DEEP VENOUS THROMBOSIS (DVT) R@N@

DEEP VENOUS THROMBOSIS:

DEEP VENOUS THROMBOSIS R@N@ T@NVEER AMc , PAKISTAN

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ETHROMBOSIS ?

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“It is a term to describe blood clots occurring in people sitting at their computers for prolonged periods of time.”

LAYOUT:

LAYOUT Definition Sites Pathophysiology Risk factors Lower limb DVT Symptoms & signs Investigations Management Complications Prevention

DEEP VENOUS THROMBOSIS (PHLEBOTHROMBOSIS):

DEEP VENOUS THROMBOSIS (PHLEBOTHROMBOSIS) DEFINITION Development of single or multiple blood clots within the deep veins of the extremities or pelvis, usually accompanied by inflammation of vessel wall.

DVT:

DVT SITES Calf vein thrombosis (Commonest) 75% Proximal femoral/iliofemoral 20% Axillary-subclavian vein thrombosis 2%

PATHOPHYSIOLOGY (Virchow’s Triad):

PATHOPHYSIOLOGY (Virchow’s Triad) DAMAGE TO ENDOTHELIUM e.g. AFTER SURGERY, PREVIOUS DVT HYPERCOAGULABILITY e.g. SURGERY , INFECTIONS, BIRTH CONTROL PILLS, DEFICIENCY OF NATURAL ANTI- COAGULANTS ABNORMAL BLOOD FLOW (stasis) e.g. SURGERY, HEART FAILURE RECENT MYOCARDIAL INFARCTION , STROKES

RISK FACTORS FOR DVT:

RISK FACTORS FOR DVT Patient’s Factors Surgical Condition Medical Conditions Haematological Disorders

Patient’s Factors:

Patient’s Factors Age >40 yrs Obesity Varicose Veins Previous deep vein thrombosis Oral contraceptives Pregnancy Dehydration Immobility

Surgical Condition:

Surgical Condition Surgery, esp. if >30min duration Abdominal/Pelvic, Orthopaedic, lower limb Medical Conditions MI/Heart Failure Inflammatory bowel disease Malignancy Nephrotic syndrome Homocystinaemia

Haematological Disorders:

Haematological Disorders Primary Proliferative polycythemia Essential thrombocytopenia Myelofibrosis Paroxysmal nocturnal haemoglobinuria Deficiency of Anticoagulants (Anti-thrombin III, Protein C, Protein S, Prothrombin, Factor V Laiden) 6. Anti-phospholipid Antibody (Lupus anticoagulant, Anticardiolipin antibody)

LOWER LIMB DVT :

LOWER LIMB DVT

SIGNS AND SYMPTOMS:

SIGNS AND SYMPTOMS DVT Lower Limb

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SWELLING PAIN REDNESS DILATED SUPERFICIAL VEINS (uncommon) LOW GRADE PYREXIA (uncommon) CALF TENDERNESS OEDEMA AT ANKLE INCREASED LOCAL TEMPERATURE NOTE : Some patients with Deep Venous Thrombosis of the lower limb may have NO symptoms in leg, but present with SEVERE DYSPNOEA, PLEURITIC PAIN & HEMOPTYSIS due to pulmonary embolism.

Phlegmasia alba dolens (painful white leg):

Phlegmasia alba dolens (painful white leg) Thrombosis involve major deep venous channels of extremity sparing collateral veins. Venous drainage is decreased but still present.

Phlegmasia cerulea dolens:

Phlegmasia cerulea dolens Collateral vessels are also involved. 40-60% capillary involvement also occurs Irreversible venous gangrene that involves skin, subcutaneous tissue and muscles.

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? ROLE OF HOMAN’S SIGN and MOSES’ SIGN

DIFFERENTIAL DIAGNOSIS:

DIFFERENTIAL DIAGNOSIS CELLULITIS RUPTURED SYNOVIAL CYST (BAKER’S CYST) LYMPHOEDEMA CALF MUSCLE HEMATOMA SUPERFICIAL THROMBOPHLEBITIS RUPTURED PLANTARIS TENDON

INVESTIGATIONS:

INVESTIGATIONS

A ) BASELINE:

A ) BASELINE BLOOD COMPLETE PICTURE SERUM LIVER FUNCTION TESTS SERUM UREA,CREATININE, ELECTROLYTES URINE ROUTINE EXAMINATION CHEST X-RAY CONTINUED…

B) SPECIAL INVESTIGATIONS:

B) SPECIAL INVESTIGATIONS DUPLEX ULTRASONOGRAPHY CONTINUED…

SPECIAL INVESTIGATIONS:

SPECIAL INVESTIGATIONS PT / APTT D-DIMERS (Negative predictive value) THROMBOPHILIA SCREEN for protein C,S, anti-thrombin III, factor V Leiden gene defect (In younger patients, recurrent venous thrombosis, venous thrombosis at unusual site) ASCENDING VENOGRAPHY (When results of duplex scanning are not helpful–Invasive : last court of appeal) ENHANCED HELICAL CT SCAN (For Pulmonary embolism)

MANAGEMENT:

MANAGEMENT

GENERAL MEASURES:

GENERAL MEASURES Admit the patient Advise complete bed rest Advise to avoid walk Legs are elevated to 20 0 Relatives are advised NOT to massage or compress the calves.

