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

VTE in VTE in OrthopaedicsOrthopaedics

Australian Orthopaedic Nurses’ Australian Orthopaedic Nurses’ AssociationAssociation

15 May 200915 May 2009

Dr Lachlan MilneDr Lachlan Milne

What is VTE?What is VTE?

Venous thromboembolism (VTE) Deep Vein Thrombosis (DVT) Pulmonary Embolism (PE)

What is VTE?What is VTE?

Why is VTE a problem?Why is VTE a problem?

VTE annual risk 1-2 per 1000 people1

40 000 per year in Australia PE: 0.2% deaths per year in

Australia2

Morbidity higher than mortalityMorbidity higher than mortality1. Ho et al. Venous thromboembolism: diagnosis and management of deep

venous thrombosis MJA 2005; 182 (9): 476-481

2.2. Australian Bureau of Statistics 2006Australian Bureau of Statistics 2006

Consequences of DVTConsequences of DVT

DeathDeath Pulmonary EmbolismPulmonary Embolism Post-thrombotic Syndrome (chronic V HT)Post-thrombotic Syndrome (chronic V HT)

Venous stasis Venous stasis Leg pain and swellingLeg pain and swelling HyperpigmentationHyperpigmentation Leg ulcersLeg ulcers

Recurrent Venous ThromboembolismRecurrent Venous Thromboembolism

1. Tovey C et al. Diagnosis, investigation, and management of deep vein thrombosis. BMJ 2003;326;1180-1184

DVT in orthopaedics?DVT in orthopaedics?

Orthopaedic patients are most at risk Orthopaedic patients are most at risk of all patients in hospitalof all patients in hospital11

Total Joint ArthroplastiesTotal Joint Arthroplasties Major TraumaMajor Trauma Hip FracturesHip 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

DVT PathophysiologyDVT Pathophysiology Virchow’s Triad

Endothelial injury Surgery

Venous stasis Tourniquet Immobilisation

Delayed ambulation Casting

Change in blood constituents ↑ ↑ platelets platelets ↑ ↑ clotting clotting ↑ ↑ viscosity viscosity

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

Risk factorsRisk factors Increased in orthopaedics:Increased in orthopaedics:

ImmobilisationImmobilisation Major surgeryMajor surgery TourniquetTourniquet

Other non orthopaedicOther non orthopaedic Obesity BMI >30 (often in arthroplasties)Obesity BMI >30 (often in arthroplasties) History of prior DVTHistory of prior DVT FemaleFemale SmokingSmoking OCPOCP Genetic (many)Genetic (many)


Course of DVT illnessCourse of DVT illness Determined by the site of thrombosisDetermined by the site of thrombosis11

CalfCalf Where DVTs startWhere DVTs start 50% resolve in 3/750% resolve in 3/7 Rarely causes PE in isolationRarely causes PE in isolation 25% extend proximally within 1 week25% extend proximally within 1 week

ProximalProximal SymptomaticSymptomatic 50% have PE at Dx 50% have PE at Dx only 1 in 5 of those is symptomatic of PEonly 1 in 5 of those is symptomatic of PE

1.1. Ho W. et al Ho W. et al Venous thromboembolism: diagnosis and management of deep Venous thromboembolism: diagnosis and management of deep venous thrombosis venous thrombosis MJA MJA 2005; 182 (9): 476-4812005; 182 (9): 476-481

VTE – Signs and VTE – Signs and SymptomsSymptoms

DVTDVT11

Leg swelling/erythemaLeg swelling/erythema Leg painLeg pain Superficial venous congestionSuperficial venous congestion

PEPE Symptoms:Symptoms:

DyspnoeaDyspnoea Pleuritic chest painPleuritic chest pain

Signs:Signs: ↑ ↑ PRPR ↓ ↓ SaO2 SaO2 ↑ ↑ RRRR


Diagnosis of DVTDiagnosis of DVT11

UnreliableUnreliable Clinical assessment algorithmClinical assessment algorithm Screening investigationsScreening investigations Definitive investigationsDefinitive investigations


