Venous Thromboembolism (Subscribe)

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Antithrombotic Therapy. SIGN Guideline. SIGN Publication No. 36 ISBN 1899893 76 8 Published March 1999

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1997 Heparin low molecular weight heparin and physical methods for preventing deep vein thrombosis and pulmonary embolism following surgery for hip fractures Cochrane Review

Prophylaxis using heparin and low molecular weight heparin
Heparins and some mechanical pumping devices may help prevent blood clots forming in the legs after surgery for hip fracture
Patients with hip fracture may develop blood clots (thrombosis) in their legs. Some of these blood clots may travel to the lungs and cause a blockage (embolism), which can be fatal. Various drugs and physical devices are sometimes used to try and prevent these complications. This review of randomised trials found that both heparins and mechanical pumping devices significantly decrease the incidence of deep vein thrombosis. There was not enough evidence to conclude about the effect on lung (pulmonary) embolism, mortality or possible side effects for either heparin or mechanical methods.
Handoll HHG, Farrar MJ, McBirnie J, Tytherleigh-Strong G, Milne AA, Gillespie WJ Last assessed as up-to-date: June 23. 2002

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Anticoagulants May Increase Mortality After Hip and Knee Surgery Medscape

NEW YORK (Reuters Health) Apr 02 - A review of studies looking at anticoagulant prophylaxis after hip and knee arthroplasty reveals that not only do these agents fail to completely prevent pulmonary embolism (PE), their use may actually increase all-cause mortality. The results, which appear in the March issue of Clinical Orthopaedics and Related Research (Clin Orthop Relat Res 2008;466:714-721), show that the risk was most pronounced with so-called potent anticoagulants, such as low-molecular weight heparin, ximelagatran, fondaparinux, and rivaroxaban. Warfarin, a slow-acting oral anticoagulant, raised the risk to a lesser extent.

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Dabigatran A New Oral Agent for Prevention of Venous Thromboembolism COA

Recently, the first oral direct thrombin inhibitor became available for the prevention of VTE in patients undergoing elective total hip or knee replacement surgery. Dabigatran etexilate (PradaxTM) is a prodrug of dabigatran, a highly specific inhibitor of both clot-bound and free thrombin that can be used in both the hospital and outpatient setting.
Fathi Abuzgaya, M.D., FRCSC COA Bulletin Issue 83 2008

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Deep Vein Thrombosis

Clinical Signs for DVT:
- exam may be unreliable but positive findings should not be ignored;
- calf tenderness, swelling, fever, & increased pulse rate may be present
- suggestive exam features for pulmonary embolism:
- sudden decrease in O2 saturation;
- tachypnea, cyanosis, and hypoxia;
- pulmonary consolidation, pleural effusion, wheeze, and cor pulmonale;
- new onset tachydysrhythmia (usually a. fib);

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Deep Venous Thrombosis Prophylaxis in Orthopedic Surgery eMedicine Orthopedics

Thrombosis is a naturally occurring physiologic process. Under normal circumstances, a physiologic balance is present between factors that promote and retard coagulation. A disturbance in this equilibrium may result in the coagulation process occurring at an inopportune time or location or in an excessive manor. Alternatively, failure of the normal coagulation mechanisms may lead to hemorrhage.
Synonyms and related keywords: deep vein thrombosis, DVT prophylaxis, pulmonary embolus, pulmonary embolism, PE, venous thromboembolism, VTE, thromboprophylaxis, DVT prevention, PE prevention, VTE prevention, venous stasis, Virchow triad, Virchow's triad, low-dose heparin, LDH, low-molecular weight heparin, LMWH, unfractionated heparin, UFH, intermittent pneumatic compression, IPC, elastic stockings, ES, post-thrombotic syndrome, postthrombotic syndrome, PTS, heparin-induced thrombocytopenia, HIT
Robert S Ennis, MD 2005

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DVT and PE prophylaxis in THR Wheeless

40-60% of THR patients who do not receive prophylaxis will get a DVT (dependment on imaging method);
in contrast, the study by Fender et al (JBJS 1997) showed that the incidence of fatal PE (as diagnosed by postmortem examination) was 4 / 2111 patients (0.19%);
Wheeless' Textbook of Orthopaedics

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DVT Prophylaxis in Hip & Knee Replacement Surgery Controversies in 2008 COA

Routine thromboprophylaxis following elective hip and knee replacement surgery remains a controversial topic. No one disputes that patients undergoing these surgical procedures are at risk for deep vein thrombosis. The combination of stasis, endothelial wall injury and hypercoagulability are almost routine following this type of hip and knee surgery. It is because of the prevalence of deep vein thrombosis in these patients that they are frequently selected for study in large clinical trials examining the efficacy of various antithrombotic agents.
Much of the discord surrounding routine thromboprophylaxis for hip and knee replacement surgery relates to the clinical trials studying these patients. They report a high incidence of venographically demonstrated thrombi in patients days or weeks following the surgical procedure in question. Only a tiny fraction of these patients with venographically proven thrombi are in fact symptomatic and an even smaller number of patients in these large studies ever develop symptomatic pulmonary embolism proven by diagnostic imaging.
James P. Waddell, M.D., FRCSC COA Bulletin Issue 83 2008

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Effectiveness of Intermittent Pneumatic Leg Compression for Preventing Deep Vein Thrombosis After Total Hip Replacement

