Deep vein thrombosis (DVT) is a blood clot that forms in a deep vein, usually in the legs. The incidence of DVT ranges from 5-9 per 10,000 people annually. Risk factors include surgery, trauma, cancer, older age, and genetic conditions. Symptoms can include leg pain and swelling. Diagnosis involves blood tests, ultrasound imaging, or CT/MRI. Treatment aims to prevent clot growth and pulmonary embolism. Initial treatment includes anticoagulants like heparin or low molecular weight heparin. Long term treatment uses oral anticoagulants like warfarin for 3-6 months.
A brief presentation regarding etiology , clinical features , and management of chronic limb ischemia. It was presented by our unit at Department of surgery , Patna medical college
A brief presentation regarding etiology , clinical features , and management of chronic limb ischemia. It was presented by our unit at Department of surgery , Patna medical college
to down load this presentation from this link
https://mohmmed-ink.blogspot.com/2020/11/deep-vein-thrombosis-dvt.html
deep vein thrombosis, diagnosis and managment.
Deep vein thrombosis (DVT), is the formation of a blood clot in a deep vein, most commonly the legs.[2][a] Symptoms may include pain, swelling, redness, or warmth of the affected area. About half of cases have no symptoms. Complications may include pulmonary embolism, as a result of detachment of a clot which travels to the lungs, and post-thrombotic syndrome.[2][3]
Risk factors include recent surgery, cancer, trauma, lack of movement, obesity, smoking, hormonal birth control, pregnancy and the period following birth, antiphospholipid syndrome, and certain genetic conditions. Genetic factors include deficiencies of antithrombin, protein C, and protein S, and factor V Leiden mutation. The underlying mechanism typically involves some combination of decreased blood flow rate, increased tendency to clot, and injury to the blood vessel wall.
whom that have sx of swelling leg, painful when walking and raise up leg, redness of leg skin, have history of accident or long journey u are suspected had deep vein thrombosis.
Pulmonary embolism - Notes are made from textbook of Internal medicine to assist medical students and residents to grasp subject in totality. Resources: Harrison's 20thEd, ESC 2019 guidelines on PE
to down load this presentation from this link
https://mohmmed-ink.blogspot.com/2020/11/deep-vein-thrombosis-dvt.html
deep vein thrombosis, diagnosis and managment.
Deep vein thrombosis (DVT), is the formation of a blood clot in a deep vein, most commonly the legs.[2][a] Symptoms may include pain, swelling, redness, or warmth of the affected area. About half of cases have no symptoms. Complications may include pulmonary embolism, as a result of detachment of a clot which travels to the lungs, and post-thrombotic syndrome.[2][3]
Risk factors include recent surgery, cancer, trauma, lack of movement, obesity, smoking, hormonal birth control, pregnancy and the period following birth, antiphospholipid syndrome, and certain genetic conditions. Genetic factors include deficiencies of antithrombin, protein C, and protein S, and factor V Leiden mutation. The underlying mechanism typically involves some combination of decreased blood flow rate, increased tendency to clot, and injury to the blood vessel wall.
whom that have sx of swelling leg, painful when walking and raise up leg, redness of leg skin, have history of accident or long journey u are suspected had deep vein thrombosis.
Pulmonary embolism - Notes are made from textbook of Internal medicine to assist medical students and residents to grasp subject in totality. Resources: Harrison's 20thEd, ESC 2019 guidelines on PE
1) Review of the Evidence on Diagnosis of Deep Venous Thrombosis and Pulmonary Embolism
2) Duration of anticoagulant therapy after a first episode of an unprovoked pulmonary embolus or deep vein thrombosis
Importance of Arterial Pump Compression & Decompression RatesACI Medical, LLC
This short presentation is a shoot-off of "Preventing Amputation with an Arterial Compression Pump." It goes into greater detail as to why rapid cuff inflation and deflation MUST occur in under 0.5 seconds in order to promote successful therapy.
