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Journal Club – Evidence Based Medicine
Deep Vein ThrombosisDeep Vein ThrombosisVenous Thromboembolism
Pulmonary Embolism in Orthopedic Surgeries
游宜勳游宜勳
骨科學複習 Orthopedic Review骨科學複習 Orthopedic Review
Deep vein thrombosis in - THA: 15~25%
TKA: 50%- TKA: 50%- Pelvis-Acetabulum fracture: 20~60%%- Spine surgery: 0.3~26%- Ankle-Foot surgery: 0.22%高加索人與非裔美國人>亞洲人- 高加索人與非裔美國人>亞洲人
Research of Tai anResearch of Taiwan
DVT after TKA- 44/48 calf thrombi; 4/48 popliteal thrombi
24/48 clinically symptomatic- 24/48 clinically symptomatic- No recurrent DVT or PE
Wang, JBJS-B, 2003
- Control/LMWH/Indocin: 71%/50%/45%28% t ti N PE- 28% symptomatic; No PE
Wang, JBJS-A, 2004
AAOS G id liAAOS Guideline
P ti f PE ft THA & TKAPrevention of PE after THA & TKA2009
Mechanical prophylaxis: allChemprophylactic agents:Chemprophylactic agents:
Standard risk of PE and major bleedingi i LMWH SP* f iaspirin, LMWH, SP*, or warfarin
Elevated risk of PE, standard risk of major bleedingLMWH, SP, or warfarin
Standard risk of PE, elevated risk of major bleeding, j gaspirin, warfarin, or none
Elevated risk of PE and major bleedingElevated risk of PE and major bleedingaspirin, warfarin or none
*: Synthetic pentasaccharides
DVT VTE & PE in Trauma PatientsDVT, VTE & PE in Trauma Patients~ Eastern Association for the Surgery of Trauma
Risk Factor of VTERisk Factor of VTE
Level I: Spinal cord injury or spine fractureLevel II:
1 Old age1. Old age2. Increasing ISSg3. Long bone, pelvic fracture, head injury
L D H i f DVT/PE P h l iLow Dose Heparin for DVT/PE Prophylaxis
Level I: Insufficient dataL l II Littl idLevel II: Little evidence
L l I d II I ffi i t d tMechanical devises for DVT/PE ProphylaxisLevel I and II: Insufficient dataLevel III:
1. SCD for spine- and head-injured patient2 A V f t b lt ti f SCD2. A-V foot pump can be alternative for SCD
* SCD: Sequential Compression Devices
LMWH i VTE P h l iLMWH in VTE Prophylaxis
Level I: insufficient evidenceLevel II:Level II:
1. Pelvic fracture requiring OP or bed rest > 5 days
2. Complex lower extremity fractures2. Complex lower extremity fractures3. Spinal cord injury
L l IIILevel III: 1. ISS>92. LMWH for several weeks in high risk patients
V C Filt f P h l i d T t t f PEVena Cava Filter for Prophylaxis and Treatment for PE
Level I: Traditional indications1. Recurrent PE despite full anticoagulantion1. Recurrent PE despite full anticoagulantion2. Proximal DVT and contraindication for full anticoagulationg3. Progression of iliofemoral clot despite anticoagulation
Level II: Extended indicationLevel II: Extended indication1. Large free-float thrombus in iliac vein or IVC2 Following massive PE2. Following massive PE3. During/after surgical embolectomy
Level III: Prophylactic vena cava filterLevel III: Prophylactic vena cava filter
Prevention of VTE ~ American College of Chest PhysiciansEvidence-Based Clinical Practice GuidelinesEvidence Based Clinical Practice Guidelines
8th Edition, 2008
Electi e Hip ReplacementElective Hip ReplacementRecommendation: LMWH, Foundaparinux, VKA (1A)Against: aspirin dextran heparin or foot pump as soleAgainst: aspirin, dextran, heparin, or foot pump as sole
method of prevention VTE (1A)High risk of bleeding: mechanical prophylaxis (1A)
* VKA: vitamin K antagonist
Electi e Knee ReplacementElective Knee ReplacementRecommendation: LMWH, Foundaparinux, VKA (1A)IPC as a alternative method of chemoprophylaxis (1B)IPC as a alternative method of chemoprophylaxis (1B)Against: aspirin (1A), heparin (1A), VFP (1B) as only
methodHigh risk of bleeding: mechanical prophylaxis (1A)High risk of bleeding: mechanical prophylaxis (1A)
* IPC: Intermittent pneumatic compression; VFP: Venous foot pump
Knee ArthroscopKnee ArthroscopyAdditional VTE risk factors
No: early mobilization (2B)No: early mobilization (2B)Yes: LMWH (1B)
Hip Fract re S rgerHip Fracture SurgeryRecommendation: Foundaparinux (1A), LMWH (1B),
VKA (1B) heparin (1B)VKA (1B), heparin (1B)Against: aspirin alone (1A)Delayed surgery: LMWH or heparin from admission to
surgery (1C)surgery (1C)High risk of bleeding: mechanical prophylaxis (1A)
