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DVT Prophylaxis in Orthopaedic Surgery

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Venogram detected DVT. Symptomatic thrombi less frequent in preop ... Venogram preop and postop. Proximal DVT significantly higher in warfarin/placebo group ... – PowerPoint PPT presentation

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Title: DVT Prophylaxis in Orthopaedic Surgery


1
Welcome
2
DVT Prophylaxis in Orthopaedic Surgery
  • Symposium, American Academy of Orthopedic
  • Surgeons, Annual Meeting, San Diego, California

February 14, 2007
3
Program Faculty
Javad Parvizi, MD, FRCS Associate
Professor Department of Orthopedics Thomas
Jefferson University Rothman Institute Philadelphi
a, PA Peter B. Hanson, MD Medical Director of
Orthopedics Chief of Staff Grossmont Hospital La
Mesa, CA Russell Hull, MBBS, MSc Professor of
Medicine Director, Thrombosis Research
Unit University of Calgary Calgary,
Alberta Canada
Eugene R Viscusi, MD Director, Acute Pain
Management Associate Professor Department of
Anesthesiology Thomas Jefferson
University Philadelphia, PA Paul F. Lachiewicz,
MD Department of Orthopaedics University of North
Carolina School of Medicine Chapel Hill, NC
4
Financial Disclosures
Javad Parvizi, MD, FRCS Grant/Research Support
NIH, OREF, DOD, Aircast, GSK, Ortho McNeill,
Pfizer, Smith and Nephew, Stryker Consultant
Stryker Orthopaedics Speakers Bureau
Endo Peter B. Hanson, MD Speakers Bureau
Eisai, sanofi-aventis, Bristol-Myers
Squibb Russell Hull, MBBS, MSc Grant/Research
Support sanofi-aventis, Bayer Consultant
sanofi-aventis, Wyeth, GSK, Leo Pharmaceuticals,
Pfizer, Bayer
Eugene R Viscusi, MD Research Support
Ortho-McNeil Pharmaceutical, Inc., Endo
Pharmaceuticals, SkyePharma, Pfizer Inc, Xsira
Pharmaceuticals, Baxter Pharmaceutical Products,
Inc., and Progenics Pharmaceuticals, Inc.
Consultant Ortho-McNeil Pharmaceutical, Inc.,
Adolor Corporation, Endo and SkyePharma Speakers
Bureau Endo Paul F. Lachiewicz, MD Consultant
Zimmer, Endo Research Grant Aircast
5
Educational Objectives
  • Learn how to explain current guidelines issued by
    national professional organizations and colleges,
    such as the AAOS, ACCP, and ASA, mandating
    risk-directed prophylaxis against DVT in
    low-to-high risk patients undergoing orthopedic
    surgery.
  • Learn how to identify factors to risk stratify
    orthopedic surgery patients undergoing THA, TKA,
    fracture repair, to assess their likelihood for
    incurring DVT.
  • Learn how to describe pharmacologic and/or
    intermittent compression devices as part of a
    multimodal prophylaxis strategy aimed at the
    incidence of DVT in the OS patient population.
  • Learn how to specify pharmacologic agents used
    for DVT prophylaxis based on an analysis of
    efficacy, safety, and pharmacoeconomic
    parameters.

6
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.

7
DVT Prophylaxis After TJAImportance
  • Catastrophic cardiopulmonary problem

Death
8
DVT Prophylaxis After TJAImportance
  • Orthopedic procedures are high risk

9
DVT Prophylaxis After TJAObjectives
  • Learn current guidelines(ACCP, AAOS)
  • Stratify orthopedic surgery patients
  • How to apply various modalities

10
DVT Prophylaxis After TJAObjectives
  • Pharmacologic agents
  • Unfractionated heparin
  • LMWH
  • Coumadin
  • Aspirin
  • Mechanical
  • Multimodal

11
DVT Prophylaxis After TJAObjectives
  • Select pharmacologic agents based on efficacy,
    safety, pharmacoeconomic parameters
  • Issues related to coadministration of anesthesia
    and DVT prophylaxis

12
DVT Prophylaxis After TJAFormat
  • Four 20 minutes talk
  • Discussion

13
DVT Prophylaxis After TJAFirst Talk
  • Russell Hull MBBS, MSc
  • Professor of Medicine, Director,Thrombosis
    Research Unit,University of Calgary
  • Current guidelines (ACCP)
  • Risk stratification

14
DVT Prophylaxis After TJASecond Talk
  • Peter Hanson, MD
  • Medical Director of Orthopedics,
  • Chief of Staff
  • Grossmont Hospital, La Mesa, CA
  • Current controversies
  • Agent selection
  • Duration of prophylaxis

15
DVT Prophylaxis After TJAThird Talk
  • Paul Lachiewicz MD
  • Professor of Orthopedic Surgery,University of
    North Carolina School of Medicine, Chapel Hill,
    NC
  • Multimodal approach
  • Evidence based
  • Clinical implications of prophylaxis

16
DVT Prophylaxis After TJAFinal Talk
  • Eugene Viscusi MD
  • Director of Acute Pain,Department of
    AnesthesiaThomas Jefferson University,Philadelph
    ia, PA
  • Challenges of coadministration of DVT prophylaxis
    and anesthesia

17
Applying The Science of DVT Prophylaxis to
Orthopedic Surgery
  • Javad Parvizi MD, FRCS
  • Rothman Institute of Orthopedics, Thomas
    Jefferson University Philadelphia, PA

18
DVT Prophylaxis After THALiterature
  • Pubmed MesH heading DVT and THA
  • 29,714 articles

19
DVT Prophylaxis After THAImportance
Fatal P.E.
  • Historic 1 - 2
  • Current 0.1 - 0.2

20
DVT Prophylaxis After THAImportance
  • In many cases the complication is preventable
  • We (not the internists) are responsible for
    choosing and administering prophylaxis

21
DVT Prophylaxis After THAIntroduction
  • What agent?
  • How long
  • Screening

22
DVT Prophylaxis After THAIntroduction
  • 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

23
DVT Prophylaxis After THAProphylaxis No
  • Warwick, JBJS, Br, 1995
  • 1162 THA
  • No chemical prophylaxis
  • Fatal PE 0.34
  • Murray et al, JBJS Br, 1996
  • Meta-analysis
  • 130,000 THA
  • Reported fatal PE 0.1 - 0.2

