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VTE in VTE in OrthopaedicsOrthopaedics
Australian Orthopaedic Nurses’ Australian Orthopaedic Nurses’ AssociationAssociation
15 May 200915 May 2009
Dr Lachlan MilneDr Lachlan Milne
What is VTE?What is VTE?
Venous thromboembolism (VTE) Deep Vein Thrombosis (DVT) Pulmonary Embolism (PE)
What is VTE?What is VTE?
Why is VTE a problem?Why is VTE a problem?
VTE annual risk 1-2 per 1000 people1
40 000 per year in Australia PE: 0.2% deaths per year in
Australia2
Morbidity higher than mortalityMorbidity higher than mortality1. Ho et al. Venous thromboembolism: diagnosis and management of deep
venous thrombosis MJA 2005; 182 (9): 476-481
2.2. Australian Bureau of Statistics 2006Australian Bureau of Statistics 2006
Consequences of DVTConsequences of DVT
DeathDeath Pulmonary EmbolismPulmonary Embolism Post-thrombotic Syndrome (chronic V HT)Post-thrombotic Syndrome (chronic V HT)
Venous stasis Venous stasis Leg pain and swellingLeg pain and swelling HyperpigmentationHyperpigmentation Leg ulcersLeg ulcers
Recurrent Venous ThromboembolismRecurrent Venous Thromboembolism
1. Tovey C et al. Diagnosis, investigation, and management of deep vein thrombosis. BMJ 2003;326;1180-1184
DVT in orthopaedics?DVT in orthopaedics?
Orthopaedic patients are most at risk Orthopaedic patients are most at risk of all patients in hospitalof all patients in hospital11
Total Joint ArthroplastiesTotal Joint Arthroplasties Major TraumaMajor Trauma Hip FracturesHip Fractures
1. White et al: Risk factors for venous thromboembolism after total hip and knee replacement surgery. Current Opinion in Pulmonary Medicine 2002, 8:365–371
DVT PathophysiologyDVT Pathophysiology Virchow’s Triad
Endothelial injury Surgery
Venous stasis Tourniquet Immobilisation
Delayed ambulation Casting
Change in blood constituents ↑ ↑ platelets platelets ↑ ↑ clotting clotting ↑ ↑ viscosity viscosity
1.1. Virchow RLK (1856). Virchow RLK (1856). Thrombosis und EmbolieThrombosis und Embolie. Gefässentzündung und septische . Gefässentzündung und septische Infektion". Infektion". Gesammelte Abhandlungen zur wissenschaftlichen MedicinGesammelte Abhandlungen zur wissenschaftlichen Medicin. pp. 219–732. . pp. 219–732.
Risk factorsRisk factors Increased in orthopaedics:Increased in orthopaedics:
ImmobilisationImmobilisation Major surgeryMajor surgery TourniquetTourniquet
Other non orthopaedicOther non orthopaedic Obesity BMI >30 (often in arthroplasties)Obesity BMI >30 (often in arthroplasties) History of prior DVTHistory of prior DVT FemaleFemale SmokingSmoking OCPOCP Genetic (many)Genetic (many)
1. White et al: Risk factors for venous thromboembolism after total hip and knee replacement surgery. Current Opinion in Pulmonary Medicine 2002, 8:365–371
Course of DVT illnessCourse of DVT illness Determined by the site of thrombosisDetermined by the site of thrombosis11
CalfCalf Where DVTs startWhere DVTs start 50% resolve in 3/750% resolve in 3/7 Rarely causes PE in isolationRarely causes PE in isolation 25% extend proximally within 1 week25% extend proximally within 1 week
ProximalProximal SymptomaticSymptomatic 50% have PE at Dx 50% have PE at Dx only 1 in 5 of those is symptomatic of PEonly 1 in 5 of those is symptomatic of PE
1.1. Ho W. et al Ho W. et al Venous thromboembolism: diagnosis and management of deep Venous thromboembolism: diagnosis and management of deep venous thrombosis venous thrombosis MJA MJA 2005; 182 (9): 476-4812005; 182 (9): 476-481
VTE – Signs and VTE – Signs and SymptomsSymptoms
DVTDVT11
Leg swelling/erythemaLeg swelling/erythema Leg painLeg pain Superficial venous congestionSuperficial venous congestion
PEPE Symptoms:Symptoms:
DyspnoeaDyspnoea Pleuritic chest painPleuritic chest pain
Signs:Signs: ↑ ↑ PRPR ↓ ↓ SaO2 SaO2 ↑ ↑ RRRR
1. Tovey C et al. Diagnosis, investigation, and management of deep vein thrombosis. BMJ 2003;326;1180-1184
Diagnosis of DVTDiagnosis of DVT11
