Venothrombotic Disease & Urological Surgery
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Transcript of Venothrombotic Disease & Urological Surgery
Venothrombotic Disease&
Urological Surgery
Jeffrey P Schaefer MSc MD FRCPC
April 27, 2007
Biography• 1986 BSc microbiology U Sask• 1991 MD distinction U Sask• 1995 FRCPC Internal Medicine U Calg• 1999 MSc CHS (Epidemiology) U Calg• 2000 RGH Site Chief, Medicine• Interests:
– education– integrative medicine– information technology
Why have this talk?
• Define• Risk• Diagnosis• Prevention• Therapy• Prognosis
Venothrombotic disease (VTED)
• superficial thrombophlebitis
• deep vein thrombosis– lower limb– upper limb
• pulmonary thromboembolism
• post-thrombotic syndrome
Superficial Vein Thrombophlebitis
Superficial Vein Thrombophlebitis
Superficial Leg Veins Saphenous (L & S)
Potentially Lethal Misnomer SFV = deep
Deep Vein Thrombosis
Pulmonary Thromboembolism
Pulmonary Thromboembolism
Post-Thrombotic Syndrome
• Variously defined– pain and swelling post-DVT– 20 – 50%
DVT - diagnosis
• Clinical Suspicion• D-dimer screen• Compression Ultrasound• Venography
• (MRI expensive)• (IPG ‘discredited’)
DVT - diagnosis• Clinical Suspicion - performs poorly
Well’s Criteria
- study excluded those with previous VTED, needed indefinite anti-coagulation, imminent death
D - dimer• D-dimer Assay
– D-dimer is breakdown product of fibrinolysis
– high sensitivity (98%) & modest specificity (~50%)
– useful for excluding DVT and PE– not useful for confirming diagnosis
– SHOULD NOT TO BE USED•post-operative patient• pregnant patient• patient with malignancy
Duplex Ultrasonography
• Duplex US – above knee DVT
• Sens = 96%• Spec = 96%
Haemostasis 23:61-7
• calf dvt– sens = 80%
Venography• Gold standard (sens 100%, spec 100%)
Pulmonary Thromboembolism
Pulmonary Thromboembolism
• Diagnosis– Clinical– Ventilation - Perfusion Scan (V/Q scan)– Spiral CT Scan– Pulmonary Angiogram
PE - clinical diagnosis• Symptoms of PE in 117 previously normal
patients– dyspnea 73%– pleuritic pain 66– cough 37– leg swelling 28– leg pain 26– hemoptysis 13– palpitations 10– wheezing 9– angina-like pain 4 Chest 100:598, 1991
PE - clinical diagnosis• Signs of PE in 117 previously normal patients
– tachypnea (20/min) 70%– rales (crackles) 51– tachycardia (>100/min) 30– fourth heart sound 24– increased P2 23– diaphoresis 11– temperature >38.5°C 7– wheezes 5– Homans' sign 4– right ventricular lift 4– pleural friction rub 3– third heart sound 3
Well’s PE Clinical Prediction Rule• Signs/Symptoms of DVT 3.0
– measured leg swelling AND– pain with palpation in the deep vein region
• Alternative diagnoses less likely than PE 3.0– history, physical exam, chest X-ray, EKG, lab results
• Pulse > 100 beats/min 1.5• Immobilization 1.5
– bedrest (except access to BR) 3 days OR– surgery in previous 4 weeks
• Previous DVT or PE 1.5• Hemoptysis 1.0• Malignancy 1.0
– receiving active treatment for cancer OR– have received treatment for cancer within the past 6 months OR– are receiving palliative care for cancer
• TOTAL: >6 (high 78%), 2-6 (mod 28%), < 2 (low 3%)Thromb Haemost 2000;83;418
PE - diagnosis (V/Q scan)
• high probability V/Q scan (2 defects)
V/Q scan
normal PE ruled outnear normal PE ruled out
low probability can’t rule in nor outindeterminate can’t rule in nor out
high probability PE ruled in
Most V/Q Scans are non-diagnostic
PE - diagnosis (spiral CT scan)
Sprial CT Scanning
PE - diagnosisVenography
- gold standard - (100% / 100%)
Overview of Prevention / Treatment
DVT PE
Prevent DVT
Patient at Risk
Death
Treat PE =Prevent
More PE
Treat DVT =Prevent PE
Treat PE
Magnitude of the Problem
Risk of VTE in absence of prophylaxis
• General medicine patients 10-26%• Congestive heart failure 20-40%• Myocardial infarction 17-34%• Stroke 55%• Orthopedic Surgery 40-80%• Cancer 7-17%
Geerts et al. Chest 2001;119: 132S-175S
Risk of DVT no thrombophylaxis
Major Urological Surgery
15 – 40% risk of DVT