24
DVT Prophylaxis After THAProphylaxis Yes
  • Effective prophylaxis is necessary in these
    patients THA, TKA . . .
  • NIH consensus panel, 1986
  • European consensus conference 1992

25
DVT Prophylaxis After THA
  • In 2007 in North America we are obligated to do
    something

26
DVT Prophylaxis After THAAgents Available
  • Unfractionated heparin
  • LMWH
  • Aspirin
  • Mechanical prophylaxis

27
DVT Prophylaxis After THALMWH
  • Advantages
  • Predictable dose response
  • Proven efficacy
  • Disadvantages
  • Bleeding complications
  • Injection required

28
DVT Prophylaxis After THALMWH Results
  • LMWH BID
  • 194 THA
  • DVT rate 5
  • 8 major bleeding episodes

Colwell et al, JBJS Am, 1994
29
DVT Prophylaxis After THAWarfarin vs. LMWH
  • Prospective, randomized
  • Venography endpoint
  • LMWH started 2 hrs postop
  • Proximal DVT 5 (LMWH) vs 8 (Warfarin), p 0.19
  • More bleeding in LMWH group (p0.001)

Francis, et al JBJS (A), 1995
30
DVT Prophylaxis After THALMWH
  • Randomized, double blind
  • 1472 THA
  • Dalteparin before or early after vs warfarin
  • Venogram detected DVT
  • Symptomatic thrombi less frequent in preop
    dalteparin group (plt0.02)
  • Increased bleeding at surgical site for preop
    dalteparin group
  • Modified regimen (postoperative)

Hull R et al Arch Intern Med. 2000
31
DVT Prophylaxis After THALMWH
  • Bottom Line
  • Effective
  • 2nd most commonly used agent in N. America
  • Probably increased bleed risk esp. if given too
    early

32
DVT Prophylaxis After THAResults Summary
  • Coumadin and LMWH equally effective at preventing
    DVT after THA
  • A slightly higher bleeding rate with LMWH
  • Coumadin is harder to use (outpatient monitoring)

33
DVT Prophylaxis After THAPreventative Measures
  • Expeditious surgery
  • Minimize time vessels kinked in surgery
  • Mobilize promptly
  • Calf exercises in bed
  • Elastic stockings (?)
  • Epidural anesthesia

Lemos, Clin. Orth. 1992
34
DVT Prophylaxis After THAProphylaxis Options
  • What is the best agent for prophylaxis?

35
OREF Survey
  • 434 surgeons representing 48 states and three
    countries (Canada, Egypt, Pakistan)
  • Surgeons have been in practice an average of 19
    years
  • gt96 prophylax for DVT in their THA and TKA
    patients

36
OREF Survey
37
DVT Prophylaxis After THAWhich LMWH
  • Certoparin (18 mg), dalteparin 30 mg, enoxaparin
    (24 mg)
  • 188 patients undergoing TJA, or spine sx
  • Changes in venous flow pre and postop doppler
  • DVT 1.1
  • Bleeding 11.2 (13 in certoparin, 4 in each)
  • No difference in APTT, TCT, blood count
  • All as efficacious


Janni W, et al.Zentralbl Chir. 2001
38
DVT Prophylaxis After THASummary
  • Proven efficacy
  • Works for you

39
DVT Prophylaxis After THADuration of Prophylaxis
  • How long should prophylaxis becontinued after
    THA?

40
DVT Prophylaxis After THADuration of Prophylaxis
  • LMWH
  • Conflicting data
  • Warfarin
  • Amstutz 15 days
  • Colwell 7 days

41
DVT Prophylaxis After THALMWH
  • Randomized, double blind
  • 569 THA
  • dalteparin vs warfarin in hospital and placebo
    out of hospital (35 days)
  • Venogram preop and postop
  • Proximal DVT significantly higher in
    warfarin/placebo group
  • No major bleeding

Hull R et al Arch Intern Med. 2000
42
DVT Prophylaxis After THADuration of Prophylaxis
  • Markov-based decision analysis
  • Outcome measures PE prevented, hemorrhages
    induced, overall cost, overall cost for each PE
    prevented
  • Agents LMWH, warfarin, ASA, nothing
  • Extending to 4 weeks was safe for all agents
  • LMWH-most effective
  • ASA-most cost effective
  • Conclusion Safe to extend the prophylaxis to 4
    but NOT 6 weeks

Sarasin FP, Bounameaux H.Thromb Haemost 2002
43
DVT Prophylaxis After THADuration of Prophylaxis
  • Patients with no specific risk factors (1-3
    weeks)
  • Patients with specific risk factor (6 weeks)
    (like previous DVT)

44
DVT Prophylaxis After THAScreening
  • Do patients need routine screening for DVT after
    THA?

45
DVT Prophylaxis After THAScreening
  • Advantages
  • Identify and treat clots
  • Disadvantages
  • Accuracy of tests varies
  • Problem of treating asymptomatic clots
  • Unproven advantage
  • Cost

46
DVT Prophylaxis After THAScreening
  • A large prospective randomized trial comparing
    discharge ultrasound with sham ultrasound showed
    NO advantage to screening

Robinson, KS et al. Ann Intern Med. 1997 Sep
15127(6)439-45
47
  • Good judgment comes from experience and
    experience comes from bad judgment
  • Winston Churchill

48
Current Guidelines for DeepVein Thrombosis
Prophylaxis in Orthopedic Surgery ACCP
Guidanceand Risk Stratification Strategies
Matching Intensity of Therapy with Patient
Subgroups
Russell D. Hull Professor of Medicine,Thrombosis
Research Unit University of Calgary
49
Diagnosis Of Fatal Pulmonary Embolism In North
America Is Problematic Due To The Low Autopsy Rate
50
Evidence-Based Guidelines Recommendations
Two Components
  • Methodological Quality of a Recommendation
  • Grade A
  • Grade B

Or
  • Grade C
  • Benefit/Risk
  • Grade 1

Or
  • Grade 2

The 7th ACCP Conference on Antithrombotic and
Thrombolytic Therapy.Chest 2004 126 179S-187S.
51
Methodologic Quality
Grade A
Consistent findings by randomized trials
Grade B
Randomized clinical trials with inconsistent
results
Grade C
Observational studies
Chest 2004 126 179S-187S.
52
Benefit/Risk
Chest 2004 126 179S-187S.
53
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)

