Non Pharmacological Method for Prevention and Treatment Of
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Transcript of Non Pharmacological Method for Prevention and Treatment Of
Non pharmacological method for
prevention and treatment of DVT
Dr L.M.Darlong. MS,FIAGES,FMASNorth-eastern Indira Gandhi Regional Institute of health and medical sciences (NEIGRIHMS). Shillong. India
DVT
• An intravascular deposit composed of fibrin and red blood cells with a variable platelet and leucocyte component.
• Occurs in region of slow blood flow
• Pulmonary embolism -fragment of this clot breaks and migrates to the lung and lodges in the pulmonary artery or its branch.– Most severe complication-
Cause • Usually not
known• Universally
attributed to Virchows triad
– STASIS – HYPERCOAGUL
ABILITY– INTIMAL INJURY
VenousVenousStasisStasis
Tourniquet
Immobilization and bed rest
VascularVascularInjuryInjury
Surgical manipulation of the limb
Endothelial injury
HypercoagulabilityHypercoagulability Increase in thromboplastin
agents
Natural History of DVT
• Without treatment, approx 20 to 25% of calf vein thrombi extend into the popliteal and femoral veins causing proximal DVT.
• Without treatment approximately half of patients with proximal DVT develop PE
• (Hull, RD, (Hull, RD, Raskob Raskob, GE, Hirsh, J Prophylaxis of venous thromboembolism : an overview.
• Chest1986;89,374S
Natural History ofPulmonary Embolism
• The mortality rate of patients treated for pulmonary embolism has decreased from 8% to < 5%.
• The majority of deaths due to PE ( ie > 90%) occur in pts who are not treated because the diagnosis is not made.
Prevention
• Prevention of pulmonary embolism is of paramount importance because the disorder is difficult to detect, and treatment of established pulmonary embolism is not universally successful.
DVT risk stratification for surgery patients
• Low risk Low• Uncomplicated surgery in patients aged <40 years with
minimal immobility postoperatively and no risk factors factors
• Moderate risk • Minor surg in pt with additional risk factor• Surg in 40-60 yrs with no additional risk factor• High risk• Surgery in patients aged >60 years,or 40-60 yrs with
additional risk factor• Very high risk• Surgery in patients with multiple risk factor (>40
years,previous venous thromboembolism,cancer or known hypercoagulable state)
• Major orthopedic surgery ( hip/knee arthroplasty)• elective neurosurgery• multiple trauma• spinal cord injury
What Are We Trying To Prevent?
• Asymptomatic DVT?
• Symptomatic DVT?
• All PE’s?
• Fatal PE’s?
• Post-phlebitic Syndrome?
Mechanism of action
• Stasis – Nonpharmacologic
• Hypercoagulable – Blood thinning agents
( Pharmacologic agents )
• Intimal injury – Minimal trauma / Tissue handling ( Non-Pharmacologic )
Non-Pharmacologic
• Early ambulation remains the most important nonpharmacologic
Mechanism
• Augmentation of venous blood flow in the lower limbs via external mechanical devices.- Decreases venous stasis.
• Venous compression secondary to external compression device results in the release of Plasminogen (Natural fibrinolytic ) and Nitric oxide ( Vasodilator) into the blood stream from the endothelial layer of the vein.
• Inferior vena caval filter ( IVC filter ); This are mechanical devices to trap blood clots arising from the lower limb and prevent them from traveling to the pulmonary circulation.
Non-Pharmacologic
Early ambulation
• Should be routine part of all postop care – Unless absolute contraindicated
• Acceptable as VTE prophylaxis for low risk surgical patients
Elastic stockings
• Improved venous flow ,reduce vessel wall damage caused by passive venous dilatation ,during surgery
• Applied preop and continued throughout the hospital
• Recommended as adjunct in moderate and high risk case
• Avoid improper fitting stockings
-Pneumatic Compression Devices (PCD) VasoPress
-Sequential Compression Devices (SCD) Kendall
• Intermittent regimen that delivers a sustained pressure in distal to proximal manner.
• The difference-Compartments in PCD devices are uniformly inflated to the same pressure rather than in a graded-sequential fashion as in SCD devices.
Intermittent Pneumatic Compression
IPC
• Intermittently inflates and deflates bladders contained within the garment (20-40 mmHg).
• Cycle times vary from manufacturer to manufacturer.
• Typically, the inflation (compression) cycle is 10-15 seconds with a 45-50 second relaxation (rest)
Intermittent Pneumatic Compression
• Direct pumping effect- Reduce stasis• Promotes clearance of local pro
thrombo clotting factor, increase local plasminogen activators
• Obese individual – Doubtful• Only effective used continously-
nonambulat• Presumed additive prophylactic effect
– pharmacologic
IPC
•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•
• Wide variety of devices– foot pump– calf– thigh-calf
Not recommended – Sole agent
• High risk – Gen Surgical pt• High risk – Urology surg pt• Orthopaedics –Hip or knee surgery
Method of choice when pt at increased risk of bleeding with anticoagulants
Solo thromboprophylaxis for moderate to high risk gynae surg
Current accepted indications• Absolute contra to anticoagulant• Life threatening hemorrhage on
anticoagulant• Failure of adequate anticoagulation
Prophylactic filter not recommended
It is an invasive procedure
IVC Filter
Recommendation Air TravelLong distance travel ( >6 h duration):.Avoid constrictive clothing.around lower extremities / waist .Avoid dehydration.Do frequent calf muscle stretching
Additional risk factors .If active prophylaxis/perceived increased risk .Suggest the use of properly fitted, below-knee GCS,providing 15 to 30 mm Hg of pressure at the ankle
Non pharmacologic management of PE
Catheter extraction or fragmentation for the initial rx of
PE
• Against use of mechanical approaches for most pts with PE.
• Use selected highly compromised pts who are unable to receive thrombolytic therapy or whose critical status does not allow sufficient time to infuse thrombolytic therapy
» Mortality of aprox 20-30%
Pulmonary embolectomyfor the initial treatment of PE
• Pulmonary embolectomy continues to be performed in emergency situations when more conservative measures have failed.
• If it is attempted the following criteria req:– 1) massive PE (angiographically documented if
possible)– 2) hemodynamic instability (shock) despite
heparin, resuscitative efforts;– 3) failure of thrombolytic therapy or a
contraindication to its use.
• Operative mortality from 10 to 75% in uncontrolled retrospective case series. (in the era of immediately available cardiopulmonary bypass has )
Risk Factor-Short-term (30-day) postoperative
• > 50 years • Varicose veins • Myocardial
infarction • Cancer • Atrial fibrillation • Ischemic stroke • Diabetes mellitus
• Other additional factors• -DVT• -heart failure• -Obesity• -paralysis,
• inherited conditions, • -factor V Leiden • -prothrombin gene
mutation,• -protein S deficiency• -protein C deficiency• -antithrombin
deficiency.
Barriers in DVT
• Routinely assess the risk / Asses as risk factor for heart disease.
• Encourage routine prophylaxis for pt at risk
• Prophylaxis underused – Consensus APHA.
• Lack of awareness of DVT risk• Percieved diff in risk asses and
percieved risk of bleed with prophylaxis
ACCP Recommendation
• Primarily in patients who are at high risk of bleeding
• Adjunct to anticoagulant-based prophylaxis
• Careful attention be directed toward ensuring the proper use of, and optimal compliance with, the mechanical device
Thank you