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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). What is VTE?. Why is VTE a problem?. VTE annual risk 1-2 per 1000 people 1

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Vte in orthopaedics l.jpg

VTE in Orthopaedics

Australian Orthopaedic Nurses’ Association

15 May 2009

Dr Lachlan Milne


What is vte l.jpg
What is VTE?

  • Venous thromboembolism (VTE)

    • Deep Vein Thrombosis (DVT)

    • Pulmonary Embolism (PE)



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Why is VTE a problem?

  • VTE annual risk 1-2 per 1000 people1

    • 40 000 per year in Australia

  • PE: 0.2% deaths per year in Australia2

  • Morbidity higher than mortality

  • Ho et al. Venous thromboembolism: diagnosis and management of deep venous thrombosis MJA 2005; 182 (9): 476-481

  • Australian Bureau of Statistics 2006


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Consequences of DVT

  • Death

  • Pulmonary Embolism

  • Post-thrombotic Syndrome (chronic V HT)

    • Venous stasis

    • Leg pain and swelling

    • Hyperpigmentation

    • Leg ulcers

  • Recurrent Venous Thromboembolism

  • Tovey C et al. Diagnosis, investigation, and management of deep vein thrombosis. BMJ 2003;326;1180-1184


Dvt in orthopaedics l.jpg
DVT in orthopaedics?

  • Orthopaedic patients are most at risk of all patients in hospital1

    • Total Joint Arthroplasties

    • Major Trauma

    • Hip Fractures

  • White et al: Risk factors for venous thromboembolism after total hip and knee replacement surgery. Current Opinion in Pulmonary Medicine2002, 8:365–371


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DVT Pathophysiology

  • Virchow’s Triad

    • Endothelial injury

      • Surgery

    • Venous stasis

      • Tourniquet

      • Immobilisation

        • Delayed ambulation

        • Casting

    • Change in blood constituents

      • ↑ platelets

      • ↑ clotting

      • ↑ viscosity

  • Virchow RLK (1856). Thrombosis und Embolie. Gefässentzündung und septische Infektion". Gesammelte Abhandlungen zur wissenschaftlichen Medicin. pp. 219–732.


Risk factors l.jpg
Risk factors

  • Increased in orthopaedics:

    • Immobilisation

    • Major surgery

    • Tourniquet

  • Other non orthopaedic

    • Obesity BMI >30 (often in arthroplasties)

    • History of prior DVT

    • Female

    • Smoking

    • OCP

    • Genetic (many)

  • White et al: Risk factors for venous thromboembolism after total hip and knee replacement surgery. Current Opinion in Pulmonary Medicine2002, 8:365–371


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Course of DVT illness

  • Determined by the site of thrombosis1

    • Calf

      • Where DVTs start

      • 50% resolve in 3/7

      • Rarely causes PE in isolation

      • 25% extend proximally within 1 week

    • Proximal

      • 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 l.jpg
VTE – Signs and Symptoms

  • DVT1

    • Leg swelling/erythema

    • Leg pain

    • Superficial venous congestion

  • PE

    • Symptoms:

      • Dyspnoea

      • Pleuritic chest pain

    • Signs:

      • ↑ PR

      • ↓ SaO2

      • ↑ RR

  • Tovey C et al. Diagnosis, investigation, and management of deep vein thrombosis. BMJ 2003;326;1180-1184


Diagnosis of dvt 1 l.jpg
Diagnosis of DVT1

  • 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


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Clinical assessment algorithm1

  • Low prob ≤0

  • Mod prob 1-2

  • High prob ≥3

  • Tovey C et al. Diagnosis, investigation, and management of deep vein thrombosis. BMJ 2003;326;1180-1184


Screening investigations l.jpg
Screening Investigations

  • 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

  • Gold standard

  • Invasive

  • Painful

  • Risks:

    • Thrombosis

    • Contrast allergy

  • Venogram showing popliteal vein thrombosis

  • Tovey C et al. Diagnosis, investigation, and management of deep vein thrombosis. BMJ 2003;326;1180-1184


Definitive ix ultrasound l.jpg
Definitive Ix - Ultrasound

  • Non invasive

  • Safe

  • Good Sensitivity

    • 97% proximal

    • 75% calf1

  • Compression US

  • Doppler

  • Kraaijenhagen RA et al. Diagnostic management of venous thromboembolism. Baillières Clin Haematol 1998;11: 541-86.