Chest 2004 126 179S-187S.
54
ASA
We recommend against the use of ASA alone as
prophylaxis against VTE for any patient group
(Grade 1A)
Chest 2004 126 179S-187S.
55
X
Antiplatelets
-ASA
56
Screening for DVT
We recommend against the routine use of DUS
screening at the time of hospital discharge in
asymptomatic patients following major orthopedic
surgery (Grade 1A)
Chest 2004 126 338S-400S.
57
Levels of Thromboembolism Risk in Surgical
Patients Without Prophylaxis
Risk Stratification
Patients are stratified as
  • Low Risk
  • Moderate Risk
  • High Risk
  • Highest Risk

Chest 2004 126 338S-400S.
58
High Risk
DVT,
PE,
Calf
Proximal
Clinical
Fatal
Surgery in patients with multiple risk factors
(age gt40 yr, cancer prior VTE)
40-80
10-20
4-10
0.2-5
Hip or knee arthroplasty, HFS
Major trauma SCI
Successful Prevention Strategies
LMWH (gt3,400 U daily), fondaparinux, oral VKAs
(INR, 2-3), or IPC/GCS LDUH/LMWH
Chest 2004 126 338S-400S.
59
Orthopaedic Surgery
60
Elective Hip Surgery
Highest risk
61
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, (2.5 mg started 6 to 8h after
    surgery)
  • Adjusted-dose VKA started preoperatively or the
    evening after surgery (INR target, 2.5 INR
    range, 2.0 to 3.0) all Grade 1A

Chest 2004 126 338S-400S.
62
Elective Hip Arthroplasty
We recommend against the use of
  • ASA
  • Dextran
  • Low-dose unfractionated heparin
  • Graduated compression stockings
  • Intermittent pneumatic compression
  • Venous foot pump

As the only method of thromboprophylaxis in these
patients (Grade 1A)
Chest 2004 126 338S-400S.
63
Elective Hip Arthroplasty
  • Underlying values and preferences
  • We have not recommended the use of
  • fondaparinux over LMWH and VKA
  • Or the use of LMWH over VKA
  • Because we place a relatively low value on the
    prevention of venographic thrombosis and a
    relatively high value on minimizing bleeding
    complications

Chest 2004 126 338S-400S.
64
Elective Knee Surgery
Highest risk
65
Elective Knee Arthroplasty
  • For patients undergoing elective TKA, we
    recommend routine thromboprophylaxis using
  • LMWH (at the usual high-risk dose)
  • Fondaparinux
  • Adjusted-dose VKA (target INR, 2.5 INR range,
    2.0 to 3.0)
  • all Grade 1A

Chest 2004 126 338S-400S.
66
Elective Knee Arthroplasty
  • The optimal use of IPC is an alternative option
    to anticoagulant prophylaxis (Grade 1B)
  • We recommend against the use of any of the
    following as sole methods of thromboprophylaxis
  • ASA (Grade 1A)
  • LDUH (Grade 1A)
  • Or venous foot pump (Grade 1B)

Chest 2004 126 338S-400S.
67
Elective Knee Arthroplasty
  • Underlying values and preferences
  • We have not recommended
  • fondaparinux over LMWH and VKA
  • Or LMWH over VKA
  • Because we place a relatively low value on the
    prevention of venographic thrombosis and a
    relatively high value on minimizing bleeding
    complications

Chest 2004 126 338S-400S.
68
Hip Fracture Surgery
Highest risk
69
Hip Fracture Surgery
  • For patients undergoing hip fracture surgery, we
    recommend the routine use of
  • fondaparinux (Grade 1A)
  • LMWH at the usual high-risk dose (Grade 1C)
  • Adjusted-dose VKA (target INR, 2.5 INR range,
    2.0 to 3.0) (Grade 2B)
  • Or LDUH (Grade 1B)

Chest 2004 126 338S-400S.
70
Hip Fracture Surgery
  • We recommend against the use of ASA alone (Grade
    1A)
  • If surgery will likely be delayed, we recommend
    that prophylaxis with either LDUH or LMWH be
    initiated during the time between hospital
    admission and surgery (Grade 1C)
  • We recommend mechanical prophylaxis if
    anticoagulant prophylaxis is contraindicated
    because of a high risk of bleeding (Grade 1C)

Chest 2004 126 338S-400S.
71
Distal Fracture of the Lower Extremity
72
Isolated Lower Extremity Injuries
We suggest that clinicians not use
thromboprophylaxis routinely in patients with
isolated lower extremity injuries (Grade 2A)
Chest 2004 126 338S-400S.
73
Special Considerations
  • Timing of Thromboprophylaxis
  • Knee arthroscopy
  • Thrombocytopenia

74
Timing of Thromboprophylaxis
75
North American Dalteparin Trial (NAFT)
  • We performed a randomized, double-blind trial
  • Patients received either
  • Just-in-time subcutaneous dalteparin sodium once
    daily (initiated immediately pre-operatively or
    early post-operatively)
  • Or warfarin during the acute hospital stay

Hull et al. Arch Intern Med 2000 160
2199-2207.Hull et al. Arch Intern Med 2000
160 2208-2215.
76
NAFT
  • Multicentre 28 centres in the United States and
    Canada
  • Randomized
  • Double-blind

Hull et al. Arch Intern Med 2000 160
2199-2207.Hull et al. Arch Intern Med 2000
160 2208-2215.
77
NAFT
Overall Study Design
Phase I
Phase II
Day 0
(surgery)
Day 62
Day 72
Day 352




Pre-op Dalteparin
(5,000 IU)
(2,500 IU)
Dalteparin
Post-op Dalteparin
(5,000 IU)
(2,500 IU)
Dalteparin
Warfarin
Placebo for
Warfarin


Venography
Venography
Hull et al. Arch Intern Med 2000 160
2199-2207.Hull et al. Arch Intern Med 2000
160 2208-2215.
78
Frequency of DVT Acute Hospital Phase
Relative Risk Reductions
  • Pre-op dalteparin vs warfarin All DVT 55
    (plt0.001) Proximal DVT 72 (p0.035)
  • Post-op dalteparin vs warfarin All DVT 45
    (plt0.001) Proximal DVT 72 (p0.033)
  • Combined pre- and post-op dalteparin vs warfarin
    All DVT 50 (plt0.001) Proximal DVT 72 (p0.009)

