45 yo fall from ladder

7th Annual Nuts and Bolts of Orthopaedics Naples, FL October 2, 2015

DVT and PE Prophylaxis in Lower

Extremity Trauma

Daniel T. Altman, MD

Associate Professor of Orthopaedic Surgery Drexel University College of Medicine Temple University School of Medicine

Allegheny General Hospital

45 yo fall from ladder

• Proximal femur fx • CMN on PTD #1 • D/c to home POD #4 • Presents to ED POD #14 with SOB • Admitted to ICU/Ventilatory support

Goals

•

Review pathophysiology of the

hypercoagulable state

•

Understand current

recommendations

•

Review current options and

future directions

History

•

Rudolf Virchow

– Father of thrombogenesis

–??Developed the Triad theory

–“Education, freedom and prosperity” – 1849 –Suspended from Charité hospital then reinstated

•

DVTs first described in – 1271

–Raoul of Normandy

History

•

The Triad

–Albrecht von Haller - 1786

•Venous stasis

–Joseph Hodgson - 1815

Alexander Copeland Hutchinson - 1829 •Endothelial damage

–Andral - 1842

•Hypercoagulable state

From Virchow R.L.K. Cellular Pathology. 1863.

Where It All Began

• The Sunnybrook Study with Trauma Patients

–Polytrauma outcome with NO prophylaxis

•Lower extremity DVT – 58% •Proximal-vein DVT – 18% •Fatal PE – 1%

•69% of patients w/ LE orthopaedic injuries

– Geerts WH, et. al.: A prospective study of venous thromboembolism after major trauma

45 yo fall from ladder

• Proximal femur fx • CMN on PTD #1 • D/c to home POD #4 • Presents to ED POD #14 with SOB • Admitted to ICU/Ventilatory support

Right Heart Strain Pattern

Massive Bilateral PEs

Epidemiology

•

Prevalence of DVT in pelvic fractures

–W/o treatment 60%, proximal vein 25%

•

Prevalence of PE 2-10%

–Fatal in up to 50%

–Most common cause of death >7days post injury

•

Lower extremity suspected source in 75-95%

–Screening studies often Negative for DVT –?pelvic veins as source

Moed BR, et al. J Trauma. 2012. 72;443. Stover MD, et al. J Orthop Trauma. 2002. 16;613.

Pathophysiology

Hypercoagulable state: production of all factors

Venous Stasis (+) Intimal Injury (+) Heparin/ Lovenox (-) Fondaprinaux/ Arixtra Rivaroxaban/ Xarelto

Warfarin factors II, VII, IX, X, C and S

Hip Fractures

•

In elderly people with hip fx fixation, the

incidence of fatal PE is probably higher than in

elective surgery, at around

4%

and these

patients are likely to benefit from prophylaxis

ACCP 9

th

Clinical Guidelines (2012)

•

Not specific to pelvic trauma or trauma

patients in general

–Major Orthopaedic Surgery •LMWH 12 hrs pre or post operatively •Continue for up to 35 days post-op (TKA&THA) •Dual Prophylaxis: Mechanical and Chemical •Suggest against use of IVCF as primary prophylaxis •No routine screening in asymptomatic patients

Chest, Feb 2012

Hip Fractures – ACCP 2012

• “In patients undergoing hip fx surgery - recommend

use of one of the following rather than no

antithrombotic prophylaxis for a minimum of 10 to

14 days”

–LMWH, fondaparinux, LDUH(sq heparin), adjusted-dose VKA (coumadin), aspirin (Grade 1B)

–or IPCD (Grade 1C)

• “We suggest the use of LMWH in preference to the

other agents we have recommended as alternatives: fondaparinux, LDUH (Grade 2B) , adjusted-dose VKA, or aspirin (Grade 2C) ”

• High Risk Polytrauma Patients (not defined by AACP)

–Spinal cord injury

–Lower extremity, pelvic and spine fxs –Head trauma

–Femoral venous line, vascular repair –Multiple operations

–Older age –Immobility (>3days)

Geerts 1994

Do Injuries Below the

Knee Need Prophylaxis?

