45 yo fall from ladder

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1 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 7 th Annual Nuts and Bolts of Orthopaedics Naples, FL October 2, 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 1

2 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 Venous stasis Joseph Hodgson Alexander Copeland Hutchinson Endothelial damage Andral Hypercoagulable state From Virchow R.L.K. Cellular Pathology 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 NEJM Dec 2

3 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 3

4 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 ;443. Stover MD, et al. J Orthop Trauma ;613. Pathophysiology Hypercoagulable state: production of all factors Warfarin factors II, VII, IX, X, C and S Venous Stasis (+) (+) Intimal Injury Heparin/ Lovenox Fondaprinaux/ Arixtra Rivaroxaban/ Xarelto (-) 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 4

5 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) So Who Should We Treat? 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

6 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 Hsu JE, et al. Arch Orthop Trauma Surg ;27. 6

7 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 ;443. Stover MD, et al. J Orthop Trauma ;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 Moed BR, et al. J Trauma ;443. 7

8 Diagnosis Is MRV or CTV valuable in diagnosis? MRV and CTV for DVT obtained 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 ;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 Turpie AG, et.al. JAAOS Nov 8

9 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 Risk Thrombosis risk Bleeding risk Low Days since injury 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 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 (6): 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):

10 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 10

11 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): 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

12 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 ;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 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! 12

13 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 Thank You 13