Hull et al. Arch Intern Med 2000 160
2199-2207.Hull et al. Arch Intern Med 2000
160 2208-2215.
79
Low-Molecular-Weight Heparin Prophylaxis Using
Dalteparin in Close Proximity to Surgery Vs
Warfarin in Hip Arthroplasty Patients
  • A modified dalteparin regimen in close proximity
    to surgery resulted in substantive risk
    reductions for all and proximal deep vein
    thrombosis, compared with warfarin therapy
  • Such findings have not been observed
    withlow-molecular-weight heparin therapy
    commenced 12 hours preoperatively or 12 to 24
    hours postoperatively vs oral anticoagulants

Hull et al. Arch Intern Med 2000 160 2199-2207.
80
Low-Molecular-Weight Heparin Prophylaxis Using
Dalteparin in Close Proximity to Surgery Vs
Warfarin in Hip Arthroplasty Patients
  • Increased major but not serious bleeding occurred
    in patients receiving preoperative dalteparin
  • Dalteparin therapy initiated postoperatively
    provided superior efficacy vs warfarin without
    significantly increased overt bleeding

Hull et al. Arch Intern Med 2000 160 2199-2207.
81
Quadratic Fit For Study Odds Ratio For DVT Vs
Number Of Hours From Surgery For The First Dose
Of LMW Heparin
Odds Ratio
Hours from Surgery
Upper and lower dashed lines indicate the 95
confidence interval for the true odds ratio
Hull et al. Arch Intern Med 2001 161 1952-60
82
Impact of Timing of Prophylaxis Total DVT
in Patients Undergoing Elective Hip
Surgery
Relative Risk (95 CI)
Time of Initiation (hrs)
Relative Risk
p Value
Expt n/N ()
Ctrl n/N ()
Study
0.89 1.01 0.57 0.50
0.444 0.984 0.008 lt0.001
Hull (1993) Hamulyak Francis Hull (2000)
69/332 (20.8) 27/195 (13.8) 28/192
(14.6) 80/673 (11.8)
79/340 (23.2) 27/196 (13.8) 49/190 (25.8) 81/338
(24.0)
Post18-24 Pre12 Pre? 2 Pre? 2 Post4-6
1.00
100.0
0.10
10.0
0.01
Favours LMWH
Favours Oral Anticoagulants
CI Fixed
Hull et al. Arch Intern Med 2001 161 1952-60
83
Impact of Timing of Prophylaxis Proximal DVT
in Patients Undergoing Elective Hip
Surgery
Relative Risk (95 CI)
Time of Initiation (hrs)
Relative Risk
p Value
Expt n/N ()
Ctrl n/N ()
Study
Hull (1993) Hamulyak Francis Hull (2000)
1.26
0.526
16/332 (4.8)
13/340 (3.8)
Post18-24
9/196 (4.6)
1.34
12/195 (6.2)
0.495
Pre12
0.218
Pre? 2
10/192 (5.2)
16/190 (8.4)
0.62
0.28
Pre? 2
6/712 (0.8)
11/363 (3.0)
0.011
Post4-6
1.00
100.0
0.10
10.0
0.01
Favours LMWH
Favours Oral Anticoagulants
CI Fixed
Hull et al. Arch Intern Med 2001 161 1952-60
84
Timing of Initial Administration of
Low-Molecular-Weight Heparin Prophylaxis Against
Deep Vein Thrombosis in Patients Following
Elective Hip Arthroplasty
  • The timing of initiating LMWH significantly
    influences antithrombotic effectiveness
  • The practice of delayed initiation of LMWH
    prophylaxis results in suboptimal antithrombotic
    effectiveness without a substantive safety
    advantage

Hull et al. Arch Intern Med 2001 161 1952-60
85
Timing of Prophylaxis
  • For major orthopedic surgical procedures, we
    recommend that a decision about the timing of the
    initiation of pharmacologic prophylaxis be based
    on the efficacy-to-bleeding tradeoffs for that
    particular agent (Grade 1A)
  • For LMWH, there are only small differences
    between starting preoperatively or
    postoperatively, and both options are acceptable
    (Grade 1A)

Chest 2004 126 338S-400S.
86
Dosing Options for Patients UndergoingHip
Replacement Surgery
Dose of Dalteparin to be Given Subcutaneously
Timing of First Dose of Dalteparin
10-14 hrPre-op
Within 2 hr Pre-op
4-8 hrPost-op1
Post-op Period2
Post-op start
---
---
2500 IU3
5000 IU qd
Pre-op start-day of surgery
---
2500 IU
2500 IU3
5000 IU qd
Pre-op start-evening before surgery4
---
5000 IU
5000 IU
5000 IU qd
1 Or later, if hemostasis has not been
achieved. 2 Up to 14 days of treatment was well
tolerated in controlled clinical trials, where
the usual duration of treatment was 5 to 10 days
postoperatively. 3 Allow a minimum of 6 hours
between this dose and the dose to be given on
PostoperativeDay 1. Adjust the timing of the
dose on Postoperative Day 1 accordingly. 4 Allow
approximately 24 hours between doses.
www.fda.gov/medwatch/SAFETY/2003/03Feb_PI/Fragmin_
pdf
87
Knee Arthroscopy
88
Knee Arthroscopy
We suggest clinicians do not use routine
thromboprophylaxis in these patients, other than
early mobilization (Grade 2B)
Chest 2004 126 338S-400S.
89
Knee Arthroscopy
  • For patients undergoing arthroscopic knee surgery
    who are at a higher than usual risk based on
  • Pre existing VTE risk factors
  • Or following a prolonged or complicated
    procedure
  • We suggest thromboprophylaxis with LMWH(Grade
    2B)

Chest 2004 126 338S-400S.
90
Thrombocytopenia
The Harbinger of Doom for Unfractionated Heparin
91
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 1062710-15
92
How Frequently is VTE in Heparin-Treated Patients
Associated with Heparin-Induced Thrombocytopenia
(HIT)
  • VTE is associated with HIT infrequently (lt1) in
    LMWH-treated patients, yet often (approximately
    one in eight cases) in unfractionated
    heparin-treated patients.
  • Physicians should suspect the possibility of HIT
    if VTE develops during or soon after
    unfractionated heparin use if thrombocytopenia
    is present, alternative anticoagulation should be
    used until HIT is excluded.

