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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


    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


    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


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