Transcript Slide 1

Dr Rajendra Prasad FRCS(Glas) FRCS(Neurosurgery)
Senior Consultant Neurosurgeon
Apollo Hospitals. New Delhi. India
 The goal of prophylaxis against VT is to reduce the
incidence of DVT and, by doing so, decrease the morbidity
associated with the postthrombotic syndrome and the
morbidity and mortality associated with PE. Acceptable
means of prophylaxis must be not only effective but also
demonstrably safe. many neurosurgeons have not modified
their thromboprophylaxis strategies, presumably for safety
reasons.
 Both mechanical and pharmacologic methods of
prophylaxis are available and are used to varying degrees to
prevent perioperative VT. While most general and
orthopedic surgeons have shifted away from relying solely
on mechanical methods of prophylaxis, and now use
pharmacologic agents to a greater degree.
Prevention of thromboembolism after neurosurgery for brain and
spinal tumors. (Original Article).
Publication: Southern Medical Journal
Publication Date: 01-JAN-03
 Article Excerpt
Objective: Deep venous thrombosis (DVT) is a major cause
of morbidity and mortality after surgery for primary and
metastatic brain tumors.
Methods: We conducted a confidential survey of American
neurosurgeons interested in tumor surgery to assess DVT
risk awareness and thromboprophylaxis patterns.
 Results: Of the 172 respondents, 108 (63%) underestimated the
DVT risk after brain tumor surgery. After performing brain
tumor surgery, 76.2% of respondents reported using solely
mechanical methods of prophylaxis "always" or "most of the
time."
Conclusion: American neurosurgeons tend to underestimate the
risk of DVT associated with brain tumor surgery and to use
mechanical thromboprophylaxis despite the availability of
effective pharmacologic anti-thrombotics. A better appreciation
of the risk of thrombosis, combined with clinical studies to
address safety, may enhance the use of prophylaxis and the
perceived safety of antithrombotics in this setting.
7/17/2015
 VENOUS THROMBOEMBOLISM AND SPINAL SURGERY
.T. Pitham; A. Cree; A. Kam; M. Dexter; G. Dandie; C.
New; M. Fearnside; J. Cummine; K. Hitos; K. Saker; and J.
Fletcher Journal of Bone and Joint Surgery - British
Volume, Vol 87-B, Issue SUPP_III, 401-402.
A prospective cohort study was conducted to assess the
incidence of venous thromboembolism (VTE) in 300
patients undergoing elective spinal surgery
.
 Bilateral lower extremity venous duplex scans were
performed pre-operatively, within one week
postoperatively and at 4 to 6 weeks post-operatively.
Information was collected regarding age, gender, body
mass index, type and duration of surgical procedure, intraoperative blood loss and blood transfusion, pre- and postoperative mobility and other risk factors for VTE. All
patients received vigorous mechanical prophylaxis with
56% of patients receiving pharmacological prophylaxis
(unfractionated or low molecular weight heparin)
according to surgeon preference.
 Results The overall incidence of post-operative deep vein
thrombosis (DVT) was 3.4%. The incidence in those
receiving pharmacological prophylaxis was 1.2% versus
6.3% in those who received mechanical prophylaxis alone
(p<0.05).
 A 27.8% incidence of pre-operative venous abnormalities
may reflect pre-operative immobility due to pain in this
group of patients, and justifies the use of ultrasound
scanning as an important pre-operative screening tool. In
addition, the high incidence of late-onset DVT justifies the
need for follow-up scanning several weeks after discharge.
Perioperative assessment of coagulability in neurosurgical patients using
thromboelastography
John M. Abrahams, M.D., Maria B. Torchia, R.N., Michael M. McGarvey,
M.D., Mary Putt, Sc.D., Ph.D., Dimitri Baranov, M.D., Grant P. Sinson, M.D.
 Thrombelastography is a useful technique for
evaluating coagulability. We hypothesized that it could
be used to determine postoperative hematologic
complications during and after neurologic surgery.
CONCLUSIONS
 Increased coagulability begins between induction of
anesthesia and skin incision, and continues to increase
throughout surgery. These changes are more pronounced
in patients undergoing craniotomy compared to patients
undergoing spine procedures.
 Risk factors and prophylaxis for deep venous
thrombosis in neurosurgery. Smith SF, Biggs MT,
Sekhon LH. Surg Technol Int. 2005;14:69-76. Neurosurgery
Department and Spinal Injuries Unit, Royal North Shore
Hospital, St. Leonards, New South Wales, Australia.