Levine et al. CHEST 2006 130(3) 681-687.
93
Electronic Medical Alerts So Simple, So Complex
 One of the most consistent findings in health
research is the gap between evidence and
practice.
Durieux. N Engl J Med 2005 352 1034-1036
94
(No Transcript)
95
Appendix
96
Obesity
97
The Safety of Dosing Dalteparin Based on Actual
Body Weight for the Treatment of Acute Venous
Thromboembolism in Obese Patients
Our study suggests that it is safe to administer
dalteparin at or near full dose based on actual
body weight for the treatment of acute venous
thromboembolism without an increased risk of
major hemorrhage Limiting the dose of
dalteparin to 18 000 IU could lead to an
increased risk of recurrence of venous
thromboembolism
Al-Yaseen et al. J Thromb Haemost 2005 3
100-102.
98
Dosing in Heavy-Weight/Obese Patients with the
LMWH, Tinzaparin A Pharmacodynamic Study
Subcutaneous tinzaparin dosing in heavy or obese
patients is appropriate based on body weight
alone the dose need not be capped at a maximal
absolute dose
Hainer J et al. J Thromb Haemost 2002 87
817-823.
99
Renal Impairment
100
Is Impaired Renal Function a Contraindication to
the Use of Low-Molecular-Weight Heparin?
  • The use of a 30-mL/min (0.50-mL/s) cutoff is not
    justified, on the basis of currently available
    evidence, to select individuals at increased risk
    of accumulation when LMW heparin is used
  • The pharmacokinetic response to impaired renal
    function may differ among low-molecular-weight
    heparin preparations

Nagge et al. Arch Intern Med 2002 162
2605-2609.
101
Evidence-Based Guidelines Recommendations
  • Two Components
  • Methodological Quality of a Recommendation
  • Grade A
  • Grade B or
  • Grade C
  • Benefit/Risk
  • Grade A or
  • Grade B

The 7th ACCP Conference on Antithrombotic and
Thrombolytic Therapy. Chest 2004 126 179S-187S.
102
Venous Thromboembolism Recognizing and Treating
thePatient at Risk
Peter Hanson, MD Medical Director of
Orthopaedics Chief of Staff Grossmont Hospital,
La Mesa, CA
103
What Are We Trying To Prevent?
  • Asymptomatic DVT?
  • Symptomatic DVT?
  • All PEs?
  • Fatal PEs?
  • Post-phlebitic Syndrome?

104
Dear Surgeon..
105
(No Transcript)
106
(No Transcript)
107
Virchows TriadThrombosis Risk in Orthopedic
Surgery
  • VascularInjury
  • Surgical manipulation of the limb
  • Endothelial injury
  • Venous
  • Stasis
  • Tourniquet
  • Immobilization and bed rest

Very High Risk Medium/High Risk Low/Medium Risk
  • Hypercoagulability
  • Increase in thromboplastin agents

108
DVT Prevention in Knee Replacement(Total DVT by
venography)
109
Preventing DVT in TKR With AspirinAspirin Alone
Is Not Effective Prophylaxis After TKR
110
DVT Prophylaxis in Total Knee Replacement (TKR)
LMWH vs Warfarin
Proximal DVT
Total DVT
Plt0.001
Plt0.001
45.4
50
40
25.4
30
20
10
0
Enoxaparin 30 mg sc twice daily(n173)
Warfarin dose-adjusted INR 2-3 (n176)
Spiro et al. Blood. 199484(suppl 1)246a.
111
Bleeding in Total Knee Replacement (TKR) LMWH vs
Warfarin
P0.04
40
33.5
30
23.3
20
6.4
10
5.2
3.4
2.3
0
Major Bleeding
Wound Complications
Overall Bleeding
(clinically significant)
Enoxaparin30 mg sc bid
Warfarindose-adjustedINR 2-3
Spiro et al. Blood. 199484(suppl 1)246a.
112
Enoxaparin vs Warfarin inTotal Knee Replacement
Leclerc JR et al. Ann Intern Med. 1996,
124.619-626.
113
Fondaparinux Targeted Mechanism of Action
Extrinsic pathway
Intrinsic pathway
3
1
2
Antithrombin
Xa
Xa
ATIII
ATIII
ATIII
Fondaparinux
IIa
II
Fibrinogen
Fibrin clot
ATIII antithrombin III
Adapted with permission from Turpie AGG, et al. N
Engl J Med. 2001344619-625.
114
TKR Efficacy Results Primary Endpoint
Incidence of patients with VTE up to day 11
32
27.8
RRR 55 P 0.0000003
28
24
20
Patients ()
16
n 101
12.5
12
8
n 45
4
0
Fondaparinux 2.5 mg QD (n361)
Enoxaparin 30 mg BID(n363)
95 CI 9.2 16.3 23.3
32.7
Pentamaks
115
TKR Efficacy ResultsSecondary Endpoint
Incidence of patients with VTE up to day 11
30
27.1
Fondaparinux Enoxaparin
25
21.3
20
Patients ()
15
12.5
9.4
10
5.4
5
2.4
0
Any DVT P lt 0.0001
Proximal DVT P 0.056
Distal DVT only P 0.000009
Pentamaks
116
TKR Safety Bleeding

From 1st injection to day 11 all treated
patients
P value
Enoxaparin 30 mg BID
Fondaparinux 2.5 mg QD
NS
Fatal bleeding, n
0
0
Nonfatal bleeding in critical organ, n
NS
0
0
Bleeding leading to reoperation, n ()
NS
2 (0.4)
1 (0.2)
Bleeding with transfusion 2 units and/or hg
decrease 2 g/dL, n ()
lt0.05
9 (1.7)
0 (0.0)
NS
Other bleeding (minor), n ()
15 (2.9)
21 (4.0)
PentamaksNS no statistically significant
difference
117
Thromboprophylaxis for Knee ReplacementDalteparin
vs Warfarin Post-Hoc Analysis
Post-hoc analysis of patients (n155) who
received the 1st dose of dalteparin gt7.5 hours
postoperatively
40
30.0
30
25.7
Incidence of VTE ()
19.7
20
10
0
gt7.5 and ?9 hrs (n61)
gt9 and ?12 hrs (n74)
gt13 hrs (n20)
Time to first dalteparin dose
VTE, venous thromboembolism
Ayers DC et al. Poster presented at American
Academy of Orthopaedic Surgeons 2006 Annual
Meeting March 22, 2006 Chicago, IL.
118
Rationale for Extended Prophylaxis After THR/TKR
Cumulative Risk of Thromboembolic Events
DuringFirst 3 Months Postoperatively
All VTE
PE
The incidence of thromboembolic events does not
stabilize untilapproximately 10 weeks after THR
White et al. Arch Intern Med. 19981581525-1531.
119
Rationale for Extended Prophylaxis
Incidence of PE within 3 months post-surgery
1.1
of patients with PE
1.0
0.8
0.5
0
Total Hip Arthroplasty n 19,000
Total Knee Arthroplasty n 24,000
White et al. Arch Intern Med. 19981581525-1531.
120
Rationale for Extended Prophylaxis
76
80
60
47
40
20
0
Total Hip
Total Knee
Replacement
Replacement
n19,000
n24,000
White et al. Arch Intern Med. 19981581525-1531.
121
Rationale for Extended Prophylaxis
Median Time of DVT Diagnosis After Surgery (Days)
Total Hip
Arthroplasty
17 Days
n19,000
Total Knee
7 Days
Arthroplasty
n24,000
0
5
10
15
20
White et al. Arch Intern Med. 19981581525-1531.
122
NAFT Study Design
Extended Phase
Acute Phase
Day 6
Day 7
Day 35
Day 0 (surgery)
Dalteparin
Dalteparin (pre-op)
Screening
Dalteparin
Dalteparin (post-op)
visit
Warfarin
Switched to Placebo
Venography
Venography
123
NAFT Results
  • Extended Outpatient Phase (Day 35 2)
  • (Patients with negative bilateral venograms at
    day 62)

