Total Joint

Replacement

AgendaAgendaTimeTime TopicTopic SpeakerSpeaker

0700-07300700-0730 IntroductionIntroduction Total Joint Replacement in Chinook HealthTotal Joint Replacement in Chinook Health TJR: What is it?TJR: What is it? TJR: IndicationsTJR: Indications

Kathy Sassa, Educator- SurgeryKathy Sassa, Educator- Surgery

0730-08000730-0800 Preop Assessment Total Joint ClinicPreop Assessment Total Joint Clinic Susan Folkerson, UM Unit 3BSusan Folkerson, UM Unit 3B

0800-09000800-0900 The Surgical ProcessThe Surgical Process Gail Kiefuik, OR RNGail Kiefuik, OR RN

0900-09150900-0915 BreakBreak

0915-10000915-1000 Post-Op CarePost-Op Care Post-Op OrdersPost-Op Orders

Tracey KuskTracey Kusk

1000-11151000-1115 Role of Physiotherapy & Occupational TherapyRole of Physiotherapy & Occupational Therapy OT/PTOT/PT

1115-11301115-1130 ComplicationsComplications Kathy SassaKathy Sassa

1130-12001130-1200 LunchLunch

1200-13001200-1300 Role of PharmacyRole of Pharmacy AnticoagulationAnticoagulation

Sheila Seely, PharmacistSheila Seely, Pharmacist

1300-14001300-1400 Discharge PlanningDischarge Planning Kevin Elder, Charge RN Unit 4AKevin Elder, Charge RN Unit 4A

1400-14151400-1415 BreakBreak

1415-15001415-1500 4A Mass Casualty Response Plan: Burns4A Mass Casualty Response Plan: Burns Kathy SassaKathy Sassa

INCIDENCE OF POST-OP COAGULATION INCIDENCE OF POST-OP COAGULATION COMPLICATIONS WITHOUT PROPHYLAXISCOMPLICATIONS WITHOUT PROPHYLAXIS

THR DVT becomes symptomatic av. 17 days post-opTHR DVT becomes symptomatic av. 17 days post-opTKR DVT becomes symptomatic av. 6.7 days post-opTKR DVT becomes symptomatic av. 6.7 days post-op

Incidence of DVTIncidence of DVT Incidence of Fatal Incidence of Fatal PEPE

Elective Knee SurgeryElective Knee Surgery 61%61% 5-12%5-12%Elective Hip SurgeryElective Hip Surgery 51%51% 2.4%2.4%Hip FractureHip Fracture 44%44% 5.9%5.9%General SurgeryGeneral Surgery 25%25% 0.9%0.9%

Post-Operative Post-Operative Anticoagulation Anticoagulation

TherapyTherapy

The purpose of The purpose of anticoagulant therapy is anticoagulant therapy is preventionprevention & treatment of & treatment of thromboembolic disordersthromboembolic disorders

Anticoagulants Anticoagulants DO NOTDO NOT dissolve clotsdissolve clots

Anticoagulants affect the Anticoagulants affect the balance between balance between coagulation and coagulation and fibrinolysisfibrinolysis

Anticoagulation TherapyAnticoagulation Therapy

Virchow’s TriadVirchow’s Triad

Identifies the threeIdentifies the three primary componentsprimary components

that contribute to that contribute to pathological clot pathological clot formation (i.e. DVT formation (i.e. DVT and PE)and PE)TKR and THR ptsTKR and THR pts

automatically have automatically have 2 of the 3 risks2 of the 3 risks

CH Anticoagulation GuidelinesCH Anticoagulation Guidelines

Based on CHEST Evidence-based Based on CHEST Evidence-based guidelinesguidelinesReviewed periodically & approved by P&T Reviewed periodically & approved by P&T (last revision 2001, currently under review)(last revision 2001, currently under review)Risk Assessment ToolRisk Assessment ToolProphylaxis GuidelinesProphylaxis GuidelinesTreatment GuidelinesTreatment Guidelines

CH Anti-coagulation GuidelinesCH Anti-coagulation GuidelinesRisk Assessment (Value Noted in Brackets):Risk Assessment (Value Noted in Brackets):

