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Total Joint Replacement

Total Joint Replacement. Agenda. INCIDENCE OF POST-OP COAGULATION COMPLICATIONS WITHOUT PROPHYLAXIS. THR DVT becomes symptomatic av. 17 days post-op TKR DVT becomes symptomatic av. 6.7 days post-op. Post-Operative Anticoagulation Therapy. Anticoagulation Therapy.

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Total Joint Replacement

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  1. Total Joint Replacement

  2. Agenda

  3. INCIDENCE OF POST-OP COAGULATION COMPLICATIONS WITHOUT PROPHYLAXIS • THR DVT becomes symptomatic av. 17 days post-op • TKR DVT becomes symptomatic av. 6.7 days post-op

  4. Post-Operative Anticoagulation Therapy

  5. Anticoagulation Therapy • The purpose of anticoagulant therapy is prevention & treatment of thromboembolic disorders • Anticoagulants DO NOT dissolve clots • Anticoagulants affect the balance between coagulation and fibrinolysis

  6. Virchow’s Triad • Identifies the three primary components that contribute to pathological clot formation (i.e. DVT and PE) • TKR and THR pts automatically have 2 of the 3 risks

  7. CH Anticoagulation Guidelines • Based on CHEST Evidence-based guidelines • Reviewed periodically & approved by P&T (last revision 2001, currently under review) • Risk Assessment Tool • Prophylaxis Guidelines • Treatment Guidelines

  8. Risk Assessment (Value Noted in Brackets): Major orthopedic surgery of lower limbs: total knee arthroplasty [ 5 ] hip fracture [ 5 ] total hip arthroplasty [ 4 ] Extensive abdominal or pelvic surgery for malignancy [ 4 ] Multiple trauma [ 4 ]. Acute spinal cord injury with paralysis [ 4 ] History of DVT/PE [ 3 ] Advanced age: age over 70 years [ 3 ] age 61 to 70 years [ 2 ] age 41 to 60 years [ 1 ] Stroke [ 1 ] CHF [ 1 ] MI [ 1 ] Varicose Veins [ 1 ] Obesity (greater than 20% of IBW) [ 1 ] Congenital and acquired aberrations in hemostatic mechanisms [ 1 ] General surgery lasting more than 30 minutes [ 1 ] History of pelvic or long bone fracture [ 1 ] Leg edema, ulcers, stasis [ 1 ] Pregnancy or postpartum <1 month [ 1 ] Inflammatory bowel disease [ 1 ] Severe infection [ 1 ] High dose estrogen use [ 1 ] Other CH Anti-coagulation Guidelines

  9. Recommendations: • Low Risk [ 1 ]: • Early ambulation • Moderate Risk [ 2 to 3 ]: • Low Dose Unfractionated Heparin at 5000 IU sc bid OR • Intermittent pneumatic compression OR • Low Molecular Weight Heparin – Tinzaparin (Innohep) 3500 IU sc qd until patient is mobilized. Start 6 hours post-op. • High Risk[ 4 or more ]: • Low Molecular Weight Heparin -- Tinzaparin (Innohep) 4500 IU sc qd until patient is mobilized. Start 12 hours post-op. • If patient is less than 55kg use 3500 iu. If patient is greater than 70kg consider dosing at 75iu/kg • Low intensity oral anticoagulation -- INR 2 - 3. OR • Intermittent pneumatic compression plus Low Molecular Weight Heparin or Low Dose Unfractionated Heparin.

  10. Guidelines for Treatment of Venous Thrombosis/Pulmonary Embolism: Venous Thrombosis: • Intravenous Unfractionated Heparin as per Weight Adjusted PE/DVT Heparin Protocol. OR • LMWH: Tinzaparin (Innohep) 175 iu/kg body weight sc q24h.or Enoxaparin (Lovenox) 1mg/kg (max.100mg) sc q12h or 1.5mg/kg sc qd (max.180mg) Pulmonary Embolism: • Intravenous unfractionated Heparin as per PE/DVT Heparin Protocol OR • LMWH: Tinzaparin 175iu/kg body weight sc q24H • Warfarin (Coumadin): • Should be started within 24 hours after initiation of Heparin or Low Molecular Weight Heparin and the dose adjusted in the usual manner. • Heparin or Low Molecular Weight Heparin should be continued for a minimum of five days. • INR should be in the therapeutic range (2 to 3) for two consecutive days prior to discontinuing heparin or Low Molecular Weight Heparin

  11. High Risk (4 or more): • Low Molecular Weight Heparin -- Tinzaparin (Innohep) 4500 IU sc qd until patient is mobilized. Start 12 hours post-op. • If patient is less than 55kg use 3500 iu. If patient is greater than 70kg consider dosing at 75iu/kg • Low intensity oral anticoagulation -- INR 2 - 3. OR • Intermittent pneumatic compression plus Low Molecular Weight Heparin or Low Dose Unfractionated Heparin.

  12. Clotting Cascade • Warfarin affects Factors II, VII, IX, X, the factors involved in Vitamin K metabolism • Low Molecular Weight Heparins (eg Tinzaparin) inhibit Factor Xa and inactivate thrombin

  13. Anticoagulant Example: Warfarin Classification: • Vitamin K Antagonist Monitoring: INR, goal range 2.0-3.0 Indications: • Prophylaxis & treatment of: • Venous thrombosis • Pulmonary embolism • Atrial fibrillation with embolization • Embolization after MI, including stroke

  14. AnticoagulantExample:Tinzaparin Classification: • Low Molecular weight Heparin Monitoring: CBC and Creatinine baseline and twice weekly Indications: • Prevention of DVT & PE after: • Abdominal surgery • Hip/knee surgery or replacement

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