Total Joint Replacement While many surgeons and bioengineers contributed to the concepts, techniques and designs of implants for total hip replacement, one pioneer stands out, Sir John Charnley. He reported his experience with a steel femoral component and a plastic socket cup in 1961. He also revolutionized the field with the use of the self-curing acrylic cement used to fix the implants into the bone. These advances greatly improved the success rate of total hip replacement. The Charnley concepts of the hip implants are still in use today in large measure. First, it is important to bear in mind that an artificial hip joint is not a normal hip. This is because a total hip replacement (you will see it referred to as THR) is not able to withstand repeated heavy impact, such as jumping and long-distance running. Tennis--singles, at least--jogging, and volleyball are not recommended. Swimming, golf and bike riding are safe.

Agenda Time Topic Speaker 0700-0730 Introduction Total Joint Replacement in Chinook Health TJR: What is it? TJR: Indications Kathy Sassa, Educator- Surgery 0730-0800 Preop Assessment Total Joint Clinic Susan Folkerson, UM Unit 3B 0800-0900 The Surgical Process Gail Kiefuik, OR RN 0900-0915 Break 0915-1000 Post-Op Care Post-Op Orders Tracey Kusk 1000-1115 Role of Physiotherapy & Occupational Therapy OT/PT 1115-1130 Complications Kathy Sassa 1130-1200 Lunch 1200-1300 Role of Pharmacy Anticoagulation Sheila Seely, Pharmacist 1300-1400 Discharge Planning Kevin Elder, Charge RN Unit 4A 1400-1415 1415-1500 4A Mass Casualty Response Plan: Burns

INCIDENCE OF POST-OP COAGULATION COMPLICATIONS WITHOUT PROPHYLAXIS THR DVT becomes symptomatic av. 17 days post-op TKR DVT becomes symptomatic av. 6.7 days post-op Incidence of DVT Incidence of Fatal PE Elective Knee Surgery 61% 5-12% Elective Hip Surgery 51% 2.4% Hip Fracture 44% 5.9% General Surgery 25% 0.9%

Post-Operative Anticoagulation Therapy

Anticoagulation Therapy The purpose of anticoagulant therapy is prevention & treatment of thromboembolic disorders Anticoagulants DO NOT dissolve clots Anticoagulants affect the balance between coagulation and fibrinolysis

Virchow’s Triad Identifies the three primary components that contribute to pathological clot formation (i.e. DVT and PE) TKR and THR pts automatically have 2 of the 3 risks

CH Anticoagulation Guidelines Based on CHEST Evidence-based guidelines Reviewed periodically & approved by P&T (last revision 2001, currently under review) Risk Assessment Tool Prophylaxis Guidelines Treatment Guidelines

CH Anti-coagulation Guidelines Risk Assessment (Value Noted in Brackets): Major orthopedic surgery of lower limbs: total knee arthroplasty [ 5 ] hip fracture [ 5 ] total hip arthroplasty [ 4 ] Extensive abdominal or pelvic surgery for malignancy [ 4 ] Multiple trauma [ 4 ]. Acute spinal cord injury with paralysis [ 4 ] History of DVT/PE [ 3 ] Advanced age: age over 70 years [ 3 ] age 61 to 70 years [ 2 ] age 41 to 60 years [ 1 ] Stroke [ 1 ] CHF [ 1 ] MI [ 1 ] Varicose Veins [ 1 ] Obesity (greater than 20% of IBW) [ 1 ] Congenital and acquired aberrations in hemostatic mechanisms [ 1 ] General surgery lasting more than 30 minutes [ 1 ] History of pelvic or long bone fracture [ 1 ] Leg edema, ulcers, stasis [ 1 ] Pregnancy or postpartum <1 month [ 1 ] Inflammatory bowel disease [ 1 ] Severe infection [ 1 ] High dose estrogen use [ 1 ] Other

Recommendations: Low Risk [ 1 ]: Early ambulation Moderate Risk [ 2 to 3 ]: Low Dose Unfractionated Heparin at 5000 IU sc bid OR Intermittent pneumatic compression Low Molecular Weight Heparin – Tinzaparin (Innohep) 3500 IU sc qd until patient is mobilized. Start 6 hours post-op. High Risk [ 4 or more ]: Low Molecular Weight Heparin -- Tinzaparin (Innohep) 4500 IU sc qd until patient is mobilized. Start 12 hours post-op. If patient is less than 55kg use 3500 iu. If patient is greater than 70kg consider dosing at 75iu/kg Low intensity oral anticoagulation -- INR 2 - 3. Intermittent pneumatic compression plus Low Molecular Weight Heparin or Low Dose Unfractionated Heparin.

Guidelines for Treatment of Venous Thrombosis/Pulmonary Embolism: Intravenous Unfractionated Heparin as per Weight Adjusted PE/DVT Heparin Protocol. OR LMWH: Tinzaparin (Innohep) 175 iu/kg body weight sc q24h.or Enoxaparin (Lovenox) 1mg/kg (max.100mg) sc q12h or 1.5mg/kg sc qd (max.180mg) Pulmonary Embolism: Intravenous unfractionated Heparin as per PE/DVT Heparin Protocol LMWH: Tinzaparin 175iu/kg body weight sc q24H Warfarin (Coumadin): Should be started within 24 hours after initiation of Heparin or Low Molecular Weight Heparin and the dose adjusted in the usual manner. Heparin or Low Molecular Weight Heparin should be continued for a minimum of five days. INR should be in the therapeutic range (2 to 3) for two consecutive days prior to discontinuing heparin or Low Molecular Weight Heparin

High Risk (4 or more): Low Molecular Weight Heparin -- Tinzaparin (Innohep) 4500 IU sc qd until patient is mobilized. Start 12 hours post-op. If patient is less than 55kg use 3500 iu. If patient is greater than 70kg consider dosing at 75iu/kg Low intensity oral anticoagulation -- INR 2 - 3. OR Intermittent pneumatic compression plus Low Molecular Weight Heparin or Low Dose Unfractionated Heparin.

Clotting Cascade Warfarin affects Factors II, VII, IX, X, the factors involved in Vitamin K metabolism Low Molecular Weight Heparins (eg Tinzaparin) inhibit Factor Xa and inactivate thrombin

Anticoagulant Example: Warfarin Classification: Vitamin K Antagonist Monitoring: INR, goal range 2.0-3.0 Indications: Prophylaxis & treatment of: Venous thrombosis Pulmonary embolism Atrial fibrillation with embolization Embolization after MI, including stroke Adverse Reactions: Bleeding Cramps & nausea Dermal necrosis Fever

Anticoagulant Example: Tinzaparin Adverse Reactions: Bleeding, anemia, rash, thrombocytopenia, ecchymosis Dizziness, headache, insomnia Edema Constipation, vomiting, nausea, reversible increase in liver enzymes Urinary retention Heparin-Induced Thrombocytopenia (HIT) Erythema at injection site, hematoma, pain, irritation Fever Classification: Low Molecular weight Heparin Monitoring: CBC and Creatinine baseline and twice weekly Indications: Prevention of DVT & PE after: Abdominal surgery Hip/knee surgery or replacement