Total
Joint
Replacement
Agenda
Time
Topic
Speaker
0700-0730
Introduction
Total Joint Replacement in Chinook Health
TJR: What is it?
TJR: Indications
Kathy Sassa, Educator- Surgery
0730-0800
Preop Assessment Total Joint Clinic
Susan Folkerson, UM Unit 3B
0800-0900
The Surgical Process
Gail Kiefuik, OR RN
0900-0915
Break
0915-1000
Post-Op Care
Post-Op Orders
Tracey Kusk
1000-1115
Role of Physiotherapy & Occupational Therapy
OT/PT
1115-1130
Complications
Kathy Sassa
1130-1200
Lunch
1200-1300
Role of Pharmacy
Anticoagulation
Sheila Seely, Pharmacist
1300-1400
Discharge Planning
Kevin Elder, Charge RN Unit 4A
1400-1415
1415-1500
Break
4A Mass Casualty Response Plan: Burns
Kathy Sassa
INCIDENCE OF POST-OP COAGULATION
COMPLICATIONS WITHOUT PROPHYLAXIS
THR DVT becomes symptomatic av. 17 days post-op
TKR DVT becomes symptomatic av. 6.7 days post-op
Incidence of DVT
Incidence of Fatal
PE
Elective Knee Surgery
61%
5-12%
Elective Hip Surgery
51%
2.4%
Hip Fracture
44%
5.9%
General Surgery
25%
0.9%
Post-Operative
Anticoagulation
Therapy
Anticoagulation Therapy
 The purpose of
anticoagulant therapy is
prevention & treatment of
thromboembolic disorders
 Anticoagulants DO NOT
dissolve clots
 Anticoagulants affect the
balance between
coagulation and
fibrinolysis
Virchow’s Triad
Identifies the three
primary components
that contribute to
pathological clot
formation (i.e. DVT
and PE)
TKR and THR pts
automatically have
2 of the 3 risks
CH Anticoagulation Guidelines
Based on CHEST Evidence-based
guidelines
Reviewed periodically & approved by P&T
(last revision 2001, currently under review)
Risk Assessment Tool
Prophylaxis Guidelines
Treatment Guidelines
CH Anti-coagulation Guidelines
Risk Assessment (Value Noted in Brackets):
Major orthopedic surgery of lower limbs:
CHF [ 1 ]
total knee arthroplasty [ 5 ]
MI [ 1 ]
hip fracture [ 5 ]
total hip arthroplasty [ 4 ]
Extensive abdominal or pelvic surgery for
malignancy [ 4 ]
Varicose Veins [ 1 ]
Obesity (greater than 20% of IBW) [ 1 ]
Congenital and acquired aberrations in
hemostatic mechanisms [ 1 ]
Multiple trauma [ 4 ].
General surgery lasting more than 30
minutes [ 1 ]
Acute spinal cord injury with paralysis [ 4 ]
History of pelvic or long bone fracture [ 1 ]
History of DVT/PE [ 3 ]
Leg edema, ulcers, stasis [ 1 ]
Advanced age:
Pregnancy or postpartum <1 month [ 1 ]
age over 70 years [ 3 ]
age 61 to 70 years [ 2 ]
age 41 to 60 years [ 1 ]
Stroke [ 1 ]
Inflammatory bowel disease [ 1 ]
Severe infection [ 1 ]
High dose estrogen use [ 1 ]
Other
Recommendations:
Low Risk [ 1 ]:
– Early ambulation
Moderate Risk [ 2 to 3 ]:
– Low Dose Unfractionated Heparin at 5000 IU sc bid
OR
– Intermittent pneumatic compression
OR
– Low Molecular Weight Heparin – Tinzaparin (Innohep) 3500 IU sc qd until patient
is mobilized. Start 6 hours post-op.
High Risk [ 4 or more ]:
– Low Molecular Weight Heparin -- Tinzaparin (Innohep) 4500 IU sc qd until patient
is mobilized. Start 12 hours post-op.
– If patient is less than 55kg use 3500 iu. If patient is greater than 70kg consider
dosing at 75iu/kg
– Low intensity oral anticoagulation -- INR 2 - 3.
OR
– Intermittent pneumatic compression plus Low Molecular Weight Heparin or Low
Dose Unfractionated Heparin.
Guidelines for Treatment of Venous Thrombosis/Pulmonary Embolism:
Venous Thrombosis:
– Intravenous Unfractionated Heparin as per Weight Adjusted PE/DVT
Heparin Protocol.
OR
– LMWH: Tinzaparin (Innohep)
175 iu/kg body weight sc q24h.or
Enoxaparin (Lovenox)
1mg/kg (max.100mg) sc q12h or
1.5mg/kg sc qd (max.180mg)
Pulmonary Embolism:
– Intravenous unfractionated Heparin as per PE/DVT Heparin Protocol
OR
– LMWH: Tinzaparin 175iu/kg body weight sc q24H
– Warfarin (Coumadin):
Should be started within 24 hours after initiation of Heparin or Low Molecular
Weight Heparin and the dose adjusted in the usual manner.
Heparin or Low Molecular Weight Heparin should be continued for a minimum
of five days.
INR should be in the therapeutic range (2 to 3) for two consecutive days prior
to discontinuing heparin or Low Molecular Weight Heparin
High Risk (4 or more):
Low Molecular Weight Heparin -- Tinzaparin (Innohep)
4500 IU sc qd until patient is mobilized. Start 12 hours
post-op.
If patient is less than 55kg use 3500 iu. If patient is
greater than 70kg consider dosing at 75iu/kg
Low intensity oral anticoagulation -- INR 2 - 3.
OR
Intermittent pneumatic compression plus Low Molecular
Weight Heparin or Low Dose Unfractionated Heparin.
Clotting Cascade
Warfarin affects Factors
II, VII, IX, X,
the factors involved in
Vitamin K metabolism
Low Molecular Weight
Heparins (eg
Tinzaparin)
inhibit Factor Xa and
inactivate thrombin
Anticoagulant Example: Warfarin
Classification:
Vitamin K Antagonist
Monitoring:
INR, goal range 2.0-3.0
Indications:
Prophylaxis & treatment of:
– Venous thrombosis
– Pulmonary embolism
– Atrial fibrillation with
embolization
– Embolization after MI,
including stroke
Adverse Reactions:
Bleeding
Cramps & nausea
Dermal necrosis
Fever
Anticoagulant Example: Tinzaparin
Classification:
Low Molecular weight
Heparin
Monitoring: CBC and
Creatinine baseline and
twice weekly
Indications:
Prevention of
DVT & PE after:
– Abdominal surgery
– Hip/knee surgery
or replacement
Adverse Reactions:
Bleeding, anemia, rash, thrombocytopenia,
ecchymosis
Dizziness, headache, insomnia
Edema
Constipation, vomiting, nausea, reversible
increase in liver enzymes
Urinary retention
Heparin-Induced Thrombocytopenia (HIT)
Erythema at injection site, hematoma, pain,
irritation
Fever