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VTE Prophylaxis Guidelines for Orthopaedic Exams
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VTE Prophylaxis Guidelines for Orthopaedic Exams
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2024-05-31T00:00:00.0000000
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Language: EN.
Segment:0 .
This is one of the registrars I'm giving this talk today on the NICE guidelines on DVT. And the reason I just chose that because DVT is something which is very closely monitored. If you have any DVT in hospital, then there is always an inquiry, whether there was something which was preventable in that.
Also, DVT incidents are widely published. You will see newspapers coming out with all hospital gave this picture of preventable DVT. And as we all know, it can be life threatening. But most important for FRC is examiners hate anticoagulants. They don't like this rivaroxaban and all that because it leads to all this hematoma and infection chest infection rates. And second, most important thing the DVT, a guideline by night, has been recently updated.
So it could be a hot topic to just see that whether you are up to date with the new guidelines. Right? so what does the guideline say? The guideline says that all patients which are seen by orthopedics, should have a DVT assessment as soon as they present for admission. And there is a risk assessment tool in which you take like you take into consideration the patient's morbidity as patients mobility status and their bleeding risk.
And you have to balance the risk of DVT versus the risk of bleeding from the prophylaxis, which you will be giving. And if you decide to give a chemical prophylaxis, then it should ideally be started within 14 hours. That's what the NICE guidelines say. And in this current time of medical legal cases, it's very important to tell the patient and the carer about the benefits, as well as the risks of the prophylaxis, which you will be giving, like it's a common practice to tick the box.
OK, start enoxaparin. But if that patient has a very easy aneurysm and they develop intracranial bleed from it, then they will come back and said, did you tell the patient that you are at an increased risk of bleeding with the enoxaparin, so it needs to be talked to the patient and the relative and documented?
Right, so what all is advised for DVT prophylaxis is first is a embolic stockings, so for that, just for general knowledge, you should be aware that they should be, of the correct size and the size needs to be reassessed after surgery because there can be some edema of that leg. The pressure of that stocking is 15 millimeters of mercury. And they need to be removed at least twice a day. And contraindications to their use are peripheral vascular disease, someone with paralysis or someone with Fragile skin or gross deformities of the leg.
Now, the most important things which could be asked in the exam is the DVT prophylaxis in patients who are undergoing elective hip and knee replacement. That's where the change has happened recently. So previously, it was all 28 days to 35 days of either enoxaparin or rivaroxaban. But I think last year it has now been updated, and aspirin, which was initially not considered to be enough to cover, has been brought back into the picture.
So the current guidelines say that it has to be 10 days of low molecular weight heparin, and then you can shift the patient to 28 days of aspirin along with this talking's. Or you can carry on with the previous schedule, which were like low molecular weight for 28 days or rivaroxaban for 28 days. And someone who has contraindications for all of these can also be put on apixaban or dabigatran.
Similarly, with the total knee replacement guidelines, the important thing here you can manage without any enoxaparin or rivaroxaban, so that's the biggest change. The consultant used to hate their patients coming back with big hematoma, wounds getting secondary infections. So you can put them only on aspirin. That's what the current NICE guidelines say. So this might be of interest to any knee surgeon if they don't like the rivaroxaban, but you can still carry on with 14 days of the low molecular weight heparin or rivaroxaban again if none of them is suitable to the patient apixaban dabigatran.
Right now, we come to the other surgery, so anyone undergoing arthroscopy if the surgery is less than 90 minutes in a low risk patient, then there is no need to give any prophylaxis. However, if the patient is high risk or surgery more than 90 minutes, then again, like a knee replacement, 14 days of low molecular weight heparin with stockings. Foot and ankle surgery, same profile now more than 90 minutes, high risk patient you're putting below elbow below me or above me, plaster, then 42 days, that's six weeks of anticoagulants to them.
A polymer surgery somewhat similar. General anesthesia more than 90 minutes high risk patient surgery, which might lead to reduce mobility, such as shoulder surgery in a patient who uses a Zimmer frame or someone thing which is going to make them less mobile, then you give them again. Prophylaxis in their mobility is better. Now this is a controversial area, so elective spinal surgery.
The guideline says that if the patient is at low risk, then you just put them on stockings and intermittent calf compression. Whereas if they are at high risk, then you start the low molecular weight heparin after 24 to 48 hours. Now, if you give it before 24 hours, then you need to do an MDT approach. Use, take help from a hematologist and any other comorbidities if they are here to talk to the specialist.