Clinical assessment Clinical assessment algorithmalgorithm11

Low prob ≤0Low prob ≤0

Mod prob 1-2Mod prob 1-2

High prob High prob ≥3 ≥3

Clinical featureClinical feature ScorScoree

Active cancer <6/12 agoActive cancer <6/12 ago 11

Recent immobilisation of legsRecent immobilisation of legs 11

Recently bedridden >3/7 Recently bedridden >3/7 AND/ORAND/OR

Major surgery <4/52Major surgery <4/52

11

Tender over deep venous systemTender over deep venous system 11

Entire leg swollenEntire leg swollen 11

Calf swelling >3cmCalf swelling >3cm 11

Collateral superficial non varicose Collateral superficial non varicose veinsveins

11

Pitting oedema > asymptomaticPitting oedema > asymptomatic 11

Alternative diagnosis likelyAlternative diagnosis likely -2-21. Tovey C et al. Diagnosis, investigation, and management of deep vein

thrombosis. BMJ 2003;326;1180-1184

Screening InvestigationsScreening Investigations

D Dimer assay D Dimer assay Degradation product of fibrinDegradation product of fibrin Elevated in 80% of VTEElevated in 80% of VTE FastFast Low specificityLow specificity Useless in context of surgeryUseless in context of surgery

Definitive Ix – Definitive Ix – VenographyVenography11

Gold standardGold standard InvasiveInvasive PainfulPainful Risks:Risks:

ThrombosisThrombosis Contrast allergy Contrast allergy

Venogram showing Venogram showing popliteal vein popliteal vein thrombosisthrombosis


Definitive Ix - UltrasoundDefinitive Ix - Ultrasound

Non invasiveNon invasive SafeSafe Good SensitivityGood Sensitivity

97% proximal 97% proximal 75% calf75% calf11

Compression USCompression US Doppler Doppler

1.1. Kraaijenhagen RA et al. Kraaijenhagen RA et al. Diagnostic management of venous thromboembolism. Diagnostic management of venous thromboembolism.

Baillières Clin HaematolBaillières Clin Haematol 1998;11: 541-86. 1998;11: 541-86.

Definitive InvestigationsDefinitive Investigations

CT venographyCT venography Highly sensitive and specificHighly sensitive and specific Huge amount of radiation Huge amount of radiation Not much improvement on USNot much improvement on US Rarely usedRarely used

Definitive InvestigationsDefinitive Investigations

MRIMRI Best invasiveness to sensitivity ratioBest invasiveness to sensitivity ratio ExpensiveExpensive Unlikely to be used frequently until costs Unlikely to be used frequently until costs

decreasedecrease

Diagnosis of PEDiagnosis of PE

Clinical judgementClinical judgement Arterial Blood GasArterial Blood Gas VQ scanVQ scan

ProbabilityProbability CTPACTPA

DiagnosticDiagnostic ContrastContrast

TreatmentTreatment

Anticoagulation Anticoagulation HeparinHeparin

UnfractionatedUnfractionated Low Molecular WeightLow Molecular Weight

WarfarinWarfarin IVC filterIVC filter Compression stockingsCompression stockings

Treatment - HeparinTreatment - Heparin

Minimum 5/7 until warfarin therapeuticMinimum 5/7 until warfarin therapeutic UnfractionatedUnfractionated

InfusionInfusion Q6h monitoring Q6h monitoring Renal impairmentRenal impairment

Low Molecular Weight Heparin Low Molecular Weight Heparin consistent responseconsistent response Longer t ½ – Daily dosingLonger t ½ – Daily dosing Effective Effective ↓ ↓ haemorrhagehaemorrhage NephrotoxicNephrotoxic

Treatment - WarfarinTreatment - Warfarin

Oral dosingOral dosing Prothrombotic initiallyProthrombotic initially

Heparin/ClexaneHeparin/Clexane Monitoring with INR target 2.0 – 3.0Monitoring with INR target 2.0 – 3.0 Not used in pregnancy – crosses Not used in pregnancy – crosses

placentaplacenta 6/12 treatment6/12 treatment

Treatment – IVC filterTreatment – IVC filter

When anticoagulation When anticoagulation contraindicatedcontraindicated eg orthopaedic patients undergoing eg orthopaedic patients undergoing

surgerysurgery Recurrent DVT despite adequate Recurrent DVT despite adequate

anticoagulationanticoagulation

Treatment – StockingsTreatment – Stockings

Simple and cost effectiveSimple and cost effective Reduce likelihood of post-thrombotic Reduce likelihood of post-thrombotic

syndromesyndrome Wear for 18 months post DVT Wear for 18 months post DVT 11

1. Brandjes DP et al. Randomised trial of effect of compression stockings in patients with symptomatic proximal-vein thrombosis. Lancet 1997;349:759-62

