not-­‐pharmacological  periopera0ve  profilaxys    

 

 general  methods  mobiliza(on  hydra(on  

 elas(c  compression              caval  filters    pneuma(c  compression          

 mechanical  prophylaxis    

Velia Marta Antonini, Parma University Hospital - I° Department of Anesthesia and Intensive Care

moderate  risk  

high  risk  

very    high  risk  

Preven&on  and  management  of  venous  thromboembolism  in  the  surgical  pa&ent:  op&ons  by  surgery  type  and  individual  pa&ent  risk  factors,  The  American  Journal  of  Surgery,  Vol  199,  Jan  2010      

Velia Marta Antonini, Parma University Hospital - I° Department of Anesthesia and Intensive Care

Knudson  Ann  Surg  2004;  240:490-­‐498  

INJURED  PATIENT  

High  Risk  Factors  (Odds  ra0o  for  VTE  =  2  –  3)  •   Age  ≥  40  •   Pelvic  fx  •   Lower  extremity  fx  •   Shock  •   Spinal  cord  injury  •   Head  Injury  (AIS  ≥  3)  

Very  High  Risk  Factors  (Odds  ra0o  for  VTE  =  4  -­‐  10)  

•   Major  opera0ve  procedure  •   Venous  injury  •   Ven0lator  days  >  3    •   2  or  more  high  risk  factors  

Does  the  pa0ent  have  contraindica0ons  for  Heparin?  

Does  the  pa0ent  have  contraindica0ons  for  Heparin?  

Yes   No  

Yes  No  

Mechanical  Compression  

LMWH*  

*  Prophylac0c  dose  

LMWH*  and  Mechanical  Compression  

Mechanical  Compression  and  serial  CFDI    

OR    Temporary  IVC  filter  

Velia Marta Antonini, Parma University Hospital - I° Department of Anesthesia and Intensive Care

   

 We   recommend   that   mechanical   methods   of  thromboprophylaxis  be  used  primarily   in  pa0ents  at  high  risk    for    bleeding  (Grade  1A),    or  possibly  as   an   adjunct   to   an0coagulant   –   based  thromboprophylaxis  (Grade  2A).  

   For   pa0ents   receiving   mechanical   methods   of  thromboprophylaxis,  we   recommend   that   careful  a_en0on  be  directed  toward  ensuring  the  proper  use   of,   and   op0mal   adherence   with,   these  methods  (Grade  1A).  

 Kearon   et   al.   AnJthromboJc   Therapy   for   Venous   Thromboembolic   Disease:   American  

College  of  Chest  Physicians  Evidence-­‐Based  Clinical  PracJce  Guidelines   (8th  EdiJon).  Chest  2008;  133;  454-­‐545  

 

Velia Marta Antonini, Parma University Hospital - I° Department of Anesthesia and Intensive Care

Rimozione quotidiana per ispezione cute se riduzione significativa mobilità, integrità della cute compromessa e ridotta sensibilità 2-3 volte giorno specie talloni e prominenze ossee. Ensure that patients who develop oedema or postoperative swelling have their legs re-measured and anti-embolism stockings refitted. Use anti-embolism stockings that provide graduated compression and produce a calf pressure of 14–15 mmHg. Se collaborante coinvolgere il paziente ad indossarle in modo corretto mopnitorando la comprensione Se collaborante coinvolgere il paziente ad indossarle in modo corretto mopnitorando la comprensione

For  general   surgery  pa0ents  with  mul0ple   risk   factors   for  VTE  who  are  thought  to  be  at  par0cularly  high  risk,  we  recommend   that   a   pharmacologic   method   …   be  combined  with  the  op0mal  use  of  a  mechanical  method  (ie,   graduated   compression   stockings   [GCS]   and/or  IPC)  (Grade  1C).  

   For   general   surgery   pa0ents  with   a   high   risk   of   bleeding,  we   recommend   the   op0mal   use   of   mechanical  thromboprophylaxis   with   properly   fi_ed   GCS   or  IPC   (Grade   1A).   When   bleeding   risk   decreases,   we  recommend   that   pharmacologic   prophylaxis   be  s u b s 0 t u t e d   f o r   o r   a d d e d   t o   me c h a n i c a l  prophylaxis  (Grade  1C).  

 Kearon  et  al.  AnJthromboJc  Therapy  for  Venous  Thromboembolic  Disease:  American  College  

of  Chest  Physicians  Evidence-­‐Based  Clinical  PracJce  Guidelines  (8th  EdiJon).  Chest  2008;  133;  454-­‐545  

  Velia Marta Antonini, Parma University Hospital - I° Department of Anesthesia and Intensive Care

 SCD  

foot        impulse  devices    

sequen0al  compression  devices    

SCD

FP  

Velia Marta Antonini, Parma University Hospital - I° Department of Anesthesia and Intensive Care

         graduated  compression  stockings  

SCD                    AES  

G  C  S  

Velia Marta Antonini, Parma University Hospital - I° Department of Anesthesia and Intensive Care

DVT  anamnesis/suspect  

controindicazioni      SCD  

conges0ve  heart  failure/pulmonary  edema  Velia Marta Antonini, Parma University Hospital - I° Department of Anesthesia and Intensive Care

bone  lesions  

edema  

not  treated    -­‐  infected  sores    

recent  sutures  

 

fasci0s,  gangrene  

arterial  bypass  graging  skin  gag  

vasculopathies      neuropathies    

 

obesity    malforma0ons  

edema  

foot    pumps  !  

controindicazioni    AES/SCD  

Velia Marta Antonini, Parma University Hospital - I° Department of Anesthesia and Intensive Care

Offer   VTE   prophylaxis   to  pa0ents   undergoing  gastrointes0nal  surgery  who  are  assessed  to  be  at  increased  risk  of  VTE  or   pa0ents   undergoing  bariatric  surgery    

S t a r t   a t   admi s s ion ,  con0nue   un0l   pa0ent  n o   l o n g e r   h a s  significantly   reduced  mobility.    

Choose  any  one  of:  AES,  foot  impulse  devices,  IPC  …  Base  choice   on   individual   factors   including   clinical   condi0on,  surgical  procedure  and  pa0ent  preference.  Add   pharmacological   prophylaxis     if   low   risk   of   major  bleeding    

Venous  thromboembolism  –                                                          reducing  the  risk,  NICE  guidelines  2007  

Velia Marta Antonini, Parma University Hospital - I° Department of Anesthesia and Intensive Care