Slide 1
DVT PROPHYLAXIS IN ORTHOPEDIC SURGERIESPRESENTED BY DR SOUVIK
PAULMODERATED BY DR PRINCE RAINA
What Is Deep Vein Thrombosis ?
INTRODUCTION WHAT IS VTE ?
includes spectrum of deep vein thrombosis (DVT) and pulmonary
embolism (PE).
NEED OF DVT PROPHYLAXIS.common preventable cause of hospital
deaths
DVT in traumatic injuries 5 - 63%
Without prophylaxis
venous thrombosis -- 50% Orthopedic surgeriesFatal PE in 2.0% of
total hip arthroplasty Fatal PE in 2.5-7.5% of Fractured Hip
Ref: Campbell 12th edition Piotrowski JJ, et al Am J Surg. 1996
Aug; 172(2):210-3.
Indian J Urol. 2009 Jan-Mar; 25(1):
1116.doi:10.4103/0970-1591.45531
INCIDENCE OF DVT IN DIFFERENT SURGERIESPatient groupVTE
prevalence (%)Medical patients10-20Cardiac
patients15-40Neurosurgery15-40Stroke20-30Hip and knee
arthroplasty40-60Major trauma40-50Spinal cord injury60-80Critical
care patients10-20
Strong risk factors Hip or leg fracture Hip or knee replacement
Major general surgery Major trauma, including spinal cord
injury
Moderate risk factors Arthroscopic knee surgery Central venous
catheterization HRT or OC Pills Malignancy (active or recently
treated) Pregnancy Paralytic stroke Prior VTE Thrombophilia
(inherited or acquired)
Weak risk factors Bed rest > 3d Prolonged immobility Advanced
age Laparoscopic surgery Obesity Pregnancy Varicose veins
Anderson FA Jr,Spencer FA: Risk factors for venous
thromboembolism Circulation107[23, Suppl 1]:I9,2003
PATHOPHYSIOLOGY virchow's triad
Presentation and Physical Examination Calf pain or
tenderness
Swelling + pitting oedema
Increased skin temperature and fever
Superficial venous dilatation
Clinical examination Palpate distal pulses
Evaluate capillary refill .
Neurologic evaluation
Homans sign: pain posterior calf /knee with forced dorsiflexion
of foot.
Moses sign Gentle squeezing of lower part of calf from side to
side.
Neuhofs sign Thickening and deep tenderness elicited while
palpating deep in calf muscles
Wells Clinical Prediction GuideVariableWellsActive cancer (
within last 6 months or palliative)1Calf swelling >3 cm compared
to other 1Collateral superficial veins 1Pitting edema 1Swelling of
entire leg1
variablewellsParalysis, paresis, or recent cast immobilization
of lower extremities1Recently bedridden > 3 days, or major
surgery 1Previous DVT1Alternative diagnosis at least as likely deep
vein thrombosis-2Localized pain along distribution of deep venous
system 1
Interpretation
High probability: 3 (Prevalence of DVT - 53%)
Moderate probability: 1-2 (Prevalence of DVT - 17%)
Low probability: 0 (Prevalence of DVT - 5%)
Adapted from Anand SS, et al. JAMA. 1998; 279 [14];1094
Over 20 different VTE risk assessment modelsIndividualized
point-based scoring models e.g.:CAPRINI PADUA REVISED GENEVA
SCORE
Grouping or bucket models:NICE / NHS guidelines Classic 3 bucket
model
A TOTAL SCORE >4 INDICATES HIGH RISK OF VTE
Interpretation of revised Geneva score
0-3 score :low risk4-10 score : intermediate risk>11 score
:high risk
.
Validated in predicting risk
Can be difficult to use reliably
Caprini Model
1 point for each risk factorsAge 41-60Swollen legsVaricose
veinsObesitySepsisOCP or HRTPregnancy or postpartumAMICHFProlonged
bed restPrior major surgery
2 points for each risk factorsAge 61-74 yrsArthroscopic
surgeryMalignancyLaparoscopic surgeryImmobilisation with plaster
cast (75 yrsHistory of DVT /PE Positive factor leiden Family
history of VTEPositive lupus anticoagulantHITElevated
anticardiolipin antibodies
5 points for each risk factorsStroke (