Major orthopedic surgery of lower limbs:Major orthopedic surgery of lower limbs:

total knee arthroplasty total knee arthroplasty [ 5 ][ 5 ]hip fracture hip fracture [ 5 ][ 5 ]total hip arthroplasty total hip arthroplasty [ 4 ][ 4 ]Extensive abdominal or pelvic surgery for Extensive abdominal or pelvic surgery for malignancy malignancy [ 4 ][ 4 ]Multiple trauma Multiple trauma [ 4 ][ 4 ]..Acute spinal cord injury with paralysis Acute spinal cord injury with paralysis [ 4 ][ 4 ]History of DVT/PE History of DVT/PE [ 3 ][ 3 ]Advanced age:Advanced age:

age over 70 years age over 70 years [ 3 ][ 3 ]age 61 to 70 years age 61 to 70 years [ 2 ][ 2 ]age 41 to 60 years age 41 to 60 years [ 1 ][ 1 ]Stroke Stroke [ 1 ][ 1 ]

CHF CHF [ 1 ][ 1 ]MI MI [ 1 ][ 1 ]Varicose VeinsVaricose Veins [ 1 ] [ 1 ]Obesity (greater than 20% of IBW) Obesity (greater than 20% of IBW) [ 1 ][ 1 ]Congenital and acquired aberrations in Congenital and acquired aberrations in hemostatic mechanisms hemostatic mechanisms [ 1 ][ 1 ]General surgery lasting more than 30 minutes General surgery lasting more than 30 minutes [ 1 ][ 1 ]History of pelvic or long bone fractureHistory of pelvic or long bone fracture [ 1 ] [ 1 ]Leg edema, ulcers, stasis Leg edema, ulcers, stasis [ 1 ][ 1 ]Pregnancy or postpartum <1 month Pregnancy or postpartum <1 month [ 1 ][ 1 ]Inflammatory bowel disease Inflammatory bowel disease [ 1 ][ 1 ]Severe infection Severe infection [ 1 ][ 1 ]High dose estrogen use High dose estrogen use [ 1 ][ 1 ]OtherOther

RecommendationsRecommendations::

Low Risk [ 1 ]:Low Risk [ 1 ]:– Early ambulationEarly ambulation

Moderate Risk [ 2 to 3 ]:Moderate Risk [ 2 to 3 ]:– Low Dose Unfractionated Heparin at 5000 IU sc bidLow Dose Unfractionated Heparin at 5000 IU sc bid

OROR– Intermittent pneumatic compressionIntermittent pneumatic compression

OROR– Low Molecular Weight Heparin – Tinzaparin (Innohep) 3500 IU sc qd until patient Low Molecular Weight Heparin – Tinzaparin (Innohep) 3500 IU sc qd until patient

is mobilized. Start 6 hours post-op.is mobilized. Start 6 hours post-op.

High RiskHigh Risk [ 4 or more ]:[ 4 or more ]:– Low Molecular Weight Heparin -- Tinzaparin (Innohep) 4500 IU sc qd until patient Low Molecular Weight Heparin -- Tinzaparin (Innohep) 4500 IU sc qd until patient

is mobilized. Start 12 hours post-op.is mobilized. Start 12 hours post-op.– If patient is less than 55kg use 3500 iu. If patient is greater than 70kg consider If patient is less than 55kg use 3500 iu. If patient is greater than 70kg consider

dosing at 75iu/kgdosing at 75iu/kg– Low intensity oral anticoagulation -- INR 2 - 3. Low intensity oral anticoagulation -- INR 2 - 3.

OROR– Intermittent pneumatic compression plus Low Molecular Weight Heparin Intermittent pneumatic compression plus Low Molecular Weight Heparin oror Low Low

Dose Unfractionated HeparinDose Unfractionated Heparin..

Guidelines for Treatment of Venous Thrombosis/Pulmonary Embolism:Guidelines for Treatment of Venous Thrombosis/Pulmonary Embolism:

Venous Thrombosis:Venous Thrombosis:– Intravenous Unfractionated Heparin as per Weight Adjusted PE/DVT Intravenous Unfractionated Heparin as per Weight Adjusted PE/DVT

Heparin Protocol.Heparin Protocol.OROR

– LMWH:LMWH: Tinzaparin (Innohep)Tinzaparin (Innohep) 175 iu/kg body weight sc q24h.175 iu/kg body weight sc q24h.ororEnoxaparin (Lovenox)Enoxaparin (Lovenox) 1mg/kg (max.100mg) sc q12h 1mg/kg (max.100mg) sc q12h oror