As always, the number one goal is maximizing blood flow to the lower extremities so that diseased tissues can heal faster with the help of nutrient- and oxygen-rich blood.
"Movement is the essence of life." - Bernd Heinrich
Preventing Amputation with an Arterial Compression PumpACI Medical, LLC
This slideshow is designed to give non-professionals a "plain English" explanation of how ArtAssist®...The Arterial Assist Device® became successful at saving legs from arterial disease-related amputation.
You'll get a glimpse some of the landmark clinical studies that shaped and tested this powerful home-use arterial compression pump to be the industry standard.
Its a elaborate presentation on deep vein thrombosis by surgery resident.
Inform me if any thing needed to be correction.
thank you.
Dr Syed Aftub Uddin, MBBS,CCCD, MS ( Resident)
email: aftub_16@yahoo.com
It is estimated that 20% of American women and 7% of American men suffer from venous disease. Venous disease results in symptoms such as aching, fatigue, swelling, and pain in the legs which can interfere with daily living.Cosmetic issues may affect quality of life.
At least 20% of patients with venous disease will develop leg ulcers. This presentation outlines the normal anatomy and physiology of venous drainage of the extremities as well as the common venous disorders such as varicose veins and deep vein thrombosis.
In this playlist I have discussed some important Venous diseases like Varicose veins, deep vein thrombosis and Pulmonary embolism. If you watch all these videos together, you will become confident in managing these venous pathologies.
Deep Vein Thrombosis and Pulmonary Embolism, by Prof. Minnu M. PanditraoMinnu Panditrao
Dr. Mrs. Minnu Panditrao, goes in depth with the very important topic of Deep Vein Thrombosis, Pulmonary embolism, aetio patheogenesis, clinical features, management etc.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
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Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
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Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
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Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
2. DEEP VEIN THROMBOSIS
A thrombus is a mass formed from blood
constituents within a vessel or the heart during life.
A venous thrombus is the formation of a semi-solid
coagulum within flowing blood in the venous
system.
3. The incidence of DVT ranges between 5 and 9 per
10,000 person-years in the general population,
and the incidence of VTE (DVT and PE combined)
is approximately 14 per 10,000 person-years.
Major surgery have a significant incidence of
perioperative DVT (15 to 40%).
Major trauma : 40- 80%
Hip or knee surgery : 40- 60%
Spinal cord injury : 60-80%
4. EPIDEMIOLOGY OF DVT
occurs first time in about 1 to 2 persons per 1,000
20 – 30% of general surgical patients
Male :Female = 1:1
This incidence increases with increasing age, doubling with
each decade of life after 40
More than two thirds of these patients have DVT alone, and
the 30% will have symptomatic pulmonary embolism with
mortality of 17%
5. 50 to 60% of DVT are asymptomatic
The recurrence rate with anticoagulation has been
noted to be 6% to 7% in 6 months
DVT in upper extremity is less common- 5% of all
documented DVT but one third result in PE
Upper limb DVT may be primary or secondary
7. PATHOPHYSIOLOGY
Starts as a platelet nidus, usually in the venous valves of
the calf.
