Post on 23-Feb-2016
description
transcript
BELLARMINE UNIVERSITY, LOUISVILLE, KY
Prevention of Pulmonary Embolism in high risk trauma patients
Inferior vena cava filters, pharmaceuticals, vasocompressive devices
Sean Beard, Jimmy Crick, Ashton Curry, Erica Essex
BELLARMINE UNIVERSITY, LOUISVILLE, KY
PICO QUESTION
• P: Trauma patients at high risk for PE
• I: Use of inferior vena cava filter
• C: Prophylactic pharmaceuticals and vasocompressive devices
• O: Incidence of PE
BELLARMINE UNIVERSITY, LOUISVILLE, KY
OBJECTIVES• Background
– PE background & incidence – IVC filters (IVCF) – Why trauma patients?
• Indications vs. Contraindications • Effectiveness • Conclusions • Clinical Relevance
– Risks associated with IVCF http://www.uwmedicine.org/Patient-Care/eHealth-Articles/PublishingImages/Inferior-Vena-Cava-Filter.jpg
BELLARMINE UNIVERSITY, LOUISVILLE, KY
BACKGROUND
PE• Blood clot in lungs
• Originates in lower extremity
• Fragments and travels to lungs via the inferior vena cava
IVCF• Metal alloy device
• Inserted in the inferior vena cava
• Traps blood clots
• Prevents pulmonary emboli
(Young, 2010)http://www.youtube.com/watch?v=o-_wL3XWZ1I&app=desktop
BELLARMINE UNIVERSITY, LOUISVILLE, KY
IVCF PLACEMENT
http://www.mbcgraphics.com/images/img_port_ivcfilter.jpg
http://www.youtube.com/watch?v=UvtHCMBm0SA&app=desktop
BELLARMINE UNIVERSITY, LOUISVILLE, KY
GROSS ANATOMY LAB
Thanks to Dr. Hanks and table 2.1
BELLARMINE UNIVERSITY, LOUISVILLE, KY
IMPORTANCE
• PE’s are common (Rajasekhar, 2011)
• PE’s are deadly (Rajasekhar, 2011)
• PE’s are preventable(Stefanidis, 2006)
http://medicalcenter.osu.edu/patientcare/healthcare_services/lung_diseases/lung/embolism/Pages/index.aspx
BELLARMINE UNIVERSITY, LOUISVILLE, KY
PATIENT PROFILETypes of high risk
patients
• SCI• TBI• Fractures
– Pelvic, acetabulum, tibia-fibula, femoral shaft, foot/ankle
(Carlin, 2002)
Factors increasing venous thrombotic event (VTE) risk
• History of venous thrombotic event
• Prolonged immobility• Pelvic trauma• Age• Vascular injury• Obesity• Blood transfusions (Helling,
2009)
BELLARMINE UNIVERSITY, LOUISVILLE, KY
STANDARD OF CARE• Prophylactic low dose subcutaneous
heparin (LDH) and sequential compression devices (SCD)
• Effectively reduces the incidence of DVT or PE to <10%
• 35% of trauma patients are unable to have SCD
• 14% of high risk trauma patients unable to have LDH
(Sekharan, 2001) (Khansarinia, 1995)
BELLARMINE UNIVERSITY, LOUISVILLE, KY
CONTRAINDICATIONS TO STANDARD OF CARE
Low dose heparin (LDH)
• TBI • SCI• Major pelvic and/or
acetabulum fractures• Spleen or liver injury• Gastrointestinal
bleeding• Hematuria• Stroke• Traumatic aortic
rupture
Sequential compression devices
(SCD)• LE orthopedic fractures• Casting
(Carlin, 2002)
BELLARMINE UNIVERSITY, LOUISVILLE, KY
INDICATIONS FOR USE OF IVCF
• Patients with known VTE• Anticoagulants contraindicated • Recurrent PE despite anticoagulant
therapy• Hx of complication related to
anticoagulant therapy
(Young, 2010)
(Rajasekhar, 2011)
• Inserted within 48 hours of injury (Carlin, 2002)
BELLARMINE UNIVERSITY, LOUISVILLE, KY
