Updated: 5/11/2019

Thromboembolism (PE & DVT)

Topic
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Questions
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https://upload.orthobullets.com/topic/9056/images/coagulation cascade aaos_moved.jpg
Introduction
  • Incidence
    • DVT
    • pulmonary embolism
      • 700,000 symptomatic PE/yr in USA
      • of these 200,000 are fatal
  • Risk factors for thromboembolism
    • Virchow's triad 
      • venous stasis
      • hypercoagulable state
      • intimal injury
    • primary hypercoagulopathies (inherited)
      • MTHFR/C677T/TT gene mutation carries highest risk 
      • factor V Leiden mutation  
      • antithrombin III deficiency 
      • protein C deficiency
      • protein S deficiency
      • activated protein C resistance
    • secondary factors (acquired)
      • malignancy
        • recently been associated with up to 20% of all new diagnoses of VTE
      • elevated hormone conditions
        • recombinant erythropoeitin 
        • hormone replacement
        • oral contraceptive therapy
        • late pregnancy
      • elevated antiphospholipid antibody conditions
        • lupus anticoagulant
        • anticardiolipin antibody
      • history of thromboembolism
      • obesity
      • aging
      • CHF
      • varicose veins
      • smoking
      • general anesthetics (vs. epidural and spinal)
      • immobilization
      • increased blood viscosity
Pathophysiology
  • Mechanism of clot formation
    • stasis
    • fibrin formation
      • thromboplastin (aka Tissue Factor (TF), platelet tissue factor, factor III, or CD142) is released during dissection which leads to activation of the extrinsic pathway and fibrin formation 
    • clot retraction
    • propagation
Prophylaxis 
  • Overview
    • prevention of deep vein thrombosis (DVT) and pulmonary embolism (PE) is most important factor in decreasing morbidity and mortality
    • prophylaxis treatment should be determined by weighing risk of bleeding vs risk of pulmonary embolus
      • AAOS risk factors for major bleeding
        • bleeding disorders
        • history of a recent gastrointestinal bleed
        • history of a recent hemorrhagic stroke
      • AAOS risk factors for pulmonary embolus
        • hypercoagulable state
        • previous documented pulmonary embolism
  • Prophylaxis in hip & knee replacement
    • mechanical prophylaxis 
      • compressive stockings recommended
      • pneumatic compression devices are recommended by the AAOS across all risk (low to high risk of either bleeding or pulmonary embolism) groups undergoing total hip or total knee arthroplasty  
        • increase venous return and endothelial-derived fibrinolysis
        • decrease venous compliance and venous stasis
    • chemical prophylaxis
      • American Academy of Orthopaedic Surgeons (AAOS) and American College of Chest Physicians (ACCP) support ASA as a monotherapy  
    • medical treatment
      • see anticoagulation section below
Deep Venous Thrombosis
  • Introduction
    • procedures associated with greater frequency of DVT
      • spine fracture with paralysis 
      • elective total knee arthroplasty 
        • 2-3X greater rate of DVT than THA
      • elective total hip arthroplasty 
      • hip fracture 
      • polytrauma 
    • based on AAOS review, the rate of DVT does not correlate with PE or death following THA or TKA
  • Physical exam
    • often more helpful than imaging
      • pain and swelling 
      • Homan's sign is not very specific
  • Imaging
    • venography is gold standard
    • for proximal DVTs (proximal to trifurcation)
      • venous duplex ultrasound is 96% sensitive, 98% specific 
      • plethysmography is 75% sensitive, 90% specific
      • CT is 90% sensitive, 95% specific
  • Treatment
    • heparin therapy followed by long term coumadin
      • indications
        • postoperative DVT above knee
        • treatment for DVT below knee is controversial
    • vena cava filter placement
      • indications
        • preoperative identification of DVT in a patient with lower extremity or pelvic trauma who is high risk for DVT development
        • see anticoagulation topic
Pulmonary Embolism
  • Introduction
    • 700,000 asymptomatic PE/yr in USA
      • of these 200,000 are fatal
    • procedures associated with pulmonary embolism
      • hip fracture 
      • elective total hip arthroplasty
        • the greatest risk of activation of the clotting cascade during total hip arthroplasty occurs during insertion of the femoral component  
      • elective total knee arthroplasty
      • spine fracture with paralysis 
    • early diagnosis and treatment is most important factor for survival
  • Presentation
    • PE should be suspected in postoperative patients with
      • acute onset pleuritic pain and dyspnea 
      • tachypnea 
      • tachycardia 
  • Evaluation
    • EKG; S1Q3T3
    • ABG
  • Imaging
    • CXR
    • nuclear medicine ventilation-perfusion scan (V/Q)
    • pulmonary angiography
      • is gold standard
    • helical chest CT
      • widely considered first line imaging modality 
  • Treatment
    • continuous IV heparin infusion followed by warfarin therapy
      • indications
        •  in most cases as first line treatment
      • technique
        • continuous IV heparin infusion typically given for 7-10 days
        • warfarin therapy typically given for 3 months
        • monitor heparin therapy with PTT (partial thromboplastin time)
        • monitor coumadin therapy with INR (international normalized ratio)
    • thrombolytics
      • indications
        •  in specific cases
      • technique
        • see anticoagulation topic
the greatest risk of activation of the clotting cascade during total hip arthroplasty occurs during insertion of the femoral component;
 

