Preoperative preparation of patient with DVT {Phase A Written}


Preoperative preparation of patient with DVT

Definition:
Blood coagulation and its deposition due to venous stasis is called DVT.

Pathogenesis/factors responsible

Virchow’s triad:
1.     Stasis
2.     Vascular injury
3.     Hypercoagulability







Risk factors:
  • Age more than 60 years
  • Race- white
  • Obesity
  • Trauma or surgery
  • Reduced mobility for more than 3 days
  • Pregnancy/puerperium
  • Varicose vein with phelebitis
  • Drugs estrogen contraceptive, HRT
  • Smoking
  • Known active cancer or on treatment significant medical co morbidities e.g heart failure, critical care admission
  • Family/personal history of thrombosis e.g deficiency in antithrombin Ⅲ, protein C, protein S
  • Polycythemia
  • Pulmonary embolism
  • Uncontrolled DM
  • Arteriopathy


Presentation:
Asymptomatic upto half of the patient

Symptomatic:
Dull ache in the calf
Swelling
Pyrexia

Sign:
Color changes- phlegmasia
Tenderness in the calf muscle
Pedal oedema
Tachycardia
Homann’s sign

Investigation of symptomatic patient
Duplex ultrasound

Treatment:
                    A.   General measure
a.      Bed rest
b.     Elevation of the affected limb
c.      Analgesics
d.     Graduated compression stocking
e.      Systemic broad spectrum antibiotics  

B.Specific measures
a.      Medical treatment
                                                             i.      Systemic anticoagulant
1.     Unfractionated heparin
2.     Low molecular weight heparin
3.     Warfarin
                                                           ii.      Thrombolytic therapy
catheter directed thrombolytic therapy using streptokinase or urokinase for the lysis of the thrombus. Activity depends on the age and size of the thrombus. More than 72 hours, no action, so treatment should be within 72 hours. Cannot lyse big thrombus. Dose- 5 lac unit bolus then 6 lac unit 6 hourly.
Disadvantage- chance of PE and MI
b.     Surgical treatment:
                                                             i.      Open thrombectomy
                                                           ii.      Fogarty embolectomy
                                                        iii.      IVC filter

Prophylaxis against DVT                                                                                 
   A.   Physical method:
                                                             i.      Early ambulation
                                                           ii.      Graduated compression stocking
                                                        iii.      Intraoperative intermittent pneumatic cuff compression
   B.    Pharmacological method:
                                                             i.      Subcutaneous heparin
                                                           ii.      Unfractionated heparin
                                                        iii.      LMWH
Choices of prophylactic agent:
   A.   Low risk group – minor surgery/age<40 min="" nbsp="" o:p="" operation="" time="" years="">
                                                             i.      Early ambulation
                                                           ii.      Graduated compression stocking
   B.    Moderate risk group- abdominal or thoracic surgery/age >40 y/   operation time >30min
                                                             i.      LMWH
                                                           ii.      Intraoperative intermittent pneumatic cuff compression
                                                        iii.      Post op- graduated compression stocking
   C.    High risk group- extensive pelvic or hip surgery/recent H/O thromboembolism or MI
                                                             i.      Low dose unfractionated heparin
                                                           ii.      LMWH
                                                        iii.      Intraoperative intermittent pneumatic compression cuff
                                                         iv.      Early ambulation.
Complications of DVT:
       a)     Short term
                                                             i.      Pulmonary embolism, HTN
                                                           ii.      Recurrent DVT
                                                        iii.      Sudden death (MI,stroke)
       b)    Long term
                                                             i.      Chronic venous insufficiency
                                                           ii.      Varicose vein
                                                        iii.      Venous ulcer
Conclusion
All patients receiving prophylactic or therapeutic heparin using unfractionated or LMWH should have a platelet count performed prior to commencement of heparin on the day following and every 2 days.   


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