美国深静脉血栓预防指南.pdf

1、Deep Venous Thrombosis ProphylaxisArthroplasty: American AcademySurgeons GuidelinesMD,to selecthaveandexactmeasure the efficacy of prophylaxis. This article discusses some of the recentuncertainty about which particular thromboem-bolic event the orthopedic community is attemptingto prevent. Although

2、 it is most desirable to preventthromboembolic events after joint arthroplasty,issued guidelines 1. These guidelines were devel-oped based on evaluation of the available literatureDVT was chosen as the end point because mostrandomized studies, particularly those sponsored byenthusiasm by the orthope

3、dic community 2,whodeclared that the ACCP had chosen an “inappropri-ate” end point. Distal DVT is a relatively commonPA 19107. 2008 Elsevier Inc. All rights reserved.0883-5403/08/2307-0002$34.00/0The Journal of Arthroplasty Vol. 23 No. 7 Suppl. 1 2008doi:10.1016/j.arth.2008.06.028the pharmaceutical

4、industry, were compelled to usean end point with a relatively common incidence.Choosing PE with its very low incidence as an endpoint for efficacy would require many thousands ofsubjects in such studies.The ACCP guidelines were received with littleFrom the Rothman Institute of Orthopedics at Thomas

5、JeffersonUniversity, Philadelphia, PA.Submitted May 29, 2008; accepted June 20, 2008.No benefits or funds were received in support of the study.Reprint requests: Javad Parvizi, MD, FRCS, Department ofOrthopaedic Surgery, Thomas Jefferson University Hospital,Rothman Institute, 925 Chestnut St, 5th Fl

6、oor, Philadelphia,every thromboembolic event such as distal andproximal deep venous thrombosis (DVT), postphle-using prevention of distal DVT as the end point indetermining the efficacy of various agents. Distaldevelopments in prevention and management of thromboembolism after total jointarthroplast

7、y, in particular highlighting the guidelines that were developed byAmerican Academy of Orthopedic Surgeons. Key words: total joint arthroplasty,thromboembolism, prophylaxis, AAOS guidelines. 2008 Elsevier Inc. All rights reserved.The debate as to what constitutes the most effectivestrategy to preven

8、t venous thromboembolism(VTE) after total joint arthroplasty continues.Despite all efforts, it is unlikely that a “single”strategy can be developed. There is a multitude ofreasons for failing to find the most effective agentor modality, most importantly those related to thebitic syndrome, and pulmon

9、ary embolism (PE), amodality that does all these things probably doesnot exist; and attempts to do so may result inunintended complications.A few years ago, the American College of ChestPhysicians (ACCP), in their attempt to assist theorthopedic community in preventing venousJavad Parvizi, MD, FRCS,

10、 Khalid Azzam,Abstract: The orthopedic community continuesthe prevention of thromboembolism afterforemost issue facing surgeons is howeffective in preventing the untoward consequencescausing other complications that caninclude the uncertainty regarding the doseof mechanical prophylaxis alone, and th

11、e2for Total Jointof Orthopaedicand Richard H. Rothman, MD, PhDto face a challenge with regard tototal joint arthroplasty. The first andthe best agent or modality that isof thromboembolism withoutdire consequences. Other challengesduration of various agents, the valueend points that should be used to

12、Thrombosis After Joint Arthroplasty C15 Parvizi et al 3event after joint arthroplasty; and prevention ofsuch events has not been proven to prevent theclinically more important event, PE. The orthopediccommunity also remains concerned that implemen-tation of protocols aiming to prevent distal DVT wil

13、llead to increased complications such as bleeding,reoperation, and infection, which could all lead tocomplications as serious as VTE itself. In addition,there were concerns that these guidelines would bemisconstrued as the “standard of care” for orthope-dic patients and that any deviation from the g

14、uide-lines would have legal implications.Chemoprophylaxis Increases the Risk ofBleeding, Blood Transfusion, andPeriprosthetic InfectionThere is substantial evidence in the literature thatadministration of anticoagulation chemoprophy-laxis places patients at risk of bleeding after totaljoint arthropl

15、asty. The incidence of major bleedingappears to approximate 0.5% in patients withoutchemoprophylaxis 3 and variably rises to as highas 5% in patients given chemoprophylactic agents4-8. The occurrence of major bleeding complica-tions after an elective total joint arthroplasty isregarded by most surge

16、ons as unacceptable becauseof the potential for the subsequent occurrence ofmore important complications such as infection,wound healing problems, functional disability, andloosening that have a high probability of compro-mising the surgical outcome.The ACCP guidelines do not recognize agents suchas

17、 aspirin, with minimal risk for bleeding, andadvocate lowmolecular weight heparinoids(LMWHs) and warfarin with a goal to keep theinternational normalized ratio (INR) higher than 2.The concern of the orthopedic community thatimplementation of ACCP guidelines may lead tohigher incidence of postoperati