1.5mg/kg sc qd (max.180mg)1.5mg/kg sc qd (max.180mg)Pulmonary Embolism:Pulmonary Embolism:

– Intravenous unfractionated Heparin as per PE/DVT Heparin Protocol Intravenous unfractionated Heparin as per PE/DVT Heparin Protocol OROR

– LMWH: Tinzaparin 175iu/kg body weight sc q24HLMWH: Tinzaparin 175iu/kg body weight sc q24H– Warfarin (Coumadin):Warfarin (Coumadin):

Should be started within 24 hours after initiation of Heparin or Low Molecular Should be started within 24 hours after initiation of Heparin or Low Molecular Weight Heparin and the dose adjusted in the usual manner. Weight Heparin and the dose adjusted in the usual manner. Heparin or Low Molecular Weight Heparin should be continued for a minimum Heparin or Low Molecular Weight Heparin should be continued for a minimum of five days. of five days. INR should be in the therapeutic range (2 to 3) for two consecutive days prior INR should be in the therapeutic range (2 to 3) for two consecutive days prior to discontinuing heparin or Low Molecular Weight Heparinto discontinuing heparin or Low Molecular Weight Heparin

High Risk (4 or more):High Risk (4 or more):Low Molecular Weight Heparin -- Tinzaparin (Innohep) Low Molecular Weight Heparin -- Tinzaparin (Innohep) 4500 IU sc qd until patient is mobilized. Start 12 hours 4500 IU sc qd until patient is mobilized. Start 12 hours post-op.post-op.

If patient is less than 55kg use 3500 iu. If patient is If patient is less than 55kg use 3500 iu. If patient is greater than 70kg consider dosing at 75iu/kggreater than 70kg consider dosing at 75iu/kg

Low intensity oral anticoagulation -- INR 2 - 3. Low intensity oral anticoagulation -- INR 2 - 3. OROR

Intermittent pneumatic compression plus Low Molecular Intermittent pneumatic compression plus Low Molecular Weight Heparin Weight Heparin oror Low Dose Unfractionated Heparin. Low Dose Unfractionated Heparin.

Clotting CascadeClotting CascadeWarfarin affects Factors Warfarin affects Factors II, VII, IX, X,II, VII, IX, X,the factors involved in the factors involved in Vitamin K metabolismVitamin K metabolism

Low Molecular WeightLow Molecular WeightHeparins (eg Heparins (eg Tinzaparin)Tinzaparin)inhibit Factor Xa and inhibit Factor Xa and inactivate thrombin inactivate thrombin

Anticoagulant Example: WarfarinAnticoagulant Example: WarfarinClassification:Classification:

Vitamin K AntagonistVitamin K AntagonistMonitoring:Monitoring:INR, goal range 2.0-3.0 INR, goal range 2.0-3.0 Indications:Indications:

Prophylaxis & treatment of: Prophylaxis & treatment of: – Venous thrombosisVenous thrombosis– Pulmonary embolismPulmonary embolism– Atrial fibrillation with Atrial fibrillation with

embolizationembolization– Embolization after MI, Embolization after MI,

including strokeincluding stroke

Adverse Reactions:Adverse Reactions: BleedingBleeding Cramps & nauseaCramps & nausea Dermal necrosisDermal necrosis FeverFever

AnticoagulantAnticoagulant Example:Example: TinzaparinTinzaparinClassification:Classification:

Low Molecular weight Low Molecular weight HeparinHeparin

Monitoring:Monitoring: CBC and CBC and Creatinine baseline and Creatinine baseline and twice weeklytwice weekly

Indications:Indications:Prevention of Prevention of DVT & PE after: DVT & PE after: – Abdominal surgeryAbdominal surgery– Hip/knee surgery Hip/knee surgery

or replacementor replacement

Adverse Reactions:Adverse Reactions: Bleeding, anemia, rash, thrombocytopenia, Bleeding, anemia, rash, thrombocytopenia,

ecchymosisecchymosis Dizziness, headache, insomniaDizziness, headache, insomnia EdemaEdema Constipation, vomiting, nausea, reversible Constipation, vomiting, nausea, reversible

increase in liver enzymesincrease in liver enzymes Urinary retentionUrinary retention Heparin-Induced Thrombocytopenia (HIT)Heparin-Induced Thrombocytopenia (HIT) Erythema at injection site, hematoma, pain, Erythema at injection site, hematoma, pain,

irritationirritation FeverFever