69 yr old female, posted for rt. knee - mcccq

[ArchivalUser]

I think the question here is asking what you can do prophylactically before the operation.

[ArchivalUser]

@jorj

first u cant do anything to prevent DVT post operatively.
second thing can u justify ur ans ???
first thing is everything here we are doing is prophylactic not therapeutic ..another thing how can u use warfarin preop or intraop or postop immediately???

[ArchivalUser]

Panther, I can't really understand what is the problem in giving warfarin to this patient. I know it takes time to begin its action, but this is a cold case, so postpone the operation until you reach the target INR. We only give heparin before warfarin when we need immediate anticoagulation like when there is already a DVT and we want to prevent PE urgently. This patient, however, can definately wait ...... no big deal.

I tried to find you a good reference, so please read this:

http://emedicine.medscape.com/article/284371-overview

This is a high risk patient, so the options we have are
1- LMWH
2- Fondaparinux
3- Oral Vitamin K antagonists to reach INR (2-3)


From the answers offered here, oral warfarin is the best choice.

I hope I have made this clear.

[ArchivalUser]

jorj ur confused..u should read ur article and the blog u have written up here...
in first line of ur blog ur writing its a cold case and again suggesting its highrisk case.

ok make it clear to u..

patient is a high risk patient ( no longer cold case )with chances of bleeding are high------so its nonpharmacological method should be start with and then switch to LMWH (NOT A OPTION IN THIS QUESTION)for 5 days and start warfarin with heparin to maintain INR (2-3) till 3 months postop.
there are few studies suggest that u can even give intraop heparin tooo but they all are not conclusively evident of safety.
iv fractionated heparing is highly risky for everything ....1.post of operative site bleeding 2.usually this procedure is done under regional anae.
(HOPE U KNOW BOUT BLEEDING IN KNEE REPLACEMENT------ COMPLICATIONS OF BLEEDING TOO)
i dont want to fight with but just wanted to let u know that if at all option is LMWH then i would have choose that first but not at all alone warfarin. (even i m not mentioning protein C deficiency state here which is major thing considered for starting warfarin treatment alone)

[ArchivalUser]

From Washington Manual of Medical Therapeutics (32 edition): P.2

Venous Thromoembolism prophylaxis:
postoperative patients: recommended prophylaxis is as follows:
--....
--....
--Higher-risk patients (major urgery, >40 years old, and additional risk factoers, OR nonmajor surgery, >60 years old, and additional risk factors): low dose unfractioned heparin, 5,000 units SC tid, or LMWH, 3400 units per day.

[ArchivalUser]

Panther, unfortunately, u r the one who is confused !!

The patient is high risk once she undergoes the surgery, but before the surgery, she is indeed a cold case (I hope u r not saying that she requires emergency knee replacemt or something like that !!)

To clear your confusion, we are talking about high risk of DVT and not of bleeding which is a differnt story.

Again, LMWH, fondaparinux, and oral warfarin are our choices here. We only use one of these methods (There is "or" after each of them in the article). So we can choose any methoth of those 3 and don't use them in succession like you recommended.

Please read the article carefully before argueing with me.

I quoted this for you: (I didn't write this article believe me)

"Absolute contraindications to antithrombotic or anticoagulant therapy include active bleeding, severe bleeding diathesis or platelet count less than 20,000/µL, neurosurgery, ocular surgery, or intracranial bleeding within the past 10 days. Relative contraindications include mild to moderate bleeding diathesis or platelet count of 20,000-100,000/µL, brain metastases or recent major trauma, major abdominal surgery within the past 2 days, gastrointestinal or genitourinary bleeding within the past 14 days, infective endocarditis, or malignant hypertension"

These contraindications are about previous events. The planned surgery here is not a CI because the whole article is about PREOPERATIVE management, so everyone knows that there is an operation which is going to be done.

Now the patient at least doesn't have an absolute contraindication for warfarin but has a very high risk of developing DVT POSTOPERATIVELY, so start anticoagulation. Also nothing in the article says that you can use non pharmacological methods ALONE in this very high risk patient (in terms of DVT and not in terms of bleeding)

From your first post, I knew you wanted to say that we should always use heparin before warfarin because of protein C deficiency, but for your surprise we do use warfarin without previous heparinization inspite of protein C deficiency !!

BTW, thanks for telling me that there is bleeding during surgeries cuz I thought patients leave their blood at home before surgery !! First time to know that, honestly.

One last thing, I am not here to argue with you or with anyone else. we all here have the same goal which is the CK exam, so the discussions should be kept within that frame to make this forum useful for everyone. Hope you understand this concept, which IMO, is more important than understanding the concept of DVT prevention.

Thanks for the discussion

[ArchivalUser]

yes cstopass
im totally agree with u...
if the choice would be LMWH sc then i would go with it definately...but here the choice is not saying SC but the choice is IV.....

@jorj i think i have hurted u..
i dint meant to and i wont also..
there is not point of arguement..
good luck for exams.

@mcccq watever is the answer do let us know so we wont have to argue.