2DefinitionsDeep-vein thrombosis (also known as deep-venous thrombosis or DVT) is the formation of a blood clot ("thrombus") in a deep vein.Pulmonary embolism (PE) is a condition that occurs when an artery in your lung becomes blocked.
8Diagnosis of DVTDuplex Ultra sonography - Projected sound waves bounce off structures in the leg and create images that reveal abnormalities. The addition of color Doppler imaging improves accuracy.Venography – An x-ray of leg and pelvis will show the calf and thigh veins and reveal any blockages.
9places in the leg to identify possible blockages. Diagnosis of DVTMRI - particularly effective in diagnosing DVT in the pelvis, and as effective as venography in diagnosing DVT in the thigh.Cuff-impedance plethysmography - uses blood pressure checks at differentplaces in the leg to identify possible blockages.
10Potential Complications Pulmonary emboli- most serious complication of DVTChronic venous insufficiency - Long-term DVT can degenerate the venous valves.Post- phlebotic syndrome - long-term complication of DVT which occurs due to damage and scarring to the veins and is characterized by swelling, discomfort and skin pigmentation in the affected area.Of a dvt
11DVT Risk Factors Risk Factor= 1 Point Risk Factor= 2 Points Age yearsBedrestCOPDCHF (<1 month)Acute MIPneumonia (< I month)Sepsis (<month)Inflammatory Bowel DiseaseMinor surgery plannedHx of prior major surgeryObesity (BMI>25)Swollen legsPregnancyOral ContraceptivesAge yearsAthroscopic surgeryLaparoscopic surgeyMalignancy (present or history)Major surgery (>45 Minutes)Patient confined to bed (>72 hours)Immobilizing plaster cast(<1month)Central Venous AccessInfectionNephrotic Syndrome
12DVT Risk Factors Risk Factor= 3 Point Risk Factor =5 Points Age >75 yearsMajor surgery(>3 hours)Hx of DVT/PEFamily hx of ThrombosisHeparin-induced thrombocytopeniaThrombophiliaHx of clotting disorderElective major lower extremity arthroplastyHip, pelvis, or leg fracture(<1 month)Stroke(< 1 month)Acute spinal cord injury (paralysis<1 month)
13RISK LEVEL FOR DVT….. Low Risk- DVT score 1 Moderate Risk- DVT score 2 High Risk- DVT score 3-4Highest Risk- DVT score 5 or more
15Prevention: Non-pharmacologic Mechanical methods:Used in combination with drug therapy or as monotherapy in those with lower risk or contraindications to anticoagulation prophylaxisIncludes aggressive mobilization, foot pumps, intermittent pneumatic leg pumps, graduated compression stockingsThese methods MUST be used for most of the day (>21 hours) to be effective
17Contraindications to Pharmacological Prophylaxis Active GI bleedRecent hemorrhagic stroke or hemorrhagePrevious hypersensitivity or significant drug-specific ADRPlatelet count <100 X 109/L (varies)Neurosurgical Procedure within last 30 daysVaries between institutions, physicians, and particular patient risk/benefit considerations
18Unfractionated Heparin Indications: Prophylaxis and treatment of thromboembolic disordersProphylactic Dose:5,000 Units SQ q8hrsMonitoring: PTT, Plt, Hgb, Hct, bleeding
19Unfractionated Heparin Complications: hemorrhage (most common), thrombocytopenia, hyper-sensitivityAdvantages: Cost, DVT prophylaxis of choice in pregnancy
20Warfarin (Coumadin)Indication: Treatment of venous thrombosis, pulmonary embolis, and thromboembolic disorderNot generally used for DVT/PE prophylaxis (except long term prevention, such as patients with valve replacements) due to delayed onset of action and higher risk of bleeding complicationsDose:Typical starting dose is 2.5 to 5 mgUse “bridge therapy” (LMWH or heparin + warfarin) when immediate anticoagulation is warranted
21Bridge TherapyThe anticoagulant effects of warfarin (Coumadin) are not immediateIt takes several days (~ 5 days) to a week to deplete existing Vitamin K dependent clotting factors in the bodyDuring this lag time, the patient must be protected against DVT/PE with Heparin, enoxaparin (Lovenox), daltaparin (Fragmin) or fondaparinux (Arixtra) until the therapeutic INR is achieved
22Bridge TherapyConcurrent therapy with warfarin (Coumadin) MUST be continued for a minimum of 5 days, AND 2 consecutive INR values must be seen before the discontinuation of LMWH or heparin may occur