The reason for these fine elective spinal surgery is a controversial idea regarding DVT prophylaxis. So you just mentioned this word that this is the guideline, and I would always seek opinion from a hematologist regarding the best way of prophylaxis, depending on the risk assessment. Similarly, for spinal injury, it's somewhat not very clear because, again, you are worried of hematoma developing operatively leading to compression of the cord.
So the guideline says that in a spinal injury patient, you start with only a embolic stocking and intermittent cough compression on admission and reassess it after 24 hours. And if the patient is at risk of bleeding and not going to have surgery, then you start prophylaxis chemical prophylaxis, possibilities for major trauma. The guideline says again and embolic stockings and calf compression and reassess VTE risk daily.
So again, you have to balance the risk of DVT versus the risk of bleeding, depending on the injuries they are having. Right, hip fracture, we all know hip fracture patients are on DVT prophylaxis, but what needs to be aware in the nice guideline is that you need to stop collecting 12 hours before. And if they are on for 24 hours before surgery.
And you can restart flex in six to 12 hours and for six hours post-op. And again, for lower limb mobilization, again, this is quite a hot topic because of the incidence of DVT in outpatients in our hospital, there was a big meeting regarding it. That patient who are put in below knee plasters and non weight bearing a young patient developed extensive DVT came in with pulmonary embolism.
So the guidelines is that they need to have low molecular weight heparin or for the foreign office for six weeks. And in people who are already on aspirin clopidogrel, you have to closely assess the benefits and risk of DVT. As per the guideline, aspirin or clopidogrel will not fully prevent a DVT, though they slightly reduce the risk. They might still need further anticoagulation if the patient is found to be at high risk, but that addition of that anticoagulation must be weighed against the risk of bleeding in that patient.
And if we are giving any chemical prophylaxis, we need to reduce the dose, according to the regional profile of that patient. This is a brief slide on the mechanism of action of these anticoagulants that we have just discussed. So heparin, which is the previously used anticoagulant it potentially anti-trump in three, which inhibits thrombin that is factor two and factor 10.
And click in which is a derivative, a low molecular weight heparin has more action on factor 10 than factor to. Rivaroxaban and apixaban, which are the newer ones that directly inhibit K and dabigatran, which is another oral anti coagulant, is a direct thrombin inhibitor that is factor two. So most of the anticoagulants that we are using are either inhibiting factor two or factor 10, the most common being flexing and rivaroxaban.
They both have action on factor 10. So that's something which is to be remembered dabigatran, if you can remember that factor, too. And warfarin, obviously, it inhibits the enzyme fat of vitamin K bauxite, which is needed for the activation of nine 10. So these four factors, so you need to know here the intrinsic and the extrinsic pathway of coagulation.
So the warfarin will affect both of them because of the factors involved. I think that's about the guideline I wanted to tell these, I don't expect this to be asked as a direct question, but this can come up either in the basic sciences or as a part of a discussion on hip replacement, knee replacement or trauma scenario or this controversy in spine. To be aware that you are aware of the current nice guideline, you are able to coat it with confidence.
That's what I wanted to say. Thank you. I'm happy to take any questions. Look hey. So that's a thank you. She's very intuitive and to the point of presentation. So it's a very key thing in terms of its new updates, and they will be a hot topic, particularly with the lower limb sort mobilization, because I don't think it's just not just for hospital.
I think quite a number of hospitals around the country have had similar problems. I know discussions as well. It's interesting that this is a new update, was it? When is this update policy from March last year or earlier this sometime last year, August or something? Well, with so and certainly it's worth disseminating it as well to our colleagues anyway in terms of a practical usage.
I mean, there've been quite a number of meta analysis of over the years after the omission of aspirin from the original DVT prophylaxis guidelines, which actually shows it as good as these more expensive, anticoagulant drugs with less a hematoma risk than some of these say more modern ones. But this is a very good presentation. So as I say, it's going to be on the orphan mental sort of YouTube side.
So if you missed it from the beginning, please do go and look at it. It is important because it is a common question in the survivor. And also I have had basic science station where I've been asked to draw the intrinsic and extrinsic pathway. So it's a nightmare. But just to have a refresh yourself, be able to draw it quickly and talk through it to do anything spectacular.
But if it looks like what, you're doing the exam, but they will probe questions about current guidelines and what you and what your practice is and demonstrating that you use a guideline is at minimum level seven. The evidence is evidence based, hopefully. OK right. So if no one else has any other questions to do to ask about that, we'll move on to the vyver park today, which Mickey is kindly going to do for us.
