Transcript DVT in Orthopaedics

VTE in Orthopaedics
Australian Orthopaedic Nurses’ Association
15 May 2009
Dr Lachlan Milne
What is VTE?

Venous thromboembolism (VTE)
Deep Vein Thrombosis (DVT)
 Pulmonary Embolism (PE)
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What is VTE?
Why is VTE a problem?
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VTE annual risk 1-2 per 1000 people1
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40 000 per year in Australia
PE: 0.2% deaths per year in Australia2
Morbidity higher than mortality
1.
Ho et al. Venous thromboembolism: diagnosis and management of deep venous
thrombosis MJA 2005; 182 (9): 476-481
2.
Australian Bureau of Statistics 2006
Consequences of DVT
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Death
Pulmonary Embolism
Post-thrombotic Syndrome (chronic V HT)
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Venous stasis
Leg pain and swelling
Hyperpigmentation
Leg ulcers
Recurrent Venous Thromboembolism
1.
Tovey C et al. Diagnosis, investigation, and management of deep vein thrombosis. BMJ
2003;326;1180-1184
DVT in orthopaedics?
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Orthopaedic patients are most at risk of
all patients in hospital1
Total Joint Arthroplasties
 Major Trauma
 Hip Fractures
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1.
White et al: Risk factors for venous thromboembolism after total hip and knee
replacement surgery. Current Opinion in Pulmonary Medicine 2002, 8:365–371
DVT Pathophysiology
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Virchow’s Triad
Endothelial injury
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Surgery
Venous stasis
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Tourniquet
Immobilisation
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Delayed ambulation
Casting
Change in blood constituents
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1.
↑ platelets
↑ clotting
↑ viscosity
Virchow RLK (1856). Thrombosis und Embolie. Gefässentzündung und septische Infektion".
Gesammelte Abhandlungen zur wissenschaftlichen Medicin. pp. 219–732.
Risk factors
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Increased in orthopaedics:
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Immobilisation
Major surgery
Tourniquet
Other non orthopaedic
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Obesity BMI >30 (often in arthroplasties)
History of prior DVT
Female
Smoking
OCP
Genetic (many)
1.
White et al: Risk factors for venous thromboembolism after total hip and knee
replacement surgery. Current Opinion in Pulmonary Medicine 2002, 8:365–371
Course of DVT illness
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Determined by the site of thrombosis1
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Calf
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Where DVTs start
50% resolve in 3/7
Rarely causes PE in isolation
25% extend proximally within 1 week
Proximal
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1.
Symptomatic
50% have PE at Dx
only 1 in 5 of those is symptomatic of PE
Ho W. et al Venous thromboembolism: diagnosis and management of deep venous
thrombosis MJA 2005; 182 (9): 476-481
VTE – Signs and Symptoms
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DVT1
Leg swelling/erythema
Leg pain
Superficial venous congestion
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PE
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Symptoms:
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Dyspnoea
Pleuritic chest pain
Signs:
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1.
↑ PR
↓ SaO2
↑ RR
Tovey C et al. Diagnosis, investigation, and management of deep vein thrombosis. BMJ
2003;326;1180-1184
Diagnosis of DVT1
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1.
Unreliable
Clinical assessment algorithm
Screening investigations
Definitive investigations
Tovey C et al. Diagnosis, investigation, and management of deep vein thrombosis. BMJ
2003;326;1180-1184
Clinical assessment
1
algorithm
Score
Clinical feature
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Low prob ≤0
Mod prob 1-2
High prob ≥3
1.
Active cancer <6/12 ago
1
Recent immobilisation of legs
1
Recently bedridden >3/7
Major surgery <4/52
1
AND/OR
Tender over deep venous system
1
Entire leg swollen
1
Calf swelling >3cm
1
Collateral superficial non varicose veins
1
Pitting oedema > asymptomatic
1
Alternative diagnosis likely
-2
Tovey C et al. Diagnosis, investigation, and management of deep vein thrombosis. BMJ
2003;326;1180-1184
Screening Investigations
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D Dimer assay
Degradation product of fibrin
 Elevated in 80% of VTE
 Fast
 Low specificity
 Useless in context of surgery
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Definitive Ix – Venography1
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Gold standard
Invasive
Painful
Risks:
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Thrombosis
Contrast allergy
Venogram showing
popliteal vein
thrombosis
1.
Tovey C et al. Diagnosis, investigation, and
management of deep vein thrombosis. BMJ
2003;326;1180-1184
Definitive Ix - Ultrasound
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Non invasive
Safe
Good Sensitivity
97% proximal
 75% calf1
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Compression US
Doppler
1.
Kraaijenhagen RA et al. Diagnostic management of venous thromboembolism. Baillières
Clin Haematol 1998;11: 541-86.
Definitive Investigations
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CT venography
Highly sensitive and specific
 Huge amount of radiation
 Not much improvement on US
 Rarely used
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Definitive Investigations
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MRI
Best invasiveness to sensitivity ratio
 Expensive
 Unlikely to be used frequently until costs
decrease
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Diagnosis of PE
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Clinical judgement
Arterial Blood Gas
VQ scan
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Probability
CTPA
Diagnostic
 Contrast
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Treatment
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Anticoagulation
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Heparin
Unfractionated
 Low Molecular Weight
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Warfarin
IVC filter
Compression stockings
Treatment - Heparin
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Minimum 5/7 until warfarin therapeutic
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Unfractionated
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Infusion
Q6h monitoring
Renal impairment
Low Molecular Weight Heparin
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consistent response
Longer t ½ – Daily dosing
Effective
↓ haemorrhage
Nephrotoxic
Treatment - Warfarin
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Oral dosing
Prothrombotic initially
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Heparin/Clexane
Monitoring with INR target 2.0 – 3.0
Not used in pregnancy – crosses placenta
6/12 treatment
Treatment – IVC filter
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When anticoagulation contraindicated
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eg orthopaedic patients undergoing surgery
Recurrent DVT despite adequate
anticoagulation
Treatment – Stockings
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Simple and cost effective
Reduce likelihood of post-thrombotic
syndrome
Wear for 18 months post DVT 1
1.