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Questions (20)
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(SAE07HK.61) Familial (Leiden) thrombophilia is of importance in joint arthroplasty because of an abnormality in the clotting cascade. Which of the following statements best describes the condition? Review Topic

QID: 6021
1

It is a disease caused by an abnormality of platelets that leads to increased blood clotting.

2%

(2/85)

2

It is a disease caused by an abnormality of vascular endothelium that leads to increased blood clotting.

2%

(2/85)

3

It is a disease caused by an abnormality of hepatic metabolism that leads to decreased production of factor V and decreased blood clotting.

6%

(5/85)

4

It is a disease caused by an abnormality of factor V that leads to decreased inactivation of factor Va by activated protein C (aPC) and increased blood clotting.

84%

(71/85)

5

It is a familial, genetic disease that requires placement of a Greenfield filter in all individuals who have the abnormality, prior to surgery.

1%

(1/85)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 4
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(SAE07HK.71) Which of the following prophylactic regimens for the prevention of deep venous thrombosis after knee arthroplasty has received a grade 1A recommendation in favor of its use from the American College of Chest Physicians (ACCP) in the 2004 guidelines? Review Topic

QID: 6031
1

Warfarin with a targeted international normalized ratio (INR) of 2.0 to 3.0 for 10 to 14 days

16%

(11/69)

2

Low-molecular-weight heparin used for at least 3 days

4%

(3/69)

3

Pneumatic compression sleeves used while the patient is in the hospital

49%

(34/69)

4

Fondaparinux used for 5 to 7 days

0%

(0/69)

5

Aspirin for 4 weeks

30%

(21/69)

N/A

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(OBQ08.144) Which of the following is NOT a component of Virchow's triad? Review Topic

QID: 530
1

Thrombocytopenia

7%

(91/1243)

2

Platelet dysfunction

2%

(23/1243)

3

Hypercoagulability

0%

(5/1243)

4

Venous stasis

1%

(14/1243)

5

Neither thrombocytopenia (answer 1) nor platelet dysfunction (answer 2) are components of Virchow's triad

89%

(1107/1243)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(OBQ09.265) The 2009 AAOS Clinical Guideline on prevention of pulmonary embolism in patients undergoing total hip or knee arthroplasty recommends classifying patients as having either a "standard" or "elevated" risk of bleeding complications. The presence of all of the following qualify a patient as having an "elevated" risk of major bleeding EXCEPT? Review Topic

QID: 3078
1

History of hemophilia

2%

(24/1489)

2

History of protein C deficiency

83%

(1242/1489)

3

History of a recent gastrointestinal bleed

7%

(98/1489)

4

History of a recent hemorrhagic stroke

3%

(49/1489)

5

History of Von Willebrand's Disease

5%

(71/1489)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(OBQ13.244) A 59-year-old patient undergoing total hip arthroplasty has a genetically inherited thrombophilia disorder. In this disorder, a variant co-factor cannot be inhibited by activated protein C causing overproduction of thrombin. What is this patients clotting disorder? Review Topic

QID: 4879
1

Factor V Leiden

71%

(2333/3298)

2

Antithrombin III deficiency

13%

(428/3298)

3

Familial dysfibrinogenemia

2%

(81/3298)

4

Protein S deficiency

12%

(385/3298)

5

Congenital deficiency of plasminogen

1%

(38/3298)