Risk of DVT and PE
Urological Surgery• Low Risk
– cystoscopy– transurethral resection prostate (TURP)
• High Risk– radical prostatectomy– nephrectomy– cystectomy
• Patient Factors– comorbidity, previous DVT-PE,
thrombophilia– hemorrhage
Interventions…
Overview of Prevention / Treatment
DVT PE
Prevent DVT
Patient at Risk
Death
Treat PE =Prevent
More PE
Treat DVT =Prevent PE
Treat PE
Overview of Prevention / Treatment
Prevent DVT
Patient at Risk
(Kendall TED)
Efficacy of Heparins vs Placebo
American College of Chest Physicians
CHEST SupplementSeptember 2004Volume 126(3)
www.chest.org (free)
• TURP Mobilize
• Open Procedures– heparin 5,000 U sq bid or tid– LMWH
• enoxaparin 40 mg sq od• dalteparin 5,000 u sq od
– SCD or GCS
• Mechanical for bleeder / bleeding
• Mechanical + Heparin for multiple risk pts
Overview of Prevention / Treatment
DVT PE
Prevent DVT
Patient at Risk
Death
Treat PE =Prevent
More PE
Treat DVT =Prevent PE
Treat PE
Overview of Prevention / Treatment
DVT PE
Treat PE =Prevent
More PE
Treat DVT =Prevent PE
Why Intervene?
• Risk of PE among untreated DVT ~ 15-25%
• Risk of death among PE ~ 20-30%• Risk of death among untreated DVT ~5%
• Risk of death for treated PE ~ 1.5%/yr• Risk of death for treated DVT ~ 0.4%/yr• Risk of major bleed treated PE/DVT
~1.0%/yr
Suspected DVT
• If high clinical suspicion of DVT, treat with anticoagulants while awaiting the outcome of diagnostic tests (1C+).
Confirmed DVT/PE• Clinical assessment risk / benefit of intervetion.• Draw baseline CBC, PTT, and INR and start:
Low Molecular Weight Heparinor
Adjusted Dose Unfractionated Heparin IVor
Adjusted Dose Unfractionated Heparin SQ
Any one of the three are acceptableLow Molecular Wt Heparin is preferred
(dosing, slightly better efficacy and safety)
Duration of Heparin for acute DVT/PE
• Most Adults– minimum 5 days AND– until INR therapeutic for two consecutive
days
• Active Cancer– minimum 3 – 6 months before
converting to ‘indefinite’ warfarin
Duration of Warfarin for DVT/PE
• Warfarin (if not pregnant)– start concurrently with heparin– target INR 2.0 - 3.0
• Duration of warfarin– time reversible risk factors: > 3 months*– first idiopathic DVT/PE: > 6 months– recurrent DVT/PE: > 12 months– continuing risk factor > 12 months
• cancer and thrombophilias*local tendency to tx PE x 6 months
Calf (below knee) DVT
• Below knee DVT extend proximally in 20% of patients treated with IV heparin for several days
• Recommend: treatment of below knee DVT is SAME AS proximal DVT
Overview of Prevention / Treatment
DVT PE
Prevent DVT
Patient at Risk
Death
Treat PE =Prevent
More PE
Treat DVT =Prevent PE
Treat PE
Overview of Prevention / Treatment
PE Death
Treat PE
Massive PE
• Thrombolytic Therapy– highly individualized– ICU admission
– reserved for echocardiographic right heart failure
Thrombolysis for sub-massive PE
n = 238
Endpoint = escalation of therapy or death. NEJM 2002;347;1143
Post-Thrombotic Syndrome
• Variously defined– pain and swelling post-DVT– 20 – 50%
Post-Phlebitic Syndrome• elastic compression stocking (30-40)
during 2 years after an episode of DVT (1A)
• intermittent pneumatic compression for severe edema (2B)
• elastic compression stockings for mild edema of the leg due to the PTS (2C).
--------------• Rutosides for mild edema due to PTS
(2B)
What are rutosides?• A substance produced from leaves & flowers of the
plant Sophora japonica
What to expect?
• Potential for post-phlebitic syndrome• PE chest pain may come and go• Hemoptysis may occur• Elevate legs when not ambulating• Okay to walk
What happens to the Thrombus?
How well are we doing?
• Chart review of admissions Jewish General Hospital, Montreal 1996-1997 (1 yr post 1995 guidelines)
preventable
17%
Getting better grades
Improving adherence to Thrombophylaxis Guidelines
Summary
• Define ST + DVT + PE + PTS• Risk closed = low open = high• Diagnosis doppler, helical CT or
V/Q• Prevention heparin +/- mechanical• Therapy heparin and warfarin