BELLARMINE UNIVERSITY, LOUISVILLE, KY

Prevention of Pulmonary Embolism in high risk trauma patients

Inferior vena cava filters, pharmaceuticals, vasocompressive devices

Sean Beard, Jimmy Crick, Ashton Curry, Erica Essex

BELLARMINE UNIVERSITY, LOUISVILLE, KY

PICO QUESTION

• P: Trauma patients at high risk for PE

• I: Use of inferior vena cava filter

• C: Prophylactic pharmaceuticals and vasocompressive devices

• O: Incidence of PE

BELLARMINE UNIVERSITY, LOUISVILLE, KY

OBJECTIVES• Background

– PE background & incidence – IVC filters (IVCF) – Why trauma patients?

• Indications vs. Contraindications • Effectiveness • Conclusions • Clinical Relevance

– Risks associated with IVCF http://www.uwmedicine.org/Patient-Care/eHealth-Articles/PublishingImages/Inferior-Vena-Cava-Filter.jpg

BELLARMINE UNIVERSITY, LOUISVILLE, KY

BACKGROUND

PE• Blood clot in lungs

• Originates in lower extremity

• Fragments and travels to lungs via the inferior vena cava

IVCF• Metal alloy device

• Inserted in the inferior vena cava

• Traps blood clots

• Prevents pulmonary emboli

(Young, 2010)http://www.youtube.com/watch?v=o-_wL3XWZ1I&app=desktop

BELLARMINE UNIVERSITY, LOUISVILLE, KY

IVCF PLACEMENT

http://www.mbcgraphics.com/images/img_port_ivcfilter.jpg

http://www.youtube.com/watch?v=UvtHCMBm0SA&app=desktop

BELLARMINE UNIVERSITY, LOUISVILLE, KY

GROSS ANATOMY LAB

Thanks to Dr. Hanks and table 2.1

BELLARMINE UNIVERSITY, LOUISVILLE, KY

IMPORTANCE

• PE’s are common (Rajasekhar, 2011)

• PE’s are deadly (Rajasekhar, 2011)

• PE’s are preventable(Stefanidis, 2006)

http://medicalcenter.osu.edu/patientcare/healthcare_services/lung_diseases/lung/embolism/Pages/index.aspx

BELLARMINE UNIVERSITY, LOUISVILLE, KY

PATIENT PROFILETypes of high risk

patients

• SCI• TBI• Fractures

– Pelvic, acetabulum, tibia-fibula, femoral shaft, foot/ankle

(Carlin, 2002)

Factors increasing venous thrombotic event (VTE) risk

• History of venous thrombotic event

• Prolonged immobility• Pelvic trauma• Age• Vascular injury• Obesity• Blood transfusions (Helling,

2009)

BELLARMINE UNIVERSITY, LOUISVILLE, KY

STANDARD OF CARE• Prophylactic low dose subcutaneous

heparin (LDH) and sequential compression devices (SCD)

• Effectively reduces the incidence of DVT or PE to <10%

• 35% of trauma patients are unable to have SCD

• 14% of high risk trauma patients unable to have LDH

(Sekharan, 2001) (Khansarinia, 1995)

BELLARMINE UNIVERSITY, LOUISVILLE, KY

CONTRAINDICATIONS TO STANDARD OF CARE

Low dose heparin (LDH)

• TBI • SCI• Major pelvic and/or

acetabulum fractures• Spleen or liver injury• Gastrointestinal

bleeding• Hematuria• Stroke• Traumatic aortic

rupture

Sequential compression devices

(SCD)• LE orthopedic fractures• Casting

(Carlin, 2002)

BELLARMINE UNIVERSITY, LOUISVILLE, KY

INDICATIONS FOR USE OF IVCF

• Patients with known VTE• Anticoagulants contraindicated • Recurrent PE despite anticoagulant

therapy• Hx of complication related to

anticoagulant therapy

(Young, 2010)

