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VTE in Orthopaedics Australian Orthopaedic Nurses’ Association 15 May 2009 Dr Lachlan Milne.

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Presentation on theme: "VTE in Orthopaedics Australian Orthopaedic Nurses’ Association 15 May 2009 Dr Lachlan Milne."— Presentation transcript:

1 VTE in Orthopaedics Australian Orthopaedic Nurses’ Association 15 May 2009 Dr Lachlan Milne

2 What is VTE? Venous thromboembolism (VTE) Deep Vein Thrombosis (DVT) Pulmonary Embolism (PE)

3 What is VTE?

4 Why is VTE a problem? VTE annual risk 1-2 per 1000 people per year in Australia PE: 0.2% deaths per year in Australia 2 Morbidity higher than mortality Morbidity higher than mortality 1.Ho et al. Venous thromboembolism: diagnosis and management of deep venous thrombosis MJA 2005; 182 (9): Australian Bureau of Statistics 2006

5 Consequences of DVT Death Death Pulmonary Embolism Pulmonary Embolism Post-thrombotic Syndrome (chronic V HT) Post-thrombotic Syndrome (chronic V HT) Venous stasis Venous stasis Leg pain and swelling Leg pain and swelling Hyperpigmentation Hyperpigmentation Leg ulcers Leg ulcers Recurrent Venous Thromboembolism Recurrent Venous Thromboembolism 1.Tovey C et al. Diagnosis, investigation, and management of deep vein thrombosis. BMJ 2003;326;

6 DVT in orthopaedics? Orthopaedic patients are most at risk of all patients in hospital 1 Orthopaedic patients are most at risk of all patients in hospital 1 Total Joint Arthroplasties Total Joint Arthroplasties Major Trauma Major Trauma Hip Fractures Hip 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

7 DVT 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.Virchow RLK (1856). Thrombosis und Embolie. Gefässentzündung und septische Infektion". Gesammelte Abhandlungen zur wissenschaftlichen Medicin. pp. 219–732.

8 Risk factors Increased in orthopaedics: Increased in orthopaedics: Immobilisation Immobilisation Major surgery Major surgery Tourniquet Tourniquet Other non orthopaedic Other non orthopaedic Obesity BMI >30 (often in arthroplasties) Obesity BMI >30 (often in arthroplasties) History of prior DVT History of prior DVT Female Female Smoking Smoking OCP OCP 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

9 Course of DVT illness Determined by the site of thrombosis 1 Determined by the site of thrombosis 1 Calf Calf Where DVTs start Where DVTs start 50% resolve in 3/7 50% resolve in 3/7 Rarely causes PE in isolation Rarely causes PE in isolation 25% extend proximally within 1 week 25% extend proximally within 1 week Proximal Proximal Symptomatic Symptomatic 50% have PE at Dx 50% have PE at Dx only 1 in 5 of those is symptomatic of PE only 1 in 5 of those is symptomatic of PE 1.Ho W. et al Venous thromboembolism: diagnosis and management of deep venous thrombosis MJA 2005; 182 (9):

10 VTE – Signs and Symptoms DVT 1 DVT 1 Leg swelling/erythema Leg swelling/erythema Leg pain Leg pain Superficial venous congestion Superficial venous congestion PE PE Symptoms: Symptoms: Dyspnoea Dyspnoea Pleuritic chest pain Pleuritic chest pain Signs: Signs: ↑ PR ↑ PR ↓ SaO2 ↓ SaO2 ↑ RR ↑ RR 1.Tovey C et al. Diagnosis, investigation, and management of deep vein thrombosis. BMJ 2003;326;

11 Diagnosis of DVT 1 Unreliable Unreliable Clinical assessment algorithm Clinical assessment algorithm Screening investigations Screening investigations Definitive investigations Definitive investigations 1.Tovey C et al. Diagnosis, investigation, and management of deep vein thrombosis. BMJ 2003;326;

12 Clinical assessment algorithm 1 Low prob ≤0 Low prob ≤0 Mod prob 1-2 Mod prob 1-2 High prob ≥3 High prob ≥3 Clinical feature Score Active cancer <6/12 ago 1 Recent immobilisation of legs 1 Recently bedridden >3/7 AND/OR Major surgery <4/52 1 Tender over deep venous system 1 Entire leg swollen 1 Calf swelling >3cm 1 Collateral superficial non varicose veins 1 Pitting oedema > asymptomatic 1 Alternative diagnosis likely -2 1.Tovey C et al. Diagnosis, investigation, and management of deep vein thrombosis. BMJ 2003;326;