A randomized trial was performed in consecutive patients undergoing total hip replacement to evaluate the effectiveness of sequential intermittent calf and thigh compression for preventing venous thrombosis compared with a control group given no prophylaxis. Both groups underwent case finding for deep vein thrombosis using combined fibrinogen I 125 leg scanning, impedance plethysmography, and venography. Deep vein thrombosis by venography was present in 77 (49%) of 158 control patients compared with 36 (24%) of 152 patients given intermittent compression. Proximal vein thrombosis was present in 42 controls (27%) compared with 22 patients (14%) given intermittent compression. Combined impedance plethysmography and leg scanning was insensitive in this patient group (sensitivity, 46%); venography was required to detect more than half the patients with venous thrombosis. Sequential intermittent leg compression clinically and statistically significantly reduced the frequency of both proximal vein and calf vein thrombosis. Case finding resulted in early detection and treatment of patients with venous thrombosis.
Effectiveness of Intermittent Pneumatic Leg Compression for Preventing Deep Vein Thrombosis After Total Hip Replacement Russell D. Hull, MBBS, MSc; Gary E. Raskob, MSc; Michael Gent, MSc; Dermot McLoughlin, MBBS; Denise Julian, MSc; Frank C. Smith, MB, ChB; N. Ian Dale, MBBS; Roy Reed-Davis, MD; Robert N. Lofthouse, MD; Christine Anderson, RN (JAMA. 1990;263:2313-2317) full text

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Incidence and Risk Factors for Venous Thromboembolic Disease in Podiatric Surgery Medscape

No guidelines or population-based research exist to guide management for podiatric surgery patients. The objective of our study was to determine the incidence and risk factors for postprocedure VTE in podiatric surgery.
Conclusions: We identified a low overall risk of VTE in podiatric surgery, suggesting that routine prophylaxis is not warranted. However, for patients with a history of VTE, periprocedure prophylaxis is suggested based on the level of risk. For podiatry surgery patients with two or more risk factors for VTE, periprocedure prophylaxis should be considered. Until a prospective study is completed testing recommendations, guidelines and care decisions for podiatric surgery patients will continue to be based on retrospective data, expert consensus, and clinical judgment.
Andrew H. Felcher, MD; Richard A. Mularski, MD, MSHS, MCR, FCCP; David M. Mosen, PhD, MPH; Teresa M. Kimes, MS; Thomas G. DeLoughery, MD; Steven E. Laxson, DPM CHEST. 2009;135(4):917-922.

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Prevention of Venous Thromboembolism in Major Orthopaedic Surgery The 8th ACCP Guidelines COA

Rationale for Routine Thromboprophylaxis in Major Orthopaedic Surgery
Because venous thromboembolism (VTE) is one of the most common complications following major orthopaedic surgery and is associated with both short- and long-term morbidity and occasional fatal outcome, routine prophylaxis has been the key to reducing the burden of this disease for more than 20 years. Numerous clinical trials confirm the effectiveness, safety, and cost-effectiveness of thromboprophylaxis in a broad spectrum of patient groups. The use of thromboprophylaxis has been shown to reduce the risk of DVT, proximal DVT, PE, and fatal PE by more than 60% while the risk of clinically-important bleeding is low with anticoagulant prophylaxis and is similar to the risk seen in patients not receiving prophylaxis or receiving mechanical prophylaxis1. Orthopaedic surgery is the clinical area with the highest thrombosis risk, the largest number of recent clinical trials and with the greatest adherence to recommended prophylaxis. With the routine use of thromboprophylaxis in these patients, fatal PE is very uncommon, although symptomatic VTE continues to be reported in 1-5% of arthroplasty patients within three months after surgery.
The ACCP Guidelines on the Prevention of VTE in Orthopaedic Surgery
The American College of Chest Physicians (ACCP) Guidelines on the Prevention of VTE are prepared by a multidisciplinary, international group of clinician-methodologists, including orthopaedic surgeons.
William Geerts, M.D. COA Bulletin Issue 83 2008

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The Use of Direct Factor Xa Inhibitors in the Prevention of Thromboembolism after Joint Replacement COA

Rivaroxaban is the first oral direct Factor Xa inhibitor approved in Canada for the prevention of venous thromboembolism (VTE) following elective total hip replacement (THR) and total knee replacement (TKR) surgery. The purpose of this article is to review the available information on rivaroxaban.
Bassam A. Masri, M.D., FRCSC COA Bulletin Issue 83 2008

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Thromboembolism in Hip Fracture Wheeless

See links to:
- DVT Discussion
- Pulmonary Embolism
- References
- Role of Dextran in Hip Frx
- Role of Heparin in Hip Frx
Wheeless' Textbook of Orthopaedics

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Tromboembolism eMedicine Orthopedics

Thromboembolism encompasses two interrelated conditions that are part of the same spectrum, deep venous thrombosis (DVT) and pulmonary embolism (PE). PE is the obstruction of blood flow to one or more arteries of the lung by a thrombus lodged in a pulmonary vessel (see Image 1). PE and DVT can occur in the setting of disease processes, following hospitalization for serious illness, or following major surgery. In 1856, Virchow demonstrated that 90% of all clinically important PEs result from DVT occurring in the deep veins of the lower extremities, proximal to and including the popliteal veins. However, emboli also can originate from the pelvic veins, the inferior vena cava, and the upper extremities.
Synonyms and related keywords: pulmonary embolism, PE, deep venous thrombosis, deep vein thrombosis, DVT
Vera A De Palo, MD 2005

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