Joint Replacement at Sacred Heart VTE Prophylaxis Brian Jewett, MD - PowerPoint PPT Presentation

Joint Replacement at Sacred Heart VTE Prophylaxis Brian Jewett, MD Director of Joint Replacement Surgery Systems of Care 2015

Financial Disclosures No Industry Sponsors. Paid Medical Director at SHMC Riverbend.

Risks for VTE Why are TJA patients at risk? Virchow’s Triad: Stasis - supine in OR, sedentary recovery Trauma - TJA surgeries are physical, tissue trauma Hyper-coagulability - ILs, Cytokines, Marrow Elements

Risks for VTE Why are TJA patients at risk? Other Patient Risk Factors: Age Smoking Hormones History of PE Obesity Cancer Genetics Deformity (difficult Surgery) GETA vs Regional Anesthesia 4

Risks for VTE Why are TJA patients at risk? Historical Data: Unprotected Post-op 30-50% Patients with DVT… 5-10% PE… Newer Natural History Data: 20% TKA or THA positive for DVT but zero PE 5

Prophylaxis of VTE General Overview of Years 70’s: Hip surgery’s infancy, learning about techniques, problems, DVT known - Coumadin/ASA used. 80’s: Focused on enhanced technique, management protocols - Coumadin timelines. Early studies with LMWH. 90’s: Moving patients early, better implants, SCDs, Coumadin in, Heparin/ASA out, and LMWH increased. Eugene OR: Fragmin 2500 U BID x 14 days (est. D. Collis) 6

Prophylaxis of VTE 2000’s – Drug / Technique Perspective Look at what we know: COUMADIN : Vit K antagonist – historical baseline, what everything was compared too, 6 weeks tx PRO : Historical, effective against ASA/Placebo CON : Monitoring, errors, bleeding ASPIRIN : Cyclooxygenase Inhibitor – historical thought to be weak, ineffective PRO : Cheap, simple, low bleeding CON : Is it effective? LMWH : Factor X inhibition through Thrombin inhibition – newer, proved to be more effective than ASA or Coumadin for DVT PRO : No monitoring, ? More effective CON : More bleeding, expense Rivaroxaban : Linezolid, direct Xa inhibitor – newest, effective with TKA DVT > LMWH (RECORD studies) PRO : Oral, no monitoring CON : BLEEDING, cost Mechanical Compression : historical…start in OR..effective alone or with ASA ?? PRO : Easy to use CON : Compliance, effective? 7

Prophylaxis of VTE 2000’s - Age of Guideline Conflicts 2000’s: Turn of Century Lead to “Guidelines”… Really lead to more conflict and confusion….. 8

Prophylaxis of VTE 2000’s - Age of Guideline Conflicts 2000’s: Turn of Century Lead to “Guidelines”… What Happened….. 9

2000’s - Age of Guideline Conflicts Prophylaxis of VTE 1998/2001 American College of Chest Physicians Annual Report/Guidelines General Conclusions of TJA patients: Used Asymptomatic DVT (venography), Only LMWH or Coumdain for 6 weeks not PE/Death as endpoint LMWH should be started within 12 hours of TJA Little to no consideration of Bleeding ASA or Mechanical not effective 10

2000’s - Age of Guideline Conflicts Prophylaxis of VTE 1998/2001 SCIP From the ACCP “guidelines” came SCIP Initiatives from CMS forcing TJA surgeons to use LMWH or Coumadin for patients 11

2000’s - Age of Guideline Conflicts Prophylaxis of VTE 2007 American Academy of Orthopedic Surgeon Work-Group Refuted the endpoint of asymptomatic DVT, using non-fatal or fatal PE as endpoint Reviewed studies that SCIP guidelines caused increased wound healing problems, prolo nged hospital stays, readmissions, and re-operations for bleeding Focused on bleeding - causing 3x risk of infection 12

2000’s - Age of Guideline Conflicts Prophylaxis of VTE 2007 American Academy of Orthopedic Surgeon Work-Group Patients with high risk of DVT/PE – follow ACCP guidelines with LMWH or Coumadin Patients with high risk of BLEEDING – mechanical compression alone Most patients– ASA for 6 weeks, LMWH, or Coumadin OK Rationale, is that most studies do not show any difference in PE comparing LMWH, ASA, Coumadin…………..But bleeding profile is different.. 13

2000’s - Age of Guideline Conflicts Prophylaxis of VTE ACCP Assx DVT is endpoint Bleeding Complications Eh? ASA NOT OK AAOS PE better endpoint Bleeding leads to severe morbidity Should Stratify Patients Risk ASA OK 14

GUIDELINES REVISED… Prophylaxis of VTE 2011 American Academy of Orthopedic Surgeons Guidelines Updated High risk of bleeding – mechanical compression ? Filter if also increased risk of PE High Risk of DVT/PE – LMWH, Coumadin, Xeralto Others – most patients – shared decision model – discuss risks of bleeding and clotting… Patients value on preventing clotting – LMWH, Coumadin, Xeralto Patients value on preventing bleeding complications – ASA, =/- mechanical compression 15

GUIDELINES REVISED… Prophylaxis of VTE 2012 American College of Chest Physicians Annual Report/Guidelines Updated General Conclusions of TJA patients: LMWH, Coumadin, Xeralto, ASA, compression OK Still prefer LMWH…. Mechanical Compression OK for high bleeding risk 16

ACCP 1986 – first consensus published ACCP 6 th Guidelines for Antithrombotic Therapy (2000) * LMWH or Coumadin for TJA patients, 6 weeks recommended, ASA not recommended AAOS 2007 * Patients Stratified on Risk of Bleeding and VTE * Follow ACCP for high VTE risk, ASA or Mechanical Devices for High Bleeding Risk * Multiple of acceptable methods for low risk of bleeding and normal risk of VTE, including ASA ACCP 2008 * LMWH or fondaparinux recommended, ASA and foot pumps still not recommended * High risk of bleeding = mechanical devices OK AAOS 2011 * No role for routine U/S screening, recommends antiplatlet drug discontinued prior to surgery * Introduced individual bleeding risk assessment * Use of pharmacologic agents +/- mech compression for patients not at elevated risk of VTE * History of VTE – both …early mobilization in ALL ACCP 2012 * Acceptable agents expanded to include ASA, comp devices, Xeralto * Still prefer LMWH to all other agents

Were are we now…current status of management

GUIDELINES REVISI Prophylaxis of VTE 2008 American Academy of Orthopedic Surgeon Work-Group Patients with high risk of DVT/PE – follow ACCP guidelines with LMWH or Coumadin Patients with high risk of BLEEDING – mechanical compression alone Most patients– ASA for 6 weeks, LMWH, or Coumadin OK Rationale, is that most studies do not show any difference in PE comparing LMWH, ASA, Coumadin…………..But bleeding profile is different.. 19