Treatment Group Proximal DVT RR Total
DVT RR
()
()
()
()
  • Pre-op dalteparin 3.1 67 17.2 55
  • Post-op dalteparin 2.0 79 22.2 41
  • Warfarin/placebo 9.2 (5 de novo) 36.7

RRcombined risk reduction vs. warfarin/placebo
group P0.023 Plt0.001 P0.007 P0.003
Hull RD, et al. Arch Intern Med.
20001602199-2207.
124
NAFT Results
Extended Outpatient Phase (Day 35 2) (Patients
with negative bilateral venograms at day 62)
  • MajorTreatment Group Bleeding ()
    Wound Hematoma ()
  • Complicated Uncomplicated
  • Pre-op dalteparin 0 0.5
    2.5
  • Post-op dalteparin 0 0.5
    2.1
  • Warfarin 0 1.1
    2.8

Hull RD, et al. Arch Intern Med.
20001602199-2207.
125
Enoxaparin Extended Prophylaxis
  • Comp et al 2001 JBJS
  • Enoxaparin 7-10 days vs 4 wks, TKAs and THAs
  • Extended dosing in THAs significantly decreased
    DVTs, no difference in TKAs
  • No added bleeding risk

126
Recent Studies Extended Prophylaxis
  • Eikelboom et al 2001 Lancet
  • Meta-analysis of 3999 patients, THA and TKA,
    extended prophylaxis vs placebo/no tx
  • Decreased Sxic DVT in hips (not knees)
  • Decreased Asxic DVT in hips(not knees)
  • 20 sxic DVT/1000 pts, 1death/1000 pts prevented
  • 4-7 / day in UK, 24-28 / day in US
  • No warfarin studies available

127
Extended Prophylaxis PENTasaccharide in
Hip-FRActure Surgery (PENTHIFRA Plus) Results
p lt 0.001no significant difference between
treatment groups
Eriksson BI et al. Arch Intern Med.
20031631337-1342.
128
Extended Prophylaxis with Fondaparinux Hip
Fracture Repair
35.0
35
30
25
RRR 96
Patients ()
20
n 77
15
10
1.4
5
n 3
0
Fondaparinux (n208)
Placebo (n220)
Eriksson BI et al. Arch Intern Med.
20031631337-1342.
129
Guidelines for Prevention of VTEAre They
Relevant?
Current Findings Applications for
Thromboprophylaxis in Orthopaedic Surgery The
Four Seasons Hotel, San Francisco March 10, 2004
130
Definition of Practice Guidelines
  • Practice guidelines are systematically
    developedstatements to assist practitioner and
    patient decisions about appropriate health care
    for specific clinical circumstances.

131
Seventh ACCP Recommendations
132
Seventh ACCP Recommendations
133
Seventh ACCP Recommendations
134
Duration Of Treatment (ACCP)
  • Optimal duration of prophylaxis after THR or TKR
    - at least 7-10 days
  • Extended prophylaxis with LMWH recommended at
    least for high risk patients

135
Multimodal Approach to VTED Prophylaxis for THA
and TKA
ACCP
Orthopaedists
  • Paul F. Lachiewicz, M.D.
  • Department of Orthopaedics
  • University of North Carolina - Chapel Hill

136
THA Techniques
  • Then Now
  • Bed rest 1 week lt1 day
  • Hospital stay 2-3 weeks 2-4 days
  • EBL (mean) 1650 ml 300-600 ml
  • Blood Homologous Autologous
  • Transfusion (mean) 1144 ml 0-500 ml
  • Anesthesia General Regional

137
  • These major changes in THA techniques suggest
    that our older ideas about chemoprophylaxis
    should be reconsidered in 2007

138
Multimodal Prophylaxis
  • Preoperative
  • Intraoperative
  • Postoperative

139
Preoperative Risk Factors VTED
  • Genetic predisposition
  • Hypercoaguable states
  • Prior history PE
  • Oral contraceptives (?)
  • Classic risk factors have not
  • correlated with VTED in elective THA patients

140
PreoperativeAutologous Donation
  • Retrospective study 2043 patients
  • Donation 1037 not 1006
  • DVT Donation 9.0 (p0.003)
  • (venogram) Not 13.5
  • P.E. Donation 0.3 (ns)
  • (clinical) Not 0.7

Bae et al. JBJS (B) 2001
141
Thromboembolism THRAnesthesia
  • Spinal or epidural anesthesia reduces risk by
    40-50
  • Regional anesthesia increased blood flow in lower
    extremities during and after the procedure
  • Lower blood loss, ? quicker surgery

142
Mechanical Prophylaxis THA
  • Intraoperative use does not interfere with
    positioning, exposure, placement of implants

143
Mechanical Prophylaxis THA
  • 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

144
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

145
Venous Hemodynamics After THA
  • Devices with rapid inflation time
  • Produced the greatest increase in peak venous
    velocity
  • Devices that compress calfand thigh
  • Produced the greatest increase in venous volume

146
Multimodal Prophylaxis
  • June 1991 May 2005
  • Single surgeon
  • 1042 consecutive THA
  • (388 in previous study)
  • 10 exclusions
  • (5 hemophilia, 5 other)

Lachiewicz, Soileau. Clin Orthop 2006
147
Study Group
  • 1032 hip procedures
  • 422 male, 610 female
  • Mean age 64 (22-95)
  • Primary 680
  • Revision 352
  • Patients with prior history of TED or on
    warfarin for cardiac conditions not excluded

148
Materials Methods
  • Anesthesia
  • Regional 95
  • General only 5
  • Intraoperative mechanical
  • bilateral, thigh-high
  • sterile sleeve-operative limb
  • single manufacturer
  • Recovery room until discharge
  • Duplex ultrasound prior to discharge (day 3-8)

149
Results - Mortality
30 day mortality 3 of 1032 (0.3)
  • 1 fatal pulmonary embolism (0.09)
  • 24 days postop-autopsy
  • patient in long-leg brace
  • minimal ambulation
  • 1 cerebrovascular accident
  • 1 unknown abdominal pain cardiac arrest
  • ? M.I. vs P.E.