UnreliableUnreliable Clinical assessment algorithmClinical assessment algorithm Screening investigationsScreening investigations Definitive investigationsDefinitive investigations
1. Tovey C et al. Diagnosis, investigation, and management of deep vein thrombosis. BMJ 2003;326;1180-1184
Clinical assessment Clinical assessment algorithmalgorithm11
Low prob ≤0Low prob ≤0
Mod prob 1-2Mod prob 1-2
High prob High prob ≥3 ≥3
Clinical featureClinical feature ScorScoree
Active cancer <6/12 agoActive cancer <6/12 ago 11
Recent immobilisation of legsRecent immobilisation of legs 11
Recently bedridden >3/7 Recently bedridden >3/7 AND/ORAND/OR
Major surgery <4/52Major surgery <4/52
11
Tender over deep venous systemTender over deep venous system 11
Entire leg swollenEntire leg swollen 11
Calf swelling >3cmCalf swelling >3cm 11
Collateral superficial non varicose Collateral superficial non varicose veinsveins
11
Pitting oedema > asymptomaticPitting oedema > asymptomatic 11
Alternative diagnosis likelyAlternative diagnosis likely -2-21. Tovey C et al. Diagnosis, investigation, and management of deep vein
thrombosis. BMJ 2003;326;1180-1184
Screening InvestigationsScreening Investigations
D Dimer assay D Dimer assay Degradation product of fibrinDegradation product of fibrin Elevated in 80% of VTEElevated in 80% of VTE FastFast Low specificityLow specificity Useless in context of surgeryUseless in context of surgery
Definitive Ix – Definitive Ix – VenographyVenography11
Gold standardGold standard InvasiveInvasive PainfulPainful Risks:Risks:
ThrombosisThrombosis Contrast allergy Contrast allergy
Venogram showing Venogram showing popliteal vein popliteal vein thrombosisthrombosis
1. Tovey C et al. Diagnosis, investigation, and management of deep vein thrombosis. BMJ 2003;326;1180-1184
Definitive Ix - UltrasoundDefinitive Ix - Ultrasound
Non invasiveNon invasive SafeSafe Good SensitivityGood Sensitivity
97% proximal 97% proximal 75% calf75% calf11
Compression USCompression US Doppler Doppler
1.1. Kraaijenhagen RA et al. Kraaijenhagen RA et al. Diagnostic management of venous thromboembolism. Diagnostic management of venous thromboembolism.
Baillières Clin HaematolBaillières Clin Haematol 1998;11: 541-86. 1998;11: 541-86.
Definitive InvestigationsDefinitive Investigations
CT venographyCT venography Highly sensitive and specificHighly sensitive and specific Huge amount of radiation Huge amount of radiation Not much improvement on USNot much improvement on US Rarely usedRarely used
Definitive InvestigationsDefinitive Investigations
MRIMRI Best invasiveness to sensitivity ratioBest invasiveness to sensitivity ratio ExpensiveExpensive Unlikely to be used frequently until costs Unlikely to be used frequently until costs
decreasedecrease
Diagnosis of PEDiagnosis of PE
Clinical judgementClinical judgement Arterial Blood GasArterial Blood Gas VQ scanVQ scan
ProbabilityProbability CTPACTPA
DiagnosticDiagnostic ContrastContrast
TreatmentTreatment
Anticoagulation Anticoagulation HeparinHeparin
UnfractionatedUnfractionated Low Molecular WeightLow Molecular Weight
WarfarinWarfarin IVC filterIVC filter Compression stockingsCompression stockings
Treatment - HeparinTreatment - Heparin
Minimum 5/7 until warfarin therapeuticMinimum 5/7 until warfarin therapeutic UnfractionatedUnfractionated
InfusionInfusion Q6h monitoring Q6h monitoring Renal impairmentRenal impairment
Low Molecular Weight Heparin Low Molecular Weight Heparin consistent responseconsistent response Longer t ½ – Daily dosingLonger t ½ – Daily dosing Effective Effective ↓ ↓ haemorrhagehaemorrhage NephrotoxicNephrotoxic
Treatment - WarfarinTreatment - Warfarin
Oral dosingOral dosing Prothrombotic initiallyProthrombotic initially
Heparin/ClexaneHeparin/Clexane Monitoring with INR target 2.0 – 3.0Monitoring with INR target 2.0 – 3.0 Not used in pregnancy – crosses Not used in pregnancy – crosses
placentaplacenta 6/12 treatment6/12 treatment
Treatment – IVC filterTreatment – IVC filter
