Download - بسم الله الرحمن الرحيم
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بسم الله الرحمن الرحيم
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T. J. A IS STRONG PROPENSITY FOR
T. E COMPLICATION
THAT IS POTENTIALLY LIFE -
THREATENING
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OBESITYCANCERPREVIOUS VTEFAMILY HISTORYSMOKINGADMISSION TO ICUDEHYDRATIONTHROMBOPHILIACONTRACEPTIVE USEPOST- OPERATION IMMOBILITY
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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
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DVT WITHOUT ANY PREVENTION
84%CLINICALLY P. E
1.7%FATAL P. E: -
POSITIVE VENOGRAPHY NOT ITSELF
ASSOCIATED WITH LOCAL SYMPTOMS
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PRESENTATION OF T. E DISEASE FOLLOWING T. H. A & T. K. A IS DIFFERENT
RELATED TO VIRCHOW’S TRIAD
STASIS
INTIMAL INJURY
HYPERCOAGULABILITY
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BEFORE ROUTINE USE OF
CHEMOPROPHYLAXIS
PROXIMAL DVT WAS IN 50- 60% OF
T. H. A
DISTAL WAS IN T. K. A
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PROXIMAL THROMBI ALMOST IS SEGMENTAL
AND NEAR LESSER TROCH
LARGE
MORE EMBOLIZE
GREAT HEMODYNAMIC IMBALANCE MORE P. E
RESULT
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RESULT OF INTIMAL DAMAGE TO
FEMORAL VEIN WHICH IS TWISTED
DURING POSITION OF L- L
PREPARATION & DEVICE INSERTION
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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
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PREVENTION WITH IPC AND
REGIONAL ANESTHESIA
OR
IPC + CHEMOPROPHYLAXIS
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RELEAS OF THE TOURNIQUET AFTER T. K. A TRANSESOPHAGEAL ECHOCARDIOGRAPHY HAS NOISE IN ECHO PATTERN FROM:
1- EMBOLIC
2- BONE MARROW
3- ELMENTS FAT
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FAT FROM
AFTER
INTRAMEDULLARY CANAL
INTRAVASATION
CANAL PREPARATION
PRESSURIZATION ON STEM CEMENTATION
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ORTHOPEADIC SURGEON EMPHASIS TO:
1- PROPHYLAXIS OF CLINICAL EVENTS
2- BALANCE THE RISK OF BLEEDING
MORE THAN:
PREVENTION OF VENOGRAPHIC DISEASE
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AMERICAN COLLEGE OF CHEST-
PHYSICIAN (ACCP)
SUGESST THAT ANTICOAGULANT
NEEDED AS SOON AS ELEVATED
BLEEDING RISK SUBSIDE
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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%
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2- PNEUMATIC COMPRESSION:
- I. P. C ALONE IS NOT VERY EFFECTIVE
- I. P. C & REGIONAL ANESTHESIA HAS SYNERGIC EFFECT TO PREVENT OF DVT
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WESTRICH & COLLEAGUES
SUGGEST IPC AND HEPARIN
REDUCE DVT THAT
SIGNIFICANTLY BETTER THAN
WARFARIN OR ASPIRIN
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3- ASPIRIN
OVERALL ANTIPLATELER ARE
INEFFECTIVE ON THE VENOUS
SIDE OF CIRCULATION
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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
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EMPHASIS THAT MULTIMODAL
ASPIRIN PROPHYLALY IS BETTER
ASPIRIN: REDUCE P. E.
(CLINICAL MANIFESTATION OF V.T)
SPECIALLY USE WITH REG- ANES
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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
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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
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THIS MEAN THAT PREVENTION OF DVT
AFTER T. K. A IS MORE REFRACTORY
TO BOTH TRADITIONAL AND
CONTEMPORARY DRUG
PROPHYLAXIS
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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
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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
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FONDAPARINUX IS SYNTHETIC
PENTASACCHARIDE BIND ONLY
TO THE ANTI - THROMBIN III
HEPARIN SITE AND HAD NO RISK
OF HIT
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ENOXAPARIN
PROPHYLAXIS POWER,
REDUCE V.T RATES FROM
28% TO 6%
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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
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RIVAROXABAN 1- NEED NO MONITORING
2- METABOLIZE IN LIVER
3- ONLY ORAL USE
4- 10 mg DAILY
5- NO BLEEDING EVIDENT MORE THAN ENOXAPARIN
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− 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
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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
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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
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COMBINED MECHANICAL &
DRUG FOR 10- DAY AFTER
T. K. A IS MORE EFFECTIVE
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MORE PATIENT OF ASPIRIN
GROUP MORE RETURN TO
THEATER FOR WOUND
COMPLICATION
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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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با تشكر از توجه شما