150
Pulmonary Embolism
  • Symptomatic 7 (0.7)
  • 4 early (POD 4-7)
  • 3 late
  • POD 23
  • 24 (fatal)
  • 37
  • Only 1 of 7 also had DVT or ? Duplex

151
Mechanical Prophylaxis withAspirin vs Aspirin
Alone
  • Prospective, randomized
  • 100 hips - MR venography
  • Rapid inflation device (Venaflow)
  • applied in recovery room
  • epidural hypotensive anesthesia
  • aspirin 325 mg BID
  • Mechanical aspirin 8 prox. DVT
  • aspirin alone 22 prox. DVT (plt.05)

Ryan et al. JBJS 2002
152
Multimodal Prophylaxis THA
  • Calf-thigh compression begun intraoperatively is
    effective and acceptable for 99 THA patients
  • 1032 hips
  • Fatal PE 0.09
  • Total DVT-PE 4.6
  • Pulmonary embolism 0.7

153
VTED After TKA Orthopaedic Perspective
  • Different disease than after THA
  • Most thrombi occur in calf only
  • Extension to proximal veins occurs infrequently
  • Pulmonary embolism rare

154
Orthopaedists Concerns
  • Prevention of
  • Fatal PE
  • Symptomatic PE
  • Symptomatic DVT
  • Knee bleeding

How important is it to prevent asymptomatic
venogram or Duplex scan-detected thrombi?
155
Orthopaedists Concerns Anticoagulation TKA
  • Increased risk of major bleeding into knee and
    wound complications (0.9 5.2)
  • True risk of bleeding and outcome not established
    for all TKA patients
  • Bleeding into TKA associated with hematomas,
    drainage, infection and poorer outcomes

156
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?

157
Venous Hemodynamics After TKA
Westrich et al. JBJS (B) 1998
158
Mechanical Prophylaxis TKA
  • 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
  • What matters most
  • velocity or volume?

159
Two Mechanical Devices for Prophylaxis of
Thromboembolism After TKA
Prospective, randomized study
Lachiewicz et al. JBJS (B), Nov 2004. University
of North Carolina-Chapel Hill
160
Patient Population
  • 423 patients, 472 knees
  • Mean age 66.8 yrs (23-94)
  • Mean wt 87.3 kg (45-148)
  • Diagnosis DJD 307
  • RA 25
  • Rev. 64
  • Other 27

161
Results
  • Asymmetrical Circumferential
  • Compression Compression
  •  
  • Patients 206 217
  • Knees 232 240
  • Mortality 0 1 (.46)
  • Pulm. Embolism 0 1 (.46)
  • Thrombi 16 (6.9) 36 (15) p .007
  •   Calf 15 30
  • Proximal 1 6

162
ThromboembolismKnee Procedure
  • Asymmetrical Circumferential
  • Compression Compression
  •  Unilateral, primary
  •  
  • Knees 155 158
  •   Thrombi 13 (8.4) 26
    (15.8) p 0.03
  •  
  • Bilateral, primary
  • Patients (knees) 25 (50) 22 (44)
  •  
  • Patients-thrombi 1 (4) 5
    (22.7) p 0.09
  •   Limbs-thrombi 2 (4) 7 (15.9) p
    0.05

163
Personal TKA Series Calf IPC Plus Aspirin
1991 - present
  • 856 TKAs
  • Mortality (MI) 1 (0.12)
  • Symptomatic PE 3 (0.35)
  • DVT (Duplex) 66 (7.7)
  • (56 pts)

164
Multimodal Prophylaxis TKAVenaflow LMWH vs.
Venaflow Aspirin
  • Prospective, randomized
  • 275 unilateral TKAs
  • Duplex scan 3-5 days 4-6 weeks
  • DVT 14.1 vs 17.8 (p 0.27)
  • No difference between groups!

Westrich et al. J. Arthroplasty 2006
165
VTED Prophylaxis TKAWhat is Acceptable in 2007
  • Mechanical prophylaxis plus aspirin is safe and
    effective for most TKA patients
  • Recommend rapid-inflation, asymmetric calf
    compression device
  • Anticoagulation for patients allergic to aspirin
    or with heritable coagulopathy
  • Multimodal prophylaxis is an acceptable
    alternative to ACCP Guidelines

166
Anticoagulation andthe Orthopedic Patientthe
Anesthesiologists Perspective
  • Eugene R Viscusi, MD
  • Director, Acute Pain Management
  • Associate Professor
  • Department of Anesthesiology
  • Thomas Jefferson University, Philadelphia, PA

167
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

168
Overview
  • The 2004 ACCP recommendations further increased
    the level and duration of thromboprophylasis.
    Despite the reduction of asymptomatic
    thromboembolic events, an actual reduction of
    clinically relevant events has been difficult to
    demonstrate 1,2
  • These changes create new challenges for managing
    neuraxial and invasive non-compressible
    peripheral blockade

1. Murray DW, et al. J Bone Joint Surg.
199678863-870. 2. Mantilla CB, et al.
Anesthesiology. 2002961140-1146.
169
The Challenge
  • The ACCP guidelines and the ASRA consensus
    statement on neuraxial techniques often leave the
    clinician in the zone of discomfort
  • Both statements provide important clinical
    information but dont address all situations
  • ASRA guidelines are based on knowledge of the
    agents and past adverse events rather than large
    studies. (Difficult to provide the denominator)

170
2004 ACCP Recommendations
  • Unfractionated heparin every 8 hours
  • No data documenting safety of neuraxial
    catheters complicates catheter removal
  • Fondaparinux following major orthopedic surgery
  • ASRA recommends againstepidural catheter
  • Warfarin target INR for TJA is 2.5
  • If achieved would precludeepidural catheters