Brandjes DP et al. Randomised trial of effect of compression stockings in patients with
symptomatic proximal-vein thrombosis. Lancet 1997;349:759-62
Prevention
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Orthopaedic patients most at risk
Australian Therapeutic Guidelines
Medical
Mechanical
1.
Geerts WH et al. Prevention of Venous Thromboembolism The Seventh ACCP Conference on
Antithrombotic and Thrombolytic Therapy
Prevention – Mechanical
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Should be commenced evening prior to surgery
Stockings:
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GCS – Graduated Compression Stockings
TEDs – ThromboEmbolic Deterrents
Compressors:
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SCDs – Sequential Compression Devices
IPC – Intermittent Pneumatic Compression
Prevention - Medical
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Should be commenced within 24 hours after
surgery
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LMWH enoxaparin/Clexane 40mg SC D
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Reduce to 20mg if Cr Cl < 30mL/min
Heparin 5000u SC BD
Continue 5-10 days unless Hip
Arthroplasty/Fracture 28 – 35 days
Aspirin NOT considered adequate alone
What YOU can do…
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Daily check on your patients:
Stockings or compressors
 Heparin or Clexane or Warfarin
 Remind medical staff
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What YOU can do…
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Respond to patients who complain of
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Respond to changes in your patient’s obs
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dyspnoea
pleuritic chest pain
calf pain
unexplained unilateral leg swelling
↓SaO2
↑ PR
↑ RR
Take responsibility and make the team aware
What YOU can do…
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Pre-discharge check – according to
protocol
Stockings
 Clexane
 Doppler Ultrasound
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YOU can make a difference!
Questions?
References
1.
Brandjes DP et al. Randomised trial of effect of compression
stockings in patients with symptomatic proximal-vein
thrombosis. Lancet 1997;349:759-62
2.
Geerts WH et al. Prevention of Venous Thromboembolism The
Seventh ACCP Conference on Antithrombotic and Thrombolytic
Therapy
Ho et al. Venous thromboembolism: diagnosis and management
of deep venous thrombosis MJA 2005; 182 (9): 476-481
Australian Bureau of Statistics 2006
Kraaijenhagen RA, Lensing AW, Wallis JW, van Beek EJ, ten Cate
JW, Buller HR. Diagnostic management of venous
thromboembolism. Baillières Clin Haematol 1998;11: 541-86.
3.
4.
5.
6.
Tovey C et al. Diagnosis, investigation, and management of
deep vein thrombosis. BMJ 2003;326;1180-1184
7.
Virchow RLK (1856). Thrombosis und Embolie.
Gefässentzündung und septische Infektion". Gesammelte
Abhandlungen zur wissenschaftlichen Medicin. pp. 219–732.
References
1.
Brandjes DP et al. Randomised trial of effect of compression
stockings in patients with symptomatic proximal-vein
thrombosis. Lancet 1997;349:759-62
2.
Geerts WH et al. Prevention of Venous Thromboembolism The
Seventh ACCP Conference on Antithrombotic and Thrombolytic
Therapy
Ho et al. Venous thromboembolism: diagnosis and management
of deep venous thrombosis MJA 2005; 182 (9): 476-481
Australian Bureau of Statistics 2006
Kraaijenhagen RA, Lensing AW, Wallis JW, van Beek EJ, ten Cate
JW, Buller HR. Diagnostic management of venous
thromboembolism. Baillières Clin Haematol 1998;11: 541-86.
3.
4.
5.
6.
Tovey C et al. Diagnosis, investigation, and management of
deep vein thrombosis. BMJ 2003;326;1180-1184
7.
Virchow RLK (1856). Thrombosis und Embolie.
Gefässentzündung und septische Infektion". Gesammelte
Abhandlungen zur wissenschaftlichen Medicin. pp. 219–732.
References
1.
Brandjes DP et al. Randomised trial of effect of compression
stockings in patients with symptomatic proximal-vein
thrombosis. Lancet 1997;349:759-62
2.
Geerts WH et al. Prevention of Venous Thromboembolism The
Seventh ACCP Conference on Antithrombotic and Thrombolytic
Therapy
Ho et al. Venous thromboembolism: diagnosis and management
of deep venous thrombosis MJA 2005; 182 (9): 476-481
Australian Bureau of Statistics 2006
Kraaijenhagen RA, Lensing AW, Wallis JW, van Beek EJ, ten Cate
JW, Buller HR. Diagnostic management of venous
thromboembolism. Baillières Clin Haematol 1998;11: 541-86.
3.
4.
5.
6.
Tovey C et al. Diagnosis, investigation, and management of
deep vein thrombosis. BMJ 2003;326;1180-1184
7.
Virchow RLK (1856). Thrombosis und Embolie.
Gefässentzündung und septische Infektion". Gesammelte
Abhandlungen zur wissenschaftlichen Medicin. pp. 219–732.