13 Screening Investigations D Dimer assay D Dimer assay Degradation product of fibrin Degradation product of fibrin Elevated in 80% of VTE Elevated in 80% of VTE Fast Fast Low specificity Low specificity Useless in context of surgery Useless in context of surgery

14 Definitive Ix – Venography 1 Gold standard Gold standard Invasive Invasive Painful Painful Risks: Risks: Thrombosis Thrombosis Contrast allergy Contrast allergy Venogram showing popliteal vein thrombosis Venogram showing popliteal vein thrombosis 1.Tovey C et al. Diagnosis, investigation, and management of deep vein thrombosis. BMJ 2003;326;

15 Definitive Ix - Ultrasound Non invasive Non invasive Safe Safe Good Sensitivity Good Sensitivity 97% proximal 97% proximal 75% calf 1 75% calf 1 Compression US Compression US Doppler Doppler 1.Kraaijenhagen RA et al. Diagnostic management of venous thromboembolism. Baillières Clin Haematol 1998;11:

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19 Definitive Investigations CT venography CT venography Highly sensitive and specific Highly sensitive and specific Huge amount of radiation Huge amount of radiation Not much improvement on US Not much improvement on US Rarely used Rarely used

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21 Definitive Investigations MRI MRI Best invasiveness to sensitivity ratio Best invasiveness to sensitivity ratio Expensive Expensive Unlikely to be used frequently until costs decrease Unlikely to be used frequently until costs decrease

22 Diagnosis of PE Clinical judgement Clinical judgement Arterial Blood Gas Arterial Blood Gas VQ scan VQ scan Probability Probability CTPA CTPA Diagnostic Diagnostic Contrast Contrast

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25 Treatment Anticoagulation Anticoagulation Heparin Heparin Unfractionated Unfractionated Low Molecular Weight Low Molecular Weight Warfarin Warfarin IVC filter IVC filter Compression stockings Compression stockings

26 Treatment - Heparin Minimum 5/7 until warfarin therapeutic Minimum 5/7 until warfarin therapeutic Unfractionated Unfractionated Infusion Infusion Q6h monitoring Q6h monitoring Renal impairment Renal impairment Low Molecular Weight Heparin Low Molecular Weight Heparin consistent response consistent response Longer t ½ – Daily dosing Longer t ½ – Daily dosing Effective Effective ↓ haemorrhage ↓ haemorrhage Nephrotoxic Nephrotoxic

27 Treatment - Warfarin Oral dosing Oral dosing Prothrombotic initially Prothrombotic initially Heparin/Clexane Heparin/Clexane Monitoring with INR target 2.0 – 3.0 Monitoring with INR target 2.0 – 3.0 Not used in pregnancy – crosses placenta Not used in pregnancy – crosses placenta 6/12 treatment 6/12 treatment

28 Treatment – IVC filter When anticoagulation contraindicated When anticoagulation contraindicated eg orthopaedic patients undergoing surgery eg orthopaedic patients undergoing surgery Recurrent DVT despite adequate anticoagulation Recurrent DVT despite adequate anticoagulation

29 Treatment – Stockings Simple and cost effective Simple and cost effective Reduce likelihood of post-thrombotic syndrome Reduce likelihood of post-thrombotic syndrome Wear for 18 months post DVT 1 Wear for 18 months post DVT 1 1.Brandjes DP et al. Randomised trial of effect of compression stockings in patients with symptomatic proximal-vein thrombosis. Lancet 1997;349:759-62

30 Prevention Orthopaedic patients most at risk Orthopaedic patients most at risk Australian Therapeutic Guidelines Australian Therapeutic Guidelines Medical Medical Mechanical Mechanical Prevention of Venous Thromboembolism The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy 1.Geerts WH et al. Prevention of Venous Thromboembolism The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy

31 Prevention – Mechanical Should be commenced evening prior to surgery Should be commenced evening prior to surgery Stockings: Stockings: GCS – Graduated Compression Stockings GCS – Graduated Compression Stockings TEDs – ThromboEmbolic Deterrents TEDs – ThromboEmbolic Deterrents Compressors: Compressors: SCDs – Sequential Compression Devices SCDs – Sequential Compression Devices IPC – Intermittent Pneumatic Compression IPC – Intermittent Pneumatic Compression