PreventionPrevention

Orthopaedic patients most at riskOrthopaedic patients most at risk Australian Therapeutic Guidelines Australian Therapeutic Guidelines Medical Medical MechanicalMechanical

1. Geerts WH et al. Prevention of Venous Thromboembolism Prevention of Venous Thromboembolism The Seventh ACCP The Seventh ACCP Conference on Antithrombotic and Thrombolytic TherapyConference on Antithrombotic and Thrombolytic Therapy

Prevention – MechanicalPrevention – Mechanical

Should be commenced evening Should be commenced evening priorprior to to surgerysurgery

Stockings:Stockings: GCS – Graduated Compression StockingsGCS – Graduated Compression Stockings TEDs – ThromboEmbolic DeterrentsTEDs – ThromboEmbolic Deterrents

Compressors:Compressors: SCDs – Sequential Compression DevicesSCDs – Sequential Compression Devices IPC – Intermittent Pneumatic CompressionIPC – Intermittent Pneumatic Compression

Prevention - MedicalPrevention - Medical

Should be commenced within 24 hours Should be commenced within 24 hours after surgeryafter surgery LMWH enoxaparin/Clexane 40mg SC DLMWH enoxaparin/Clexane 40mg SC D

Reduce to 20mg if Cr Cl < 30mL/minReduce to 20mg if Cr Cl < 30mL/min Heparin 5000u SC BDHeparin 5000u SC BD

Continue 5-10 days unless Hip Continue 5-10 days unless Hip Arthroplasty/Fracture 28 – 35 daysArthroplasty/Fracture 28 – 35 days

Aspirin Aspirin NOTNOT considered adequate alone considered adequate alone

What YOU can do…What YOU can do…

Daily check on your patients:Daily check on your patients: Stockings or compressorsStockings or compressors Heparin or Clexane or WarfarinHeparin or Clexane or Warfarin Remind medical staffRemind medical staff


RespondRespond to patients who complain of to patients who complain of dyspnoeadyspnoea pleuritic chest painpleuritic chest pain calf paincalf pain unexplained unilateral leg swellingunexplained unilateral leg swelling

RespondRespond to changes in your patient’s obs to changes in your patient’s obs ↓↓SaO2SaO2 ↑ ↑ PRPR ↑ ↑ RRRR

Take responsibility Take responsibility and make the team and make the team awareaware


Pre-discharge check – according to Pre-discharge check – according to protocolprotocol StockingsStockings ClexaneClexane Doppler UltrasoundDoppler Ultrasound

YOU can make a difference!YOU can make a difference!

Questions?Questions?

ReferencesReferences

1. Brandjes DP et al. Randomised trial of effect of compression stockings in patients with symptomatic proximal-vein thrombosis. Lancet 1997;349:759-62

2. Geerts WH et al. Prevention of Venous Thromboembolism Prevention of Venous Thromboembolism The The Seventh ACCP Conference on Antithrombotic and Thrombolytic TherapySeventh ACCP Conference on Antithrombotic and Thrombolytic Therapy

3. Ho et al. Venous thromboembolism: diagnosis and management of deep venous thrombosis MJA 2005; 182 (9): 476-481

4.4. Australian Bureau of Statistics 2006 Australian Bureau of Statistics 2006 5.5. Kraaijenhagen RA, Lensing AW, Wallis JW, van Beek EJ, ten Cate JW, Buller Kraaijenhagen RA, Lensing AW, Wallis JW, van Beek EJ, ten Cate JW, Buller

HR. Diagnostic management of venous thromboembolism. HR. Diagnostic management of venous thromboembolism. Baillières Clin Baillières Clin HaematolHaematol 1998;11: 541-86. 1998;11: 541-86.


7.7. Virchow RLK (1856). Virchow RLK (1856). Thrombosis und EmbolieThrombosis und Embolie. Gefässentzündung und . Gefässentzündung und septische Infektion". septische Infektion". Gesammelte Abhandlungen zur wissenschaftlichen Gesammelte Abhandlungen zur wissenschaftlichen MedicinMedicin. pp. 219–732.. pp. 219–732.


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

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