Educational Objectives

Learn to discuss the special anesthesiological needs of OS patients at risk for DVT, with a focus on timing of prophylaxis, transitioning agents, and duration of prophylaxis based on the surgical procedure. Describe how to risk stratify patients undergoing orthopedic surgery, and implement ACCP-mandated pharmacologic and non-pharmacologic measures aimed at DVT prophylaxis. Learn how to apply landmark clinical trials focusing on DVT prevention in OS patients.

DVT Prophylaxis After THA Prophylaxis: No

Warwick, JBJS, Br, 1995 1162 THA No chemical prophylaxis Fatal PE 0.34%

M u rra y e t a l J J B r, 1 9 9 6 , B S M e ta - a n a l ysi s 1 3 0 , 0 0 0 T H A R e p o rte d fa ta lP E 0 . 1 - 0 . 2 %

The absolute risk of DVT is high in patients who sustain a fracture of the hip, spine, pelvis, or lower extremity
Risks of VTE in orthopedic trauma and fracture surgery Condition DVT % Total PE % Fatal

Proxim Total al

Hip fracture [25] Polytrauma [16] Spinal cord injury [31] Pelvic or acetabular fractures [17, 18]

4064 2341 111 2963 832 67

17.5 0.11 00.8 0.52

4790 1735 511 1061 1029 28

Isolated lower extremity 1745 18 fracture [20]

15

Compression stockings Graduated compression stockings have not been formally tested in trauma patients. Nevertheless, many surgeons recommend combining graduated compression stockings with pharmacological methods for VTE prophylaxis in trauma patients. Mechanical pumps Various compression devices exist to replace or enhance the natural muscle pump function. These include the venous foot pumps developed to mimic the effect of weight bearing and sequential pneumatic compression devices that transport venous blood proximally. Generally, mechanical pumps appear to be beneficial in reducing VTE in hip fracture patients. However, their use in trauma patients has not been shown to be beneficial in DVT prevention compared with no prophylaxis [22]. Their use is recommended in patients where anticoagulation is contraindicated. Vena cava filters Filter placement is a strategy for the prevention of PE in the face of known or likely thrombosis. Its role in trauma surgery and the risks and benefits of placing the filter prophylactically are not yet fully clear.

Filters are recommended in very high-risk trauma patients who cannot receive anticoagulation because of increased bleeding risk [18]. There are retrievable ones and nonretrievable ones. A serious long-term complication of inferior vena cava filtration is thrombotic occlusion of the inferior vena cava (IVC) (in 6% to 30% of cases). Retrievable filters can be considered in younger trauma patients in whom contraindications to anticoagulation are expected to be temporary [23].

Thromboprophylaxis Regimens

Mechanical
Graduated Compression Stockings (GCS) Intermittent Pneumatic Compression (IPC)

Anticoagulants

Low-Dose Unfractionated Heparin (LDUH) Low-Molecular-Weight Heparin (LMWH/fondaparinux) Vitamin-K-Antagonists (VKA)

DVT Prophylaxis After TJA Objectives

Pharmacologic agents
Unfractionated heparin LMWH Coumadin Aspirin

Mechanical
Multimodal

 System functions as a prophylaxis for deep vein thrombosis by using an effective combination of graduated sequential compression and rapid impulse inflation. This unique collaboration of technology increases venous velocity while enhancing fibrinolysis, thus assisting in the prevention of thrombus formation

 The cuffs are latex-free and may be placed directly against the skin. Each cuff style is designed for single patient use only. 1) Calf cuff length is 11.5" (29 cm) 2) Thigh cuff length is 21.0" (53 cm) 3) Foot cuff length is 9" (23 cm)

Tube assemblies are included with the Vena Flow pump and are available in three lengths 5.5", 8.5" and 10.5". Rapid inflation combined with graduated sequential compression results in a dramatic increase in venous velocity Universal pump design is compatible with all three cuff styles (calf, foot and thigh) to minimize inventory Asymmetric compression for superior emptying of veins Light, cool, latex-free cuffs help promote patient compliance Preset alarms and patient counter available for ease of use

DVT Prophylaxis After THA Importance

Fa ta lP. E .