When anticoagulation When anticoagulation contraindicatedcontraindicated eg orthopaedic patients undergoing eg orthopaedic patients undergoing
surgerysurgery Recurrent DVT despite adequate Recurrent DVT despite adequate
anticoagulationanticoagulation
Treatment – StockingsTreatment – Stockings
Simple and cost effectiveSimple and cost effective Reduce likelihood of post-thrombotic Reduce likelihood of post-thrombotic
syndromesyndrome Wear for 18 months post DVT Wear for 18 months post DVT 11
1. Brandjes DP et al. Randomised trial of effect of compression stockings in patients with symptomatic proximal-vein thrombosis. Lancet 1997;349:759-62
PreventionPrevention
Orthopaedic patients most at riskOrthopaedic patients most at risk Australian Therapeutic Guidelines Australian Therapeutic Guidelines Medical Medical MechanicalMechanical
1. Geerts WH et al. Prevention of Venous Thromboembolism Prevention of Venous Thromboembolism The Seventh ACCP The Seventh ACCP Conference on Antithrombotic and Thrombolytic TherapyConference on Antithrombotic and Thrombolytic Therapy
Prevention – MechanicalPrevention – Mechanical
Should be commenced evening Should be commenced evening priorprior to to surgerysurgery
Stockings:Stockings: GCS – Graduated Compression StockingsGCS – Graduated Compression Stockings TEDs – ThromboEmbolic DeterrentsTEDs – ThromboEmbolic Deterrents
Compressors:Compressors: SCDs – Sequential Compression DevicesSCDs – Sequential Compression Devices IPC – Intermittent Pneumatic CompressionIPC – Intermittent Pneumatic Compression
Prevention - MedicalPrevention - Medical
Should be commenced within 24 hours Should be commenced within 24 hours after surgeryafter surgery LMWH enoxaparin/Clexane 40mg SC DLMWH enoxaparin/Clexane 40mg SC D
Reduce to 20mg if Cr Cl < 30mL/minReduce to 20mg if Cr Cl < 30mL/min Heparin 5000u SC BDHeparin 5000u SC BD
Continue 5-10 days unless Hip Continue 5-10 days unless Hip Arthroplasty/Fracture 28 – 35 daysArthroplasty/Fracture 28 – 35 days
Aspirin Aspirin NOTNOT considered adequate alone considered adequate alone
What YOU can do…What YOU can do…
Daily check on your patients:Daily check on your patients: Stockings or compressorsStockings or compressors Heparin or Clexane or WarfarinHeparin or Clexane or Warfarin Remind medical staffRemind medical staff
What YOU can do…What YOU can do…
RespondRespond to patients who complain of to patients who complain of dyspnoeadyspnoea pleuritic chest painpleuritic chest pain calf paincalf pain unexplained unilateral leg swellingunexplained unilateral leg swelling
RespondRespond to changes in your patient’s obs to changes in your patient’s obs ↓↓SaO2SaO2 ↑ ↑ PRPR ↑ ↑ RRRR
Take responsibility Take responsibility and make the team and make the team awareaware
What YOU can do…What YOU can do…
Pre-discharge check – according to Pre-discharge check – according to protocolprotocol StockingsStockings ClexaneClexane Doppler UltrasoundDoppler Ultrasound
YOU can make a difference!YOU can make a difference!
Questions?Questions?
ReferencesReferences
1. Brandjes DP et al. Randomised trial of effect of compression stockings in patients with symptomatic proximal-vein thrombosis. Lancet 1997;349:759-62
2. Geerts WH et al. Prevention of Venous Thromboembolism Prevention of Venous Thromboembolism The The Seventh ACCP Conference on Antithrombotic and Thrombolytic TherapySeventh ACCP Conference on Antithrombotic and Thrombolytic Therapy
3. Ho et al. Venous thromboembolism: diagnosis and management of deep venous thrombosis MJA 2005; 182 (9): 476-481
4.4. Australian Bureau of Statistics 2006 Australian Bureau of Statistics 2006 5.5. Kraaijenhagen RA, Lensing AW, Wallis JW, van Beek EJ, ten Cate JW, Buller Kraaijenhagen RA, Lensing AW, Wallis JW, van Beek EJ, ten Cate JW, Buller
HR. Diagnostic management of venous thromboembolism. HR. Diagnostic management of venous thromboembolism. Baillières Clin Baillières Clin HaematolHaematol 1998;11: 541-86. 1998;11: 541-86.
