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Systems of Care 2015
Joint Replacement at Sacred Heart VTE Prophylaxis Brian Jewett, MD - - PowerPoint PPT Presentation
Joint Replacement at Sacred Heart VTE Prophylaxis Brian Jewett, MD - - PowerPoint PPT Presentation
Joint Replacement at Sacred Heart VTE Prophylaxis Brian Jewett, MD Director of Joint Replacement Surgery Systems of Care 2015 Financial Disclosures No Industry Sponsors. Paid Medical Director at SHMC Riverbend. Risks for VTE Why are TJA
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Risks for VTE
Virchow’s Triad: Stasis - supine in OR, sedentary recovery Trauma - TJA surgeries are physical, tissue trauma Hyper-coagulability - ILs, Cytokines, Marrow Elements
Why are TJA patients at risk?
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Risks for VTE
Other Patient Risk Factors: Age Smoking Hormones History of PE Obesity Cancer Genetics Deformity (difficult Surgery) GETA vs Regional Anesthesia
Why are TJA patients at risk?
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Risks for VTE
Historical Data: Unprotected Post-op 30-50% Patients with DVT… 5-10% PE… Newer Natural History Data: 20% TKA or THA positive for DVT but zero PE
Why are TJA patients at risk?
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Prophylaxis of VTE
70’s: Hip surgery’s infancy, learning about techniques, problems, DVT known - Coumadin/ASA used. 80’s: Focused on enhanced technique, management protocols - Coumadin timelines. Early studies with LMWH. 90’s: Moving patients early, better implants, SCDs, Coumadin in, Heparin/ASA out, and LMWH increased. Eugene OR: Fragmin 2500 U BID x 14 days (est. D. Collis)
General Overview of Years
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Prophylaxis of VTE
Look at what we know:
2000’s – Drug / Technique Perspective
COUMADIN: Vit K antagonist – historical baseline, what everything was compared too, 6 weeks tx PRO: Historical, effective against ASA/Placebo CON: Monitoring, errors, bleeding ASPIRIN: Cyclooxygenase Inhibitor – historical thought to be weak, ineffective PRO: Cheap, simple, low bleeding CON: Is it effective? LMWH: Factor X inhibition through Thrombin inhibition – newer, proved to be more effective than ASA or Coumadin for DVT PRO: No monitoring, ? More effective CON: More bleeding, expense Rivaroxaban: Linezolid, direct Xa inhibitor – newest, effective with TKA DVT > LMWH (RECORD studies) PRO: Oral, no monitoring CON: BLEEDING, cost Mechanical Compression: historical…start in OR..effective alone or with ASA ?? PRO: Easy to use CON: Compliance, effective?
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Prophylaxis of VTE
2000’s: Turn of Century Lead to “Guidelines”… Really lead to more conflict and confusion…..
2000’s - Age of Guideline Conflicts
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Prophylaxis of VTE
2000’s: Turn of Century Lead to “Guidelines”… What Happened…..
2000’s - Age of Guideline Conflicts
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Prophylaxis of VTE
1998/2001
American College of Chest Physicians Annual Report/Guidelines
2000’s - Age of Guideline Conflicts
General Conclusions of TJA patients: Only LMWH or Coumdain for 6 weeks LMWH should be started within 12 hours of TJA ASA or Mechanical not effective
Used Asymptomatic DVT (venography), not PE/Death as endpoint Little to no consideration of Bleeding
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Prophylaxis of VTE
1998/2001
SCIP
2000’s - Age of Guideline Conflicts
From the ACCP “guidelines” came SCIP Initiatives from CMS forcing TJA surgeons to use LMWH or Coumadin for patients
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Prophylaxis of VTE
2007
American Academy of Orthopedic Surgeon Work-Group
2000’s - Age of Guideline Conflicts
Refuted the endpoint of asymptomatic DVT, using non-fatal or fatal PE as endpoint Reviewed studies that SCIP guidelines caused increased wound healing problems, prolo nged hospital stays, readmissions, and re-operations for bleeding Focused on bleeding - causing 3x risk of infection
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Prophylaxis of VTE
2007
American Academy of Orthopedic Surgeon Work-Group
2000’s - Age of Guideline Conflicts
Patients with high risk of DVT/PE – follow ACCP guidelines with LMWH or Coumadin Patients with high risk of BLEEDING – mechanical compression alone Most patients– ASA for 6 weeks, LMWH, or Coumadin OK Rationale, is that most studies do not show any difference in PE comparing LMWH, ASA, Coumadin…………..But bleeding profile is different..
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Prophylaxis of VTE
AAOS
PE better endpoint Bleeding leads to severe morbidity Should Stratify Patients Risk ASA OK
2000’s - Age of Guideline Conflicts
ACCP
Assx DVT is endpoint Bleeding Complications Eh? ASA NOT OK
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Prophylaxis of VTE
2011
American Academy of Orthopedic Surgeons Guidelines Updated
GUIDELINES REVISED…
High risk of bleeding – mechanical compression ? Filter if also increased risk of PE High Risk of DVT/PE – LMWH, Coumadin, Xeralto Others – most patients – shared decision model – discuss risks of bleeding and clotting… Patients value on preventing clotting – LMWH, Coumadin, Xeralto Patients value on preventing bleeding complications – ASA, =/- mechanical compression
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Prophylaxis of VTE
2012
American College of Chest Physicians Annual Report/Guidelines Updated
GUIDELINES REVISED…
General Conclusions of TJA patients: LMWH, Coumadin, Xeralto, ASA, compression OK Still prefer LMWH…. Mechanical Compression OK for high bleeding risk
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ACCP 1986 – first consensus published ACCP 6th Guidelines for Antithrombotic Therapy (2000) * LMWH or Coumadin for TJA patients, 6 weeks recommended, ASA not recommended AAOS 2007 * Patients Stratified on Risk of Bleeding and VTE * Follow ACCP for high VTE risk, ASA or Mechanical Devices for High Bleeding Risk * Multiple of acceptable methods for low risk of bleeding and normal risk of VTE, including ASA ACCP 2008 * LMWH or fondaparinux recommended, ASA and foot pumps still not recommended * High risk of bleeding = mechanical devices OK AAOS 2011 * No role for routine U/S screening, recommends antiplatlet drug discontinued prior to surgery * Introduced individual bleeding risk assessment * Use of pharmacologic agents +/- mech compression for patients not at elevated risk of VTE * History of VTE – both …early mobilization in ALL ACCP 2012 * Acceptable agents expanded to include ASA, comp devices, Xeralto * Still prefer LMWH to all other agents
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Were are we now…current status of management
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