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Prophylaxis for Deep Venous Thrombosis

- See:
- Coag Pathway
- Pulmonary Embolus
- DVT in Hip Frx and Surgery:
- DVT Following THR:
- DVT Following TKR:
- DVT / PE arising from Trauma and Fractures


- Prophylatic Measures
- specific agents for risk reduction:
- aspirin:
- thrombolytic therapy:


- SQ heparin
- low molecular wt heparins
- may be more effective in total hip arthroplasty as compared to total knee arthroplasty;
- typically LMWH are administered 12-24 hours following surgery and is continued for 14 days;
- recombinant hirudin desirudin:
- may offer up to 86% risk reduction of DVT;
- direct inhibitor of thrombin;
- warfarin
- danaparoid:
- low molecular wt glycosaminoglycan with potent anti factor Xa activity;
- fondaparinux
- Apixaban (oral factor Xa inhibitor)
- Apixaban for Extended Treatment of Venous Thromboembolism
ASA:
- Aspirin for Preventing the Recurrence of Venous Thromboembolism
- Editorial: Aspirin and the Prevention of Venous Thromboembolism

- bleeding complications:
- difficulty in assessing the risk of bleeding complications amongst various agents depends mainly on dose of meds used and amount of monitoring used;
- ie, to achieve the desired anticoagulation effect (and DVT prophylaxsis), how much bleeding are we willing to accept?
- published bleeding complications note 5% bleeding from LMWH, 3% bleeding from coumadin, and 2.5% from SQ heparin;
- in contrast, the bleeding complications from ASA is approximately 0.4%;


- mechanical methods for risk reduction:
- note that there is a large venous plexus in the foot which is compressed when the foot is flattened with wt bearing;
- wt bearing compresses about 30 ml out of the foot and flushes it into the deep venous system;
- foot pump systems attempt to reproduce this effect;
- TED hose (compression stockings) are recommended when using mechanical devices inorder to help control venous capacitance;
- compression stockings:
- note that mechanical compression devices that wrap around the leg cannot be used in total knee patients;
- in the study by Warwick et al (1998), DVT was noted in 18% of foot pump patients vs 13% of enoxaparin patients (no sig difference);
- patients in the enoxaparin group had significantly more bruising, thigh swelling, and wound oozing;
- the authors used venography to evaluate DVT formation;
- the authors concluded that foot pump devices had comprable efficacy to low molecular wt heparin;
- reference:
- Comparison of the use of a foot pump with the use of low-molecular-weight heparin for the prevention of deep-vein thrombosis after total hip replacement. A prospective, randomized trial.
- foot movement:
- sustained movement of the foot (30 cycles for one minute) will produce a sustained increase in the
venous outflow (22 % greater than baseline) which gradually returns to the base line after 30 min;
- reference:
- The effect of active movement of the foot on venous blood flow after after total hip replacement.
- epidural anesthesia:
- epidural anesthesia has clearly been shown to reduce prevalence of DVT;
- potential problem is that blood thinning agents cannot be used as long as the epidural catheter is in place (due to the risk of
epidural hematoma and resulting neurologic deficit);
- reference: The Prevalence of Deep Venous Thrombosis after Total Hip Arthroplasty with Hypotensive Epidural Anesthesia.
- references


References


Comparison of Enoxaparin and Warfarin for the Prevention of Venous Thromboembolic Disease After Total Hip Arthroplasty. Evaluation During Hospitalization and Three Months After Discharge

Finding the right fit: effective thrombosis risk stratification in orthopeadic patients.

Aspirin for Preventing Venous Thromboembolism