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Post-Operative Leg Swelling

Dr Swapnil Pawar February 27, 2024 59


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    Post-Operative Leg Swelling
    Dr Swapnil Pawar

 

Written by – Dr Ashly Liu

Post-operative Leg Swelling Shownotes

DVT

Deep vein thrombosis is a venous thromboembolism found in the deep veins of the body, typically in the lower extremities. They are associated with life-threatening complications such as pulmonary embolism. In NSW hospitals, there has been a movement towards reducing the incidence of hospital-related VTE with the VTE prophylaxis assessment tool

Superficial vein thrombosis is generally benign and a self-limiting disorder. However, if axial veins are involved, there is a potential to propagate into the deep vein system as well.

 

Risk factors

 

Modifiable Non-modifiable
Immobilisation for prolonged periods of time

Surgery (especially orthopaedic surgeries)

Trauma

Drugs (COCP, HRT, etc)

Pregnancy (including 6 weeks post partum)

Inherited thrombophilia (Factor V Leiden, Protein C and S deficiency, Antithrombin deficiency)

Antiphospholipid syndrome

Malignancy

 

Anatomy

Deep veins of the lower extremity

Superficial veins of the lower extremity

 

Management

Management depends on the patient’s risk of bleeding and the location of the DVT. Typically patients are definitively treated with therapeutic anticoagulation, thrombolytic therapy or an IVC filter.

Anticoagulation is the definitive therapy for the proximal and distal DVTs in patients whose bleeding risk is acceptable. Typically, treatment duration is for 3-6 months following commencement of anticoagulation. This is dependent on Haematology advice for consideration of follow-up and assessment of whether this incident is provoked or unprovoked, which would require further thrombophilia workup.

However, in patients with a high risk of bleeding and a lower risk of embolisation, serial surveillance of compressive ultrasounds may be considered acceptable. If there is a high risk of embolisation in patients with contraindications to anticoagulant therapy, an IVC filter would be considered.

 

Anticoagulation Options

 

Drugs Dosage for VTE treatment Considerations
Clexane SC 1mg/kg twice daily OR

1.5mg/kg daily

Contraindicated in renal impairment
Heparin IV As per VTE protocol, aiming for APTT 70-90s Will require intravenous access and frequent blood test monitoring

Appropriate for patients who are peri-operative or require bridging

Apixaban 10mg twice daily for 7 days, then 5mg twice daily Dose adjustment for renal impairment, age and weight
Rivaroxaban 15mg twice daily for 3 weeks, then 20mg daily  Dose adjustment for renal impairment, age and weight
Dabigatran Parenteral anticoagulation for 5-10 days, then 150mg twice daily Contraindicated/dose adjusted in renal impairment

Has reversal agent (Idarucizumab)

Warfarin Will need to be bridged until the dose is adjusted to aim INR 2-3 Adherence may be affected by frequent monitoring

Can be used in patients with renal impairment

 

References

UpToDate “Overview of the treatment of proximal and distal lower extremity deep vein thrombosis (DVT)”

 

UpToDate “Direct oral anticoagulants (DOACs) and parenteral direct-acting anticoagulants: Dosing and adverse effects”

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