Terapie mediche associate: la prevenzione della trombosi degli arti

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1 VII Congresso Regionale Simeu Lombardia Focus di traumatologia in Pronto Soccorso Varese, Palace Grand Hotel, 22 settembre 2011 Terapie mediche associate: la prevenzione della trombosi degli arti LUIGI STEIDL CENTRO PER LE MALATTIE ATEROTROMBOTICHE E TROMBOEMBOLICHE VENOSE MEDICINA INTERNA I OSPEDALE DI CIRCOLO DI VARESE

2 TEV: una stretta relazione tra TVP ed EP Circa il 50% dei pazienti con TVP prossimale degli arti inferiori presenta un EP asintomatica (1) Migrazione Embolizzazione Una TVP (soprattutto se asintomatica) è presente in circa l 80% dei pazienti con EP (2) Trombosi 1. Pesavento R, et al. Minerva Cardioangiologica. 1997;45: Girard P, et al. Chest. 1999;116:

3 Diagnosi di TEV: il TEV è spesso diagnosticato troppo tardi Oltre il 70% delle EP è riscontrato all esame post mortem (1,3) Circa l 80% delle TVP è clinicamente asintomatico (2,3) 1. Stein PD, et al. Chest. 1995;108: Lethen H, et al. Am J Cardiol. 1997;80: Sandler DA, et al. J Royal Soc Med. 1989;82:

4 Ambiti del politraumatismo nei quali la profilassi antitrombotica è stata studiata Politraumatizzato multisistemico (maggiore) Traumatismi arti: fratture arti inferiori, ferite tessuti molli, lesioni del tendine d Achille, lesioni minori Trauma cranico Trauma spinale

5 Ambiti del politraumatismo nei quali la profilassi antitrombotica è stata studiata Politraumatizzato multisistemico (maggiore) Traumatismi arti: fratture arti inferiori, ferite tessuti molli, lesioni del tendine d Achille, lesioni minori Trauma cranico Trauma spinale

6 Incidenza di tromboembolismo venoso nei pazienti ricoverati Pazienti internistici 10-20% Chirurgia generale 15-40% Chirurgia ginecologica 15-40% Chirurgia urologica 15-40% Neurochirurgia 15-40% Chirurgia ortopedica maggiore 40-60% Traumi maggiori 40-80% Terapia intensiva 10-80% Trauma spinale % Traumi minori 5-35%

7 Postinjury thromboprophylaxis: incidence in trauma patients Deep venous thrombosis (DVT) in up to 60% of cases Fatal pulmonary embolism in up to 1% Pulmonary embolism within 24 h from admission in up to 6% Pulmonary embolism within 4 days in up to 37% of trauma patients Pulmonary embolism later than 22 days from admission in up to 11% of trauma patients Geerts WH, et al, N Engl J Med 1994; 331: Sing RF, et al. J Trauma 2006; 60: Menaker J, et al, J Trauma 2007; 63:

8 Risk of death from VTE in trauma Patients PE being the third leading cause of death in those who survive beyond the first day. Geerts WH, Code KI, Jay RM, et al. N Engl J Med 1994; 331:

9 Clinical settings a maggior rischio di Tev Traumi spinali Fratture pelviche e/o delle estremità inferiori Necessità di procedure chirurgiche Età (> 45) Inserzione di cateteri venosi femorali, succlavi o giugulari e chirurgia riparativa venosa maggiore Immobilizzazione prolungata Ricovero ospedaliero prolungato

10 Ambiti del politraumatismo nei quali la profilassi antitrombotica è stata studiata Politraumatizzato multisistemico (maggiore) Traumatismi arti: fratture arti inferiori, ferite tessuti molli, lesioni del tendine d Achille, lesioni minori Trauma cranico Trauma spinale

11 Incidenza di tromboembolismo venoso nei pazienti ricoverati Pazienti internistici 10-20% Chirurgia generale 15-40% Chirurgia ginecologica 15-40% Chirurgia urologica 15-40% Neurochirurgia 15-40% Chirurgia ortopedica maggiore 40-60% Traumi maggiori 40-80% Terapia intensiva 10-80% Trauma spinale % Traumi minori 5-35%