(Rajasekhar, 2011)

• Inserted within 48 hours of injury (Carlin, 2002)

BELLARMINE UNIVERSITY, LOUISVILLE, KY

EFFECTIVENESS • IVCF’s are considered safe and

reduce incidence of VTE (Kidane, 2012)

• Compared to matched controls, PE incidence was significantly lower in IVCF group (Rajasekhar, 2011)

http://www.uofmmedicalcenter.org/fv/groups/public/documents/images/277293.jpg

BELLARMINE UNIVERSITY, LOUISVILLE, KY

EFFECTIVENESS• After 5 year follow-up, IVCF

placement is safe and durable in young active trauma patients

(Sekharan, 2001)

• In patients with IVCF, compared to no IVCF:– 12 days: 22% decrease in incidence of

PE– 2 years: 50% decrease in incidence of

PE (Decousus, 1998)

BELLARMINE UNIVERSITY, LOUISVILLE, KY

POTENTIAL COMPLICATIONS WITH

IVCF• Erosion through

vena cava wall• Filter migration• Filter infection• Thrombus

formation caudal to IVCF

• Inferior vena cava occlusion

(Stefanidis, 2006)

http://www.youtube.com/watch?v=qlaDA_FRA48

BELLARMINE UNIVERSITY, LOUISVILLE, KY

CONCLUSION • In trauma patients who are at high

risk for PE IVCF’s are more effective than standard of care at preventing the incidence of a PE

• In patients for whom standard of care is contraindicated IVCF placement is safe and recommended

BELLARMINE UNIVERSITY, LOUISVILLE, KY

RELEVANCE TO PHYSICAL THERAPY

• Awareness of IVCF• Indicates patient is at high risk for

VTE• Prolonged IVCF use correlated with

increased incidence of DVT• Wells criteria • Recognition of IVCF complication

BELLARMINE UNIVERSITY, LOUISVILLE, KY

Carlin AM, Tyburski JG, Wilson RF, Steffes C. Prophylactic and therapeutic inferior vena cava filters to prevent pulmonary emboli in trauma patients. Arch. Surg. 2002;137(5):

521–5.

Decousus H, Leizorovicz A. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. N. Engl. J. Med. 1998;338(7):409–415.

Helling TS, Kaswan S, Miller SL, Tretter JF. Practice patterns in the use of retrievable inferior vena cava filters in a trauma population: a single-center experience. J. Trauma. 2009;67(6):1293–6.

Khansarinia S, Dennis JW, Veldenz HC, Butcher JL, Hartland L. Prophylactic Greenfield filter placement in selected high-risk trauma patients. J. Vasc. Surg. 1995;22(3):231–5.

Kidney B, Madani AM, Vogt K, Girotti M, Malthaner R a, Parry NG. The use of prophylactic inferior vena cava filters in trauma patients: a systematic review. Injury, Int. J. Care Injured. 2012;43(5):542–7.

REFERENCES

BELLARMINE UNIVERSITY, LOUISVILLE, KY

REFERENCES Rajasekhar A, Lottenberg R, Lottenberg L, Liu H, Ang D. Pulmonary embolism prophylaxis with inferior vena cava filters in trauma patients: a systematic review using the meta-analysis of observational studies in epidemiology (MOOSE) guidelines. J. Thromb. Thrombolysis. 2011;32(1):40–6.

Sekharan J, Dennis JW, Miranda FE, et al. Long-term follow-up of prophylactic greenfield filters in multisystem trauma patients. J. Trauma. 2001;51(6):1087–90.

Stefanidis D, Paton BL, Jacobs DG, et al. Extended interval for retrieval of vena cava filters is safe and may maximize protection against pulmonary embolism. Am. J. Surg. 2006;192(6):789–94.

Young T, Tang H, Hughes R. Vena caval filters for the prevention of pulmonary embolism. Cochrane Database of Systematic Reviews. 2010; (2):CD006212.