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DVT and PE. Pathophysiology, prophylaxis, treatment Anton Sharapov. Cases to consider. 38 yom for elective IHR 65 yom for elective IHR 65 yom, obesity/CHF/prev DVT for IHR 25 yof post severe head injury 25 yom post trauma/abdo/chest 75 yof post hip # 65 yom post THA, obese.

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dvt and pe

DVT and PE

Pathophysiology, prophylaxis, treatmentAnton Sharapov

cases to consider
Cases to consider
  • 38 yom for elective IHR
  • 65 yom for elective IHR
  • 65 yom, obesity/CHF/prev DVT for IHR
  • 25 yof post severe head injury
  • 25 yom post trauma/abdo/chest
  • 75 yof post hip #
  • 65 yom post THA, obese
scope of the problem
Scope of the problem
  • Common postop complication
  • Asymptomatic > symptomatic
  • Difficult to study
  • Most studies evaluate asymptomatic pts
epidemiology
Epidemiology
  • VTE 48:100,000
  • PE 69:100,000
  • Incidence – 20-70% surgery pts
  • ½ begin in OR
epidemiology1
Epidemiology
  • DVT and PE – different stages of same disease process
  • 10% proximal DVTs progress to symptomatic PE
  • 25% distal DVTs become proximal
outcomes
Outcomes
  • Most asymptomatic VTE recover sans treatment and complications
  • Less then 1 in 8 confirmed clots progress to symptomatic thromboembolic disease
  • Important to observe clots over a period of time
outcomes of pe
Outcomes of PE
  • Outcomes of PE are difficult to assess
  • Registry estimates are always higher then in clinical studies (7% vs 2%)
  • Mortality is a function of RV function, clot burden, and comorbidities
  • Risk of fatal PE greatest 3-7 postop
  • Asymptomatic PE are common
    • 40% of asymptomatic prox DVTs
assessment
Assessment
  • Assess risk of DVT and risk of bleeding
  • Assess duration of prophylaxis
  • Assess Virchov triad
    • Venous stasis
    • Endothelial injury
    • hypercoagulability
risk factors venous stasis

Risk factors: venous stasis

  • Immobility & tourniquet application
  • Institutionalization
  • CVA
  • Paralysis
  • CHF
  • Travel >4 hours
  • Obesity
  • Respiratory failure
  • Varicose veins
  • Duration/extent of postop immobilization
risk factors endothelial injury
Risk factors: endothelial injury
  • Trauma
  • Atherosclerosis
  • Perioperative
  • Malignancy
  • Post-phlebitic syndrome
  • Prior DVT
  • CV catheter
  • Inflamatory condition
  • Hyperhomocysteinemia
risk factors hypercoagulability acquired
Risk factors: hypercoagulability, Acquired
  • Post op
  • Malignancy
  • Hormone replacement
  • Estrogen therapy
risk factors hypercoagulability acquired1
Risk factors: hypercoagulability, Acquired:
  • Antiphospholipid antibody
  • Lupus anticoagulant – 5-10 fold risk
  • Myeloproliferative d/o
  • Paroxysmal nocturnal hemoglobinuria
  • Nephrotic syndrome
  • Pn loosing enteropathy
risk factors hypercoagulability inherited
Risk factors: hypercoagulability, Inherited:
  • Factor V leiden – APC resistance
      • Absolute risk post op VTE is small - 1/100
      • Relative risk increased (3-5 fold)
      • Screening not recommended
  • Antithrombin, pn C/S deficiency
  • Fibrinogen/TPA defects
  • Prothrombin gene mutation
risk factors miscelaneous
Risk factors: Miscelaneous
  • Use/nonuse of thrombopophylactic measures
  • Age - rises linearly after 40
  • Ethnicity:
        • Asian/South Pacific - threefold lower
        • African American - slightly higher
        • Latin - slightly lower
  • Site/extent traumatic injury
      • Knee/spine=major trauma>hip>uro/gyny> neuro>general/thoracic
risk of dvt miscellaneous
Risk of DVT, miscellaneous
  • Surgical procedure - most important
  • Neurosurgery & ortho - 6% & 3%
  • Major vascular
  • Bowel, bladder, gastric bypass and kidney transplant
  • Radical neck, IHR, lap chole (0.3%),TURP, thyroid/parathyroid - lowest risk
need for global integrative assessment
Need for global integrative assessment
  • American College of Chest Physicians
  • Risk stratification tool
  • Problems:
    • What defines major vs minor surgeries?
    • No weighting of Risk Factors
    • Why age 40 and 60 important?
risk of bleeding

