Deep Vein Thrombosis

Notes
  • Deep vein thrombosis (DVT) and pulmonary embolism (PE) are forms of Venous thromboembolism (VTE), which has an annual global incidence of about 1 per 1000 adults.
Symptoms
  • Leg pain, warmth and tenderness
  • Erythema and oedema
  • Symptoms of PE
Diagnosis
  • Coagulation tests that include prothrombin time (PT), prothrombin ratio (PR), international normalized ratio (INR) and activated partial thromboplastin time (APTT)
  • Doppler ultra sound
  • D-dimer blood test (D-Dimer contains two crosslinked D fragments of the fibrin protein that is produced after a blood clot is degraded by fibrinolysis).
  • Venography (confirmatory test)
Differential
  • Mass/tumour of pelvic and thigh that compresses venous outflow from the leg
  • Cellulitis
  • Superficial thrombophlebitis
  • Tear of the calf muscle and / or Achilles' tendon
  • Achilles tendonitis
  • Arthritis
  • Ruptured popliteal or Baker's cyst)
  • Haematoma of calf muscle
  • Edema (e.g. due to lymph, arterial insufficiency, hepatic or renal diseases)
Prevention
  • This is recommended after surgery (especially hip surgery) or trauma or long term immobilization where the following medicines are administered:

Either;

*Heparin 5,000 IU SC BD until the condition is fully treated.

Or;

 *Enoxaparin sodium at the following dose: Moderate risk: 20mg, 1-2hours before surgery then 20mg OD for 7-10 days. High risk: 40mg 12hours before surgery then 40mg OD for 7-10 days.

Management

Non-pharmacological measures:

*Elastic compression stockings

*Early ambulation

*Stretching and flexing of the feet and pressing of  the toes (useful during          the long-hours flight).

*Placing the body onTrendelenburg position (the body is laid flat on the supine position with the feet higher than the head by 15-30 degrees)

*Adequate hydration

Pharmacological measures:

*Anticoagulants

Either;

**Unfractionated heparin: 80 IU/kg IV bolus followed by 18 IU/kg/hr infusion for 2-5 days. Monitor PTT and adjust the dose to maintain the PTT value that is 1.5 to 2.0 times of the control.

Or;

**Enoxaparin sodium 1mg/kg SC BD

Or;

**Dalteparin 200 IU / day SC.

And

**Warfarin being started from the first day; 10 mg OD x 2/7 then check INR and adjust the dose accordingly until the INR values are 2-3 times of the control for 2 consecutive days. Discontinue heparin and continue warfarin treatment for 6weeks for calf vein thrombosis and 3-6 months for proximal vein thrombosis.

  • In case of pulmonary embolism (PE) the following treatment is instituted;

**Unfractionated heparin 6,000 IU STAT

then target 24,000 - 30,000 IU per day by infusion. Monitor PTT and adjust the dose to maintain the PTT value that is 2 times of the control.

** Inferior vena cava filter (IVC filter)

** Thrombectomy

** Thrombolytics that include; Reteplase at  the following dose: 10U bolus dose followed by a second 10U bolus dose 30 minutes later [double bolus]. Each bolus is administered as a slow intravenous injection within 2 minutes. Heparin and acetylsalicylic acid should be administered before and following its administration to reduce the risk of rethrombosis.

Other medications

  • Low molecular weight heparin: Nadroparin
  • Direct thrombin inhibitor that is taken orally:

* Dabigatran that is taken at the following dose: Prophylaxis of VTE following total knee replacement surgery,adult over 18 years, 110 mg [elderly over 75 years, 75 mg] 1- 4 hours after surgery, then 220 mg [elderly over 75 years, 150 mg] once daily for 9 days. Prophylaxis of venous thromboembolism following total hip replacement surgery, adult over 18 years, 110 mg [elderly over 75 years, 75 mg] 1-4 hours after surgery, then 220 mg [elderly over 75 years, 150 mg] once daily for 27–34 days. Note: Max. 150mg daily with concomitant amiodarone or verapamil.

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