non pharmacological method for prevention and treatment of
DESCRIPTION
DVT prophylaxis, Medical, healthTRANSCRIPT
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Non pharmacological method for
prevention and treatment of DVT
Dr L.M.Darlong. MS,FIAGES,FMASNorth-eastern Indira Gandhi Regional Institute of health and medical sciences (NEIGRIHMS). Shillong. India
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DVT
• An intravascular deposit composed of fibrin and red blood cells with a variable platelet and leucocyte component.
• Occurs in region of slow blood flow
• Pulmonary embolism -fragment of this clot breaks and migrates to the lung and lodges in the pulmonary artery or its branch.– Most severe complication-
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Cause • Usually not
known• Universally
attributed to Virchows triad
– STASIS – HYPERCOAGUL
ABILITY– INTIMAL INJURY
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VenousVenousStasisStasis
Tourniquet
Immobilization and bed rest
VascularVascularInjuryInjury
Surgical manipulation of the limb
Endothelial injury
HypercoagulabilityHypercoagulability Increase in thromboplastin
agents
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Natural History of DVT
• Without treatment, approx 20 to 25% of calf vein thrombi extend into the popliteal and femoral veins causing proximal DVT.
• Without treatment approximately half of patients with proximal DVT develop PE
• (Hull, RD, (Hull, RD, Raskob Raskob, GE, Hirsh, J Prophylaxis of venous thromboembolism : an overview.
• Chest1986;89,374S
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Natural History ofPulmonary Embolism
• The mortality rate of patients treated for pulmonary embolism has decreased from 8% to < 5%.
• The majority of deaths due to PE ( ie > 90%) occur in pts who are not treated because the diagnosis is not made.
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Prevention
• Prevention of pulmonary embolism is of paramount importance because the disorder is difficult to detect, and treatment of established pulmonary embolism is not universally successful.
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DVT risk stratification for surgery patients
• Low risk Low• Uncomplicated surgery in patients aged <40 years with
minimal immobility postoperatively and no risk factors factors
• Moderate risk • Minor surg in pt with additional risk factor• Surg in 40-60 yrs with no additional risk factor• High risk• Surgery in patients aged >60 years,or 40-60 yrs with
additional risk factor• Very high risk• Surgery in patients with multiple risk factor (>40
years,previous venous thromboembolism,cancer or known hypercoagulable state)
• Major orthopedic surgery ( hip/knee arthroplasty)• elective neurosurgery• multiple trauma• spinal cord injury
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What Are We Trying To Prevent?
• Asymptomatic DVT?
• Symptomatic DVT?
• All PE’s?
• Fatal PE’s?
• Post-phlebitic Syndrome?
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Mechanism of action
• Stasis – Nonpharmacologic
• Hypercoagulable – Blood thinning agents
( Pharmacologic agents )
• Intimal injury – Minimal trauma / Tissue handling ( Non-Pharmacologic )
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Non-Pharmacologic
• Early ambulation remains the most important nonpharmacologic
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Mechanism
• Augmentation of venous blood flow in the lower limbs via external mechanical devices.- Decreases venous stasis.
• Venous compression secondary to external compression device results in the release of Plasminogen (Natural fibrinolytic ) and Nitric oxide ( Vasodilator) into the blood stream from the endothelial layer of the vein.
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• Inferior vena caval filter ( IVC filter ); This are mechanical devices to trap blood clots arising from the lower limb and prevent them from traveling to the pulmonary circulation.
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Non-Pharmacologic
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Early ambulation
• Should be routine part of all postop care – Unless absolute contraindicated
• Acceptable as VTE prophylaxis for low risk surgical patients
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Elastic stockings
• Improved venous flow ,reduce vessel wall damage caused by passive venous dilatation ,during surgery
• Applied preop and continued throughout the hospital
• Recommended as adjunct in moderate and high risk case
• Avoid improper fitting stockings
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-Pneumatic Compression Devices (PCD) VasoPress
-Sequential Compression Devices (SCD) Kendall
• Intermittent regimen that delivers a sustained pressure in distal to proximal manner.