 Acceptance is increasing for pharmacological prophylaxis
against deep vein thrombosis (DVT) and pulmonary
embolism (PE) for most types of surgery, but its use remains
controversial in neurosurgical patients because of the threat
of catastrophic hemorrhage. Consequently, mechanical
measures such as sequential calf compression and graduated
compression stockings are currently the preferred
prophylaxis for neurosurgical patients. However, some
patients remain at high risk despite these measures and may
require prophylaxis with low molecular weight heparins or
unfractionated heparin. In neurosurgical patients, known
risk factors for DVT or PE include advanced age, malignancy,
limb weakness, prolonged surgery, and cranial as opposed to
spinal surgery.
HISTORY
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27 year old male
Polio one month after birth
Was able to walk without support
Also had dorso lumbar scoliosis
Developed low back pain since 2 months
Progressive weakness of both lower limbs
Complete paralysis since 2weeks with bladder and
bowel incontinence
ON EXAMINATION
 Power of grade 0/5 in both lower limbs
 Decreased tone in both lower limbs
 Plantars mute
 Sensory level of D9
 Dorso lumbar scoliosis , no spinal tenderness
SURGERY
POST OP (Day 1)
 Developed acute DVT left leg.
 Had massive pulmonary embolism
 Sudden drop in saturation, seizure, hypotension,
bradycardia.
 Could not be revived.
Deep vein thrombosis after posterior spinal surgery
spine,vol25,number22,2962-2967.
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Ferree and wright – U/S- 185 patients- 2%.
Smith et al-317 patient- (0.6%)
Rokito et al- 329-(0.3%)
Tetzlaff et al-venography-306(10.8%)
This paper- 110 patients 15.5%
Prevelance of proximal deep venous thrombosis-0.9%
Lumbar procedures have higher risk of DVT than
cervical procedures
 Screening for detection of asymptomatic thrombosis?
DVT Prevalance
Surgical specialities and the prevelance rate of DVT.
General surgery
Gynecologic Surgey
Hip Surgery
Knee reconstruction
Multi – system/Major trauma
Myocardial infarction
Neurosurgery
Spinal Cord Injury
Stroke
35%
16%
50 – 60%
40 – 84%
50%
24%
22%
67 – 100%
55%
ACCP 2001
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Virchow’s Triad
DVT[1].wmv
Stasis
—
The slowing of the flow of circulating
blood.
Vessel Wall Damage
—
Postulated to result from surgical limb
manipulation producing vessel kinks
during manoeuvres in procedures such
as THA or TKA.
—
Pooling of venous blood is also
thought to cause venous dissention
and endothelial damage.
Coagulation Changes
—
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Postoperative Hypercoaguable state
exists with elevated blood levels of
both thromboplastin and fibrinogen,
and the activation of the extrinsic
coagulation pathway in areas of tissue
damage.
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Addressing Virchow’s Triad
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The Silent Killer
The majority of deep vein thromboses are asymptomatic.
—
“Only 25% of patients with DVTs display clinical signs”
—
“It is known that DVT may be asymptomatic and its
2
initial presentation may be that of fatal PE” .
—
60% to 80% of fatal pulmonary emboli are unsuspected
and undiagnosed.
1
1.
O’Meara et al. Prophylaxis for Venous Thromboembolism in Total Hip Arthroplasty: A Review; Orthopaedics 1990; 13:173-178
2.
D.A. Sandler et al. Autopsy proven pulmonary embolism in hospital patients: are we detecting enough deep vein thrombosis? Journal of
Royal Society of Medicine 1989, Vol 82.
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Inside the “Gap”
The “Gap” in protection is when the
patient is at risk for DVT, but the
administration of pharmacological
prophylaxis cannot begin.
“50% of deep vein thromboses (DVT) begin intraoperatively”
1
“75% of DVT develop within the first 48 hours after surgery”
1
1. O’Meara and Kaufman. Prophylaxis for Venous Thromboembolism in Total Hip Arthroplasty: A Review. Orthopaedics. 1990 13(2):173-178
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Inside the “Gap”
O'Meara
%
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Anticoagulants – Efficacy vs. Bleeding
RAMOS H-4627.pdf
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Risk Factors
Age older than 50 years
History of varicose veins
History of myocardial infarction
History of cancer
History of atrial fibrillation
History of ischemic stroke
History of diabetes mellitus
Other additional factors included previous deep venous thrombosis (DVT), heart
failure, obesity, paralysis, or the presence of an inhibitor deficiency state.