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Definitive Investigations

  • CT venography

    • Highly sensitive and specific

    • Huge amount of radiation

    • Not much improvement on US

    • Rarely used


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Definitive Investigations

  • MRI

    • Best invasiveness to sensitivity ratio

    • Expensive

    • Unlikely to be used frequently until costs decrease


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Diagnosis of PE

  • Clinical judgement

  • Arterial Blood Gas

  • VQ scan

    • Probability

  • CTPA

    • Diagnostic

    • Contrast


Treatment l.jpg
Treatment

  • Anticoagulation

    • Heparin

      • Unfractionated

      • Low Molecular Weight

    • Warfarin

  • IVC filter

  • Compression stockings


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Treatment - Heparin

  • Minimum 5/7 until warfarin therapeutic

    • Unfractionated

      • Infusion

      • Q6h monitoring

      • Renal impairment

    • Low Molecular Weight Heparin

      • consistent response

      • Longer t ½ – Daily dosing

      • Effective

      • ↓ haemorrhage

      • Nephrotoxic


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Treatment - Warfarin

  • Oral dosing

  • Prothrombotic initially

    • Heparin/Clexane

  • Monitoring with INR target 2.0 – 3.0

  • Not used in pregnancy – crosses placenta

  • 6/12 treatment


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Treatment – IVC filter

  • When anticoagulation contraindicated

    • eg orthopaedic patients undergoing surgery

  • Recurrent DVT despite adequate anticoagulation


Treatment stockings l.jpg
Treatment – Stockings

  • Simple and cost effective

  • Reduce likelihood of post-thrombotic syndrome

  • Wear for 18 months post DVT 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 l.jpg
Prevention

  • Orthopaedic patients most at risk

  • Australian Therapeutic Guidelines

  • Medical

  • Mechanical

  • Geerts WH et al. Prevention of Venous Thromboembolism The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy


Prevention mechanical l.jpg
Prevention – Mechanical

  • Should be commenced evening prior to surgery

  • Stockings:

    • GCS – Graduated Compression Stockings

    • TEDs – ThromboEmbolic Deterrents

  • Compressors:

    • SCDs – Sequential Compression Devices

    • IPC – Intermittent Pneumatic Compression


Prevention medical l.jpg
Prevention - Medical

  • Should be commenced within 24 hours after surgery

    • LMWH enoxaparin/Clexane 40mg SC D

      • 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 l.jpg
What YOU can do…

  • Daily check on your patients:

    • Stockings or compressors

    • Heparin or Clexane or Warfarin

    • Remind medical staff


What you can do34 l.jpg
What YOU can do…

  • Respond to patients who complain of

    • dyspnoea

    • pleuritic chest pain

    • calf pain

    • unexplained unilateral leg swelling

  • Respond to changes in your patient’s obs

    • ↓SaO2

    • ↑ PR

    • ↑ RR

  • Take responsibility and make the team aware


  • What you can do35 l.jpg
    What YOU can do…

    • Pre-discharge check – according to protocol

      • Stockings

      • Clexane

      • Doppler Ultrasound

    • YOU can make a difference!



    References l.jpg
    References

    • Brandjes DP et al. Randomised trial of effect of compression stockings in patients with symptomatic proximal-vein thrombosis.Lancet 1997;349:759-62

    • 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.

    • Tovey C et al. Diagnosis, investigation, and management of deep vein thrombosis. BMJ 2003;326;1180-1184

    • Virchow RLK (1856). Thrombosis und Embolie. Gefässentzündung und septische Infektion". Gesammelte Abhandlungen zur wissenschaftlichen Medicin. pp. 219–732.

    • White et al: Risk factors for venous thromboembolism after total hip and knee replacement surgery. Current Opinion in Pulmonary Medicine2002, 8:365–371


    References38 l.jpg
    References

    • Brandjes DP et al. Randomised trial of effect of compression stockings in patients with symptomatic proximal-vein thrombosis.Lancet 1997;349:759-62

    • 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.

    • Tovey C et al. Diagnosis, investigation, and management of deep vein thrombosis. BMJ 2003;326;1180-1184

    • Virchow RLK (1856). Thrombosis und Embolie. Gefässentzündung und septische Infektion". Gesammelte Abhandlungen zur wissenschaftlichen Medicin. pp. 219–732.

    • White et al: Risk factors for venous thromboembolism after total hip and knee replacement surgery. Current Opinion in Pulmonary Medicine2002, 8:365–371


    References39 l.jpg
    References

    • Brandjes DP et al. Randomised trial of effect of compression stockings in patients with symptomatic proximal-vein thrombosis.Lancet 1997;349:759-62

    • 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.

    • Tovey C et al. Diagnosis, investigation, and management of deep vein thrombosis. BMJ 2003;326;1180-1184

    • Virchow RLK (1856). Thrombosis und Embolie. Gefässentzündung und septische Infektion". Gesammelte Abhandlungen zur wissenschaftlichen Medicin. pp. 219–732.

    • White et al: Risk factors for venous thromboembolism after total hip and knee replacement surgery. Current Opinion in Pulmonary Medicine2002, 8:365–371


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