12 Risk factors for VTE following isolated lower-extremity injury Advanced age Presence of fractures rather than softtissue injuries alone Proximity of the fracture to the knee Operative repair Obesity Abelseth G, Buckley RE, Pineo GE, et al. J Orthop Trauma 1996; 10:

13 Methods of VTE Prophylaxis Unfractionated heparin (UFH) Low-molecular-weight heparins (LMWHs) New antithrombotics Oral anticoagulants (warfarin) Antiplatelet therapy Mechanical prophylaxis

14 Metodi di profilassi del TEV Metodi meccanici: Calze elastiche assenza assoluta di RCT Compressione pneumatica intermittente o foot pumps scarsa compliance, solo il 35% dei traumatizzati può indossarla Shackford SR et al, Am J Surg. 1990;159: Velmahos GC, et al. J Trauma 2000; 49:132 Filtri cavali rimovibili o permanenti

15 Prevention of Venous Thromboembolism after Injury: An Evidence-Based Report Rates of DVT among patients who received mechanical prophylaxis or no prophylaxis Velmahos GC, et al. J Trauma 2000; 49:132

16 Metodi di profilassi del TEV: filtri cavali case-report aneddotici o piccole serie, senza popolazione di controllo (McMurty AL, et al. J Am Coll Surg 1999; 189: ) Metanalisi: assenza di superiorità (Velmahos GC, et al. J Trauma 2000; 49: ) (Karmy-Jones R, et al. J Trauma 2007; 62:17 25) Sicurezza: complicanze a breve e lunga distanza (3 36 %) (Wojcik R, et al. J Trauma 2000; 49: ) (Rogers F, et al. J Intensive Care Med 2007; 22(1): 26-37)

17 Prevention of Venous Thromboembolism after Injury: An Evidence-Based Report Velmahos GC, et al. J Trauma 2000; 49:140

18 Guidelines on orthopedic thromboprophylaxis 1. The American College of Chest Physicians (ACCP) The American Academy of Orthopaedic Surgeons (AAOS) The Cardiovascular Disease Educational and Research Trust (ICS) The National Institute for Clinical health and Excellence (NICE, United Kingdom) The Scottish Intercollegiate Guidelines Network (SIGN) Die Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF, Germany) A Sociedade Brasileira de Angiologia e Cirurgia Vascular (SBACV) The South African Society of Thrombosis and Haemostasis Medical Front International Limited (Japan) The French Society for Anaesthesiology and Intensive Care (SFAR) The Australia and New Zealand working party on the management and prevention of venous thromboembolism 2007

19 Comparing consensus guidelines on thromboprophylaxis in orthopedic surgery Based on the same available literature, different guidelines recommend different thromboprophylactic regimens level of evidence world-wide disagreement relevance of different endpoints (e.g. asymptomatic DVT) fail of continuous guidelines updating Struijk-Mulder MC, Ettema HB, Verheyen CC, Bueller HR. J Thromb Haemost 2010; 8:

20 Individual risk factors and points allotted to calculate the RAP (risk assessment profile) score Conclusions: - the RAP score correctly identified trauma patients at increased risk for the development of DVT. - despite prophylaxis, the highrisk group warrants surveillance scans. - withholding prophylaxis in lowrisk patients can reduce hospital charges without risk Greenfield LJ, et al, Posttrauma thromboembolism prophylaxis. J Trauma 1997;42:100-3.

21 Thromboprophylaxis Trials in Trauma Patients Geerts WH et al, Chest 2008;133:381S-453S

22 Overview of guidelines on prevention of thromboembolism Struijk-Mulder MC, Ettema HB, Verheyen CC, Bueller HR.. J Thromb Haemost 2010; 8:

23 International guidelines

24 Prevention of Venous Thromboembolism The 8th ACCP Conference on Antithrombotic and Thrombolytic Therapy Chest 2008;133:381S-453S Recommendations: Trauma For all major trauma patients, we recommend routine thromboprophylaxis if possible (Grade 1A) In the absence of a major contraindication, we recommend that clinicians use LMWH prophylaxis starting as soon as it is considered safe to do so (Grade 1A).

