Ch 17. Systemic complications

DEEP VENOUS THROMBOSIS

DEEP VENOUS THROMBOSIS Geerts et al: ~60% trauma patient

deep venous thrombosis Diagnosis, prophylaxis, treatment

silent thrombi symptomatic deep venous thrombosis pulmonary embolism death from pulmonary embolism

2/3 patient: die of pulmonary embolism survive < 20 minutes from the onset of symptoms

prevent

incidence of death from pulmonary embolism: 1% ~ 2%

effective treatment in reducing the rate of fatal pulmonary emboli ?? no randomized prospective studies

treatment / prophylaxis

Virchow

Clinical findings: pain, swelling, tenderness: not reliable for DVT diagnosis (70% false positive)

Impedance plethysmography (IPG)(電阻體積描記器 ) X

Fibrinogen leg scanning X

Venography: invasive, difficult to perform, more accurate for calf thrombi and nonocclusive/asymptomatic DVT

Venous doppler/ultrasonography: more accurte, availableSpecificity: 95% for femoralSensitivity: 70% for calf veinsRepeat/routine exam: not cost-effective

D/US: for lower extremity thrombi Pelvic thrombi: difficult to detect by

D/US, CT, MRI

Pulmonary embolism Transient dyspnea Chest pain Hemoptysis Larger occlusive emboli Symptoms of right side heart failure /

syncope / hypotension D.D.: pulmonary infection,

musculoskeletal chest wall pain, pericarditis, esophageal spasm, anxiety

Chest radiography Electrocardiogram Oxygenation (oximetry / gas) 70% of patient with PE: have evidence

of venous thrombosis ←→ < 50% patients have PE with lower extremity D/US studies positive

Pulmonary angiography: gold standard normal pulmonary angiogram: excludes

the diagnosis normal perfusion scan: excludes PE more specific than ventilation-perfusion

scans of the lung

~1995 CT pulmonary angiogram: most frequentlysensitivity and specificity: 90% for identifying

central PE (main, lobar, segmental arteries)

venous thromboembolism, risk of recurrence: 5% to 10% per year

prevention of the first episode with prophylactic strategies

risk of recurrent: higher among men than women (20% vs. 6%)

prophylaxis for preventing deep venous thrombosis

Mechanical prophylaxis

Graduated compression stockings / Intermittent compression devices (IPC)low patient compliance lower extremity fractures

risk of pulmonary embolism or death: X As an adjutant to pharmacologic

anticoagulation / patients who have a high risk of bleeding

inferior vena cava filters: prevention of fatal pulmonary embolism in trauma patients

Indication: contraindications to anticoagulation developed venous thrombosis despite anticoagulationhead injuries, multiple long bone fractures, pelvic and

acetabular fractures, patients that have evidence of deep venous thrombosis before a major surgical procedure

increased risk for recurrent deep venous thrombosis retrievable vena cava filters anticoagulation therapy

use of systemic heparinization within the first week after THR: 50% wound complication rate from hematoma formation

Contraindications to the use of pharmacologic anticoagulation:associated intracranial bleeding, spinal cord

injuries, the observation of splenic injuries, any injury that has a high risk of developing recurrent bleeding

intracranial injury: contraindication to the use of anticoagulation

using mechanical devices or repetitive screening to avoid worsening of the intracranial injury

vena caval filters (high risk for thromboembolism)

Removable vena caval filters: OK

Pharmacologic anticoagulation mortality rate from pulmonary embolism

for patients with hip fractures: 1% to 2% after fixation of proximal femur fractures

pharmacologic prophylaxis: recommended

Fractures distal to the hip: 18% incidence of deep venous thrombosis

Factors associated with thrombi: age older than 40, a delay to surgery,

prolonged operative times

ideal agent:low complication rate, easy administration,

low cost, and excellent bioavailability

Coumadin / LMWH: several prospective and randomized studies of deep venous thrombosis after total hip replacement: LMWH reduce the incidence of silent

thrombi

differing forms of prophylaxis for venous thromboembolism ??patient's risk factorsinjuriessurgeryperiod of postoperative immobilization

OUTCOME OF CRITICAL ILLNESS ASSOCIATED WITH ORTHOPEDIC TRAUMA short-term mortality (for example,

intensive care unit, 28 day, hospital mortality)

long-term outcomes, including delayed mortality, quality of life (QOL) in survivors, and the social effects on caregivers, including family members

Pain common complaint after prolonged critical illness,

significantly impairing QOL 50 patients from a mixed intensive care unit (ICU)

with tracheotomy for prolonged critical illness 44% of patients: pain at the highest level of severity survive the acute phase prolonged chronic critical

illness having at least three components:

injury or illness and host characteristics leading to critical illness and ICU admission

ICU period of critical illness subsequent periods of post-ICU care, including hospital

ward, intermediate care and rehabilitation, and outpatient care

ARDS common complication of trauma and sepsis

severe and prolonged critical illness improvement in mortality significant impairments in physical,

psychologic, and social functioning Sepsis with ARDS QOL < trauma with

ARDS pulmonary function: improves significantly

during the first 6 months illness

Neuromuscular weakness more common 109 survivors identifying significant neuromuscular

weakness at 12 months after ARDS generalized weakness with global muscle wasting:

6-minute walk test, foot drop, large joint immobility, dyspnea

patients with critical illness–acquired neuromuscular weakness: 50% of ARDS survivors have not returned to work at 1 year after ICU discharge

weakness and fatigue increase in mortality, duration of hospital and rehabilitation care, and overall health care costs

neuromuscular weakness following critical significant and long-lasting impairments in QOL

enhance neuromuscular function after severe critical illness

limiting use of neuromuscular blockade and corticosteroids

intensive insulin protocol with tight glucose control improved neurophysiologic testing

earlier involvement of physical and occupational therapy

Survivors of ARDS: Significant impairments in psychologic and social domains

Depression more than 43% of ARDS survivors 6 to 41

months after lung injury

Post-traumatic stress syndrome (PTSD) related to the frequency of patients' recall

of traumatic events in the ICU 9% incidence of PTSD if one or fewer

traumatic events are recalled compared to 41% if two or more traumatic events are recalled

presence of delusional memories with recall of factual events development of PTSD

delusional recall appears to be retained over time but factual recall declines over time.

Cognitive impairment

common after prolonged critical illness impaired memory, attention,

concentration, or decreased mental processing speed

55 consecutive survivors of ARDS (mean ICU length of stay 29 days): 78% had cognitive impairment at 1 year after ARDS

brain injury during critical illness neuropsychologic impairment ??

Reduction in cerebral blood flow, cerebral edema, and disruption in the blood–brain barrier septic encephalopathy

systemic inflammation endothelial and neuronal cell injury, (cellular hypoxia, and leukocyte-derived inflammatory mediator and free radical injury)

Effective interventions early psychiatric consultation for

identification and treatment of depression, anxiety, and PTSD

easily miss formal neuropsychologic testing

Identification and treatment of sleep disturbance and delirium

daily interruption of sedation may reduce the development of PTSD