Date: Thu, 09 Mar 2000 14:36:25 -0600
From: Adam Starr
Subject: Pelvic Fx DVT
What sort of DVT prophylaxis do y'all use for patients with fractures of the pelvis or acetabulum?
Date: Fri, 10 Mar 2000 10:16:09 +0100
From: bruce meinhard
For DVT prophylaxis in patients with acetabular fractures, in the absence of anticoagulation, we use Low Molecular Weight Heparin and mechanical AVI foot pumps. If Anticoagulation via the chemical route is medically contraindicated, we use an IVC filter.
BPM
Date: Fri, 10 Mar 2000 09:35:19 -0600
From: Adam Starr
Have you had any problems with bleeding in the LMWH patients? We have abandoned use of LMWH for that reason.
We use subcutaneous heparin, 5000u TID, and footpumps.
I know this is a tough area to know what to do exactly. There isn't much good literature on the topic, as far as randomized trials.
Adam Starr
Date: Fri, 10 Mar 2000 15:48:15 -0500
From: bruce meinhard
No bleeding problems, even though we should have 5% wound complication rates. We are meticulous about not starting it before 12-18 hours after surgery and pre- op we stop it 12 hours before we cut skin.
BPM
Date: Fri, 10 Mar 2000 16:16
From: Bill Burman
What sort of DVT prophylaxis do y'all use for patients with fractures of the pelvis or acetabulum?
See Steve Morgan's 1999 OTA Poster
"Completed questionnaires were received from 226 (62%) surgeons, of whom 181 (80%) perform pelvic and acetabular fracture surgery. Those who responded on average, had been in practice 11- 15 years, and surgically treat 13-24 fractures per year. Preoperative DVT screening was performed by 48% of the surgeons; ultrasound was the most commonly used modality (82%). Preoperative DVT prophylaxis was administered by 88% of those surveyed; the majority (78%) used sequential compression devices (SCDs). Vena cava filters were used selectively by 83% of the respondents. Postoperative prophylaxis was used by 99%; the most commonly used modality was SCDs. Duration of prophylaxis for DVT was commonly continued until the patient was mobilizing (32% of respondents)"
Date: Sat, 11 Mar 2000 08:10:39 -0500
From: Kellam, James
Does all of this prevent fatal PEs ?
Date: Sun, 12 Mar 2000 20:16:12 -0800 (PST)
From: Chip Routt
if you haven't had problems...keep on working.
chip
Date: Mon, 13 Mar 2000 09:20:28 -0600
From: Adam Starr
Does all of this prevent fatal PEs
Who knows?
We just reviewed our experience here. With the footpumps and SQ heparin, we had 10 PE's out of a population of 500 and some pelvic and acetabular fx patients. 3 of the patients who had PE's died.
There were 40 or so other fatalities - I guess you could say that many of them were due to PE, too. But, most of the deaths occurred quickly (day 0 or day 1). So, I'd doubt that PE was the culprit for a majority.
Date: Mon, 13 Mar 2000 09:24:48 -0600
From: Adam Starr
if you haven't had problems...keep on working.
Chip, what do you use?
We had Tony Pohl from Australia visit Parkland about 2 years ago, and we talked a lot about it then. Tony just puts 'em all on coumadin. He doesn't monitor bleeding times or coags or anything. He operates on his within 2 or 3 days, so the coumadin hasn't really kicked in yet. At least that's how I remember it.
Date: Mon, 13 Mar 2000 20:38:45 -0800 (PST)
From: Chip Routt
Our efforts to prevent deep venous thromboses are adjusted for each patient based on their injuries/condition/and other factors.
It's easier but just not realistic to treat each patient the same because of their unique clinical situations.
Regardless, problems result from treatment and non-treatment. if you don't have any problems...wow.
The important issue is to consider the clinical scenario, and then do something to combat potential deep venous thromboses...then keep re-evaluating each patient as their condition/situation changes.
patient and family education regarding venous thrombosis disease are also helpful both in hospital and after discharge.
chip
Date: Tue, 14 Mar 2000 18:49:16 -0500
From: Kellam, James
Who knows?
That's the point - why are we plaguing yourself with a treatment that is worse than the problem which we can't yet define.
Date: Tue, 14 Mar 2000 17:54:39 -0600
From: Adam Starr
I don't think our treatment is worse than the problem.
We don't use any of the low molecular weight heparins anymore - they cause bleeding problems. We just use footpumps (which have an added benefit of getting rid of edema) and subcutaneous heparin. We don't have any bleeding problems, don't have to follow coags, and our DVT/PE rates are very very low.
Date: Tue, 14 Mar 2000 18:56:43 -0500
From: Kellam, James
Probably not but why not drop the heparin as it probably is only giving some drug company some revenue that they hardly need.
Date: Tue, 14 Mar 2000 18:02:51 -0600
From: Adam Starr
Because all the literature says footpumps alone don't work. Ditto for SQ heparin.
The general surgeons for years were saying that footpumps and SQ hep didn't work.
Date: Tue, 14 Mar 2000 21:25:40 -0600
From: Adam Starr
our efforts to prevent deep venous thromboses are adjusted for each patient based on their injuries/condition/and other factors.
One thing we've had happen with our regimen is heparin induced thrombocytopenia. It's pretty dang rare. We've seen that, and the occasional footpump blister.
We had a heck of a time with the low molecular weight heparins for a while. The general surgery dept here was involved in a study with Lovenox, and they would put the patients on it pretty much the day after admission.
Doing iliac crest osteotomies on a patient on Lovenox is no fun. The crest never quits bleeding.
We were able to get them to quit using it.
The place we REALLY spend a lot of money is on screening. Right now we're using MRV and sonos on everybody. I think we'll quit getting all those tests, though.
