Thromboprophylaxis following Spinal Cord Injury C P Vinod

Thromboprophylaxis following Spinal Cord Injury C P Vinod Duke of Cornwall Spinal Treatment Centre, Salisbury

Objectives o Venous Thrombo-Embolism (VTE) o Spinal Cord Injury (SCI) o Thromboprophylaxis following SCI

Venous Thrombo-Embolism o Blood Flow is essential for Life n Arteries n Veins n Capillaries o Clotting of blood is also essential for life! n Thrombus – Blood Clot n Emboli – dislodged Clot

Venous Thrombo-Embolism (VTE) o Pathophysiology n Virchow’s Triad

Venous Thrombo-Embolism (VTE) o Pathophysiology n Virchow’s Triad o Haemodynamic Changes n Cardiac § Artificial Valves § Atrial Fibrillation n Atherosclerosis § Plaques n Immobility § Bed Rest § Paralysis Venou s Stasis

Venous Thrombo-Embolism (VTE) o Pathophysiology n Virchow’s Triad o Haemodynamic Changes o Hypercoagulability n Dehydration n Infections n Malignanacy Venous Stasis Hypercoagulable State

Venous Thrombo-Embolism (VTE) o Pathophysiology n Virchow’s Triad o Haemodynamic Changes o Hypercoagulability o Endothelial Injury n Trauma n Surgery Venous Stasis Hypercoagulable State Vascular Injury

Venous Thrombo-Embolism (VTE) o Pathophysiology n Virchow’s Triad o Haemodynamic Changes o Hypercoagulability o Endothelial Injury

Venous Thrombo-Embolism (VTE) o Thrombosis/Emboli in Arteries n Stroke n Infarct n Ischemia o Thrombosis/Emboli in Veins (VTE) n Deep Vein Thrombosis n Pulmonary Embolism

Spinal Cord Injury

SCI - Epidemiology o o o Incidence - 11 to 40 per million Prevalence – 10, 000 in UK 50% of SCI seen in 16 – 30 years age group Median age 26 years Traumatic SCI more common in <40 age group Non-traumatic SCI more common in >40 age group

SCI Classification o Tetraplegia n C 8 and above o C 4 and above may be ventilator dependent o Paraplegia n T 1 and below o Below L 3 may be able to walk o Complete o Incomplete o Syndromes n n n Central Cord Brown-Sequard Anterior Cord Cauda Equina Conus Medullaris

SCI - Mortality/Morbidity o 1927 – Harvey Cushing described 80% mortality in WW 1 soldiers with SCI o Renal Failure & Pressure Sores o Today – In well organised centres 94% survive initial hospitalisation o Pneumonia, PE & Septicaemia

Thromboprophylaxis in SCI o All patients have thromboprohylaxis for at least 12 weeks post spinal cord injury (Unless contraindicated) n We use LMWH

Thromboprophylaxis in SCI o Clinical Practice Guidelines (CPG) for Spinal Cord Injury n Published by the Consortium for Spinal Cord Medicine

Thromboprophylaxis in SCI o Second Edition Published in Sep 1999 n First edition 1997

Thromboprophylaxis in SCI

Thromboprophylaxis in SCI

Thromboprophylaxis in SCI o Why is it so high following SCI? o Failure of Venous muscle pump o Transient hypercoagulable state o Alteration in Haemostasis n n Reduced fibrinolytic activity Increased factor VIII activity Dehydration Other injuries

DVT relative to time Post SCI o 80% unprophylaxed patients develop DVT within the first 2 weeks n Rossi et al 1980; Merli et al 1993 o 6% incidence at 8 week following stopping of prophylaxis n Green et al 1994

Thromboprophylaxis in SCI o Incidence of PE not influenced by degree or level of SCI n Ragnarsson et al 1995 o Post Thrombotic Syndrome seen in over 60% n Chronic oedema, induration, Skin ulceration n Monreal et al 1993

Mortality due to VTE in SCI o Autopsy in Acute SCI deaths -37% due PE n Tribe et al 1963 o Pulmonary Embolism o 3 rd leading cause of death in Paraplegia o 2 nd leading cause of death in Incomplete SCI n De. Vivo and Stover 1995 o Risk of death due to PE in acute SCI o 210 times greater than healthy population o Decreases to 8. 9 times after 5 years

Thromboprophylaxis in SCI o VTE in SCI is a silent killer o Thromboprophylaxis (Mechanical or/and Pharmacological) if in doubt o Contact the nearest Spinal Injuries Centre

Thromboprophylaxis in SCI Thank You