH KHSDULQ GR]X D]DOWÕODUDN WHGDYL VRQODQGÕUÕOPDNWDGÕU ( HU KHSDULQ DQLGHQ kesilirse bunu takip eden 2-3 gün içerisinde tekrar WURPE V ROXúDELOPHNWHGLU %X ROD\ ³KHSDULQ UHERXQG RODUDN DGODQGÕUÕOPDNWDGÕU +HSDULQ LQ GL HU ELU \DQ HWNLVL LVH WURPERVLWRSHQLGLU YH YDNDODUÕQ LOH %0.1 inde görülmektedir (15). 5HN UHQVL QOHPHN DPDFÕ\OD LON KHSDULQ tedavisinden sonra uzun süreli oral antikoagülan WHGDYL JHUHNPHNWHGLU 8]XQ \ÕOODU :DUIDULQ NXOODQÕOPÕú DQFDN WHUDS WLN DUDOÕ ÕQÕQ GDU ROPDVÕ QHGHQL\OH X]XQ V UHOL NXOODQÕPÕ VRQ \ÕOODUGD D]DOPÕúWÕU +HSDULQ VRQUDVÕ KDIWD V UHOL DQWLYLWDPLQ. WHGDYLVL EDúDUÕOÕ VRQXoODU YHUPLúWLU $QFDN NDQDPD LQVLGDQVÕQÕ E \ N RUDQGD DUWÕUPDVÕ YH X]XQ V UHOL WHGDYL V UHVLQLQ VWDQGDUGL]H HGLOPHPLú ROPDVÕ EX LODFÕQ NXOODQÕOPDVÕQÕ J oohúwulphnwhglu Kumadin derivativleri, ilk heparin tedavisini WDNLEHQ X]XQ G QHPGH HQ VÕN NXOODQÕODQ LODoODUGÕU dhúlwol SÕKWÕODúPD IDNW UOHULQL HWNLOH\HQ NXPDGLQLQ HQ QHPOL HWNL PHNDQL]PDVÕ SOD]PD SURWURPELQ NRQVDQWUDV\RQXQX D]DOWPDVÕGÕU %X QHGHQOH NOLQLNWH WHUDS WLN HWNLQOL L SURWURPELQ ]DPDQÕ LOH WDNLS edilmektedir. Kumadin tedavisinin süresi ile ilgili Journal of Turgut Özal Medical Center 5(1):

4 $PHOL\DW VRQUDVÕ WURPERHPEROLN ROD\ODUÕQ SURILODNVL YH WHGDYLVLQGH J QFHO \DNODúÕP < $UÕNDQ YH DUN GH LúLN J U úohu PHYFXWWXU gqfhohul LON '97 DWD ÕQGDQ VRQUD KHSDULQ WHGDYLVLQL WDNLEHQ KDIWD RODUDN X\JXODQDQ NXPDGLQ WHGDYLVL \DSÕODQ VRQ orn PHUNH]OL odoõúpdodugd D\ RODUDN EHOLUOHQPLúWLU %X odoõúpdgd D\GDQ GDKD X]XQ V UHOL DQWLNRDJ ODQ WHGDYLQLQ NDQDPD ULVNLQL orn DUWWÕUGÕ Õ EHOLUWLOPLúWLU.XPDGLQLQ \DQ HWNLOHUL PH\GDQD oõnwõ Õ YH\D NDQDPDODUD \RO DoWÕ Õ GXUXPODUGD H HU X]XQ V UHOL WHGDYL JHUHNL\RUVD G ú N PROHN OO KHSDULQ GH NXOODQÕODELOPHNWHGLU øohul \Dú DúÕUÕ úlúpdqoõn NDOS KDVWDOÕNODUÕ NDQVHU hareketsizlik, uzun ameliyat süresi, pelvik cerrahi JLULúLPOHU JLEL WURPE V ULVNLQL DUWWÕUDQ IDNW UOHULQ mevcudiyetinde ameliyat öncesi bacaklara elastik EDQGDM X\JXODQPDVÕ YH KHSDULQ SURILODNVLVL '97 YH pulmoner tromboemboli riskini önemli oranda D]DOWPDNWDGÕU '97 YH SXOPRQHU WURPERHPEROLQLQ HUNHQ WHúKLVL E \ N QHP WDúÕPDNWD YH WHGDYLQLQ GHUKDO EDúODQPDVÕ JHUHNPHNWHGLU 6RQ \ÕOODUGD WURPERHPEROLN ROD\ODUÕQ WHGDYLVLQGH NXOODQÕODQ N o N PROHN OO KHSDULQ \ NVHN EL\R\DUDUODQÕPÕ YH WDKPLQ HGLOHELOLU LODo G ]H\OHUL nedeniyle tercih edilmektedir. Tekrar trombüs ROXúXPXQX HQJHOOHPHN DPDFÕ\OD LON WURPERHPEROLN DWDN VRQUDVÕ D\ RUDO DQWLNRDJ ODQ WHGDYL QHULOPHNWH ve bu süreden daha fazla tedaviye devam edilmemesi EHOLUWLOPHNWHGLU.XPDGLQ WHGDYLVLQH ED OÕ \DQ HWNLOHU YH\D FLGGL NDQDPDODU J U OG QGH N o N PROHN OO KHSDULQ X]XQ V UHOHUOH NXOODQÕODELOPHNWHGLU Günümüzde antikoagülasyon farmakolojisindeki en QHPOL KHGHI DPHOL\DW VÕUDVÕQGD NDQDPDODUD \RO açmayacak, güvenilir, yan etkileri az olan ve WURPERHPEROL ULVNLQL HQ D]D LQGLUHQ DMDQODUÕQ JHOLúWLULOPHVLGLU 2OXúPXú WURPE V Q WHGDYLVL LoLQ GH HWNLOL DMDQODU JHOLúWLULOPHNWHGLU 5LVN IDNW UOHULQLQ belirlenip en uygun profilaksinin verilmesi WURPERHPEROLN ROD\ODUÕQ QOHQPHVL LoLQ NLOLW QRNWDODUGÕU KAYNAKLAR 1. Kakkar VV. Prevention of venous thromboembolism. Clin Haematol 1981;10: Baue AE. Prevention