• The difference-Compartments in PCD devices are uniformly inflated to the same pressure rather than in a graded-sequential fashion as in SCD devices.
Intermittent Pneumatic Compression
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IPC
• Intermittently inflates and deflates bladders contained within the garment (20-40 mmHg).
• Cycle times vary from manufacturer to manufacturer.
• Typically, the inflation (compression) cycle is 10-15 seconds with a 45-50 second relaxation (rest)
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Intermittent Pneumatic Compression
• Direct pumping effect- Reduce stasis• Promotes clearance of local pro
thrombo clotting factor, increase local plasminogen activators
• Obese individual – Doubtful• Only effective used continously-
nonambulat• Presumed additive prophylactic effect
– pharmacologic
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IPC
•Intraop and postop IPC is specific localized prophylaxis:
– Decreased venous stasis • increase venous velocity• increase venous volume
– Inhibits coagulation cascade• tissue factor pathway inhibitor• factor VIIa• NO and endogenous
NO synthase•
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• Wide variety of devices– foot pump– calf– thigh-calf
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Not recommended – Sole agent
• High risk – Gen Surgical pt• High risk – Urology surg pt• Orthopaedics –Hip or knee surgery
Method of choice when pt at increased risk of bleeding with anticoagulants
Solo thromboprophylaxis for moderate to high risk gynae surg
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Current accepted indications• Absolute contra to anticoagulant• Life threatening hemorrhage on
anticoagulant• Failure of adequate anticoagulation
Prophylactic filter not recommended
It is an invasive procedure
IVC Filter
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Recommendation Air TravelLong distance travel ( >6 h duration):.Avoid constrictive clothing.around lower extremities / waist .Avoid dehydration.Do frequent calf muscle stretching
Additional risk factors .If active prophylaxis/perceived increased risk .Suggest the use of properly fitted, below-knee GCS,providing 15 to 30 mm Hg of pressure at the ankle
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Non pharmacologic management of PE
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Catheter extraction or fragmentation for the initial rx of
PE
• Against use of mechanical approaches for most pts with PE.
• Use selected highly compromised pts who are unable to receive thrombolytic therapy or whose critical status does not allow sufficient time to infuse thrombolytic therapy
» Mortality of aprox 20-30%
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Pulmonary embolectomyfor the initial treatment of PE
• Pulmonary embolectomy continues to be performed in emergency situations when more conservative measures have failed.
• If it is attempted the following criteria req:– 1) massive PE (angiographically documented if
possible)– 2) hemodynamic instability (shock) despite
heparin, resuscitative efforts;– 3) failure of thrombolytic therapy or a
contraindication to its use.
• Operative mortality from 10 to 75% in uncontrolled retrospective case series. (in the era of immediately available cardiopulmonary bypass has )
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Risk Factor-Short-term (30-day) postoperative
• > 50 years • Varicose veins • Myocardial
infarction • Cancer • Atrial fibrillation • Ischemic stroke • Diabetes mellitus
• Other additional factors• -DVT• -heart failure• -Obesity• -paralysis,
• inherited conditions, • -factor V Leiden • -prothrombin gene
mutation,• -protein S deficiency• -protein C deficiency• -antithrombin
deficiency.
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Barriers in DVT
• Routinely assess the risk / Asses as risk factor for heart disease.
• Encourage routine prophylaxis for pt at risk
• Prophylaxis underused – Consensus APHA.
• Lack of awareness of DVT risk• Percieved diff in risk asses and
percieved risk of bleed with prophylaxis
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ACCP Recommendation
• Primarily in patients who are at high risk of bleeding
• Adjunct to anticoagulant-based prophylaxis
• Careful attention be directed toward ensuring the proper use of, and optimal compliance with, the mechanical device
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Thank you