Platelet adhere to the endothelium and to each other
forming a projecting mass
The liberation of thromboplastin initiates a chemical
cascade leading to coagulation
If the rate of flow is slow red cells are entangled so that the
lumen is occluded
In front and behind platelet mass, the blood stagnates
further formation of fibrin takes place, resulting in a large
solid coagulum
9. A thrombus often develops in the soleal veins of the calf,
Propagate and extend up to next venous branch and
break down to embolize
Thrombus localise to calf have less tendency to
embolise than thromboi that extend to the thigh vens
Aproximately 20% of cases of calf DVT propagate to the
thigh, and 50% of cases of thigh or proximal DVT
embolize
10. SEQUELE OF DVT
DVT- Phlegmaisa alba dolens- Phlegmasia cerulea
dolens in 1 to 2 days- Secondary arterial
insufficiency venous gangrene in 1 to 2 days
Inc capillary hydrostatic pressure leading to
massive intersital edema and hypovolemic shock-
Venous gangrene leading to amputation
PCD is assoc with amputation of 50%
12-40% PE
Mortality rate of 20%
11. RISK FACTORS
A. Malignancy
Tumor cell activation of clotting cascade
Indirect clotting activation
Reactive thrombocytosis
B.Endothelial injury
Adhesion of tumor cells
Chemotherapeutic drugs
C. Venous stasis
Immobility, venous obstruction, inc pressure, inc blood
viscosity
Reduced clerance of activated clotting factors
Endothelial hypoxia- inc expression of TF
D .OCP
Odd ratio of 3-5 for risk of DVT
12. E. Hypercoagulable states
Primary
Dec activation of protein C
Impaired heparin binding of antithrombin III
Downregulation of membrane associated plasimin production
Inc serum prothrombin lefels
Decrease thrombogenic inhibitors (antithrombinIII, protein C,
Protein S
Secondary
Antiphospholipid syndrome
Venous trauma
Surgery
Cancer
Chemotherapy
Myeloproliferative syndromes
Heparin induced thrombopathy
hyperhomocysteinemia
14. In pregnant women, it has an incidence of 0.5 to 7 per 1,000
pregnancies, and is the second most common cause of
maternal death in developed countries after bleeding
general anesthesia and prior episode of DVT have a 5 times
increased risk
Patients with acute MI who are not receiving anticoagulation have a
26-38% rate of DVT
40% of postoperative neurosurgical patients develop DVT.
Type A blood is associated with lower levels of antithrombin III and
higher levels of factor VIII than type O blood.
Women of reproductive age with type A blood are 4 times as likely
to develop DVT.
15. PRESENTATION
Pain n swelling of unilateral calf
Bilateral is uncommon-30%
Asymptomatic n may present as features of
pulmonary embolism
Pleuritic chest pain, haemoptysis n SOB
Phlegmasia alba dolens and phlegmasia cerulea
dolen
16. Phlegmasia alba dolens :
Deep venous channels of the extremity are affected while
sparing collateral veins and therefore maintaining some
degree of venous return. Present with blanching of the
extremity, edema and discomfort
Phlegmasia cerulea dolens:
Occurs with extension of thrombus into the collateral venous
system, resulting in limb pain and swelling with cyanosis a
sign of arterial ischemia
17. PHYSICAL SIGN
Pitting edema
Dilated superficial veins
stiff calf and tenderness over the course of the deep veins
Erythema
Bluish discoloration
Absent or decreased pulse
Homans’ sign – resistance (not pain) of the calf muscles to
forcible dorsiflexion –
Pratt's sign: Squeezing of posterior calf elicits pain
Low grade fever
PE- cyanosis, dyspnoea, raised neck veins, a fixed split
second heart sound and a pleural rub
19. Score
(wells score)
Clinical Parameter Score
+1
Active cancer (treatment ongoing, or within 6 mo or palliative)
+1
Paralysis or recent plaster immobilization of the lower
extremities
+1
Recently bedridden for >3 d or major surgery <4 wk
+1
Localized tenderness along the distribution of the deep
venous system
+1
Calf swelling >3 cm compared with the asymptomatic leg
+1
Pitting edema (greater in the symptomatic leg)
+1
Previous DVT documented
+1
Collateral superficial veins (non varicose)
-2
Alternative diagnosis (as likely or greater than that of DVT)
WELLS SCORE FOR DVT
20. Total of Above Score
>3
High probability
1 or 2
Moderate probability
< 0
Low probability
WELLS SCORE
21. LAB
CBC
PT ,PTT , INR
ESR
D-dimer
ABG
Protein C , S Antithrombin III
LFT
RFT
23. DUPLEX ULTRASONOGRAPHY
73%
Sensitivity in calf vein
95-97%
Sensitivity in proximal vein
95-98%
Specificity
lack of spontaneous flow
inability to compress the vein
absence of color filling of the lumen
by color flow DUS,
loss of respiratory flow variation,
Venous distension
24. DUPLEX ULTRASONOGRAPHY
Advantage
helpful to differentiate
venous thrombosis
from hematoma, Baker
cyst, abscess, and
other causes of leg
pain and edema.