6. Tovey C et al. Diagnosis, investigation, and management of deep vein thrombosis. BMJ 2003;326;1180-1184
7.7. Virchow RLK (1856). Virchow RLK (1856). Thrombosis und EmbolieThrombosis und Embolie. Gefässentzündung und . Gefässentzündung und septische Infektion". septische Infektion". Gesammelte Abhandlungen zur wissenschaftlichen Gesammelte Abhandlungen zur wissenschaftlichen MedicinMedicin. pp. 219–732.. pp. 219–732.
8. White et al: Risk factors for venous thromboembolism after total hip and knee replacement surgery. Current Opinion in Pulmonary Medicine 2002, 8:365–371
ReferencesReferences
1. Brandjes DP et al. Randomised trial of effect of compression stockings in patients with symptomatic proximal-vein thrombosis. Lancet 1997;349:759-62
2. Geerts WH et al. Prevention of Venous Thromboembolism Prevention of Venous Thromboembolism The The Seventh ACCP Conference on Antithrombotic and Thrombolytic TherapySeventh ACCP Conference on Antithrombotic and Thrombolytic Therapy
3. Ho et al. Venous thromboembolism: diagnosis and management of deep venous thrombosis MJA 2005; 182 (9): 476-481
4.4. Australian Bureau of Statistics 2006 Australian Bureau of Statistics 2006 5.5. Kraaijenhagen RA, Lensing AW, Wallis JW, van Beek EJ, ten Cate JW, Buller Kraaijenhagen RA, Lensing AW, Wallis JW, van Beek EJ, ten Cate JW, Buller
HR. Diagnostic management of venous thromboembolism. HR. Diagnostic management of venous thromboembolism. Baillières Clin Baillières Clin HaematolHaematol 1998;11: 541-86. 1998;11: 541-86.
6. Tovey C et al. Diagnosis, investigation, and management of deep vein thrombosis. BMJ 2003;326;1180-1184
7.7. Virchow RLK (1856). Virchow RLK (1856). Thrombosis und EmbolieThrombosis und Embolie. Gefässentzündung und . Gefässentzündung und septische Infektion". septische Infektion". Gesammelte Abhandlungen zur wissenschaftlichen Gesammelte Abhandlungen zur wissenschaftlichen MedicinMedicin. pp. 219–732.. pp. 219–732.
8. White et al: Risk factors for venous thromboembolism after total hip and knee replacement surgery. Current Opinion in Pulmonary Medicine 2002, 8:365–371
ReferencesReferences
1. Brandjes DP et al. Randomised trial of effect of compression stockings in patients with symptomatic proximal-vein thrombosis. Lancet 1997;349:759-62
2. Geerts WH et al. Prevention of Venous Thromboembolism Prevention of Venous Thromboembolism The The Seventh ACCP Conference on Antithrombotic and Thrombolytic TherapySeventh ACCP Conference on Antithrombotic and Thrombolytic Therapy
3. Ho et al. Venous thromboembolism: diagnosis and management of deep venous thrombosis MJA 2005; 182 (9): 476-481
4.4. Australian Bureau of Statistics 2006 Australian Bureau of Statistics 2006 5.5. Kraaijenhagen RA, Lensing AW, Wallis JW, van Beek EJ, ten Cate JW, Buller Kraaijenhagen RA, Lensing AW, Wallis JW, van Beek EJ, ten Cate JW, Buller
HR. Diagnostic management of venous thromboembolism. HR. Diagnostic management of venous thromboembolism. Baillières Clin Baillières Clin HaematolHaematol 1998;11: 541-86. 1998;11: 541-86.
6. Tovey C et al. Diagnosis, investigation, and management of deep vein thrombosis. BMJ 2003;326;1180-1184
7.7. Virchow RLK (1856). Virchow RLK (1856). Thrombosis und EmbolieThrombosis und Embolie. Gefässentzündung und . Gefässentzündung und septische Infektion". septische Infektion". Gesammelte Abhandlungen zur wissenschaftlichen Gesammelte Abhandlungen zur wissenschaftlichen MedicinMedicin. pp. 219–732.. pp. 219–732.
8. White et al: Risk factors for venous thromboembolism after total hip and knee replacement surgery. Current Opinion in Pulmonary Medicine 2002, 8:365–371