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BELLARMINE UNIVERSITY, LOUISVILLE, KY
Prevention of Pulmonary Embolism in high risk trauma patients
Inferior vena cava filters, pharmaceuticals, vasocompressive devices
Sean Beard, Jimmy Crick, Ashton Curry, Erica Essex
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BELLARMINE UNIVERSITY, LOUISVILLE, KY
PICO QUESTION
• P: Trauma patients at high risk for PE
• I: Use of inferior vena cava filter
• C: Prophylactic pharmaceuticals and vasocompressive devices
• O: Incidence of PE
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BELLARMINE UNIVERSITY, LOUISVILLE, KY
OBJECTIVES
• Background – PE background & incidence – IVC filters (IVCF) – Why trauma patients?
• Indications vs. Contraindications • Effectiveness • Conclusions • Clinical Relevance
– Risks associated with IVCFhttp://www.uwmedicine.org/Patient-Care/eHealth-Articles/PublishingImages/Inferior-Vena-Cava-Filter.jpg
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BELLARMINE UNIVERSITY, LOUISVILLE, KY
BACKGROUND
PE
• Blood clot in lungs
• Originates in lower extremity
• Fragments and travels to lungs via the inferior vena cava
IVCF
• Metal alloy device
• Inserted in the inferior vena cava
• Traps blood clots
• Prevents pulmonary emboli
(Young, 2010)http://www.youtube.com/watch?v=o-_wL3XWZ1I&app=desktop
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BELLARMINE UNIVERSITY, LOUISVILLE, KY
IVCF PLACEMENT
http://www.mbcgraphics.com/images/img_port_ivcfilter.jpg
http://www.youtube.com/watch?v=UvtHCMBm0SA&app=desktop
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BELLARMINE UNIVERSITY, LOUISVILLE, KY
GROSS ANATOMY LAB
Thanks to Dr. Hanks and table 2.1
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BELLARMINE UNIVERSITY, LOUISVILLE, KY
IMPORTANCE
• PE’s are common (Rajasekhar, 2011)
• PE’s are deadly (Rajasekhar, 2011)
• PE’s are preventable(Stefanidis, 2006)
http://medicalcenter.osu.edu/patientcare/healthcare_services/lung_diseases/lung/embolism/Pages/index.aspx
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BELLARMINE UNIVERSITY, LOUISVILLE, KY
PATIENT PROFILE
Types of high risk patients
• SCI• TBI• Fractures
– Pelvic, acetabulum, tibia-fibula, femoral shaft, foot/ankle
(Carlin, 2002)
Factors increasing venous thrombotic event (VTE) risk
• History of venous thrombotic event
• Prolonged immobility• Pelvic trauma• Age• Vascular injury• Obesity• Blood transfusions (Helling,
2009)
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BELLARMINE UNIVERSITY, LOUISVILLE, KY
STANDARD OF CARE
• Prophylactic low dose subcutaneous heparin (LDH) and sequential compression devices (SCD)
• Effectively reduces the incidence of DVT or PE to <10%
• 35% of trauma patients are unable to have SCD
• 14% of high risk trauma patients unable to have LDH
(Sekharan, 2001) (Khansarinia, 1995)
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BELLARMINE UNIVERSITY, LOUISVILLE, KY
CONTRAINDICATIONS TO STANDARD OF CARE
Low dose heparin (LDH)
• TBI • SCI• Major pelvic and/or
acetabulum fractures• Spleen or liver injury• Gastrointestinal
bleeding• Hematuria• Stroke• Traumatic aortic
rupture
Sequential compression devices
(SCD)
• LE orthopedic fractures• Casting
(Carlin, 2002)
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BELLARMINE UNIVERSITY, LOUISVILLE, KY
INDICATIONS FOR USE OF IVCF
• Patients with known VTE• Anticoagulants contraindicated • Recurrent PE despite anticoagulant
therapy• Hx of complication related to
anticoagulant therapy
(Young, 2010)
(Rajasekhar, 2011)