Non-invasive
inexpensive
Disadvantage
Venous thrombi in
iliac and tibial vein are
difficult to visualize
early n fresh thrombi
not be able to
differentiate between
old and new clots
25. VENOGRCTAPHY/ CT VENOGRAPHY
(GOLD STANDERD)
o The gold standard is intravenous venography,
o A positive study result is failure to fill the deep
system with passage of the contrast medium into
the superficial system or demonstration of discrete
filling defects
o Similar sensitivity as Ultrasound
26. MRI
– In the second and third trimester of pregnancy,
MRI is more accurate than duplex
ultrasonography because the gravid uterus alters
Doppler venous flow characteristics.
– In suspected calf vein thrombosis, MRI is more
sensitive than any other noninvasive study.
27. D-dimer testing
D-dimer antibodies account for their high sensitivity for
venous thrombo embolism.
D-dimer level may be elevated in any medical condition
where clots form. D-dimer level is elevated in trauma,
recent surgery, hemorrhage, cancer, and sepsis.
The D-dimer assays have low specificity for DVT;
therefore, they should only be used to rule out DVT, not
to confirm the diagnosis of DVT.
28. D-dimer results should be used as follows:
A negative D-dimer assay result rules out DVT in
patients with low-to-moderate risk and a Wells DVT
score less than 2.
All patients with a positive D-dimer assay result and all
patients with a moderate-to-high risk of DVT (Wells
DVT score >2) require a diagnostic study (duplex
ultrasonography).
30. Major general ,
urological. Gyne.
Cardiothoracic,vascular
or neruological surgery
Age > 40 yrs
Mahor medical illness
Major trauma or burns
Minor surgery or trauma
in pat with previous DVT,
PE
Orthopedic surgery or
amputation of LL
Lower limb paralsis
Major pelvic or abdominal
surgery for cancer
Major surgery, trauma or
illness in pat with previous
DVT, PE, Thrombophillia
Full limb paralysis
Maojor limb amputation
Moderate risk High risk
31. Frequency of
Fatal PE
Frequency of
Proximal Vein
Thrombosis
Frequency of
Calf Vein
Thrombosis
Category
>1%
10-30%
40-80%
High-risk
0.1-1%
1-10%
10-40%
Moderate-
risk
<0.1%
<1%
<10%
Low-risk
32. PROPHYLAXSIS
All patient admitted should be assessed for risk for DVT
Overall, low-dose UFH and LMWH reduce the risk for
symptomatic and non symptomatic VTE by 60 to 70%.
Low risk
Graduated compression stockings, Early mobilisation and leg
elevation
Moderate risk
Leg elevation, early mobilization, and either graduated
compression stockings or s/c UFH or LMWH
High risk
Leg elevation, early mobilisation, TEDs, UFH or LMWH
33. Heparin
5,000 unit ,S/C 2 hours before surgery and every 8 or 12 hourly
Graduated elastic compression (GEC)
stockings reduce the incidence of asymptomatic DVT by
approximately 50-60%
Intermittent pneumatic compression (IPC)
reduces the incidence of asymptomatic DVT by approximately
69%
Aspirin
reduces DVT by 30% and PE by 50%
Prophylactic insertion of IVC filters
Fondaparinux has similar results like LMWH
34. • In the Women's Health Study, supplementation with
vitamin E (alpha-tocopherol, 600 IU every other day)
reduced the risk of venous thrombo embolism in women,
especially those with a prior history or genetic
predisposition.
• High-risk patients should also be prescribed a single
prophylactic subcutaneous 40 mg dose of enoxaparin
prior to a long plane trip (>6 h).