18、ve bleeding wasdemonstrated in a recent study 9. Compliancewith the ACCP-1A protocol by administering a10-day course of enoxaparin sodium at 30 mg twicedaily after total hip arthroplasty led to an increase inthe incidence of major complications that includedreadmission to hospital (4.7%), reoperatio

19、n forwounddrainageandbleeding(3.4%),andprolongedhospitalization because of wound drainage (5.1%).Return to the operating room for wound complica-tions occurred 3 times more frequently with the useof enoxaparin than the previous anticoagulationprotocol using warfarin. Despite the use of enox-aparin,

20、symptomatic DVTs still occurred in 3.8% ofpatients; and nonfatal pulmonary emboli werediagnosed in 1.3% of the patients 9.in the clinical scenario where the risk of VTE clearlyoutweighs the risk of major bleeding complicationsafter operation, the AAOS guidelines are in agree-ment with the AACP guide

21、lines advocating admin-istration of chemoprophylaxis other than aspirin.The AAOS GuidelinesThe AAOS convened a group of experts andrepresentatives from various organizations includ-ing the Hip Society, the Knee Society, theAmerican Association of Hip and Knee Surgeons,and the Orthopedic Trauma Assoc

22、iation andexperts from the Evidence Based Division atAnother study on 1035 patients, evaluating thepredictors for transfusion after total hip arthro-plasty, demonstrated that administration of lowmolecular weight heparins increased the likelihoodof the need for transfusion (P b .0001, odds ratio =2.

23、76) 10. In a case-control study of 3500 patients,patients with higher INR were more likely todevelop prosthetic joint infections 11. A recentstudy by Dorr et al 12 showed that the use ofLMWH/warfarin for VTE prophylaxis in high-riskpatients was associated with a significantly higherincidence of hema

24、toma formation compared withthe use of antiplatelet agents combined with me-chanical prophylaxis 12.Chemoprophylaxis Does NotReduce MortalityIt appears that despite administration of variouschemoprophylactic agents, the orthopedic commu-nity has made little impact on the incidence of fataland nonfat

25、al pulmonary embolus over the last 10 to15 years 13,14.An interesting recent study evaluated the avail-able literature and found that the incidence ofall-cause mortality was in fact higher after adminis-tration of chemoprophylaxis compared withmechanical compression devices and aspirin 15.Although t

26、he finding of this study may at first sightappear counterintuitive, it can be comprehended inthe context of increased complications that mayoccur after administration of chemoprophylaxis,some of which can be fatal. It is also interesting tonote that the evaluation of the literature by theAmerican Ac

27、ademy of Orthopaedic Surgeons(AAOS) workgroup revealed that there was nodifference in efficacy among different agents withregard to prevention of PE; and hence, these guide-linesrecognizemechanicalprophylaxisandaspirinasa modalityof choice for preventionof VTE. However,cation should be implemented w

28、hen, for any given4 The Journal of Arthroplasty Vol. 23 No. 7 Suppl. 1 October 2008individual, the risk of bleeding should be weighedagainst the risk for VTE.An important point to recall, however, is thatbecause of the very low incidence of pulmonaryemboli, a proper study evaluating the difference i

29、nefficacy between agents would be impractical. Thelatter constitutes the reason why the recommenda-tions of the AAOS workgroup are based onnonrandomized and historical studies.These guidelines were created as an educationaltool to guide the qualified orthopedic surgeonsthrough a series of diagnostic

30、 and treatmentdecisions in an effort to improve the quality andefficiency of care. Hence, these guidelines take a“holistic” approach to VTE prophylaxis, providingguidance with regard to preoperative, intraopera-tive, and postoperative care.Preoperative CareAll patients should be assessed preoperativ

31、elyfor risk of DVT after surgery (Table 1). Patientswithout previous history of thromboembolicdisorders, not currently being treated withanticoagulants, and able to mobilize easily aregenerally not at increased risk of DVT/PE.All patients should be assessed preoperativelyfor risk of major bleeding i

32、n response to DVTprophylaxis (Table 1, available online at www.arthroplastyjournal.org).Patients at increased risk for PE and increasedrisk for major bleeding should be consideredfor vena cava filter placement. In addition,patients at high risk for PE who have contra-indications to chemoprophylaxis

33、should alsobe considered for vena cava filter.Tufts University to evaluate the available data todetermine the efficacy of various agents inpreventing what is believed to be more importantfor orthopedic surgeons, namely, fatal and non-fatal pulmonary emboli 16.Although both the ACCP and the AAOS guid

34、e-lines were devised with the good intention ofminimizing the impact of VTE in patients under-going total joint arthroplasty, because of usingdifferent “end points,” the guidelines differ insubstance. Besides choosing fatal and nonfatalpulmonary emboli as the end points for measuringefficacy, the AA