Risk of bleeding

  • Bleeding d/o
  • Use of antiplatelet meds
  • Previous GI bleed
  • Cancer
  • Hepatic/renal insufficiency
  • ?age
vte prophylaxis what s available
VTE prophylaxis: what’s available?
  • Intermittent compression devise
  • Stockings
  • ASA 80-325 mg
  • UF heparin 5000 bid, tid
  • LMW bid
  • Warfarin
  • Anti – Xa pentasaccharide (fondaparinix)
early ambulation
Early ambulation
  • Routine for all pts
  • Acceptable as sole mode for low risk
  • Useful adjunct esp post knee/hip surgery
elastic stockings
Elastic stockings
  • First shown to work in 1952
  • Decrease venous pooling
  • Evidence of benefit for mod/high risk, but used only as adjunct
  • Harmful if not work correctly
slide23
ICD
  • Work very well
  • Not useful form BMI >25
  • Only effective if used correctly and continuously when pt not ambulating
  • Have potential to reduce ambulation
  • Recommended in mod-high risk gyn surgery as solo
  • Not recommended as sole mode in
      • Highest risk – except neurosurgery
      • High risk urological
      • Hip and knee surgery
slide24
IVC
  • For absolute contraindication of anticoagulation
  • For life-threatening hem on AC
  • For failure of AC
  • Used to prevent fatal PE
  • Temporary filters preferred
  • If left in place, cause DVTs
aspirin
Aspirin
  • Not recommended as sole prophylaxis
  • Beneficial post hip-fracture
    • 160 mg OD, 5/52, 13,000 pts
    • Combined with routine prophylaxis
    • PE – 0.7 vs 1.2
    • Fatal PE 18 vs 43
uf heparin
UF heparin
  • Good for moderate risk gen surgery
  • Modest increase in bleeding
    • Compared to LMWH (2.65% vs 1.8%)
  • Additive effect of stockings and ICD]
  • Risk of HIT
warfarin
warfarin
  • For very high risk with lower extremity orthopedic and neuro surgery
  • For gen surgery other methods work just as well…
  • Good for extended prophylaxis
  • Delayed onset of action, may start preop!
  • Recommended for
    • Hip #, THA, TKA
lmw heparin and pentasaccharideds
LMW heparin and Pentasaccharideds
  • Preferential inhibition of factor Xa
  • FDA approved for DVT prophylaxis
  • Not FDA approved as of yet for DVT prophylaxis in pregnancy, spinal cord injury, trauma, neurosurgery… but are being used
lmw heparin and pentasaccharideds cont d
LMW heparin and Pentasaccharideds cont’d
  • Effective for mod risk general surgery
  • Gyn/obs
    • second line to mechanical
  • Trauma
    • Method of choice only if risk of bleeding is not significant. If it is – stocking+/-ICD
  • Recommended for ortho lower extremity surgery
  • Fondoparinix reduces asymptomatic DVTs only…
lmw heparin and pentasaccharideds cont d1
LMW heparin and Pentasaccharideds cont’d
  • Risk of epidural hematoma
  • Strategies
    • Avoid regional anesth in those prone to bleed
    • Needle in 12 h after onset of LMWH
    • Single dose anesthetic better then infusion
    • D/c cath in 12 h
    • No dosing of LMWH within 2 h of cath d/c
direct thrombin inhibitors
Direct thrombin inhibitors
  • Effective in initial studies
  • Comparable to LMWH
  • For HIT pts
duration of prophylaxis
Duration of prophylaxis
  • Start immediately after or prior to surgery
  • 7-10 days post
  • Warfarin may be started 10/7 prior but INR should be less then 1.5
  • Argument for prolonged (30 day) prophylaxis for high risk. DVT incidence
    • sympt – 3% vs 1% on treatment
    • Asympt – 19% vs 9% on treatment
prolonged prophylaxis
Prolonged prophylaxis
  • Orthopedics
    • Post THA for 4-6 weeks with LMWH or warfarin, especially with Risk Factors
      • Obesity, sedentary, prior DVT
  • General surgery
    • Prolonged treatement with LMWH prevents out-pt DVTs but at a marginal cost that was deemed inappropriate
screening for dvt
Screening for DVT?
  • Not in the asymptomatic pts….
diagnostic strategy of dvt
Diagnostic strategy of DVT
  • Suspect
  • Dupplex
  • For proximal or ANY symptomatic – treat
  • For distal AND asymptomatic – follow with serial duplex US
accuracy of tests for diagnosis of pe
Accuracy of Tests for Diagnosis of PE
  • Clinical suspicion is paramount
diagnostic strategy for pe
Diagnostic strategy for PE
  • Suspect
  • VQ
  • If normal AND D-Dimer low – ruled out
  • If high probability – start treatment
  • If indeterminate/nondiagnostic – angio, angio CT
treatment
Treatment
  • IV heparin, aPTT 1.5- 2.3 normal 5/7
  • May use LMW
  • Coumadin INR 2-3
  • Overlap heparin and warfarin 4/7
  • On warfarin 3-6/12
  • Consider ECHO/trop to evaluate RVF for PE to id High Risk pts.
treatment1
Treatment
  • Hemodynamically unstable PE may require pressure support, fluid status monitoring, and/or thromolysis / surgery
cases to consider1
Cases to consider
  • 38 yom for elective IHR
      • None, low risk
  • 65 yom for elective IHR
      • Moderate risk, Consider UN heparin pre-op, ambulation, stockings post op
  • 50 yom, obesity/CHF/prev DVT for IHR
      • High risk, consider LMWH preop/post op. Conisder warfarin
cases concluded
Cases concluded
  • 25 yof post severe head injury
      • High risk, mechanical,
  • 25 yom post trauma/abdo/chest
      • High risk, mechanical initially, consider LMWH when risk of bleeding is low
  • 75 yof post hip #
      • High, consider LMWH periop, warfarin or aspirin post op
  • 65 yom post THA, obese
      • High, consider LMWH periop, warfarin or aspirin post op
ad