of venous thrombosis and pulmonary embolism. JAMA 1986;256: Office of Medical Applications of Research, National Institute of Health: Prevention of venous thrombosis and pulmonary embolism. JAMA 1986;256: Virchow R. Die celluler pathologie in Ihrer Begrundung auf Physiologische und Pathologische Gewebelehre, Berlin, Rogers JS. Hypercoagulable states. W V Med J 1993;89: Storti S, Crucitti P, Cina G. Risk factors and prevention of venous thromboembolism. Rays 1996;21: McLachlin J, Richards T, Paterson JC. An evaluation of clinical signs in the diagnosis of venous thrombosis. Arch Surg 1962;85: Wheeler HB. Diagnosis of deep venous thrombosis: review of clinical evaluation and impedence plethysmography. Am J Surg 1985;150: Moossa AR, Lavelle-Jones M, Scott M. Surgical complications In: Sabiston DC (ed) Textbook of Surgery, Philadelphia: WB Saunders Company 1986: Clarke- Pearson DL, Creasman WT, Coleman RE, Synan IS, Hinshaw WM. Perioperative external pneumatic calf compression as thromboembolism prophylaxis in gynecologic oncology: report of a randomized controlled trial. Gynecol Oncol 1984; 18: Muhe E. Intermittant sequential high-pressure compression of the leg: a new method of preventing deep venous thrombosis. Am J Surg 1984;147: Vanscoy GJ, Coax WC. Oral anticoagulation: improving the risk-benefit ratio. J Fam Pract 1995;41: Agnelli G. Anticoagulation in the prevention and treatment of pulmonary embolism. Chest 1995;107:Suppl, 39S-44S. 14. Baglin TP. Low-molecular-weight heparins and new strategies for the treatment of patients with established venous thrombosis. Haemostasis 1996;26:Suppl, Gulba DC. Anticoagulant drugs. Herz 1996;21: Ten Cate JW, Koopman MM, Prins MH, Büller HR. Teatment of venous thromboembolism. Thromb Haemost 1995;74: Sarasin FP, Bounameaux H. Cost-effectiveness of prophylactic anticoagulation prolonged after hospital discharge following general surgery. Arch Surg 1996;131: Jerjes-Sánchez C, Ramírez Rivera A, Arriaga Nava R, Pimentel Morales G. High doses and the rapid infusion of streptokinase for the treatment of massive pulmonary thromboembolism. Arch Inst Cardiol Mex 1993;63: Reilly BM, Raschke RA. New method to predict patients' intravenous heparin dose requirements. J Gen Intern Med 1996;11: DeWeese JA. Venous and lymphatic disease. In: Schwartz SI(ed) Principles of Surgery, Singapore: McGraw-Hill Book Company 1983: Ferrari E, Baudouy M, Morand P. Duration of antivitamin K therapy in venous thromboembolic disease. Arch Mal Coeur Vaiss 1995;88: Schulman S, Granqvist S, Holmström M, et al. The duration of oral anticoagulant therapy after a second episode of venous thromboembolism. The Duration of Anticoagulation Trial Study Group. N Engl J Med 1997;336: Harenberg J, Huhle G, Piazolo L, Giese C, Heene DL. Longterm anticoagulation of outpatients with adverse events to oral anticoagulants using low-molecular-weight heparin. Semin Thromb Hemost 1997;23: XUJXWg]DO7ÕS0HUNH]L'HUJLVL

5 $UÕNDQ < et al. <D]ÕúPD DGUHVL: Dr. Yüksel ARIKAN $ø%h ' ]FH 7ÕS )DN OWHVL Genel Cerrahi ABD Düzce BOLU Tel: Fax: Journal of Turgut Özal Medical Center 5(1):