A 65-year-old male with mild congestive heart failure is to receive total hip replacement. He has no other underlying diseases and no history of hypertension, recent surgery, or bleeding disorder. The best approach to prevention of pulmonary embolus in this patient is ?
1. Aspirin 75 mg/d
2. Aspirin 325 mg/d
3. Warfarin with INR of 2 to 3
4. Early ambulation
5. Enoxaparin
6. Elastic stockings
7. 4 & 6
Is it Enoxoparin...the best
For prevention should be 7
Warfarin is the principal agent recommended for the prophylaxis of acute pulmonary embolus in patients who receive total hip replacement. Warfarin is started preoperatively, and the daily dose is adjusted to maintain an international normalized ratio (INR) of 2 to 2.5. Low-molecular-weight heparin (Enoxaparin) given twice daily subcutaneously is also a recommended regimen. The value of aspirin in this setting is unclear. Early ambulation and elastic stockings are also important in preventing thromboembolism, but are not adequate in themselves in this high-risk situation. Although Enoxaparin has less complications than Warfarin but the standard of care still remains to be warfarin.
Above explanation is of experts but my question is why cannot we use Enoxaparin when it has less number of complications than Warfarin. Anybody with logical explanation.
I know warfarin after hip surgery..but before hip surgery???? beats me..The pt will bleed like crazy during surgery..actually Warfarin is contraindicated before any surgery and needs to be reversed with FFP/Vit K before taking the pt up for surgery..There seems to be something wrong with the answer..where is the Q from?
What Do Most Surgeons Do
Eighty-six members of the hip and knee societies in North America were surveyed to determine what they do after total hip replacement to minimize the chance of blood clots.
All surgeons responding used some type of prophylaxis. Sixty-four percent of the time warfarin was used, fifteen percent of the time low molecular weight heparin was used, and twenty-one percent of the time aspirin was used. Ten percent of surgeons gave intra-operative heparin during their surgeries in addition to one of these other regimens.
Mechanical DVT prophylaxis, such as compression stockings, were used in 76% of cases in addition to one of the medicines.
Source:
http://www.orthoassociates.com/dvt.htm
Routine use of adjusted low-dose warfarin to prevent venous ³
thromboembolism after total hip replacement. Paiement GD. Wessinger SJ. Hughes R. Harris WH. Journal of Bone & Joint Surgery - American 75(6):893-8, 1993 Jun.
The efficacy and safety of routine use of adjusted low-dose warfarin for twelve weeks--without sonography or venography--for the prophylaxis of deep-vein thrombosis after total hip replacement was assessed in 268 patients (134 men and 134 women) who were between the ages of forty and eighty-five years (average, sixty-one years). The patients were given warfarin orally both before and after the operation. The initial dose was usually ten milligrams on the night before the operation and five milligrams on the night after the operation. Thereafter, the dose was adjusted to keep the prothrombin time between fourteen and sixteen seconds. The control time was ten to twelve seconds. The partial thromboplastin time was also measured, and the dose of warfarin was reduced if the value was more than fifty seconds. All 268 patients continued to take low-dose warfarin for twelve weeks after the operation. There were 170 primary and ninety-eight revisional total hip-replacement operations. Thirty-four patients (13 per cent) had a history of thromboembolic disease or venous stasis in a lower limb. Neither phlebography nor sonography was done routinely. All of the patients were followed for six months after the operation. There were no fatal pulmonary emboli during the period of the study and no known pulmonary emboli after any patient was discharged from the hospital. Two non-fatal pulmonary emboli were identified, both during hospitalization. Ten patients (4 per cent) had an episode of major bleeding--a wound hematoma in nine and a gastrointestinal hemorrhage in one--during hospitalization.
Source:
http://www.wheelessonline.com/ortho/rout...nt_venous_