Deep Vein Thrombosis

1
Deep Vein Thrombosis

• Prevention and treatment

2
Venous Thromboembolism

• DVT of the lower limb and/or PE 2/1000pa
• Asymptomatic or minor leg discomfort/swelling
  gt65
• Venogram and Doppler for those gtknee
• Clots extending above the knees
• - PE
• -post-thrombotic limb syndrome
• All patients admitted to hospital as well as
  pregnant or puerperal women, should be assessed
  for risk or DVT

3
High Risk Situations For DVT

• Orthopaedic surgery- elective knee or hip
• -hip or major lower limb fracture
• -spinal cord injury with lower limb paralysis
• General surgery- Major pelvic or abdominal
  surgery for cancer
• Vascular surgery- critical limb ischemia
• -major amputation
• Medical- acute stroke/lower limb paralysis
• All- major trauma surgery or medical illness
• Previous DVT or PE
• Known thrombophillia

4
Moderate Risk situations for DVT

• Trauma- major trauma
• Medical- MI, heart failure, chest infection,
  malignancy, inflammatory bowel, nephrotic
  syndrome
• All- minor trauma, surgery or medical illness in
  people with
• Previous DVT or PE
• Known thrombophillia (Factor V Leiden,
  antithrombin III, PC, PS deficiency)
• Surgery- major gt30min with
• Anaesthetic 2x more in GA than spinal/epidural
• Markedly obese
• Agegt40 yrs
• Immobility 4 or more days
• Pregnancy/puerperium
• High-dose oestrogens
• Medical illness

5
PROPHYLAXIS

• General- hydration, early mobilization, TEDs
• Aspirin- elective orthopaedics (high risk)
• Low-dose standard heparin 5000u sub cut
  8-12hrly, no need to monitor APTT
• Adjusted-dose warfarin INR 2-2.5 (moderate risk)
  and 2-3 (high-risk)
• Low-molecular-weight heparin once daily sub cut
  more effective than low dose heparin

6
SIGN Guidelines for prophylaxis

• Aspirin- 150mg/day started preoperatively and
  continued for 35 days is effective prophylaxis of
  asymptomatic and symptomatic DVT in surgical
  patients (also reduces CV events in acute MI and
  ischemic stroke)
• Subcutaneous low dose heparin (UFH or LMWH)-
  effective prophylaxis of asymptomatic and
  symptomatic DVT in surgical and medical patients

7
Treatment for DVT

• Heparin 5000u(100u/kg) IV followed by infusion
  1000-2000u/hr APTT (4hrly) 2.5-3.5
• Maintained on Sub cut heparin and/or warfarin INR
  2.5-3
• 6weeks for those with transient/reversible
  predisposing factors or 6 months for idiopathic
  DVT