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SEMINAR ON DEEP VEINSEMINAR ON DEEP VEIN

THROMBOSIS (DVT)THROMBOSIS (DVT)NATIONAL ORTHOPAEDIC

HOSPITAL,DALA-KANOTHURSDAY, 2ND FEB, 2012

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NonNon--pharmacologicalpharmacologicalprophylaxis of Deepprophylaxis of Deep

Vein ThrombosisVein Thrombosis(DVT)(DVT)

Dr Tella A.O.NOH, Dala-Kano

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OutlineOutline

Introduction- Scope of the problem

Rationale for prophylaxisRisk assessment/stratification

Methods of prophylaxis

- Non-pharmacological- pharmacological

Challenges of DVT prophylaxis

Conclusion

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IntroductionIntroduction

--Possible clinical scenariosPossible clinical scenariosAsymptomatic DVT

Symptomatic DVT

Pulmonary Embolism

Chronic pulm. hypertension

Post-phlebitic Syndrome

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IntroductionIntroduction

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Rationale for prophylaxisRationale for prophylaxis

High prevalence of DVT- Usually clinically silent

- Screening for DVT is neither effectivenor cost-effective

Adverse consequences of DVT- Symptomatic DVT and fatal PE

- Increased future risk of recurrent DVT- Risks and costs of DVT Rx is more thanprophylaxis costs

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Rationale for prophylaxisRationale for prophylaxis

Efficacy and effectiveness ofprophylaxis:

- Prophylaxis against DVT is effective

- The prevention of DVT also prevents

PE

- DVT prophylaxis is cost-effective

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RiskRisk

assessment/stratificationassessment/stratificationLOW RISK:- Minor surgery 30 min; 40 yrs; No other riskfactors

- Major medical illness: Heart/Lung diseases- Major trauma/Burns- Minor surgery, trauma, medical illness in pxswith previous DVT, PE or Thrombophilia.

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RiskRisk

assessment/stratificationassessment/stratificationHIGH RISK:- Major orthopaedic surgery

- # pelvis, hip, lower limb- Major surgery, trauma, medical illnessin a px with hx of DVT, PE orThrombophilia

- Limb paralysis (e.g stroke, paraplegia)- Major LL amputation

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Methods of prophylaxisMethods of prophylaxis

Non-pharmacological (Mechanical):

- General

- Specific

Pharmacological (chemical)

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Methods of prophylaxisMethods of prophylaxis

General:- Patients should spend as littletime as possible waiting for surgery- Deep breathing exercises- Active and frequent exercises of

the limbs- Regional anaesthesia- Surgical technique- Early ambulation of patients

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Early ambulationEarly ambulation

Early ambulation remainsthe most important non-

pharmacologic methodShould be routine part ofall post-op care (Unlessabsolutely contraindicated)

Acceptable as DVTprophylaxis for low risksurgical patients

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Specific MechanicalSpecific Mechanical

DevicesDevicesGraduated Elastic Stockings- Thigh-high- Calf-highIntermittent pneumatic CompressionDevices

- Pneumatic Compression Devices(PCDs)- Sequential Compression Devices

(SCDs)

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MechanismMechanism

Decreased venous stasis

- increase venous velocity

- increase venous volume

Inhibits coagulation cascade

- tissue factor (plasminogen)

- factor VIIa- Nitric Oxide

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Specific methodsSpecific methods

Graduated Elastic stockings:

- Improved venous flow, useful in non-

trauma patients- Applied pre-op and continuedthroughout hospital stay

- Recommended as adjunct in moderateand high risk case

- Must be properly fitted and remain inplace

- Contraindicated in limb ischaemia

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Specific methodsSpecific methods

Intermittent Pneumatic CompressionDevices:

- Intermittent regimen that delivers asustained pressure in distal to proximalmanner

- Intermittently inflates and deflatesbags contained within the garment (20-40 mmHg).

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Intermittent PneumaticIntermittent Pneumatic

Compression DevicesCompression Devices- Cycle times vary from manufacturer tomanufacturer.

- Typically, the inflation (compression) cycleis 10-15 seconds with a 45-50 secondrelaxation (rest)

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Intermittent PneumaticIntermittent Pneumatic

Compression DevicesCompression DevicesDirect pumping effect help reduce stasis

Promotes clearance of local pro-

thrombotic factors and increase localplasminogen activators

Doubtful efficacy in obese individuals

Only effective when used continouslyPresumed additive prophylactic effect pharmacologic

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Wide variety of devices

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Pneumatic CompressionPneumatic Compression

DevicesDevicesNot recommended as sole agent in:- High risk surgical patients

- Orthopaedics Hip or knee surgery

Method of choice when patient is atincreased risk of bleeding fromanticoagulants

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VenaVena CavalCaval InterruptionInterruption

Inferior Vena Cavalfilters (IVC filter);

These are mechanicaldevices to trap bloodclots arising from thelower limb, thus

preventing pulmonaryembolism

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IVC FilterIVC Filter

Current accepted indicationsAbsolute contraindications to

anticoagulant Rx

Life threatening hemorrhage from

anticoagulant Rx

Failure of adequate anticoagulation -recurrence

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Challenges of DVTChallenges of DVT

prophylaxisprophylaxisRoutine assessment of the risk

Perceived diff in risk assessment and risk of

bleeding with anticoagulantEncouragement of routine prophylaxis for ptat risk

Prophylaxis underused Consensus APHA.Mechanical devices are expensive, pt maynot be compliant

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ACCP RecommendationsACCP Recommendations

Primarily in patients who are at high risk ofbleeding from anticoagulant Rx

Adjunct to anticoagulant-based prophylaxis

Careful attention be directed towards

ensuring the proper use of, and optimalcompliance with the mechanical devices

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ConclusionConclusionDVT/PE remain important clinical entitiesin hospitalised patients

Risk assessment & re-assessment needto be undertaken on admission andthroughout hospital stay

Non-pharmacological prophylaxis iseffective (as adjunct) in moderate &high-risk surgical patients

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Thank you

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ReferencesReferences

Brian Ostrow, Venous Thromboembolism: What Surgeons in lowincome countries need to know - Office of InternationalSurgery, Univ. of Toronto, Canada (www.ptolemy.ca)

David Warwick, A Report of DVT Prophylaxis in Orth.Practice-European Musculoskeletal Review 2007; 48-50

E.A Badoe, E.Q Archampong, J.T da Rocha Afodu,Principlesand practice of Surgery including Pathology in the tropics 3rd

ed; 215-217

M.A.R Al-Fallouji, Postgraduate Surgery: The Candidates

Guide 2nd ed; 368Serdar Toker, david J. Hak & Steven J. Morgan, DVTprophylaxis in Trauma Patients- Review Article, 2011.

Wiley W. Souba, Fink P. Mitchell et al, ACS Surgery:Principles & practice 2007 ed.