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Prevention of Pulmonary Embolism in high risk trauma patients

Prevention of Pulmonary Embolism in high risk trauma patients. Inferior vena cava filters, pharmaceuticals, vasocompressive devices . Sean Beard, Jimmy Crick, Ashton Curry, Erica Essex. PICO QUESTION. P: Trauma patients at high risk for PE I: Use of inferior vena cava filter

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Prevention of Pulmonary Embolism in high risk trauma patients

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  1. Prevention of Pulmonary Embolism in high risk trauma patients Inferior vena cava filters, pharmaceuticals, vasocompressive devices Sean Beard, Jimmy Crick, Ashton Curry, Erica Essex

  2. PICO QUESTION • P: Trauma patients at high risk for PE • I: Use of inferior vena cava filter • C: Prophylactic pharmaceuticals and vasocompressive devices • O: Incidence of PE

  3. OBJECTIVES • Background • PE background & incidence • IVC filters (IVCF) • Why trauma patients? • Indications vs. Contraindications • Effectiveness • Conclusions • Clinical Relevance • Risks associated with IVCF http://www.uwmedicine.org/Patient-Care/eHealth-Articles/PublishingImages/Inferior-Vena-Cava-Filter.jpg

  4. BACKGROUND http://www.youtube.com/watch?v=o-_wL3XWZ1I&app=desktop

  5. IVCF PLACEMENT http://www.youtube.com/watch?v=UvtHCMBm0SA&app=desktop http://www.mbcgraphics.com/images/img_port_ivcfilter.jpg

  6. GROSS ANATOMY LAB Thanks to Dr. Hanks and table 2.1

  7. IMPORTANCE • PE’s are common (Rajasekhar, 2011) • PE’s are deadly (Rajasekhar, 2011) • PE’s are preventable (Stefanidis, 2006) http://medicalcenter.osu.edu/patientcare/healthcare_services/lung_diseases/lung/embolism/Pages/index.aspx

  8. PATIENT PROFILE Types of high risk patients Factors increasing venous thrombotic event (VTE) risk History of venous thrombotic event Prolonged immobility Pelvic trauma Age Vascular injury Obesity Blood transfusions • SCI • TBI • Fractures • Pelvic, acetabulum, tibia-fibula, femoral shaft, foot/ankle (Carlin, 2002) (Helling, 2009)

  9. STANDARD OF CARE • Prophylactic low dose subcutaneous heparin (LDH) and sequential compression devices (SCD) • Effectively reduces the incidence of DVT or PE to <10% • 35% of trauma patients are unable to have SCD • 14% of high risk trauma patients unable to have LDH (Sekharan, 2001) (Khansarinia, 1995)

  10. CONTRAINDICATIONS TO STANDARD OF CARE

  11. INDICATIONS FOR USE OF IVCF • Patients with known VTE • Anticoagulants contraindicated • Recurrent PE despite anticoagulant therapy • Hx of complication related to anticoagulant therapy (Young, 2010) (Rajasekhar, 2011) • Inserted within 48 hours of injury (Carlin, 2002)

  12. EFFECTIVENESS • IVCF’s are considered safe and reduce incidence of VTE (Kidane, 2012) • Compared to matched controls, PE incidence was significantly lower in IVCF group (Rajasekhar, 2011) http://www.uofmmedicalcenter.org/fv/groups/public/documents/images/277293.jpg

  13. EFFECTIVENESS • After 5 year follow-up, IVCF placement is safe and durable in young active trauma patients (Sekharan, 2001) • In patients with IVCF, compared to no IVCF: • 12 days: 22% decrease in incidence of PE • 2 years: 50% decrease in incidence of PE (Decousus, 1998)

  14. POTENTIAL COMPLICATIONS WITH IVCF • Erosion through vena cava wall • Filter migration • Filter infection • Thrombus formation caudal to IVCF • Inferior vena cava occlusion (Stefanidis, 2006) http://www.youtube.com/watch?v=qlaDA_FRA48

  15. CONCLUSION • In trauma patients who are at high risk for PE IVCF’s are more effective than standard of care at preventing the incidence of a PE • In patients for whom standard of care is contraindicated IVCF placement is safe and recommended

  16. RELEVANCE TO PHYSICAL THERAPY • Awareness of IVCF • Indicates patient is at high risk for VTE • Prolonged IVCF use correlated with increased incidence of DVT • Wells criteria • Recognition of IVCF complication

  17. REFERENCES Carlin AM, Tyburski JG, Wilson RF, Steffes C. Prophylactic and therapeutic inferior vena cava filters to prevent pulmonary emboli in trauma patients. Arch. Surg.2002;137(5): 521–5. DecoususH, Leizorovicz A. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. N. Engl. J. Med. 1998;338(7):409–415. HellingTS, Kaswan S, Miller SL, Tretter JF. Practice patterns in the use of retrievable inferior vena cava filters in a trauma population: a single-center experience. J. Trauma. 2009;67(6):1293–6. KhansariniaS, Dennis JW, Veldenz HC, Butcher JL, Hartland L. Prophylactic Greenfield filter placement in selected high-risk trauma patients. J. Vasc. Surg. 1995;22(3):231–5. Kidney B, Madani AM, Vogt K, Girotti M, Malthaner R a, Parry NG. The use of prophylactic inferior vena cava filters in trauma patients: a systematic review. Injury, Int. J. Care Injured. 2012;43(5):542–7.

  18. REFERENCES Rajasekhar A, Lottenberg R, Lottenberg L, Liu H, Ang D. Pulmonary embolism prophylaxis with inferior vena cava filters in trauma patients: a systematic review using the meta-analysis of observational studies in epidemiology (MOOSE) guidelines. J. Thromb. Thrombolysis. 2011;32(1):40–6. Sekharan J, Dennis JW, Miranda FE, et al. Long-term follow-up of prophylactic greenfield filters in multisystem trauma patients. J. Trauma. 2001;51(6):1087–90. Stefanidis D, Paton BL, Jacobs DG, et al. Extended interval for retrieval of vena cava filters is safe and may maximize protection against pulmonary embolism. Am. J. Surg. 2006;192(6):789–94. Young T, Tang H, Hughes R. Vena caval filters for the prevention of pulmonary embolism. Cochrane Database of Systematic Reviews. 2010; (2):CD006212.

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