TREATMENT:

TREATMENT ANTI-COAGULANTS THROMBOLYSIS VENOUS THROMBECTOMY

i) Anti-coagulants:

i) Anti-coagulants ANTICOAGULANT DOSE & DURATION MONITORING AIM IV HEPARIN (IMMEDIATE THERAPY) 80 units/Kg STAT 18 units/Kg/hr as continuous IV infusion till INR becomes >1.5-3 APTT Target : 3xcontrol To decrease risk of pulmonary embolism To encourage thrombus to resolve ORAL WARFARIN (MAINTENANCE THERAPY) 5-10mg OD Started 1-3days after starting heparin For 3-6 months PT/INR Target INR: 2.5-3.5xcontrol To decrease risk of recurrence of venous thrombosis In persons with multiple risks and congenital deficiencies of anti-clotting factors …………LIFE LONG THERAPY.

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ii) Thrombolysis catheter passed into affected vein fibrinolytic drug e.g. streptokinase, urokinase or tissue plasminogen activator(t-PA) infused directly into clot iii) Venous thrombectomy (Rarely used) if there is any evidence of venous gangrene. Femoral vein is opened surgically via an incision in the groin all clots are removed from deep veins of leg and pelvis.

FOLLOW UP:

FOLLOW UP Elevation of legs Strict compliance to warfarin Patient monitoring (Monitor PT/INR daily, then weekly, then monthly) Report if any bleeding occurs or any other adverse effects of warfarin seen. Regular follow up in surgical OPD. Advice patient to use low-estrogen birth control pills when possible

POSSIBLE COMPLICATIONS:

POSSIBLE COMPLICATIONS PULMONARY EMBOLISM IVC Filters

POSSIBLE COMPLICATIONS:

POSSIBLE COMPLICATIONS BLEEDING POST-PHLEBITIC SYNDROME VENOUS ULCERATION HEPARIN INDUCED THROMBOCYTOPENIA

They say, ”Prevention is better than cure”:

They say, ”Prevention is better than cure” So let’s have a look on this ASPECT of DVT!

PREVENTION of DVT:

PREVENTION of DVT PATIENT EDUCATION (HIGH RISK) Advice women taking Estrogen of the risks Discourage prolonged immobility MECHANICAL METHODS Graduated compression stockings Sequential pneumatic compression devices PHARMACOLOGICAL METHODS Low dose heparin LMWH (Low Molecular Weight Heparin)

VENOUS THROMBOEMBOLISM (VTE) PROPHYLAXIS FOR GENERAL SURGERY:

VENOUS THROMBOEMBOLISM (VTE) PROPHYLAXIS FOR GENERAL SURGERY EASY AND SIMPLE 3 STEP PROPHYLAXIS CHECK ASSESSING VTE RISK STRATIFYING VTE RISK STARTING VTE PROPHYLAXIS

1) ASSESSING VTE RISK:

1) ASSESSING VTE RISK AGE FACTOR HISTORY MEDICAL FACTORS SURGICAL FACTORS HEMATOLOGICAL / GENETIC 40-60 yrs (1) 61-70 yrs (2) > 70 yrs (3) DVT / PE (3) Family history (3) Immobilization>12hrs (1) Pelvic/long bone fracture (1) Leg swelling,ulcers,varicose (1) Confining air/ground travel (1) CCF (1) Cancer (1) Stroke (1) MI (1) Obesity (1) IBD (1) HRT (1) Postpartum (1) Pregnancy (1) GA > 2hrs (1) Multiple trauma (1) Spinal cord injury with paralysis (1) Plasminogen/activator def. (1) MPD (1) Thrombophilia (3) Dysfibrinogene-mia (1) Hyperviscosity syndrome (1) Protein C resistance (1) Anti-phospholipid Antibodies (3) AntiThriii def (1) Pr C/S def (1)

2) STRATIFYING VTE RISK:

2) STRATIFYING VTE RISK LOW RISK MODERATE RISK HIGH RISK VERY HIGH RISK SCORE OF < 1 SCORE OF 2 or 3 SCORE OF 3 or 4 SCORE OF > 4

3) STARTING VTE PROPHYLAXIS:

3) STARTING VTE PROPHYLAXIS LOW RISK Minor surgery Pt. < 40yrs MODERATE RISK Minor surgery with risk factors / age 40-60 HIGH RISK High risk general surgery / pt. > 60 yrs VERY HIGH RISK Multiple risk factors / major trauma /hip or knee arthroplasty Early and aggressive mobilization Enoxaparin 20mg S/C , Graduated compression stockings Enoxaparin 40mg S/C OD stockings Post hospital discharge prophylaxis with LMWH Enoxaparin 40mg S/C OD GCS

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PREVENTION OF TRAVELLER’S THROMBOSIS GRADUATED COMPRESSION STOCKINGS EXERCISE DURING FLIGHT AVOIDANCE OF ALCOHOL AND SLEEPING TABLETS HIGH RISK PASSENGERS : S/C LMWH before flight

ATTENTION ! BUTTERFLY SWIMMERS:

ATTENTION ! BUTTERFLY SWIMMERS

AXILLARY-SUBCLAVIAN VEIN THROMBOSIS :

AXILLARY-SUBCLAVIAN VEIN THROMBOSIS Associated with physical exercise involving shoulder girldle Axillary-subclavian vein catheters Thoracic outlet syndrome Cervical rib