Journal Club – Evidence Based Medicine

Deep Vein ThrombosisDeep Vein ThrombosisVenous Thromboembolism

Pulmonary Embolism in Orthopedic Surgeries

游宜勳游宜勳

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

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

AAOS G id liAAOS Guideline

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

DVT VTE & PE in Trauma PatientsDVT, VTE & PE in Trauma Patients~ Eastern Association for the Surgery of Trauma

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

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

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

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

Prevention of VTE ~ American College of Chest PhysiciansEvidence-Based Clinical Practice GuidelinesEvidence Based Clinical Practice Guidelines

8th Edition, 2008

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

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

Knee ArthroscopKnee ArthroscopyAdditional VTE risk factors

No: early mobilization (2B)No: early mobilization (2B)Yes: LMWH (1B)

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)

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)

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)

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

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

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

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

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

D f Ch h l ti A tDoses of Chemoprophylactic Agents

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

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

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)

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)

So What WILL We Do?So, What WILL We Do?