Σάββας Σουρμελής Διευθυντής Β Ορθοπαιδικής Κλινικής ΔΘΚΑ «Υγεία» Αναγνώριση παραγόντων κινδύνου της φλεβικής θρόμβωσης.

Transcription

1 Σάββας Σουρμελής Διευθυντής Β Ορθοπαιδικής Κλινικής ΔΘΚΑ «Υγεία» Αναγνώριση παραγόντων κινδύνου της φλεβικής θρόμβωσης.

2

3 VTE: deep vein thrombosis (DVT) and pulmonary embolism (PE) PE Migration Embolus Thrombus DVT

4 VTE: Often undetected until too late Over 70% of fatal PE are detected post mortem 1,3 Approximately 80% of DVTs are clinically silent 2,3

5 Venous thromboembolism (VTE) in Europe A. Cohen, G. Agneli et al Thromb. Haemost. 98: , 764, 2007

6 Number of VTE related deaths in EU per annum Breast cancer Prostate cancer Road traffic accidents AIDS

7 ENDORSE: VTE risk and prophylaxis in the acute hospital care setting a multinational cross-sectional sectional study Data from Cohen AT et al. Lancet 2008;371: countries 358 hospitals patients enrolled

8

9 Surgical Patients Acceptable surgical patients At-risk surgical patients At-risk surgical patients receiving any prophylaxis At-risk surgical patients receiving ACCP-recommended prophylaxis Germany % 94% 92% Greece % 74% 72% USA % 80% 71% Total % 64% 59%

10 Patients with VTE have unacceptably high short-term term mortality and long-term morbidity, which makes prevention of VTE paramount. A Validated Risk Model to Predict 90-Day VTE Events in Postsurgical Patients Christopher J. Pannucci et al CHEST 145:3, MARCH 2014

11 Inadequate VTE risk assessment and delay to chemoprophylaxis carry independent and significant increased risk for VTE. Inadequate Venous Thromboembolism Risk Stratification Predicts Venous Thromboembolic Events in Surgical Intensive Care Unit Patients Christopher J Pannucci et al. J Am Coll Surg 4:1-7, 2014

12 Current VTE prophylaxis guidelines strongly promote risk assessment on the individual level. This score sums 7 risk factors into risk categories: Low Risk, 2-3 Moderate 2 risk, >=4 high risk. Validating the IMPROVE Venous Thromboembolism (VTE) Risk Score: Retrospective Analysis of Electronic Data From a Large Health System David Rosenberg et al. Chest. 145, 2014

13 Intensive care unit patients with VTE have in-icu mortality rates between 7% and 16% and in- hospital mortality rates between 10% and 28%. The 2005 Caprini score is currently the most widely used and well-validated RAM among surgical patients. Inadequate Venous Thromboembolism Risk Stratification Predicts Venous V Thromboembolic Events in Surgical Intensive Care Unit Patients Christopher J Pannucci et al. J Am Coll Surg 4:1-7, 2014

14

15 Risk assessment as a guide for the prevention of the many faces of venous thromboembolism Joseph A. Caprini, M.D. The American Journal of Surgery :199,Suppl. January 2010

16 Risk assessment as a guide for the prevention of the many faces of venous thromboembolism Joseph A. Caprini, M.D. The American Journal of Surgery :199,Suppl. January 2010

17 Risk assessment as a guide for the prevention of the many faces of venous thromboembolism Joseph A. Caprini, M.D. The American Journal of Surgery :199,Suppl. January 2010

18 Perioperative VTE risk among surgical patients varies by 20-fold, which highlights the importance of risk stratification to identify high- risk patients, in whom chemoprophylaxis can decrease VTE risk, and low-risk patients, for whom the risk-benefit relationship of prophylaxis may be unfavorable. A Validated Risk Model to Predict 90-Day VTE Events in Postsurgical Patients Christopher J. Pannucci et al CHEST 145:3, MARCH 2014

19 Models that predict VTE risk based on pre-, intra-,, and postoperative events. can predict a patient s s VTE risk only at the end of their hospitalization, when the opportunity for acute prophylaxis has passed. A Validated Risk Model to Predict 90-Day VTE Events in Postsurgical Patients Christopher J. Pannucci et al CHEST 145:3, MARCH 2014

20 The perceived risk of hemorrhage is a recognized barrier to physicians providing chemoprophylaxis after surgery. We recommend that further work present data on the risk-stratified stratified response to prophylaxis side by side with the risks stratified data on bleeding complications. A Validated Risk Model to Predict 90-Day VTE Events in Postsurgical Patients Christopher J. Pannucci et al CHEST 145:3, MARCH 2014

21 The Caprini score was created based on expert opinion > 20 years ago but has subsequently been validated retrospectively in multiple populations. However, the model requires yes/no answers to 40 risk factor questions, which may limit physician compliance with completion. A Validated Risk Model to Predict 90-Day VTE Events in Postsurgical Patients Christopher J. Pannucci et al CHEST 145:3, MARCH 2014

22 Reduced models with fewer risk factors have been shown to predict risk similarly to full models. The goal of this study was to create a risk- prediction tool that could risk stratify patients prior to surgery. A Validated Risk Model to Predict 90-Day VTE Events in Postsurgical Patients Christopher J. Pannucci et al CHEST 145:3, MARCH 2014

23 Both of the studied RAMs had high specificities and positive-predictive predictive values, minimizing the risk of overprophylaxis. Improving the sensitivity of such RAMs can help for timely risk assessment for a greater array of real-world patients. Comparison of three risk assessment methods for venous thromboembolism bolism prophylaxis. Behnood Bikdeli et al Wolters Kluwer Health Lippincott Williams & Wilkins

24 This study supports that the 3 category RAM can reliably differentiate low risk patients from those at higher risk for a hospital acquired VTE. It may be reasonable to withhold prophylaxis from low risk patients. Validating the IMPROVE Venous Thromboembolism (VTE) Risk Score: Retrospective Analysis of Electronic Data From a Large Health System David Rosenberg et al. Chest. 145, 2014

25

26 VTE in orthopedic surgery: A major risk for fatal PE Major lower limb surgery: A very high VTE risk on its own, whatever the accompanying risk factors 1,2 VTE rates without prophylaxis Elective hip replacement Total knee replacement Hip fracture % DVT rate (range) % Fatal PE (range)

27

28

29

30

31

32

33