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Orthopaedic

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Arthritis

Question
98 out of 101
 

A pt after hip replacement developes severe chest pain and CVS collapse? (AIIMS Nov 2012)



A Pul Embolism
B AMI

C Hypotensive shock
D Cardiac Temponade

Ans. A

Pul Embolism Ref: Harrison’s 17th Edition, Page 165

Pulmonary Embolism

a. Thromboembolic disease is one of the most common serious complications arising from total hip arthroplasty.

b. The 30-day mortality rate from pulmonary embolism is 0.04%, behind myocardial infarction and cardiorespiratory arrest.

c. In early reports of total hip arthroplasty without routine prophylaxis, venous thrombosis occurred after total hip replacement in 50% of patients, and fatal pulmonary emboli occurred in 2%.

d. Several factors increase the risk of thromboembolism. Spinal and epidural anesthesia carry a lower risk of deep vein thrombosis and pulmonary embolism than general anesthesia.

Risk Factors for Venous Thromboembolic Disease

Clinical Risk Factors

Hemostatic Abnormalities (Hypercoagulable States)

Advanced age

Antithrombin III deficiency

Fracture of pelvis, hip, femur, or tibia

Protein C deficiency

Protein S deficiency

Paralysis or prolonged immobility

Dysfibrinogenemia

Prior venous thromboembolic disease

Lupus anticoagulant and antiphospholipid antibodies

Operation involving abdomen, pelvis, or lower extremities

Myeloproliferative disorder

Heparin-induced thrombocytopenia

Obesity

Congestive heart failure

Disorders of plasminogen and plasminogen activation

Myocardial infarction

Stroke

a. Thromboembolism can occur in vessels in the pelvis, thigh, and calf. Of all thromboses, 80% to 90% occur in the operated limb.

b. The temporal relationship of deep vein thrombosis and pulmonary embolism to surgery is controversial. The peak incidence of deep vein thrombosis is on day 4 after surgery and minimal after day 17.

c. The clinical diagnosis of deep vein thrombosis usually is made on the basis of pain and tenderness in the calf and thigh, positive Homan sign, unilateral swelling and erythema of the leg, low-grade fever, and rapid pulse. In at least 50% of patients, the diagnosis is not clinically apparent, however.

d. The clinical diagnosis of pulmonary embolism is based on symptoms of chest pain (especially if pleuritic in nature), evaluation by electrocardiogram and chest radiographs, and determination of arterial blood gas levels.

e. Most pulmonary emboli are not clinically apparent.

f. For deep vein thrombosis and pulmonary embolism, adjunctive radiographic testing is required to make the diagnosis.

g. Currently, venography is still considered the most sensitive and specific test for the detection of calf and thigh thromboses. It does not reliably detect pelvic vein thrombosis.

h. B-mode or duplex Doppler ultrasound approaches venography in accuracy of detection of femoral thrombosis, but it is not as helpful in diagnosis of calf and pelvic thrombi.

i. The diagnosis of pulmonary embolism usually is confirmed by radionuclide perfusion lung scanning. It is noninvasive and can be done at the bedside with portable equipment. Pulmonary angiography is invasive and carries higher risks, but is required occasionally when perfusion lung scanning is equivocal.

j. It also is generally agreed that pharmacological prophylaxis should be used in almost all patients, although the ideal agent has not been clearly established.

k. The most commonly used agents are warfarin, low-molecular-weight heparin (LMWH), fondaparinux, and aspirin. Adjusted-dose and low-dose heparin and dextran have been used in the past, but have largely been replaced by more effective and safer medications.

l. Warfarin has been used in prophylaxis and treatment of established thromboembolism. Warfarin given in traditional doses, maintaining prothrombin time at 2.5 to 3 times control, has been associated with an excessive risk of bleeding and is no longer recommended.

m. Low-dose warfarin has proved to be effective, however, while maintaining an acceptably low risk of bleeding complications.

n. Treatment is begun on the night before or the night of surgery, and the dosage is adjusted daily to maintain an international normalized ratio (INR) of approximately 2.5. Most studies comparing warfarin and LMWH have shown a higher prevalence of deep vein thrombosis for warfarin, but higher bleeding complications with LMWH. Other problems with warfarin include regular monitoring of the INR, delayed onset of action, drug interactions, and dietary restrictions for patients on warfarin therapy.

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