Adam
Date: Sun, 19 Mar 2000 22:53:11 -0600
From: Steven Rabin
The general surgery dept here was involved in a study with Lovenox
our general surgeons are still in the lovenox phase. a lot of other areas besides the iliac crest bleed a lot when the patient has been on lovenox.
Date: Wed, 22 Mar 2000 02:40:39 PST
From: george thomas
Although the Cochrane collaboration website in a review dated 1997 suggests that unfractionated heparin is as good as low molecular weight heparin for DVT prophlaxis, the book Evidence Based Cardiology published by BMJ books 1998, editors Yusuf,Cairns,Camm, Fallen and Gersh in the chapter Venous Thromboembolic Disease page 1016, says that based on meta analysis, low molecular weight heparin is clearly superior especially in orthopaedic surgery.
Dr. Thomas George, Railway Hospital, Perambur, Chennai, India.
Date: Wed, 22 Mar 2000 06:03:22 -0600
From: Adam Starr
I disagree.
Low molecular weight heparin clearly increases bleeding complications, and clearly increases cost of prophylaxis.
Our current DVT rate with unfractionated heparin is 4%. Fatal PE rate is 0.6%.
I'll stick with the heparin and footpumps.
Adam Starr, Dallas
Date: Wed, 23 Oct 2002 11:05:49 EDT
From: Krausepc
A general question for the group about thromboembolism prophylaxis and pelvic/acetabular fxs. What are people using postoperatively and for how long?
Is anybody treating for 75 days with LMWH as suggested by Letournel?
Thanks,
Peter Krause, M.D.
LSU
Date: Wed, 23 Oct 2002 11:47:01 -0400
From: James Carr
This is truly a question that needs a large study.
I can say I don't use anything, and have "only" a .1% mortality rate from PE. In other words, I can go a long time before I see a problem. Since the numbers are low for a significant event IE PE, or death, the #'s to show a treatment difference are large. I currently treat people while in the hospital with lovenox, and continue at home 2 weeks postop. I used to use coumadin for 6 weeks, but quit when too many near OD's occurred- my treatment was worse than the disease.
James B. Carr, MD
Palmetto Health Orthopedics
Date: Thu, 24 Oct 2002 01:53:46 EDT
From: Aobonedoc
My one and only ORIF acetabular fracture (with a traumatic, preoperative sciatic nerve neuropraxia) did develop a calf DVD.
I think I would treat acetabular fxs as I do joint arthroplasties.
Sincerely and respectively,
M. Bryan Neal, MD
Arlington Orthopedics and Hand Surgery Specialists, Ltd.
Arlington Heights, Illinois 60005
Date: Thu, 24 Oct 2002 11:10:52 -0400
From: Bill Burman
Peter
You might want to refer to a prior inconclusive discussion of this topic
The thread ends with disagreement over a meta-analysis.
While Ken Mattox on the AAST list has said that
"Meta-analysis is to analysis as Meta-Physics is to physics",
at the Maine Orthopaedic Review, Vincent Pelligrini from U Maryland in an overview of the anticoagulation conundrum, was also critical of meta-analysis.
"The problem with meta-analysis (e.g. JBJS 82A:929 2000) is that what you put in dictates what you get out (GIGO). In that meta-analysis, they did not stratify for anesthetic type, operative times, early mobilization. During the time of this meta-analysis, it has spanned 30 years. In 30 years the anticoagulation targets for warfarin have decreased dramatically. We used to anticoagulate to a prothrombin time twice control. Now it is 1.3 times control or an INR of 2)...
The real problem was in the literature because a major bleed was defined if the patient died, had a greater transfusion risk, needed another operation or stayed in the hospital longer than the predetermined length-of-stay. A wound hematoma or a persistently draining wound was not defined as a major bleed. But, in fact, those are things that you and I lose sleep over and get gray about."
Dr. Pelligrini ended up agreeing with Adam Starr that there is a slightly increased risk of bleeding with LMWH compared to warfarin (Hoek 1992, Hull 1993, Colwell 1994) - but would not, for hip surgery, support the use of foot pumps.
"No matter which way you operate - sideways, upside down or frontside up, you torque the femoral vein when you put the femoral component in. A retractor there will cause intimal damage. That is where the clot will start. Those clots are only reasonably prophylaxed by anticoagulants. Pneumatic compression has not been effective in preventing those clots (Paiement 1987)."
In terms of anticoagulation duration, Dr. Pelligrini had this to say:
"You have two choices.
1) In practice, extended prophylaxis can be universally prescribed. Taking all this information collectively, the consensus right now says that 3-5 days of warfarin or fractionated heparin or ginger root is not enough and that the treatment ought to extend to 6 weeks or
2) perform routine screening (venography) and selectively treat in order to reduce the risk of bleeding.
If screening is not selected and all patients receive extended prophylaxis, the problem now is that the bleeding risk in the octogenarian population is not trivial.
3 per cent of 80 year olds on coumadin will bleed in the first month. Pretty big numbers. You know what? They don't come and see us. They go to their internists. Every month thereafter the bleeding incidence goes up 0.8 per cent.
So if you put someone on coumadin for 3 months, they have about a 5 per cent risk that they will have a major bleed in the 3 months that you prophylax them after their operation. This is because they either have diverticulosis, or a GI ulcer or some hidden carcinoma that they haven't been diagnosed with yet."
Dr. Pelligrini's data was derived mostly from reasonably compliant patients with THRA surgery without major pelvic venous disruption. There may be some similarity to the acetabular/pelvic ORIF patient but clearly better trauma data is needed - however
According to the OTA Multicenter Research Projects page:
"A DVT Prophylaxis multi-center study was attempted, but has been abandoned by Dr. Helfet and HSS because of methodologic concerns/issues."