25 Prevention of Venous Thromboembolism The 8th ACCP Conference on Antithrombotic and Thrombolytic Therapy Chest 2008;133:381S-453S Recommendations: Trauma We recommend that mechanical prophylaxis with IPC, or possibly with GCS alone, be used if LMWH prophylaxis is delayed or if it is currently contraindicated due to active bleeding or a high risk for hemorrhage (Grade 1B). When the high bleeding risk decreases, we recommend that pharmacologic thromboprophylaxis be substituted for or added to the mechanical thromboprophylaxis (Grade 1C) In trauma patients, we recommend against routine DUS screening for asymptomatic DVT (Grade 1B). We do recommend DUS screening in patients who are at high risk for VTE (eg, in the presence of a SCI, lower extremity or pelvic fracture, major head injury, or an indwelling femoral venous line) and who have received suboptimal prophylaxis or no prophylaxis (Grade 1C)

26 Prevention of Venous Thromboembolism The 8th ACCP Conference on Antithrombotic and Thrombolytic Therapy Chest 2008;133:381S-453S Recommendations: Trauma For major trauma patients, we recommend the continuation of thromboprophylaxis until hospital discharge (Grade 1C). For trauma patients with impaired mobility who undergo inpatient rehabilitation, we suggest continuing thromboprophylaxis with LMWH or a VKA (target INR, 2.5; range, 2.0 to 3.0) (Grade 2C)

27 Prevention of Venous Thromboembolism The 8th ACCP Conference on Antithrombotic and Thrombolytic Therapy Chest 2008;133:381S-453S Recommendations: Trauma We recommend against the use of IVCFs as primary prophylaxis in trauma patients (Grade 1C). Practice Management Guidelines of the Eastern Association for the Surgery of Trauma (EAST) for the prevention of VTE in trauma patients (Rogers FB, et al. J Trauma. 2002;53: ).recommendation for consideration of VCF insertion in high-risk patients who cannot receive prophylactic doses of anticoagulation

28 Nei pazienti politraumatizzati maggiori, con la tromboprofilassi, abbiamo ridotto il rischio di Tev da ~70% a ~5-15%: è un buon risultato, ma ancora molto lavoro ci aspetta...

29 Prevention of Venous Thromboembolism The 8th ACCP Conference on Antithrombotic and Thrombolytic Therapy Chest 2008;133:381S-453S Recommendation: Isolated Lower Extremity Injuries distal to the knee We suggest that clinicians not use thromboprophylaxis routinely in patients with isolated lower extremity injuries distal to the knee (Grade 2A)

30 Thromboprophylaxis is effective in reducing the rate of VTE during immobilization of the lower extremities Meta-analysis 1456 pts, 6 RCT End-point: venography or c-us Outcome: controls 17,1% VTE LMWH 9.6% VTE (Ettema HB, Kollen BJ, Verheyen CC, Bueller HR. J Thromb Haemost 2008; 6: ) Cochrane review leg injury, immobilized, plaster cast or brace Controls: VTE % LMWH: VTE 0-37% OR: 0.49 (Testroote M, Stigter W, De Visser DC, Janzing H. Cochrane Database of Syst Rev 2008; CD006681)

31 Relative risk estimate for prevention of venous thromboembolism in the immobilized lower extremity Ettema HB, Kollen BJ, Verheyen CCPM, Bueller HR. J Thromb Haemost 2008; 6:

32 Relative risk estimate for prevention of venous thromboembolism in the immobilized lower extremity Ettema HB, Kollen BJ, Verheyen CCPM, Bueller HR. J Thromb Haemost 2008; 6:

33 William H. Geerts, David Bergqvist, Graham F. Pineo, John A. Heit, Charles M. Samama, Michael R. Lassen and Clifford W. Colwell Chest 2008;133; Among patients with below-knee injuries, the limited evidence does not allow us to help clinicians decide which patients, if any, might benefit from thromboprophylaxis, or the dose or duration of thromboprophylaxis

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