• Inserted within 48 hours of injury (Carlin, 2002)
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BELLARMINE UNIVERSITY, LOUISVILLE, KY
EFFECTIVENESS
• IVCF’s are considered safe and reduce incidence of VTE
(Kidane, 2012)
• Compared to matched controls, PE incidence was significantly lower in IVCF group (Rajasekhar, 2011)
http://www.uofmmedicalcenter.org/fv/groups/public/documents/images/277293.jpg
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BELLARMINE UNIVERSITY, LOUISVILLE, KY
EFFECTIVENESS
• After 5 year follow-up, IVCF placement is safe and durable in young active trauma patients
(Sekharan, 2001)
• In patients with IVCF, compared to no IVCF:– 12 days: 22% decrease in incidence of
PE– 2 years: 50% decrease in incidence of
PE
(Decousus, 1998)
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BELLARMINE UNIVERSITY, LOUISVILLE, KY
POTENTIAL COMPLICATIONS WITH
IVCF• Erosion through
vena cava wall• Filter migration• Filter infection• Thrombus
formation caudal to IVCF
• Inferior vena cava occlusion
(Stefanidis, 2006)
http://www.youtube.com/watch?v=qlaDA_FRA48
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BELLARMINE UNIVERSITY, LOUISVILLE, KY
CONCLUSION
• In trauma patients who are at high risk for PE IVCF’s are more effective than standard of care at preventing the incidence of a PE
• In patients for whom standard of care is contraindicated IVCF placement is safe and recommended
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BELLARMINE UNIVERSITY, LOUISVILLE, KY
RELEVANCE TO PHYSICAL THERAPY
• Awareness of IVCF• Indicates patient is at high risk for
VTE• Prolonged IVCF use correlated with
increased incidence of DVT• Wells criteria • Recognition of IVCF complication
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BELLARMINE UNIVERSITY, LOUISVILLE, KY
Carlin AM, Tyburski JG, Wilson RF, Steffes C. Prophylactic and therapeutic inferior vena cava filters to prevent pulmonary emboli in trauma patients. Arch. Surg. 2002;137(5):
521–5.
Decousus H, Leizorovicz A. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. N. Engl. J. Med. 1998;338(7):409–415.
Helling TS, Kaswan S, Miller SL, Tretter JF. Practice patterns in the use of retrievable inferior vena cava filters in a trauma population: a single-center experience. J. Trauma. 2009;67(6):1293–6.
Khansarinia S, Dennis JW, Veldenz HC, Butcher JL, Hartland L. Prophylactic Greenfield filter placement in selected high-risk trauma patients. J. Vasc. Surg. 1995;22(3):231–5.
Kidney B, Madani AM, Vogt K, Girotti M, Malthaner R a, Parry NG. The use of prophylactic inferior vena cava filters in trauma patients: a systematic review. Injury, Int. J. Care Injured. 2012;43(5):542–7.
REFERENCES
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BELLARMINE UNIVERSITY, LOUISVILLE, KY
REFERENCES
Rajasekhar A, Lottenberg R, Lottenberg L, Liu H, Ang D. Pulmonary embolism prophylaxis with inferior vena cava filters in trauma patients: a systematic review using the meta-analysis of observational studies in epidemiology (MOOSE) guidelines. J. Thromb. Thrombolysis. 2011;32(1):40–6.
Sekharan J, Dennis JW, Miranda FE, et al. Long-term follow-up of prophylactic greenfield filters in multisystem trauma patients. J. Trauma. 2001;51(6):1087–90.
Stefanidis D, Paton BL, Jacobs DG, et al. Extended interval for retrieval of vena cava filters is safe and may maximize protection against pulmonary embolism. Am. J. Surg. 2006;192(6):789–94.
Young T, Tang H, Hughes R. Vena caval filters for the prevention of pulmonary embolism. Cochrane Database of Systematic Reviews. 2010; (2):CD006212.