deep vein thrombosisdeep vein thrombosis venous … · 2012-08-01 · in orthopedic surgeries ......
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Journal Club – Evidence Based Medicine
Deep Vein ThrombosisDeep Vein ThrombosisVenous Thromboembolism
Pulmonary Embolism in Orthopedic Surgeries
游宜勳游宜勳
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骨科學複習 Orthopedic Review骨科學複習 Orthopedic Review
Deep vein thrombosis in - THA: 15~25%
TKA: 50%- TKA: 50%- Pelvis-Acetabulum fracture: 20~60%%- Spine surgery: 0.3~26%- Ankle-Foot surgery: 0.22%高加索人與非裔美國人>亞洲人- 高加索人與非裔美國人>亞洲人
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Research of Tai anResearch of Taiwan
DVT after TKA- 44/48 calf thrombi; 4/48 popliteal thrombi
24/48 clinically symptomatic- 24/48 clinically symptomatic- No recurrent DVT or PE
Wang, JBJS-B, 2003
- Control/LMWH/Indocin: 71%/50%/45%28% t ti N PE- 28% symptomatic; No PE
Wang, JBJS-A, 2004
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AAOS G id liAAOS Guideline
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P ti f PE ft THA & TKAPrevention of PE after THA & TKA2009
Mechanical prophylaxis: allChemprophylactic agents:Chemprophylactic agents:
Standard risk of PE and major bleedingi i LMWH SP* f iaspirin, LMWH, SP*, or warfarin
Elevated risk of PE, standard risk of major bleedingLMWH, SP, or warfarin
Standard risk of PE, elevated risk of major bleeding, j gaspirin, warfarin, or none
Elevated risk of PE and major bleedingElevated risk of PE and major bleedingaspirin, warfarin or none
*: Synthetic pentasaccharides
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DVT VTE & PE in Trauma PatientsDVT, VTE & PE in Trauma Patients~ Eastern Association for the Surgery of Trauma
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Risk Factor of VTERisk Factor of VTE
Level I: Spinal cord injury or spine fractureLevel II:
1 Old age1. Old age2. Increasing ISSg3. Long bone, pelvic fracture, head injury
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L D H i f DVT/PE P h l iLow Dose Heparin for DVT/PE Prophylaxis
Level I: Insufficient dataL l II Littl idLevel II: Little evidence
L l I d II I ffi i t d tMechanical devises for DVT/PE ProphylaxisLevel I and II: Insufficient dataLevel III:
1. SCD for spine- and head-injured patient2 A V f t b lt ti f SCD2. A-V foot pump can be alternative for SCD
* SCD: Sequential Compression Devices
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LMWH i VTE P h l iLMWH in VTE Prophylaxis
Level I: insufficient evidenceLevel II:Level II:
1. Pelvic fracture requiring OP or bed rest > 5 days
2. Complex lower extremity fractures2. Complex lower extremity fractures3. Spinal cord injury
L l IIILevel III: 1. ISS>92. LMWH for several weeks in high risk patients
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V C Filt f P h l i d T t t f PEVena Cava Filter for Prophylaxis and Treatment for PE
Level I: Traditional indications1. Recurrent PE despite full anticoagulantion1. Recurrent PE despite full anticoagulantion2. Proximal DVT and contraindication for full anticoagulationg3. Progression of iliofemoral clot despite anticoagulation
Level II: Extended indicationLevel II: Extended indication1. Large free-float thrombus in iliac vein or IVC2 Following massive PE2. Following massive PE3. During/after surgical embolectomy
Level III: Prophylactic vena cava filterLevel III: Prophylactic vena cava filter
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Prevention of VTE ~ American College of Chest PhysiciansEvidence-Based Clinical Practice GuidelinesEvidence Based Clinical Practice Guidelines
8th Edition, 2008
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Electi e Hip ReplacementElective Hip ReplacementRecommendation: LMWH, Foundaparinux, VKA (1A)Against: aspirin dextran heparin or foot pump as soleAgainst: aspirin, dextran, heparin, or foot pump as sole
method of prevention VTE (1A)High risk of bleeding: mechanical prophylaxis (1A)
* VKA: vitamin K antagonist
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Electi e Knee ReplacementElective Knee ReplacementRecommendation: LMWH, Foundaparinux, VKA (1A)IPC as a alternative method of chemoprophylaxis (1B)IPC as a alternative method of chemoprophylaxis (1B)Against: aspirin (1A), heparin (1A), VFP (1B) as only
methodHigh risk of bleeding: mechanical prophylaxis (1A)High risk of bleeding: mechanical prophylaxis (1A)
* IPC: Intermittent pneumatic compression; VFP: Venous foot pump
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Knee ArthroscopKnee ArthroscopyAdditional VTE risk factors
No: early mobilization (2B)No: early mobilization (2B)Yes: LMWH (1B)
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Hip Fract re S rgerHip Fracture SurgeryRecommendation: Foundaparinux (1A), LMWH (1B),
VKA (1B) heparin (1B)VKA (1B), heparin (1B)Against: aspirin alone (1A)Delayed surgery: LMWH or heparin from admission to