• RCT – Lower extremity fractures below the knee

–Rapid ORIF 24 hrs or less (simple ankle and tibia fractures) –Enoxaparin versus placebo

• No difference in DVT rate or embolus rate

–Suspected low rate because of early surgery/mobility

Goel & Buckley JBJS(B)March2009

What About Isolated

Fx Below the Knee?

•

ACCP 2012

–Suggest no prophylaxis rather than pharmacologic thromboprophylaxis in patients with isolated lower-leg injuries requiring leg immobilization (Grade 2C) .

–Cochran database review and a multicenter study

Upper Extremity Trauma

• Limited evidence available

–VTE in isolated UE injury incidence ~ 1-5%

• Retrospective review at Level I trauma center –Rate of VTE in UE trauma 4.95%

•Identical to rate of VTE in all trauma patients

–UE surgery for acute trauma compared with elective surgery

•No significant increase in VTE rates has been found

–Presence of UE trauma

•Not an independent risk factor for VTE

•Does not necessitate more aggressive anticoagulation •No additional risk of VTE beyond individual patient-related factors

AAOS Workgroups (2007 / 2011)

• Review of the literature by the American Academy of Orthopaedic

Surgeons (AAOS) workgroups – Re: THA / TKA

– no difference in efficacy among different agents with regard to prevention of PE

• AAOS guidelines

– recognize mechanical prophylaxis and aspirin as a modality of choice for prevention of VTE

• When the risk of VTE clearly outweighs the risk of major bleeding complications, the AAOS guidelines are in agreement with the AACP guidelines advocating chemoprophylaxis other than aspirin

Diagnosis

•

Diagnosis of DVT difficult, particularly in

proximal veins

•

Modalities

–Ultrasound with duplex –CT venography

–MRI/MRA

–Invasive venography

Moed BR, et al. J Trauma. 2012. 72;443. Stover MD, et al. J Orthop Trauma. 2002. 16;613.

Diagnosis

• Should asymptomatic patients be screened for

proximal DVT?

• Preop Ultrasound and/or Pre-d/c scan

• Positive Preop  IVC filter

• Negative Preop  Pre-d/c scan

• Positive prior to d/c  therapeutic dosing

• Increased diagnosis rate of DVT • Did not decrease rates of PE

Diagnosis

• Is MRV or CTV valuable in diagnosis?

• MRV and CTV for DVT obtained 24-48 hrs preop

• Patients with positive scan had selective venography

• If DVT confirmed on venogram then IVC filter placed

• 30 patients screened, 2 (+) CTV, 4 (+) MRV

• 1/5 had confirmed DVT on venography

Stover MD, et al. J Orthop Trauma. 2002. 16;613.

Prophylactic Duplex?

•

Both AACP and AAOS

guidelines

recommend against

routine duplex

ultrasound!

The Push for Prophylaxis

•

AAOS

–“The high risk of DVT and PE associated with major orthopaedic surgery suggests the need to reduce the incidence of asymptomatic DVT with effective thromboprophylaxis…”

The Push for Prophylaxis

•

AACP (2008)

–“A vast number of randomized clinical trials over

the past 30 yrs provide irrefutable evidence that

primary thromboprophylaxis reduces DVT and

pulmonary embolism (PE), and there are studies that have also shown that fatal PE is prevented by

thromboprophylaxis.”

When to Start?

High

Low

0 1 2 3 4 5 6 7

Days since injury Risk

Thrombosis risk Bleeding risk

Role for Early Prophylaxis

• Typical protocols address postop period –Preop prophylaxis may be valuable in pelvis injuries –LMWH within 24 hrs of injury or when stable

–Higher rate of DVT when LMWH NOT given within 24 hrs of injury 3% v 22% (p <0.01)

•No Complications of LMWH reported

Steele N, et al. JBJS Br. 2005. 87-B;209.

–Early use of LMWH did not place patients at increased risk for intracranial bleeding compared with placebo

Phelan HA, et al. J Trauma 2012. 73(6):1434-1441.