32 Prevention - Medical Should be commenced within 24 hours after surgery Should be commenced within 24 hours after surgery LMWH enoxaparin/Clexane 40mg SC D LMWH enoxaparin/Clexane 40mg SC D Reduce to 20mg if Cr Cl < 30mL/min Reduce to 20mg if Cr Cl < 30mL/min Heparin 5000u SC BD Heparin 5000u SC BD Continue 5-10 days unless Hip Arthroplasty/Fracture 28 – 35 days Continue 5-10 days unless Hip Arthroplasty/Fracture 28 – 35 days Aspirin NOT considered adequate alone Aspirin NOT considered adequate alone

33 What YOU can do… Daily check on your patients: Daily check on your patients: Stockings or compressors Stockings or compressors Heparin or Clexane or Warfarin Heparin or Clexane or Warfarin Remind medical staff Remind medical staff

34 What YOU can do… Respond to patients who complain of Respond to patients who complain of dyspnoea dyspnoea pleuritic chest pain pleuritic chest pain calf pain calf pain unexplained unilateral leg swelling unexplained unilateral leg swelling Respond to changes in your patient’s obs Respond to changes in your patient’s obs ↓ SaO2 ↓ SaO2 ↑ PR ↑ PR ↑ RR ↑ RR Take responsibility and make the team aware Take responsibility and make the team aware

35 What YOU can do… Pre-discharge check – according to protocol Pre-discharge check – according to protocol Stockings Stockings Clexane Clexane Doppler Ultrasound Doppler Ultrasound YOU can make a difference! YOU can make a difference!

36 Questions?

37 References Brandjes DP et al. Randomised trial of effect of compression stockings in patients with symptomatic proximal-vein thrombosis. Lancet 1997;349: Prevention of Venous Thromboembolism The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy 2.Geerts WH et al. Prevention of Venous Thromboembolism The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy Ho et al. Venous thromboembolism: diagnosis and management of deep venous thrombosis MJA 2005; 182 (9): Australian Bureau of Statistics Kraaijenhagen RA, Lensing AW, Wallis JW, van Beek EJ, ten Cate JW, Buller HR. Diagnostic management of venous thromboembolism. Baillières Clin Haematol 1998;11: Tovey C et al. Diagnosis, investigation, and management of deep vein thrombosis. BMJ 2003;326; Virchow RLK (1856). Thrombosis und Embolie. Gefässentzündung und septische Infektion". Gesammelte Abhandlungen zur wissenschaftlichen Medicin. pp. 219– White et al: Risk factors for venous thromboembolism after total hip and knee replacement surgery. Current Opinion in Pulmonary Medicine 2002, 8:365–371

38 References Brandjes DP et al. Randomised trial of effect of compression stockings in patients with symptomatic proximal-vein thrombosis. Lancet 1997;349: Prevention of Venous Thromboembolism The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy 2.Geerts WH et al. Prevention of Venous Thromboembolism The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy Ho et al. Venous thromboembolism: diagnosis and management of deep venous thrombosis MJA 2005; 182 (9): Australian Bureau of Statistics Kraaijenhagen RA, Lensing AW, Wallis JW, van Beek EJ, ten Cate JW, Buller HR. Diagnostic management of venous thromboembolism. Baillières Clin Haematol 1998;11: Tovey C et al. Diagnosis, investigation, and management of deep vein thrombosis. BMJ 2003;326; Virchow RLK (1856). Thrombosis und Embolie. Gefässentzündung und septische Infektion". Gesammelte Abhandlungen zur wissenschaftlichen Medicin. pp. 219– White et al: Risk factors for venous thromboembolism after total hip and knee replacement surgery. Current Opinion in Pulmonary Medicine 2002, 8:365–371

39 References Brandjes DP et al. Randomised trial of effect of compression stockings in patients with symptomatic proximal-vein thrombosis. Lancet 1997;349: Prevention of Venous Thromboembolism The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy 2.Geerts WH et al. Prevention of Venous Thromboembolism The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy Ho et al. Venous thromboembolism: diagnosis and management of deep venous thrombosis MJA 2005; 182 (9): Australian Bureau of Statistics Kraaijenhagen RA, Lensing AW, Wallis JW, van Beek EJ, ten Cate JW, Buller HR. Diagnostic management of venous thromboembolism. Baillières Clin Haematol 1998;11: Tovey C et al. Diagnosis, investigation, and management of deep vein thrombosis. BMJ 2003;326; Virchow RLK (1856). Thrombosis und Embolie. Gefässentzündung und septische Infektion". Gesammelte Abhandlungen zur wissenschaftlichen Medicin. pp. 219– White et al: Risk factors for venous thromboembolism after total hip and knee replacement surgery. Current Opinion in Pulmonary Medicine 2002, 8:365–371


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