بسم الله الرحمن الرحيم
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بسم الله الرحمن الرحيم
T. J. A IS STRONG PROPENSITY FOR
T. E COMPLICATION
THAT IS POTENTIALLY LIFE -
THREATENING
OBESITYCANCERPREVIOUS VTEFAMILY HISTORYSMOKINGADMISSION TO ICUDEHYDRATIONTHROMBOPHILIACONTRACEPTIVE USEPOST- OPERATION IMMOBILITY
CHARNLEY & CO:
7959 CASES OF T. J. A 1962- 73
P- E : 8%
FATAL CONDITION: 1%
INSALL INCREASE ATTENTION TO T. E DISEAS
AND EMPHASIS PREVENTION
DVT WITHOUT ANY PREVENTION
84%CLINICALLY P. E
1.7%FATAL P. E: -
POSITIVE VENOGRAPHY NOT ITSELF
ASSOCIATED WITH LOCAL SYMPTOMS
PRESENTATION OF T. E DISEASE FOLLOWING T. H. A & T. K. A IS DIFFERENT
RELATED TO VIRCHOW’S TRIAD
STASIS
INTIMAL INJURY
HYPERCOAGULABILITY
BEFORE ROUTINE USE OF
CHEMOPROPHYLAXIS
PROXIMAL DVT WAS IN 50- 60% OF
T. H. A
DISTAL WAS IN T. K. A
PROXIMAL THROMBI ALMOST IS SEGMENTAL
AND NEAR LESSER TROCH
LARGE
MORE EMBOLIZE
GREAT HEMODYNAMIC IMBALANCE MORE P. E
RESULT
RESULT OF INTIMAL DAMAGE TO
FEMORAL VEIN WHICH IS TWISTED
DURING POSITION OF L- L
PREPARATION & DEVICE INSERTION
POTENT ANTICOAGULANTS
MITIGATE INTIMAL INJURY & REDUCE PROXIMIL THROMBI IN T. H. A
DISTAL THROMBI AFTER T. K. A IS MORE RELATED TO BLOOD STASIS
1 -FOLDING
3 -OCCLUSION
TOURNIQUET & ANTIGOAGULANT AND IPC ALONE ARE NOT EFFECTIVE
IN PREVENTION
OF POPLITEAL VEIN
PREVENTION WITH IPC AND
REGIONAL ANESTHESIA
OR
IPC + CHEMOPROPHYLAXIS
RELEAS OF THE TOURNIQUET AFTER T. K. A TRANSESOPHAGEAL ECHOCARDIOGRAPHY HAS NOISE IN ECHO PATTERN FROM:
1- EMBOLIC
2- BONE MARROW
3- ELMENTS FAT
FAT FROM
AFTER
INTRAMEDULLARY CANAL
INTRAVASATION
CANAL PREPARATION
PRESSURIZATION ON STEM CEMENTATION
ORTHOPEADIC SURGEON EMPHASIS TO:
1- PROPHYLAXIS OF CLINICAL EVENTS
2- BALANCE THE RISK OF BLEEDING
MORE THAN:
PREVENTION OF VENOGRAPHIC DISEASE
AMERICAN COLLEGE OF CHEST-
PHYSICIAN (ACCP)
SUGESST THAT ANTICOAGULANT
NEEDED AS SOON AS ELEVATED
BLEEDING RISK SUBSIDE
REGIONAL ANESTHESIA
REDUCE DVT
VASODILATATION BETTER VENOUS RETURN
RESEMBLE OF SYMPATHECTOMY
NO EFFECT ON INTRAOPERATIVE THROMBOGENIE BUT VASODILATION STIMULATE OF INTIMAL FIBRINOLYSIS
SPINALEPIDURAL
PROXIMAL CLOT 50%DISTAL CLOT 20%
2- PNEUMATIC COMPRESSION:
- I. P. C ALONE IS NOT VERY EFFECTIVE
- I. P. C & REGIONAL ANESTHESIA HAS SYNERGIC EFFECT TO PREVENT OF DVT
WESTRICH & COLLEAGUES
SUGGEST IPC AND HEPARIN
REDUCE DVT THAT
SIGNIFICANTLY BETTER THAN
WARFARIN OR ASPIRIN
3- ASPIRIN
OVERALL ANTIPLATELER ARE
INEFFECTIVE ON THE VENOUS
SIDE OF CIRCULATION
RESULT OF STUDY IN 12291 PATIENT WITH T. J. A THAT ANALYSIS MORTALITY AT
1-6W
2- 3 MON
G:A L. MW. H- XIMELAGTRAN - FONDAPARINUX
G:B REGIONAL ANESTHESIA WITH OR
WITHOUT
1- HEPARIN
2- IPC
3- ASPIRIN
G: C WARFARIN
EMPHASIS THAT MULTIMODAL
ASPIRIN PROPHYLALY IS BETTER
ASPIRIN: REDUCE P. E.