Historic Current

1 - 2% 0.1 - 0.2%

DVT Prophylaxis After THA Importance

In many cases the complication is preventable

We (not the internists) are responsible for choosing and administering prophylaxis

DVT Prophylaxis After THA Introduction

Data Difficult to Interpret:

Different methods of diagnosis clinical - ultrasound venography - scans Different endpoints death - DVT proximal vs distal clinical PE or DVT Different definitions of complications bleeding: major, minor post phlebitic syndrome

DVT Prophylaxis After THA Prophylaxis: Yes

Effective prophylaxis is necessary in these patients [THA, TKA] . . . NIH consensus panel, 1986 European consensus conference 1992

OREF Survey

434 surgeons representing 48 states and three countries (Canada, Egypt, Pakistan) Surgeons have been in practice an average of 19 years >96% prophylax for DVT in their THA and TKA patients

OREF Survey

Orthopaedic Surgery

Elective Hip Arthroplasty Elective Hip Arthroplasty

For patients undergoing elective THR, we recommend the routine use of one of the following three anticoagulants:
LMWH

(at a usual high-risk dose, started 12 h before surgery or 12 to 24 h after surgery, or 4 to 6 h after surgery at half the usual high-risk dose and then increasing to the usual high-risk dose the following day)
fondaparinux, Adjusted-dose

(2.5 mg started 6 to 8h after surgery)

VKA started preoperatively or the evening after surgery (INR target, 2.5; INR range, 2.0 to 3.0) [all Grade 1A]

Risk for Heparin-Induced Thrombocytopenia with Unfractionated and Low Molecular-Weight Heparin Thromboprophylaxis: A Meta-Analysis
Heparin-induced

thrombocytopenia (HIT) is an uncommon but potentially devastating complication of anticoagulation with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) The inverse varianceweighted average that determined the absolute risk for HIT with LMWH was 0.2%, and with UFH the risk was 2.6%. Most studies were of patients after orthopedic surgery

Martel et al. Blood 2005; 106:2710-15

Mechanical Prophylaxis THA

Wide variety of devices
foot pump calf thigh-calf

Each device has its own mechanics with resultant change in peak venous velocity and venous volume For THA, optimal characteristics of pneumatic compression are not known

Venous Hemodynamics After THA

Devices with rapid inflation time Produced the greatest increase in peak venous velocity Devices that compress calf and thigh Produced the greatest increase in venous volume

Orthopaedists Concerns Anticoagulation TKA

Increased risk of major bleeding into knee and wound complications (0.9 True risk of bleeding and outcome not established for all TKA patients Bleeding into TKA associated with hematomas, drainage, infection and poorer outcomes
5.2%)

Mechanical Prophylaxis TKA

Wide variety of devices thigh-calf calf only foot pump Each device has its own mechanics with different changes in peak venous velocity and volume Optimal characteristics for devices?

Venous Hemodynamics After TKA

Increase in verious velocity (%)

DPF

A-V impulse system

PlexiPulse foot

PlexiPulse foot-calf Foot calf

VenaFlow

Flowtron DVT SCD system

Jobst athrombic pump

Foot

Calf

Calf-thigh

Westrich et al. JBJS (B) 1998

Two Mechanical Devices for Prophylaxis of Thromboembolism After Prospective, randomized study TKA

Results

Asymmetrical Compression

Circumferential Compression 217 240

Patients 206 Knees 232 Mortality 0 Pulm. Embolism 0 Thrombi 16 (6.9%)

1 (.46%) 1 (.46%)
36 (15%) p = .007 15 30 1 6

Calf Proximal

Overview
Venous thromboembolism (VTE), DVT and PE are real and significant threats to the orthopedic patient The anesthesia and analgesia plan must accommodate treatment of VTE Anesthesia and pain management can be challenging and pose risks to the patient in the absence of communication and cooperation between care teams