I'm not going to record it. Don't worry.
Segment:0 .
This is one of the registrars I'm giving this talk today on the NICE guidelines on DVT. And the reason I just chose that because DVT is something which is very closely monitored. If you have any DVT in hospital, then there is always an inquiry, whether there was something which was preventable in that.
Also, DVT incidents are widely published. You will see newspapers coming out with all hospital gave this picture of preventable DVT. And as we all know, it can be life threatening. But most important for FRC is examiners hate anticoagulants. They don't like this rivaroxaban and all that because it leads to all this hematoma and infection chest infection rates. And second, most important thing the DVT, a guideline by night, has been recently updated.
So it could be a hot topic to just see that whether you are up to date with the new guidelines. Right? so what does the guideline say? The guideline says that all patients which are seen by orthopedics, should have a DVT assessment as soon as they present for admission. And there is a risk assessment tool in which you take like you take into consideration the patient's morbidity as patients mobility status and their bleeding risk.
And you have to balance the risk of DVT versus the risk of bleeding from the prophylaxis, which you will be giving. And if you decide to give a chemical prophylaxis, then it should ideally be started within 14 hours. That's what the NICE guidelines say. And in this current time of medical legal cases, it's very important to tell the patient and the carer about the benefits, as well as the risks of the prophylaxis, which you will be giving, like it's a common practice to tick the box.
OK, start enoxaparin. But if that patient has a very easy aneurysm and they develop intracranial bleed from it, then they will come back and said, did you tell the patient that you are at an increased risk of bleeding with the enoxaparin, so it needs to be talked to the patient and the relative and documented?
Right, so what all is advised for DVT prophylaxis is first is a embolic stockings, so for that, just for general knowledge, you should be aware that they should be, of the correct size and the size needs to be reassessed after surgery because there can be some edema of that leg. The pressure of that stocking is 15 millimeters of mercury. And they need to be removed at least twice a day. And contraindications to their use are peripheral vascular disease, someone with paralysis or someone with Fragile skin or gross deformities of the leg.
Now, the most important things which could be asked in the exam is the DVT prophylaxis in patients who are undergoing elective hip and knee replacement. That's where the change has happened recently. So previously, it was all 28 days to 35 days of either enoxaparin or rivaroxaban. But I think last year it has now been updated, and aspirin, which was initially not considered to be enough to cover, has been brought back into the picture.
So the current guidelines say that it has to be 10 days of low molecular weight heparin, and then you can shift the patient to 28 days of aspirin along with this talking's. Or you can carry on with the previous schedule, which were like low molecular weight for 28 days or rivaroxaban for 28 days. And someone who has contraindications for all of these can also be put on apixaban or dabigatran.
Similarly, with the total knee replacement guidelines, the important thing here you can manage without any enoxaparin or rivaroxaban, so that's the biggest change. The consultant used to hate their patients coming back with big hematoma, wounds getting secondary infections. So you can put them only on aspirin. That's what the current NICE guidelines say. So this might be of interest to any knee surgeon if they don't like the rivaroxaban, but you can still carry on with 14 days of the low molecular weight heparin or rivaroxaban again if none of them is suitable to the patient apixaban dabigatran.
Right now, we come to the other surgery, so anyone undergoing arthroscopy if the surgery is less than 90 minutes in a low risk patient, then there is no need to give any prophylaxis. However, if the patient is high risk or surgery more than 90 minutes, then again, like a knee replacement, 14 days of low molecular weight heparin with stockings. Foot and ankle surgery, same profile now more than 90 minutes, high risk patient you're putting below elbow below me or above me, plaster, then 42 days, that's six weeks of anticoagulants to them.
A polymer surgery somewhat similar. General anesthesia more than 90 minutes high risk patient surgery, which might lead to reduce mobility, such as shoulder surgery in a patient who uses a Zimmer frame or someone thing which is going to make them less mobile, then you give them again. Prophylaxis in their mobility is better. Now this is a controversial area, so elective spinal surgery.
The guideline says that if the patient is at low risk, then you just put them on stockings and intermittent calf compression. Whereas if they are at high risk, then you start the low molecular weight heparin after 24 to 48 hours. Now, if you give it before 24 hours, then you need to do an MDT approach. Use, take help from a hematologist and any other comorbidities if they are here to talk to the specialist.