Electi e Spine S rgerElective Spine SurgeryAdditional VTE risk factors
No: early and frequent mobilization (2C)No: early and frequent mobilization (2C)Yes: postOP heparin (1B), LMWH (1B), or periOP
IPC (1B)Multiple risk factors: pharmacologic + mechanical (2C)Multiple risk factors: pharmacologic + mechanical (2C)
I l t d L E t it I j Di t l t th KIsolated Lower-Extremity Injury Distal to the Knee
Not routinely use thromboprophylaxis (2A)
Cochrane LibrarCochrane Library- Heparin, LMWH and physical methods for
preventing DVT and PE following surgery for hippreventing DVT and PE following surgery for hip fracture ~ 2008Interventions for prevention VTE in adults- Interventions for prevention VTE in adults undergoing knee arthroscopy ~ 2008Di t th bi i hibit it i K- Direct thrombin inhibitors versus vitamin K antagonists or LMWH for prevention of VTE f ll i THA TKA 2010following THA or TKA ~ 2010
- Elastic compression stockings for prevention of p g pDVT ~ 2010
Heparin, LMWH and physical methods for preventingHeparin, LMWH and physical methods for preventing DVT and PE following surgery for hip fracture
2008
Data base: Cochrane library, Medline, EMBASE, CINAHL, and Current Contentsand Current Contents
Selection criteria: randomized or quasi-randomizedResult: 31 trials involving 2 958 patientsResult: 31 trials, involving 2,958 patientsConclusion:
1 Insufficient evidence of either (heparin and LMWH)1. Insufficient evidence of either (heparin and LMWH) protection against PE or an overall benefit
2 Foot and calf pumping device can prevent DVT PE2. Foot and calf pumping device can prevent DVT, PE and reduce mortality
Interventions for prevention VTE in adults undergoingInterventions for prevention VTE in adults undergoing knee arthroscopy
2008
Data base: Cochrane library, Medline, EMBASE, and CENTRAL
Selection criteria: RCTs and CCTsResult: 4 trials and 527 patientsConclusion:
1. LMWH reduce DVT, but overall benefit is uncertain2. No strong evidence was found to conclude
thromboprophylaxis is effective to prevent VTE
Direct thrombin inhibitors versus vitamin K antagonistsDirect thrombin inhibitors versus vitamin K antagonists or LMWH for prevention of VTE following THA or TKA
2010
Data base: Cochrane library, and CENTRALSelection criteria: RCTResult: 14 trials and 21,642 patientsConclusion
1. Direct thrombin inhibitors are as effective as LMWH or vitamin K antagonist in the prevention VTE in THA or TKA; but higher mortality and bleeding than LMWH
2. Use of ximelagatran is not recommended for VE prevention in orthopedic surgery
El ti i t ki f ti f DVTElastic compression stockings for prevention of DVT2010
Data base: Cochrane library, and CENTRALSelection criteria: RCTSelection criteria: RCTResult: 18 trialsConclusion:Conclusion:
Elastic compression stockings are effective in diminishing the risk in hospitalized patientsdiminishing the risk in hospitalized patients
D f Ch h l ti A tDoses of Chemoprophylactic Agents
Pre ention of PE AAOSPrevention of PE ~ AAOS• Aspirin: 325mg, 2#/d, for 6 wks
LMWH: 12 to 24 h post OP for 7 12 d• LMWH: 12 to 24 h post OP, for 7~12 d• SP: 12 to 24 h post OP, for 7~12 d• Warfarin: INR
Pre ention of VTE ACCPPrevention of VTE ~ ACCP• LMWH: 12 h before surgery or 12 to 24 h after
surgery or 4-6 h after surgery (half dose full dose)surgery or 4-6 h after surgery (half dose full dose)• Fondaparinux: 2.5mg started 6 to 24 h after surgery• VKA: INR=2.5
VKA: Vitamin K antagonist
D ti f Th b h l i ACCPDuration of Thromboprophylaxis ~ ACCP
• For THR, TKR, and hip fracture surgeryat least 10 daysat least 10 days
• For THR extend 10 to 35 days (1A)LMWH (1A), VKA (1B), fondaparinux (1C)
• For TKR extend 10 to 35 daysFor TKR extend 10 to 35 daysLMWH (1C), VKA (1C), fondaparinux (1C)
• For hip fracture surgeryextend 10 to 35 daysyfondaparinux (1A), LMWH (1C), VKA (1C)
What DID We Do?What DID We Do?
Aug 2nd ~ Aug 6thHip arthroplasty: 21 Knee arthroplasty: 32Knee arthroplasty: 32Lower limb fracture surgery: 30 g y
Aspirin: 7 (100mg/qd)H i + W f i 1 (f MI)Heparin + Warfarin: 1 (for MI)
So What WILL We Do?So, What WILL We Do?