The strongest risk factor (odds ratio >10) for venous thromboembolism (VTE)
was seen after hip or leg fracture/replacement, major general surgery, major
trauma, or spinal cord injury.
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How Should High Risk Patients Be Prophylaxed?
With aggresive prophylaxis:
— LMWH at prophylaxis dose
— OR
Coumadin at INR 2-3 range
— OR
Arixtra
If above contraindicated, then consider:
— IVC filter (prevents PE, not DVT)
— Pneumatic
— Serial
compression > 23hr/day
doppler surveillance
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Contraindications to antithrombotic or anticoagulant
therapy
Active bleeding, severe bleeding diathesis or platelet count less than
20,000/µL
Neurosurgery, ocular surgery, or intracranial bleeding within the past 10
days.
Relative contraindications include mild to moderate bleeding diathesis
or platelet count of 20,000-100,000/µl
Brain metastases or recent major trauma,
Major abdominal surgery within the past 2 days,
Gastrointestinal or genitourinary bleeding within the past 14 days,
Infective endocarditis, or malignant hypertension.
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What Other Special Considerations for Anticoagulation
Exist?
Discontinue use of LDUH or LMWH 12 hours prior to the
placement/removal of a spinal catheter.
Hold LDUH or LMWH for at least 2 hours after placement of removal
of spinal catheter.
Platelet count < 30 X 109/L
Status post brain, spinal, or ophthalmic surgery.
Hemorrhagic stroke
Bacterial endocarditis
Diabetic retinopathy
Concomitant antiplatelet therapy
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How Should These Considerations Be Handled?
In most cases, neurosurgery- permits aggressive
prophylaxis after a week post-op brain or spinal
surgery or a week post intracerebral bleed.
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A review of the risks and benefits of differing prophylaxis
regimens for the treatment of deep venous thrombosis
and pulmonary embolism in neurosurgery.
Epstein NE. Bronx, NY 10461, USA. Surg Neurol. 2005
Oct;64(4):295-301.
METHODS: Neurosurgical studies focusing on different
methods of prophylaxis used for the prevention of DVT and
PE were reviewed. The efficacy, risks, and benefits of
varied treatment options were evaluated, with particular
emphasis on minor and major hemorrhages occurring
where heparin-based protocols were used.
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.
RESULTS: In Flinn et al series (Arch Surg. 1996;131(5):472-80), the
incidence of DVT was greater for cranial (7.7%) than spinal procedures
(1.5%). Although intermittent pneumatic compression devices provided
adequate reduction of DVT/PE in some cranial and combined
cranial/spinal series, low-dose subcutaneous unfractionated heparin or
low molecular-weight heparins further reduced the incidence, not
always of DVT, but of PE (Br J Neurosurg 1995;9(2):159-63; J Intensive
Care Med 2003;18(2):59-79).
Nevertheless, low-dose heparin-based prophylaxis in cranial and spinal
series risks minor and major postoperative hemorrhages: 2% to 4% in a
cranial series, 3.4% minor and 3.4% major hemorrhages in a combined
cranial/spinal series, and a 0.7% incidence of major/minor hemorrhages
in a spinal series (J Neurosurg 2003;99(4):680-4; Neurosurgery
1986;18(4):440-5; Eur Spine J 2004;13(1):1-8; J Intensive Care Med
2003;18(2):59-79.
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• CONCLUSIONS: Although mechanical prophylaxis
provided effective prophylaxis against DVT/PE in many
series, the added efficacy of low-dose heparin
regimens has to be weighed against risks of major
postoperative hemorrhages and their neurological
sequelae.
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Our protocol
Screening for DVT for para/quadriplegics with grade02/5 power.
Graduated compression stocking- Graduated
compression stocking reduces venous stasis by
applying a gradient pressure pattern on the limb and
prevents vein wall distention.
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Low molecular weight heparin - binds to anti-thrombin III as
a catalyst for anti-Factor X-a; therefore, there is no need to
monitor partial thromboplastin time.- till patient is
discharged.
DVT Pump- at the time of surgery till patient has been
mobilised.
Early mobilisation-patients are mobilized as early as
postoperative day 2.
Limb physiotherapy
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Apollo Hospital New Delhi
• Orthopaedics
• Obstetrics & Gynaecology
• Oncology
• Surgery
• Neuroscience
• Cardiology and Vascular Surgery
• Urology
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THANK
YOU
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