35、OS workgroup also attempted toevaluate the risk of bleeding, reoperation, andhospital readmission with the use of various agents.As the latter complications are not uncommonafter administration of chemoprophylaxis, theAAOS workgroup also advocated that risk stratifi-Intraoperative CareUnless contrai

36、ndicated, all patients shouldhave intraoperative and/or immediate post-operative mechanical prophylaxis.Patients at increased risk of thromboembolismshould preferably receive regional anesthesia(spinal/epidural) and operative time of lessthan 2 hours.Postoperative/Inpatient CareAll patients should b

37、e mobilized as soon asfeasible to the full extent of medical safety andcomfort postoperatively. A plan for painmanagement that allows control for thepatient to be out of bed and subsequentlyambulate should be in place before surgery.All patients should be out of bed to a sittingchair several times a

38、 day for several hours at atime to encourage deep breathing and avoidrecumbency. Practices should be in place toguarantee that appropriate physical therapy,ambulatory assistance, and support are pro-vided by the first postoperative day.Patients who are treated with epidural cathe-ters postoperativel

39、y should be out of bedto chair as above. Standing and ambulationshould begin for these patients when they arephysically capable.Patients who have an occurrence or event thatrestricts mobility should be considered to be atincreased riskfor DVT.Following are examples:Infection (eg, urinary tract infec

40、tion,pneumonia, severe wound infection)Electrocardiogram changes thatrestrict ambulationPostoperative ileusActive exercises should be started within theconfines of medical safety and pain tolerance.At a minimum, patients should be taught toactively dorsiflex and plantarflex the ankleand toes. This e

41、xercise should be performedin sets of 10 to 20 every half hour when thepatient is awake.Mechanical prophylaxis should remain inplace when the patient is out of bed and bediscontinued only for ambulation. Mechanicalagents have no bleeding risk, but it has notbeen demonstrated that they reduce theinci

42、dence of PE. Therefore, they remain anadjunct in the armamentarium for prophylaxisin routine total joint surgery. In a normal,rapidly mobilized patient, they may beconsidered for use in bed in the hospital aftersurgery.Therearenodataontheextendeduseof mechanical agents.Routine screening for thromboe

43、mbolism post-operatively in asymptomatic patients is notrecommended. There neither is a sufficientlysensitive noninvasive screening tool nor isthere a clear definition of the period of risk forVTE as to make routine screening reliablypredictive or cost-effective in preventing PE.The AAOS guidelines

44、stratify patients based onand complications in 2,012 total hip arthroplasties.enoxaparin and warfarin. J Bone Joint Surg Am2001;83-A:900.6. Brookenthal KR, Freedman KB, Lotke PA, et al.A meta-analysis of thromboembolic prophylaxis intotal knee arthroplasty. J Arthroplasty 2001;16:293.7. Turpie AG, B

45、auer KA, Eriksson BI, et al. Fondapar-inux vs enoxaparin for the prevention of venousthromboembolism in major orthopedic surgery: ameta-analysis of 4 randomized double-blind studies.Arch Intern Med 2002;162:1833.8. Freedman KB, Brookenthal KR, Fitzgerald Jr RH,et al. A meta-analysis of thromboemboli

46、c prophy-laxis following elective total hip arthroplasty.Thrombosis After Joint Arthroplasty C15 Parvizi et al 5J Bone Joint Surg Am 1973;55:1487.4. Enyart JJ, Jones RJ. Low-dose warfarin for preven-tion of symptomatic thromboembolism after ortho-pedic surgery. Ann Pharmacother 2005;39:1002.5. Fitzg

47、erald Jr RH, Spiro TE, Trowbridge AA, et al.Preventionof venousthromboembolic diseasefollow-ing primary total knee arthroplasty. A randomized,multicenter, open-label, parallel-group comparison oftheir risk for bleeding and risk for developing VTE.Therefore, the type of prophylaxis used for eachgroup

48、 differs based on these factors (Table 2,available at www.arthroplastyjournal.org). Theguidelines provided dosage and timing for thechemoprophylactic agents also (Table 3, availableat www.arthroplastyjournal.org).References1. Geerts WH, Pineo GF, Heit JA, et al. Prevention ofvenous thromboembolism:

49、the Seventh ACCP Con-ference on Antithrombotic and Thrombolytic Ther-apy. Chest 2004;126(3 Suppl):338S.2. Callaghan JJ, Dorr LD, Engh GA, et al. Prophylaxis forthromboembolic disease: recommendations from theAmerican College of Chest Physiciansare theyappropriate for orthopaedic surgery? J Arthroplasty2005;20:273.3. Coventry MB, Nolan DR, Beckenbaugh RD. “De-layed” prophylactic anticoagulation: a study of resultsJ Bone Joint Surg Am 2000;82-A:929.9. Burnett RS, Clohisy JC, Wright RW, et al. Failure ofthe American College of Chest Physicians1A proto-col for enoxa