EFFECTIVENESS • IVCF’s are considered safe and
reduce incidence of VTE (Kidane, 2012)
• Compared to matched controls, PE incidence was significantly lower in IVCF group (Rajasekhar, 2011)
http://www.uofmmedicalcenter.org/fv/groups/public/documents/images/277293.jpg
BELLARMINE UNIVERSITY, LOUISVILLE, KY
EFFECTIVENESS• After 5 year follow-up, IVCF
placement is safe and durable in young active trauma patients
(Sekharan, 2001)
• In patients with IVCF, compared to no IVCF:– 12 days: 22% decrease in incidence of
PE– 2 years: 50% decrease in incidence of
PE (Decousus, 1998)
BELLARMINE UNIVERSITY, LOUISVILLE, KY
POTENTIAL COMPLICATIONS WITH
IVCF• Erosion through
vena cava wall• Filter migration• Filter infection• Thrombus
formation caudal to IVCF
• Inferior vena cava occlusion
(Stefanidis, 2006)
http://www.youtube.com/watch?v=qlaDA_FRA48
BELLARMINE UNIVERSITY, LOUISVILLE, KY
CONCLUSION • In trauma patients who are at high
risk for PE IVCF’s are more effective than standard of care at preventing the incidence of a PE
• In patients for whom standard of care is contraindicated IVCF placement is safe and recommended
BELLARMINE UNIVERSITY, LOUISVILLE, KY
RELEVANCE TO PHYSICAL THERAPY
• Awareness of IVCF• Indicates patient is at high risk for
VTE• Prolonged IVCF use correlated with
increased incidence of DVT• Wells criteria • Recognition of IVCF complication
BELLARMINE UNIVERSITY, LOUISVILLE, KY
Carlin AM, Tyburski JG, Wilson RF, Steffes C. Prophylactic and therapeutic inferior vena cava filters to prevent pulmonary emboli in trauma patients. Arch. Surg. 2002;137(5):
521–5.
Decousus H, Leizorovicz A. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. N. Engl. J. Med. 1998;338(7):409–415.
Helling TS, Kaswan S, Miller SL, Tretter JF. Practice patterns in the use of retrievable inferior vena cava filters in a trauma population: a single-center experience. J. Trauma. 2009;67(6):1293–6.
Khansarinia S, Dennis JW, Veldenz HC, Butcher JL, Hartland L. Prophylactic Greenfield filter placement in selected high-risk trauma patients. J. Vasc. Surg. 1995;22(3):231–5.
Kidney B, Madani AM, Vogt K, Girotti M, Malthaner R a, Parry NG. The use of prophylactic inferior vena cava filters in trauma patients: a systematic review. Injury, Int. J. Care Injured. 2012;43(5):542–7.
REFERENCES
BELLARMINE UNIVERSITY, LOUISVILLE, KY
REFERENCES Rajasekhar A, Lottenberg R, Lottenberg L, Liu H, Ang D. Pulmonary embolism prophylaxis with inferior vena cava filters in trauma patients: a systematic review using the meta-analysis of observational studies in epidemiology (MOOSE) guidelines. J. Thromb. Thrombolysis. 2011;32(1):40–6.
Sekharan J, Dennis JW, Miranda FE, et al. Long-term follow-up of prophylactic greenfield filters in multisystem trauma patients. J. Trauma. 2001;51(6):1087–90.
Stefanidis D, Paton BL, Jacobs DG, et al. Extended interval for retrieval of vena cava filters is safe and may maximize protection against pulmonary embolism. Am. J. Surg. 2006;192(6):789–94.
Young T, Tang H, Hughes R. Vena caval filters for the prevention of pulmonary embolism. Cochrane Database of Systematic Reviews. 2010; (2):CD006212.