dvt prophylaxis

1. DVT PROPHYLAXIS Dr. E M. Regis Jr. Dept. Of Orthopaedics 10/08/15

2. Overview Definition Incidence Aeitology/ Risk Factors Pathophysiology Signs/ Symptoms Diagnosis Complications Prophylaxis Conclusion

3. Definition thrombus (clot) formation predominately in the deep veins of the legs. eg. femoral vein, popliteal vein

4. Incidence 1-2 per 1000 annually in the United States 60,000-100,000 die of DVT {10-30% within 1st month of diagnosis}

5. Aeitology/ Risk Factors Virchow’s Triad a) stasis b) hypercoagulability c) vessel wall damage (intima)

6. INJURY TO VEIN; fractures severe muscle injury major surgery (abdominal, pelvis, hip or legs) SLOW BLOOD FLOW; confinement to bed limited movement sitting for prolong periods with crossed legs paralysis

7. INCREASED ESTROGEN; birth control pills HRT sometimes used after menopause Pregnancy, up to 6 weeks postpartum OTHER FACTORS; previous DVT or PE family history of DVT or PE age (risk increase as age increases) obesity catheter located in a central vein inherited clotting disorders (protein c deficiency, antithrombin deficiency)

8. Signs & Symptoms pain or tenderness warmth swelling redness or discoloration distention of surface veins difficulty breathing (S.O.B) tachycardia or irregular heart beat chest pain or discomfort anxiety haemoptysis hypotension/ lightheadedness

9. Diagnosis HISTORY & PHYSICAL EXAMINATION CHEST X-RAY ECG Labs including D-dimers DUPLEX ULTRASOUND VENOGRAPHY spiral CT chest V:Q scan (ventilation/perfusion) pulmonary angiogram

10. Complications Pulmonary Embolism Death Post-thrombotic Syndrome

11. Prophylaxis Mechanical compression stockings intermittent pneumatic compression devices ivc filters

12. Pharmacological Platelet Active Drugs {aspirin 50-100mg/d} Courmarins {Warfarin} Heparins (UFH) Low Molecular Weight Heparins (LMWH) {Enoxaparin} Factor Xa Inhibitors {Rivaroxaban}

13. DVT Prophylaxis Based on Risk Stratification Levels 1 point assigned to following: age 41-60yrs minor surgery history of major surgery within 1 month pregnancy or postpartum within 1 month varicose veins inflammatory bowel disease swelling of legs obesity oral contraceptives, patch or HRT

14. 2 points assigned to the following: age >60yrs malignancy or current chemo or radiation therapy major surgery (>45min) laparoscopic surgery (>45min) confined to bed > 72hrs immobilizing cast shorter than 1 month central venous access <1month tourniquet time >45mins

15. 3 points assigned to the following: age >75yrs history of DVT or PE family history of thrombosis Factor V Leiden/activated protein C resistance medical patient with risk factors of MI, CHF or COPD congenital or acquired thrombophillia

16. 5 points assigned to the following: major, elective lower extremity arthoplasty, total knee replacement, total hip replacement hip, pelvis or leg fracture within 1 month stroke within 1 month multiple trauma within 1 month acute spinal cord injury with paralysis within 1 month

17. Risk Group Classification for Orthopaedic Patients

18. Low Risk Patients; no specific prophylaxis is required other than early and aggressive mobilisation Moderate Risk Patients; low dose UFH {LDUF q12hrs}, LMWH {<3,400 U qd}, and IPC High Risk Patients; low dose UFH q8h, LMWH {>3400 U qd}, with or without IPC Very High Risk Patients; LMWH {>3400 U qd}, fondaparinux, and coumarins (INR 2-3). Dose-adjusted low-dose UFH or LMWH may be used with or without IPC.

19. Conclusion Based on history and physical examination findings, there should be a high index of suspicion in diagnosing DVT confirmed with labs and necessary investigations. Aim should be geared towards prevention than treatment. Prophylaxis is tailored independently based on numerous of patient factors. Treatment is a multidisciplinary approach involving chest physicians and primary surgical team.

20. References www.google.com/images Deep Venous Thrombosis Prophylaxis In Orthopedic Surgery, DAVID A FORSH MD. August 15, 2014 www.sages.org/publications/guidelines Venous thromboembolism prophylaxis.- National Guideline Antithrombotic Guidelines, 9th ED| Guidelines & Consensus. American College of Chest Physicians