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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

VTE in Orthopaedics

Australian Orthopaedic Nurses’ Association

15 May 2009

Dr Lachlan Milne

what is vte
What is VTE?
  • Venous thromboembolism (VTE)
    • Deep Vein Thrombosis (DVT)
    • Pulmonary Embolism (PE)
why is vte a problem
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
consequences of dvt
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
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
dvt pathophysiology
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
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
course of dvt illness
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
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
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
clinical assessment algorithm 1
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
Screening Investigations
  • D Dimer assay
    • Degradation product of fibrin
    • Elevated in 80% of VTE
    • Fast
    • Low specificity
    • Useless in context of surgery
definitive ix venography 1
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
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.
definitive investigations
Definitive Investigations
  • CT venography
    • Highly sensitive and specific
    • Huge amount of radiation
    • Not much improvement on US
    • Rarely used
definitive investigations21
Definitive Investigations
  • MRI
    • Best invasiveness to sensitivity ratio
    • Expensive
    • Unlikely to be used frequently until costs decrease
diagnosis of pe
Diagnosis of PE
  • Clinical judgement
  • Arterial Blood Gas
  • VQ scan
    • Probability
  • CTPA
    • Diagnostic
    • Contrast
treatment
Treatment
  • Anticoagulation
    • Heparin
      • Unfractionated
      • Low Molecular Weight
    • Warfarin
  • IVC filter
  • Compression stockings
treatment heparin
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
treatment warfarin
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
treatment ivc filter
Treatment – IVC filter
  • When anticoagulation contraindicated
    • eg orthopaedic patients undergoing surgery
  • Recurrent DVT despite adequate anticoagulation
treatment stockings
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
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
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
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
What YOU can do…
  • Daily check on your patients:
    • Stockings or compressors
    • Heparin or Clexane or Warfarin
    • Remind medical staff
what you can do34
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
What YOU can do…
  • Pre-discharge check – according to protocol
    • Stockings
    • Clexane
    • Doppler Ultrasound
  • YOU can make a difference!
references
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
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
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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