35. TREATMENT
Principles are:
To prevent clot propagation
Reduce the risk of PE and
Enhance the resolution of the clot to minimize the post –
thrombotic syndrome
Options are
Anticoagulants/ Pharmacotherapy
Catheter directed intra-thrombus thrombolysis
Inferior vena caval filters
Venous thrombectomy
36. ANTICOAGULATION THERAPY
HEPARIN
Increases the binding of coagulatoin factors IXa, Xa,
XIa, XII and thrombin to antithrombin-III
Discourage further clot formation and facilitate
endogenous clot lysis
onset of action
10-18 mins IV
20-60 min S/C ( peak at 4-6 hrs n last up to 12 hrs)
Half life – 90 mins
Safe in pregnancy
Monitoring done with APTT 6 hrly (1.5 to 2.5 times)
Platelet count should be done every 3 days
APTT >1.5 should be achieved with in 24 hrs
37. Heparinization
Continous IV infusion
Loading dose- 5000 to 10000 unit( 80 U/kg)
Continuous infusion- 1300 units /hour (18 U/Kg)
Intermittent intravenous adminstration
70-100 units /kg every 4 hours
Subcutaneous adminstration
5000 unit every 8 0r 12 hourly
Should be continued for 4-6 days
Oral anticoagulant after 24 hours and overlapped for 4
days
Heparin should be discontinued when INR is >2 for 2
consecutive days
Warfarin is continued for minimum 3 months to maintain
INR between 2.0 to 4.5
38. Advantages of Low Molecular Weight Heparin
Greater activity against factor Xa
Lower risk of bleeding
Longer half life(4-6 hrs)
Produce little effect on test APTT or PT so no need
of monitoring
Can be started simultaneously with warfarin
Weight-based once- or twice-daily SC LMWH
injections
Incidence of HIT is<2%
Can be used as outpatient therapy
Less recurrence (8.6% vs 6.9%)
39. Adverse affects are
Harmorrhage- 5%
Thrombocytopenia( HAAbs)
1-5%
Repeated exposure 21%
HIT type I
HIT type II
Hypersensitivity
hyperkalemia
40. WARFARIN
Inhibits the enzyme vitamin K epodxide
Thus indirectly inhibit the the synthesis of vitamin K
dependent clotting factors
5mg orally
Onset: 36 -48hrs
Duration: 2-6 days
Half life: 36-40hrs
Bioavailability: 100%
Can cross placenta/ appears in milk/
The target INR 2 to 3
Adverse affects
Haemorrhage (0.5 to 1% per month)
Skin necrosis
Teratogenecity
Liver damage
41. Duration
First attack- 3 mth
Second attack- 1 year
Third attack- life long
Life time warfarin is aslo indicated for
Thrombophilia
Patients with first VTE and malignancy
Recurrence rate is 2.6% for life long therapy
42. NEWER AGENTS
Fondaparinux
synthetic pentasaccharide
Its five-polysaccharide sequence binds and activates
antithrombin, causing specific inhibition of factor Xa
The drug is administered SC once daily with a weight-
based dosing protocol: 5 mg, 7.5 mg, or 10 mg for
patients weighing <50 kg, 50 to 100 kg, or >100 kg,
respectively
Half life is 17 hrs
The rates of recurrent VTE ranged from 3.8 to 5%, with
rates of major bleeding of 2 to 2.6%, for all treatment
arms
43. Direct Thrombin inhibitors
recombinant hirudin, argatroban, and bivalirudin
bind to thrombin, inhibiting the conversion of fibrinogen
to fibrin as well as thrombin-induced platelet activation.
reserved for (a) patients in whom there is a high clinical
suspicion or confirmation of HIT, and (b) patients who
have a history of HIT or test positive for heparin-
associated antibodies
administered for at least 7 days, or until the platelet
count normalizes. Warfarin may then be introduced
slowly, overlapping therapy with a DTI for at least 5 days
45. INFERIOR VENACAVAL FILTER
Kimray-Greenfield filter in 1973
Traps emboli as small as 3mm
Made of titanium or nickel titanium alloy
Placed percutaneously under LA via the
common femoral, internal juglar or antecubital vein
Positioned in the infra-renal cava
20 years follow up – 96 % patency
Complications associated with IVC filter placement
include insertion site thrombosis, filter migration, erosion
of the filter into the IVC wall, and IVC thrombosis.