The reason for these fine elective spinal surgery is a controversial idea regarding DVT prophylaxis. So you just mentioned this word that this is the guideline, and I would always seek opinion from a hematologist regarding the best way of prophylaxis, depending on the risk assessment. Similarly, for spinal injury, it's somewhat not very clear because, again, you are worried of hematoma developing operatively leading to compression of the cord.
So the guideline says that in a spinal injury patient, you start with only a embolic stocking and intermittent cough compression on admission and reassess it after 24 hours. And if the patient is at risk of bleeding and not going to have surgery, then you start prophylaxis chemical prophylaxis, possibilities for major trauma. The guideline says again and embolic stockings and calf compression and reassess VTE risk daily.
So again, you have to balance the risk of DVT versus the risk of bleeding, depending on the injuries they are having. Right, hip fracture, we all know hip fracture patients are on DVT prophylaxis, but what needs to be aware in the nice guideline is that you need to stop collecting 12 hours before. And if they are on for 24 hours before surgery.
And you can restart flex in six to 12 hours and for six hours post-op. And again, for lower limb mobilization, again, this is quite a hot topic because of the incidence of DVT in outpatients in our hospital, there was a big meeting regarding it. That patient who are put in below knee plasters and non weight bearing a young patient developed extensive DVT came in with pulmonary embolism.
So the guidelines is that they need to have low molecular weight heparin or for the foreign office for six weeks. And in people who are already on aspirin clopidogrel, you have to closely assess the benefits and risk of DVT. As per the guideline, aspirin or clopidogrel will not fully prevent a DVT, though they slightly reduce the risk. They might still need further anticoagulation if the patient is found to be at high risk, but that addition of that anticoagulation must be weighed against the risk of bleeding in that patient.
And if we are giving any chemical prophylaxis, we need to reduce the dose, according to the regional profile of that patient. This is a brief slide on the mechanism of action of these anticoagulants that we have just discussed. So heparin, which is the previously used anticoagulant it potentially anti-trump in three, which inhibits thrombin that is factor two and factor 10.
And click in which is a derivative, a low molecular weight heparin has more action on factor 10 than factor to. Rivaroxaban and apixaban, which are the newer ones that directly inhibit K and dabigatran, which is another oral anti coagulant, is a direct thrombin inhibitor that is factor two. So most of the anticoagulants that we are using are either inhibiting factor two or factor 10, the most common being flexing and rivaroxaban.
They both have action on factor 10. So that's something which is to be remembered dabigatran, if you can remember that factor, too. And warfarin, obviously, it inhibits the enzyme fat of vitamin K bauxite, which is needed for the activation of nine 10. So these four factors, so you need to know here the intrinsic and the extrinsic pathway of coagulation.
So the warfarin will affect both of them because of the factors involved. I think that's about the guideline I wanted to tell these, I don't expect this to be asked as a direct question, but this can come up either in the basic sciences or as a part of a discussion on hip replacement, knee replacement or trauma scenario or this controversy in spine. To be aware that you are aware of the current nice guideline, you are able to coat it with confidence.
That's what I wanted to say. Thank you. I'm happy to take any questions. Look hey. So that's a thank you. She's very intuitive and to the point of presentation. So it's a very key thing in terms of its new updates, and they will be a hot topic, particularly with the lower limb sort mobilization, because I don't think it's just not just for hospital.
I think quite a number of hospitals around the country have had similar problems. I know discussions as well. It's interesting that this is a new update, was it? When is this update policy from March last year or earlier this sometime last year, August or something? Well, with so and certainly it's worth disseminating it as well to our colleagues anyway in terms of a practical usage.
I mean, there've been quite a number of meta analysis of over the years after the omission of aspirin from the original DVT prophylaxis guidelines, which actually shows it as good as these more expensive, anticoagulant drugs with less a hematoma risk than some of these say more modern ones. But this is a very good presentation. So as I say, it's going to be on the orphan mental sort of YouTube side.
So if you missed it from the beginning, please do go and look at it. It is important because it is a common question in the survivor. And also I have had basic science station where I've been asked to draw the intrinsic and extrinsic pathway. So it's a nightmare. But just to have a refresh yourself, be able to draw it quickly and talk through it to do anything spectacular.
But if it looks like what, you're doing the exam, but they will probe questions about current guidelines and what you and what your practice is and demonstrating that you use a guideline is at minimum level seven. The evidence is evidence based, hopefully. OK right. So if no one else has any other questions to do to ask about that, we'll move on to the vyver park today, which Mickey is kindly going to do for us.
I'm not going to record it. Don't worry.
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