1. DEEP VEIN THROMBOSIS

2. Definitions
Deep-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.

3. Thrombosis

4. Virchow’s Triad
It is the result of 1 of 3 factors known as Virchow’s Triad.
Endothelial damage
Venous blood stasis
Hypercoagulability

5. Signs & Symptoms Pain in the leg
Tenderness in the calf (one of the most important signs)
Leg tenderness
Swelling of the leg
Increased warmth of the leg
Redness in the leg
Bluish skin discoloration

6. DIAGNOSIS OF DVT
Clinical examination
Investigations

7. CLINICAL EXAMINATION Homan’s sign Moses’ sign
Phlegmasia alba dolens (white leg)
Phlegmasia cerulea dolens (blue leg)

8. Diagnosis of DVT
Duplex 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.

9. places in the leg to identify possible blockages.
Diagnosis of DVT
MRI - 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 different
places in the leg to identify possible blockages.

10. Potential Complications
Pulmonary emboli- most serious complication of DVT
Chronic 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

11. DVT Risk Factors Risk Factor= 1 Point Risk Factor= 2 Points
Age years
Bedrest
COPD
CHF (<1 month)
Acute MI
Pneumonia (< I month)
Sepsis (<month)
Inflammatory Bowel Disease
Minor surgery planned
Hx of prior major surgery
Obesity (BMI>25)
Swollen legs
Pregnancy
Oral Contraceptives
Age years
Athroscopic surgery
Laparoscopic surgey
Malignancy (present or history)
Major surgery (>45 Minutes)
Patient confined to bed (>72 hours)
Immobilizing plaster cast(<1month)
Central Venous Access
Infection
Nephrotic Syndrome

12. DVT Risk Factors Risk Factor= 3 Point Risk Factor =5 Points
Age >75 years
Major surgery(>3 hours)
Hx of DVT/PE
Family hx of Thrombosis
Heparin-induced thrombocytopenia
Thrombophilia
Hx of clotting disorder
Elective major lower extremity arthroplasty
Hip, pelvis, or leg fracture(<1 month)
Stroke(< 1 month)
Acute spinal cord injury (paralysis<1 month)

13. RISK LEVEL FOR DVT….. Low Risk- DVT score 1 Moderate Risk- DVT score 2
High Risk- DVT score 3-4
Highest Risk- DVT score 5 or more

14. Prevention DVT/PE
Pharmacologic
Non-pharmacologic

15. Prevention: Non-pharmacologic
Mechanical methods:
Used in combination with drug therapy or as monotherapy in those with lower risk or contraindications to anticoagulation prophylaxis
Includes aggressive mobilization, foot pumps, intermittent pneumatic leg pumps, graduated compression stockings
These methods MUST be used for most of the day (>21 hours) to be effective

16. Prevention: Pharmacologic
Unfractionated Heparin
Low Molecular Weight Heparin (LMWH)
daltaparin (Fragmin), enoxaparin (Lovenox)
Factor Xa Inhibitor
fondaparinux (Arixtra)
Warfarin (Coumadin)

17. Contraindications to Pharmacological Prophylaxis
Active GI bleed
Recent hemorrhagic stroke or hemorrhage
Previous hypersensitivity or significant drug-specific ADR
Platelet count <100 X 109/L (varies)
Neurosurgical Procedure within last 30 days
Varies between institutions, physicians, and particular patient risk/benefit considerations

18. Unfractionated Heparin
Indications: Prophylaxis and treatment of thromboembolic disorders
Prophylactic Dose:
5,000 Units SQ q8hrs
Monitoring: PTT, Plt, Hgb, Hct, bleeding

19. Unfractionated Heparin
Complications: hemorrhage (most common), thrombocytopenia, hyper-sensitivity
Advantages: Cost, DVT prophylaxis of choice in pregnancy

20. Warfarin (Coumadin)
Indication: Treatment of venous thrombosis, pulmonary embolis, and thromboembolic disorder
Not 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 complications
Dose:
Typical starting dose is 2.5 to 5 mg
Use “bridge therapy” (LMWH or heparin + warfarin) when immediate anticoagulation is warranted

21. Bridge Therapy
The anticoagulant effects of warfarin (Coumadin) are not immediate
It takes several days (~ 5 days) to a week to deplete existing Vitamin K dependent clotting factors in the body
During 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

22. Bridge Therapy
Concurrent 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