The rate of fatal complications is <0.12%
46. Absolute indication are
DVT or PE with contraindication to anticoagulation therapy
prior hemorrhagic stroke
Recent neurosurgical procedure or major surgery
Multiple trauma
Active internal bleeding
Intracranial neoplasm
Bleeding diathesis
Pregnancy
DVT or PE having complication with anticoagulation therapy
Failure of anticoagulation therapy
Free-floating iliofemoral or caval thrombus
Relative indication
Prior history of chronic pulmonary HTN
Morbidly obese with BMI >55
47. Catheter Directed Intra-thrombus thrombolysis
Placement of thrombolysis catheter within the clot
Rapid clearance of the DVT
SITE: IJV, contralateral CFV, popliteal, tibial vein
Thrombolytic drugs: streptokinase, alteplase , reteplase, and
tenecteplase, urokinase
convert plasminogen to plasmin, which leads to the degradation of fibrin.
Higher success in acute DVT n new onset DVT and upper limb
< 10 days with 34% and > 10 days 19%
1 year patency 79% for complete lysis and 32% for partial lysis
Overall one year patency is 60%
Major bleeding -11%
Mortality 0.4%
Contraindicated in:Recent surgery, active or recent bleeding, bleeding
diathesis, pregnancy and cerebral disease
48. VENOUS THROMBECTOMY
Inidcation
Phlegmasia alba dolens
Phlegmasia cerulea dolens with impending venous gangrene
threatening to the patient’s life and limb
Failed or contraindicated anticoagulation and thrombolysis
If the patient has phlegmasia cerulea dolens, a fasciotomy
of the calf compartments is first performed
Useful in relatively young patient who has cause other
than malignant dis for the DVT
49. An intraoperative completion venogram is obtained to
determine if any residual thrombus or stenosis is
present.
Post op managed with limb elevation, calf exercise,
compression stockings, antibioitc therapy, heparin for 5
days and warfarin for 6 months or life long
Good result if performed with in 7-10 days of event
Mortality rate is 1%
Intraoperative PE occurs in 20%
10 yrs follow up patency 77%
Severe PCD and venous gangrene have poor outcome
50. TREATMENT IN PREGNANCY
The treatment of DVT in pregnancy is similar to
the treatment of non pregnant.
Heparin SC or small pump infusion
Avoid warfarin in pregnancy If warfarin therapy
is essential, it should be avoided at least during
the first trimester (because of teratogenicity)
and from about 2 to 4 weeks before delivery to
reduce risk of hemorrhagic complications
Compression stockings
51. COMPLICATIONS OF DVT
• pulmonary embolism
• post-thrombotic syndrome
• occurs in 15% of patients with deep vein
thrombosis (DVT). It presents with leg oedema,
pain, nocturnal cramping, venous claudication,
skin pigmentation, dermatitis and ulceratiaion
(usually on the medial aspect of the lower leg).
52. High clinical pretest probability- DVT likely
Doppler ultrasound
Ultrasound positive for DVT
Diagnoses of DVT confirmed
Begin treatment
Ultrasound negative
for DVT
D-Dmer test (if available and reliable)
Otherwise skip
to repeat ultrasound
D-Dimer positive Repeat
ultrasound in 1 week
D-Dimer negative
DVT ruled out
Repeat ultrasound positive for DVT
Diagnoses of DVT confirmed
Begin treatment
Suspect DVT
Low clinical pretest
probability- DVT likely
Consider starting with D-dimer
test first
(if available and reliable )
Or skip to ultrasound
D-dimer positive
D-Dimer negative
DVT ruled out
Doppler ultrasound
Ultrasound positive for DVT
Diagnose of DVT confirmed
Begin treatment
Ultrasound negative
for DVT
DVT ruled out
(consider repeat
ultrasound if
D-dimer not available)