ML 3

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(OBQ12.206) A 52-year-old male underwent a right total knee arthroplasty 3 days ago and reports new onset dyspnea. His vitals signs include a temperature of 98.8, pulse of 133, blood pressure of 130/77, respiratory rate of 28, and oxygen saturation of 91% on room air. A chest radiograph shows atelectasis. Which of the following findings is most likely also present? Review Topic

QID: 4566
1

Hyperchloremic metabolic acidosis

7%

(276/3737)

2

Jugular venous distention with tracheal deviation

3%

(125/3737)

3

EKG demonstrating S-wave in lead I Q-wave in lead III T-wave inversion in lead III

74%

(2753/3737)

4

Pleural effusion with pleural/serum protein >0.5 and pleural/serum LDH > 0.6

5%

(181/3737)

5

Increased carbon monoxide diffusing capacity (DLCO)

10%

(363/3737)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ10.67) A 67-year-old man complains of low-grade fevers and calf pain 2 weeks following a total knee arthroplasty. What is the next appropriate step in management of this patient? Review Topic

QID: 3154
1

Plethysmography of lower extremity

1%

(19/2678)

2

MRI of lower extremity

0%

(9/2678)

3

CT angiography of lower extremity

1%

(19/2678)

4

Venous ultrasonography

95%

(2545/2678)

5

Knee aspiration to evaluate for septic joint

3%

(80/2678)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(OBQ05.27) During total hip arthroplasty, which of the following interventions increases the risk of pulmonary ventilation-perfusion mismatch the greatest? Review Topic

QID: 64
1

Acetabular reaming

3%

(53/1788)

2

Cement pressurization of the femoral canal

93%

(1670/1788)

3

Use of a modular femoral stem

2%

(31/1788)

4

Intra-operative sequential compressive device on the non-operative leg

1%

(11/1788)

5

Posterior approach

1%

(16/1788)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(OBQ10.189) A 30-year-old male with Protein C deficiency sustains a large subarachnoid hemorrhage and bilateral calcaneus fractures after falling off of a roof. The patient has been in the intensive care unit for 5 days for monitoring of his head injury. All of the following factors are appropriate reasons to obtain a helical chest CT scan EXCEPT: Review Topic

QID: 3282
1

Elevated alveolar-arterial gradient (> 20 mm Hg or 2.7 kPa) on arterial blood gas

9%

(265/2809)

2

Pulse oximetry reading of 99% with respiratory rate of 35 breaths/min

28%

(774/2809)

3

Pulse rate of 125 beats/min with new onset right bundle branch block

9%

(251/2809)

4

Paco2 > 35 mm Hg (or 4.7 kPa) on arterial blood gas

47%

(1334/2809)

5

Pao2 < 80 mm Hg (or 10.7 kPa) on arterial blood gas

6%

(163/2809)

ML 4

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PREFERRED RESPONSE 4

(OBQ04.224) A 25-year-old healthy male is scheduled to undergo a a nine-level posterior spinal fusion for scoliosis. Administering preoperative recombinant erythropoietin would place the patient at increased risk of developing which of the following complications? Review Topic

QID: 1329
1

Acute renal failure

6%

(35/576)

2

Increased bleeding time

4%

(21/576)

3

Thrombotic event

82%

(470/576)

4

Wound complications

3%

(16/576)

5

Delayed spinal fusion

5%

(30/576)

ML 2

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PREFERRED RESPONSE 3

(OBQ04.273) A 65-year-old female undergoes a total knee arthroplasty. In addition to chemoprophylaxis for deep vein thrombosis (DVT) prevention she is given pneumatic compression devices. Which of the following is associated with pneumatic compression devices? Review Topic

QID: 1378
1

Increased endothelial fibrinogenesis

6%

(38/633)

2

Decreased bleeding times

0%

(2/633)

3

Increased endothelial injury

3%

(16/633)

4

Increased venous compliance

9%

(56/633)

5

Increased venous blood flow

82%

(519/633)

ML 2

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PREFERRED RESPONSE 5

(OBQ05.172) A 65-year-old man undergoes total knee replacement and is found to have deep vein thrombosis two days later. What molecule is thought to be involved in this process when it is released during surgical dissection? Review Topic

QID: 1058
1

Prothrombin

36%

(601/1653)

2

RANKL

1%

(19/1653)

3

IL-1b

12%

(198/1653)

4

Thromboplastin

46%

(760/1653)

5

Factor XI

4%

(72/1653)

ML 4

Select Answer to see Preferred Response

PREFERRED RESPONSE 4
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