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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

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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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What is VTE?


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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


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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.


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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What YOU can do…

  • Daily check on your patients:

    • Stockings or compressors

    • Heparin or Clexane or Warfarin

    • Remind medical staff


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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!


    Questions l.jpg

    Questions?


    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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