DVT PROPHYLAXIS

Dr. E M. Regis Jr.Dept. Of Orthopaedics

10/08/15

OverviewDefinition

Incidence

Aeitology/ Risk Factors

Pathophysiology

Signs/ Symptoms

Diagnosis

Complications

Prophylaxis

Conclusion

Definition

thrombus (clot) formation predominately in the deep veins of the legs.

eg. femoral vein, popliteal vein

Incidence

1-2 per 1000 annually in the United States

60,000-100,000 die of DVT {10-30% within 1st month of diagnosis}

Aeitology/ Risk Factors

Virchow’s Triad

a) stasis

b) hypercoagulability

c) vessel wall damage (intima)

INJURY TO VEIN;

fractures

severe muscle injury

major surgery (abdominal, pelvis, hip or legs)

SLOW BLOOD FLOW;

confinement to bed

limited movement

sitting for prolong periods with crossed legs

paralysis

INCREASED ESTROGEN;

birth control pills

HRT sometimes used after menopause

Pregnancy, up to 6 weeks postpartum

OTHER FACTORS;

previous DVT or PE

family history of DVT or PE

age (risk increase as age increases)

obesity

catheter located in a central vein

inherited clotting disorders (protein c deficiency, antithrombin deficiency)

Signs & Symptomspain or tenderness

warmth

swelling

redness or discoloration

distention of surface veins

difficulty breathing (S.O.B)

tachycardia or irregular heart beat

chest pain or discomfort

anxiety

haemoptysis

hypotension/ lightheadedness

DiagnosisHISTORY & PHYSICAL EXAMINATION

CHEST X-RAY

ECG

Labs including D-dimers

DUPLEX ULTRASOUND

VENOGRAPHY

spiral CT chest

V:Q scan (ventilation/perfusion)

pulmonary angiogram

Complications

Pulmonary Embolism

Death

Post-thrombotic Syndrome

Prophylaxis

Mechanical

compression stockings

intermittent pneumatic compression devices

ivc filters

Pharmacological

1. Platelet Active Drugs {aspirin 50-100mg/d}

2. Courmarins {Warfarin}

3. Heparins (UFH)

4. Low Molecular Weight Heparins (LMWH) {Enoxaparin}

5. Factor Xa Inhibitors {Rivaroxaban}

DVT Prophylaxis Based on Risk Stratification Levels

1 point assigned to following:

age 41-60yrs

minor surgery

history of major surgery within 1 month

pregnancy or postpartum within 1 month

varicose veins

inflammatory bowel disease

swelling of legs

obesity

oral contraceptives, patch or HRT

2 points assigned to the following:

age >60yrs

malignancy or current chemo or radiation therapy

major surgery (>45min)

laparoscopic surgery (>45min)

confined to bed > 72hrs

immobilizing cast shorter than 1 month

central venous access <1month

tourniquet time >45mins

3 points assigned to the following:

age >75yrs

history of DVT or PE

family history of thrombosis

Factor V Leiden/activated protein C resistance

medical patient with risk factors of MI, CHF or COPD

congenital or acquired thrombophillia

5 points assigned to the following:

major, elective lower extremity arthoplasty, total knee replacement, total hip replacement

hip, pelvis or leg fracture within 1 month

stroke within 1 month

multiple trauma within 1 month

acute spinal cord injury with paralysis within 1 month

Risk Group Classification for Orthopaedic Patients

Low Risk Patients;

no specific prophylaxis is required other than early and aggressive mobilisation

Moderate Risk Patients;

low dose UFH {LDUF q12hrs}, LMWH {<3,400 U qd}, and IPC

High Risk Patients;

low dose UFH q8h, LMWH {>3400 U qd}, with or without IPC

Very High Risk Patients;

LMWH {>3400 U qd}, fondaparinux, and coumarins (INR 2-3). Dose-adjusted low-dose UFH or LMWH may be used with or without IPC.

Conclusion

Based on history and physical examination findings, there should be a high index of suspicion in diagnosing DVT confirmed with labs and necessary investigations.

Aim should be geared towards prevention than treatment.

Prophylaxis is tailored independently based on numerous of patient factors.

Treatment is a multidisciplinary approach involving chest physicians and primary surgical team.

Referenceswww.google.com/images

Deep Venous Thrombosis Prophylaxis In Orthopedic Surgery, DAVID A FORSH MD. August 15, 2014

www.sages.org/publications/guidelines

Venous thromboembolism prophylaxis.- National Guideline

Antithrombotic Guidelines, 9th ED| Guidelines & Consensus. American College of Chest Physicians