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DVT PROPHYLAXIS IN ORTHOPEDIC SURGERIES PRESENTED BY –DR SOUVIK PAUL MODERATED BY –DR PRINCE RAINA

DVT PROPHYLAXIS IN ORTHOPEDIC SURGERIES

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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 (