Chest. Sept 2004, supp
171
2004 ACCP Recommendations
  • Dosing of LMWH early in the postoperative period
    was associated with an increased risk of
    neuraxial bleeding
  • Anticoagulate a minimum of 10 days 28-35 for
    total hip
  • Interaction of prolonged thromboprophylaxis,
    neuraxial instrumentation, difficult or traumatic
    needle insertion is UNKNOWN

172
1,260,000 spinals 450,000 epidurals
  • 33 spinal hematomas
  • 24 in females, 25 with epidural
  • Coagulopathy in 11
  • Time of occurrence 24 hours (6H-14D)
  • 5 of 33 recovered (delay in treatment)
  • 4 patients with indwelling epidural catheters
    received 5,000 U heparin during surgery

Moen V, et al. Anesthesiology. 2004101950-959
173
  • Authors calculated risk for females undergoing
    TKA 13,600! (female, age, spinal canal
    pathology, duration of catheter,
    thromboprophylaxis)
  • Onethird of all spinal hematomas occurred in
    patients receiving thromboprophylaxis in
    accordance with current guidelines

Moen V, et al. Anesthesiology. 2004101950-959
174
Spinal Hematoma
  • May occur in the absence of identifiable risk
    factors
  • Neurological monitoring is critical for early
    intervention
  • Early recognition and treatment is key to
    improved outcome (laminectomy within 8 hours) 1
  • Focus not only on prevention but also improving
    neurological outcome

Vandermeulen ER, et al. Anesth Analg
1994791165-77
175
Warfarin
  • INR of less than 1.5 is recommended for removal
    of epidural catheters1
  • Check INR
  • Every day with an indwelling epidural catheter
  • Prior to needle insertion if given more than 36
    hours prior

1. 2nd ASRA Consensus Conference on Neuraxial
Anesthesia and Anticoagulation. Reg Anesth Pain
Med. 200328172-197.
176
Can Epidural Anesthesia andWarfarin be
Coadministered?1
  • Prudence must be exercised when enforcing these
    guidelines, both in the upper INR limit as well
    as potential reversal of anticoagulation1
  • 11,235 patients no detectable hematomas
  • 1030 randomly reviewed charts 398 patients had
    INR greater than 1.5 (1.54 mean, range 0.93-4.25)

1. Parvizi J, Viscusi ER. CORR, 2007( in press)
177
Can Epidural Anesthesia andWarfarin be
Coadministered?1
  • If the INR is elevated, should anticoagulation
    be reversed?
  • Pulmonary embolism is aserious risk
  • FFP is not without risk in itself
  • Decision should be taken case by case and the
    thought process fully documented!

1. Parvizi J, Viscusi ER. CORR, 2007( in press)
178
Standard (Unfractionated) Heparin
  • BID dosing is theoretically safe if catheter
    removal is timed with trough levels
  • TID dosing no data exists but PTT (anecdotally)
    may remain elevated
  • Heparin induced thrombocytopena (HIT) is a real
    concern
  • Platelet count is indicated after 5 days of
    unfractionated heparin

179
Standard Heparin andRegional Anesthesia
  • No contraindication following subcutaneous
    injection prior to spinal/epidural needle
    insertion
  • Delay administration for one hour following
    needle placement
  • Remove indwelling catheter at trough level or one
    hour prior to next dose
  • Prolonged therapy is linked to increase in spinal
    hematoma
  • Traumatic needle insertion may increase risk of
    spinal hematoma

ASRA consensus guidelines
180
LMWH
  • Restrict to once daily dosing regimen with
    epidural catheter
  • LMWH dosing minimum of 2 hours after catheter
    removal
  • Spinal hematomas have been reported with this
    regimen (The last chapter hasnt been written)

ASRA consensus guidelines
181
LMWH
  • Consider the risk/benefit ratio of thromboembolic
    event vs. spinal hematoma
  • Timing With once daily dosing, time epidural
    catheter removal in a safe window before next
    dose
  • Minimize delay of next dose
  • Renal function affects metabolism of LMWH (and
    other drugs). Elderly at particular risk. Dose
    accordingly 1

DSousa G, Viscusi ER. ASA 2006 (abstract)
182
Antiplatelet Medications
  • Uncommon as primary agents for thromboprophylaxis
    but may be used chronically by orthopedic
    patients1
  • A number of large studies demonstrated relative
    safety
  • However, if this is combined with heparin there
    may be increased (but unquantified) risk

Horlocker T, Wedel D. Anesth Analg 199580303-309
183
Platelet Aggregation Inhibitors
  • Interfere with platelet-fibrinogen binding and
    platelet-platelet interaction
  • Ticlopidine stop 14 days
  • Clopidogrel stop 7 days
  • Platelet glycoprotein IIb/IIIa receptor
    antagonists
  • 48 hours abciximab
  • 8 hours eptifibatide, tirofiban

ASRA consensus guidelines
184
Fondaparinux
  • Factor Xa inhibitor with half-life of21 hours1
  • Clinical trials
  • Atraumatic epidural needle placement
  • Epidural catheter removed 2 hours prior to dosing
  • Avoid indwelling epidural catheters with this drug

Turpie AG et al.LetterNEJM. 2001 345292
185
Recommendations for Safety with Neuraxial
Techniques
  • Know the ASRA guidelines
  • Employ single agent anticoagulation
  • Understand risks of each individual agent
  • Follow developments with peripheral nerve blocks
  • Careful monitoring of dose timing, coagulation
    studies and neurologic function are critical
  • Atraumatic needle placement if possible

186
Analgesic Techniques Hip
  • Intrathecal Morphine
  • Lumbar Plexus Block
  • Single injection or continuous catheter
  • Epidural Analgesia
  • Single injection, standard morphine
  • Extended-release Epidural Morphine
  • Indwelling epidural catheter

187
Analgesic Techniques Knee
  • Femoral Block
  • Single injection or catheter
  • Lumbar plexus (posterior approach)
  • Single injection or continuous catheter
  • Epidural analgesia
  • Indwelling continuous catheter
  • Extended-release Epidural Morphine
  • Single injection standard morphine

188
Summary
  • Safe and effective anesthesia and pain management
    for the orthopedic patient can be achieved in the
    presence of VTE prophylaxis when the entire care
    team (orthopedics, anesthesiology, nursing)
    understands the limitations, risks and works
    together
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