(CLINICAL MANIFESTATION OF V.T)
SPECIALLY USE WITH REG- ANES
ACCORDINGLY: THERE IS BOTH EVIDENCE AND MOMENTUM GROWING TO JUSTIFY A RANDMIZED CLINICAL TRIAL COMPARING ASPIRIN – WARFARIN AND NEWER AGENT IN CONJUCTION WITH REG – ANES FOR VT PROPHYLAXIS AFTER T. J. A
SYMPTOMATIC & FATAL P. T. E IS
MORE IN T. H. A THAN T. K. A
RESIDUAL VENOGRAPHIC
PREVALANCE OF DVT HAS BEEN
MORE AFTER T. K. A
THIS MEAN THAT PREVENTION OF DVT
AFTER T. K. A IS MORE REFRACTORY
TO BOTH TRADITIONAL AND
CONTEMPORARY DRUG
PROPHYLAXIS
L. M. W. H OR FRACTIONAL MORE
BINDING TO ANTI- THROMBIN III
THAN CONVENTIONAL HEPARIN
SO MORE EFFECT TO DVT
PREVENTION IN T. J. A
HEPARIN INDUCED THROMBOCYTOPENIA (HIT)
AND DEVASTING COMPLICATION OF ALL FORM OF HEPARIN UNCOMMON
2.6 % IN CONVENTIONAL- H
0.2 % IN L. M. W. H
FONDAPARINUX IS SYNTHETIC
PENTASACCHARIDE BIND ONLY
TO THE ANTI - THROMBIN III
HEPARIN SITE AND HAD NO RISK
OF HIT
ENOXAPARIN
PROPHYLAXIS POWER,
REDUCE V.T RATES FROM
28% TO 6%
RIVAROXABAN IN 2011 APPROVED BY FOOD & DRUG ADMINISTRATION
REDUCE OVERALL DVT & ALL CAUSE MORTALITY. RATE UNDER 7% (IN 3148 T. K. A)
31.4% REDUCTION COMPARED WITH ENOXAPARIN
RIVAROXABAN 1- NEED NO MONITORING
2- METABOLIZE IN LIVER
3- ONLY ORAL USE
4- 10 mg DAILY
5- NO BLEEDING EVIDENT MORE THAN ENOXAPARIN
− V. T OF CALF MANAGE WITH 6 WEEKS PERIOPERATIVE OF WARFARIN
− PROXIMAL DVT WITH 12 WEEK WARFARIN − P. E WITH 3- 6 MONTHS − THERAPEUTIC (INR 2- 3) WARFARIN AFTER
INITIAL ANTICOAGULATION WITH L. M. W. H
MORE RECENTLY IN THE ERA OF L. M. W. H, IMMEDIATE OUTPATIENT TREATMENT OF V. T HAS BECOME POPULAR
HOW EVER, IN POSTOPERATIVE PATIENT WITH A SBSTANTIAL ATTENDANT RISK OF BLEEDING, INITIATION OF ANTICOAGULATION AS AN INPATIENT FOLLOWED BY OUT PATIENT THERAPY AFTER ANTICOAGULANT DOSING AND INTENSITY HAVE BEEN STABILIZED IS A MORE PRUDENT APPROACH
JBJS 2013/ 1/115670 T. J. A 5- YEAR 90 DAYFOLLOWEDNO DIFFERENCE BETWEEN ASPIRIN ANDL. M. W. H IN: T. E COMPLICATIONP. EMORTALITYCONFIDENCE INTERVALMAJOR HEMORROGE
COMBINED MECHANICAL &
DRUG FOR 10- DAY AFTER
T. K. A IS MORE EFFECTIVE
MORE PATIENT OF ASPIRIN
GROUP MORE RETURN TO
THEATER FOR WOUND
COMPLICATION
CHARNLEY & CO 2012
7959 T. J. A 11 YEARS
1- PE: 8%
2- FATAL CASES 1%
IN T. J. A WITHOUT PROPHYLAXIS DVT 84%
CLINICALLY P.E 1.7%
FATAL CASE
OVERALL: IPC + L. M. W.H IS BETTER OF IPC + ASPIRIN OR WARFARIN
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