–Early LMWH administration was only intervention that decreased both DVT and PE in review of

thromboprophylaxis for pelvic and acetabular surgery Slobogean GP, et al. J Orthop Trauma 2009;23(5):379-384.

When to Start – ACCP 2012

•

For patients undergoing major orthopedic

surgery (THA, TKA, HFS) and receiving LMWH

as thromboprophylaxis, recommend starting

either 12 h or more preop or 12 h or more

postop rather than within 4 h or less postop

(Grade 1B)

When to Stop?

•

Mobilization is not a reliable end point for

stopping!

–It is protective and should be instituted early

• AACP 2012

–For patients undergoing major orthopedic surgery, suggest extending thromboprophylaxis for up to

35 days from the day of surgery rather than for only 10 to 14 days (Grade 2B)

Mechanical Prophylaxis

• Compression stockings, pneumatic compression devices, foot pumps

–Shown to be effective in reducing rates of DVT, esp in multimodal treatments

• AACP 2012

–In patients undergoing major orthopedic surgery suggest dual prophylaxis with antithrombotic agent and IPCD during hospital stay

Evidence for Mechanical Prophylaxis

•

Mechanical prophylaxis - nearly universal

practice

•Stimulates blood flow •Increases fibrinolytic activity

•

Pulsatile compression pumps may be better

than sequential compression devices

(not

statistically significant)

Stannard JP, et al. JBJS 2001

•

Some form of mechanical prophylaxis may be

better than none (not statistically significant!)

Fisher CG, et al. J Ortho Trauma 1995

Mechanical Prophylaxis

• IVC Filter

–IVC filters are not for primary prophylaxis

–Consistent reduction in PE and fatal PE with IVCF placement, without reduction in DVT or mortality

•Haut ER, et al. JAMA Surg 2014;149(2):194-202. • ACCP 2012

–In patients undergoing major orthopedic surgery, suggest against IVC filter placement for 1⁰ prevention over no thromboprophylaxis in pts with an increased bleeding risk or contraindications to both pharmacologic and mechanical thromboprophylaxis (Grade 2C)

The Other Side…

• Incidence of all-cause mortality was higher after chemoprophylaxis compared with mechanical compression devices and aspirin

–LMWH, Fondaparinux, etc – 0.41% –Coumadin – 0.4%.

–Regional anesthesia, SCD, ASA – 0.19%

Sharrock NE, et. al.: Potent anticoagulants are associated with a higher all-cause mortality rate after hip and knee arthroplasty. CORR 2008

The Bottom Line

•

Specific evidence is sparse

–No Strong population specific evidence for DVT/PE prophylaxis guidelines

–Most studies are small

–Few studies provide statistically significant differences in methods of prophylaxis

•

Large Multicenter studies needed to clarify

Slobogean GP. J Orthop Trauma. 2009. 23;379

Huge Questions Remain

• What exactly is “major orthopaedic surgery”? • What is the link between DVT and fatal PE?

–“Anticoagulation for thromboprophylaxis after THA and TKA has not been confirmed to diminish all-cause mortality”

•Sharrock NE et.al. CORR. 2008 March

–Evidence of peripheral DVT by ultrasound or autopsy is not always present in those with symptomatic PE. Pharmacologic prophylaxis lowers rate of DVT formation, but PE-related mortality remain high

•Stannard JP et al. JBJS 2006;88(2).

• Who do we listen to (conflicts-of-interest)? • Newer agents? – Oral Xa inhibitors (Rivaroxiban)

Have a Plan!

•

Review the literature, the recommendations

of the AACP and AAOS and work with your

colleagues to develop your own “standard of

care” for your local area or institution.

•

Document your treatment decisions

•

Educate the patient!

Summary

• DVT risk high in proximal femur fxs

• Every institution should have established guidelines and QA

• Symptomatic/fatal PE does occur • LMWH is efficacious and safe

• Mechanical prophylaxis is safe supplement to any regimen but less effective independently