surgery (1C)surgery (1C)High risk of bleeding: mechanical prophylaxis (1A)
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Electi e Spine S rgerElective Spine SurgeryAdditional VTE risk factors
No: early and frequent mobilization (2C)No: early and frequent mobilization (2C)Yes: postOP heparin (1B), LMWH (1B), or periOP
IPC (1B)Multiple risk factors: pharmacologic + mechanical (2C)Multiple risk factors: pharmacologic + mechanical (2C)
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I l t d L E t it I j Di t l t th KIsolated Lower-Extremity Injury Distal to the Knee
Not routinely use thromboprophylaxis (2A)
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Cochrane LibrarCochrane Library- Heparin, LMWH and physical methods for
preventing DVT and PE following surgery for hippreventing DVT and PE following surgery for hip fracture ~ 2008Interventions for prevention VTE in adults- Interventions for prevention VTE in adults undergoing knee arthroscopy ~ 2008Di t th bi i hibit it i K- Direct thrombin inhibitors versus vitamin K antagonists or LMWH for prevention of VTE f ll i THA TKA 2010following THA or TKA ~ 2010
- Elastic compression stockings for prevention of p g pDVT ~ 2010
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Heparin, LMWH and physical methods for preventingHeparin, LMWH and physical methods for preventing DVT and PE following surgery for hip fracture
2008
Data base: Cochrane library, Medline, EMBASE, CINAHL, and Current Contentsand Current Contents
Selection criteria: randomized or quasi-randomizedResult: 31 trials involving 2 958 patientsResult: 31 trials, involving 2,958 patientsConclusion:
1 Insufficient evidence of either (heparin and LMWH)1. Insufficient evidence of either (heparin and LMWH) protection against PE or an overall benefit
2 Foot and calf pumping device can prevent DVT PE2. Foot and calf pumping device can prevent DVT, PE and reduce mortality
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Interventions for prevention VTE in adults undergoingInterventions for prevention VTE in adults undergoing knee arthroscopy
2008
Data base: Cochrane library, Medline, EMBASE, and CENTRAL
Selection criteria: RCTs and CCTsResult: 4 trials and 527 patientsConclusion:
1. LMWH reduce DVT, but overall benefit is uncertain2. No strong evidence was found to conclude
thromboprophylaxis is effective to prevent VTE
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Direct thrombin inhibitors versus vitamin K antagonistsDirect thrombin inhibitors versus vitamin K antagonists or LMWH for prevention of VTE following THA or TKA
2010
Data base: Cochrane library, and CENTRALSelection criteria: RCTResult: 14 trials and 21,642 patientsConclusion
1. Direct thrombin inhibitors are as effective as LMWH or vitamin K antagonist in the prevention VTE in THA or TKA; but higher mortality and bleeding than LMWH
2. Use of ximelagatran is not recommended for VE prevention in orthopedic surgery
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El ti i t ki f ti f DVTElastic compression stockings for prevention of DVT2010
Data base: Cochrane library, and CENTRALSelection criteria: RCTSelection criteria: RCTResult: 18 trialsConclusion:Conclusion:
Elastic compression stockings are effective in diminishing the risk in hospitalized patientsdiminishing the risk in hospitalized patients
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D f Ch h l ti A tDoses of Chemoprophylactic Agents
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Pre ention of PE AAOSPrevention of PE ~ AAOS• Aspirin: 325mg, 2#/d, for 6 wks
LMWH: 12 to 24 h post OP for 7 12 d• LMWH: 12 to 24 h post OP, for 7~12 d• SP: 12 to 24 h post OP, for 7~12 d• Warfarin: INR
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Pre ention of VTE ACCPPrevention of VTE ~ ACCP• LMWH: 12 h before surgery or 12 to 24 h after
surgery or 4-6 h after surgery (half dose full dose)surgery or 4-6 h after surgery (half dose full dose)• Fondaparinux: 2.5mg started 6 to 24 h after surgery• VKA: INR=2.5
VKA: Vitamin K antagonist
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D ti f Th b h l i ACCPDuration of Thromboprophylaxis ~ ACCP
• For THR, TKR, and hip fracture surgeryat least 10 daysat least 10 days
• For THR extend 10 to 35 days (1A)LMWH (1A), VKA (1B), fondaparinux (1C)
• For TKR extend 10 to 35 daysFor TKR extend 10 to 35 daysLMWH (1C), VKA (1C), fondaparinux (1C)
• For hip fracture surgeryextend 10 to 35 daysyfondaparinux (1A), LMWH (1C), VKA (1C)
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What DID We Do?What DID We Do?
Aug 2nd ~ Aug 6thHip arthroplasty: 21 Knee arthroplasty: 32Knee arthroplasty: 32Lower limb fracture surgery: 30 g y
Aspirin: 7 (100mg/qd)H i + W f i 1 (f MI)Heparin + Warfarin: 1 (for MI)
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So What WILL We Do?So, What WILL We Do?
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