Anticoagulation protocols

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PMG03470

PMG03470

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To break away from all the posts speaking about the profession and its flaws I would like to start a discussion on anticoagulation protocols. If anyone is willing to share I am interested in hearing what everyone’s personal protocols are.

I recently had an ambulatory patient develop a PE and I am considering changing how I do things. For background the patient had a 1st MPJ fusion and 2nd PIPJ fusion and were ambulatory starting day of surgery in CAM walker. I did not anticoagluate in any way.

Let’s make this educational!
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There are no guidelines for F&A in the way there are for THA/TKA/etc. The risks for F&A generally outweight benefits...


If you choose to do anything (decide to acknowledge the risk being significant in F&A, for whatever reason, and decide to do surgery anyways), you should use the most effective means available at the time - or follow the guidelines and do nothing.

...Personally, I just keep the surgery as short as possible, avoid tourniquet whenever possible (basically all amps or forefoot or Achilles, some rearfoot) or keep cuff time short when it's needed. Contralateral pneumatic mechanical prophylax is standard everywhere I've ever done surgery. I tell some people - usually trauma or prolonged immobilize - that it's fine to take ASA 325 in place of their breakfast ibuprof/naprox, but that's not documented since it's not the EBM most effective prophylax.

I have handful of DVTs over the years (mostly older ppl and/or ppl who had a fall in their boot/cast), and they were just recognized and treated promptly (usually apixaban these days)... no PEs since residency, when we were doing much more surgery, more sketchy medical candidates and bigger recons... as any good teaching hospital will.
 
PMG03470 said:
To break away from all the posts speaking about the profession and its flaws I would like to start a discussion on anticoagulation protocols. If anyone is willing to share I am interested in hearing what everyone’s personal protocols are.

I recently had an ambulatory patient develop a PE and I am considering changing how I do things. For background the patient had a 1st MPJ fusion and 2nd PIPJ fusion and were ambulatory starting day of surgery in CAM walker. I did not anticoagluate in any way.

Let’s make this educational!
Click to expand...

1. How much discussion did you have with them before the surgery about the risk of a DVT/PE? This is an interesting subject to me ie. how do you discuss with a patient the likelihood/severity of an unlikely event that can have a high severity.
2. Now that you've had the complication - after the fact - have you discovered any relevant information that would have changed your original treatment plan not to put them on a blood thinner? ie. the patient tells you now "oh btw, I've had a blood clot before".
3. Did you let them remove the boot during the day, at night etc?

My suspicion is - you are just very unlucky.
 
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Unless there’s a history of DVT/PE, sickle cell then studies show it’s really not necessary. Back in the day McGlamry’s had a study where 3.5% of FA surgery pt developed DVT/PE and more recently Wukich study of 6,000+ patients and <1.5% developed DVT/PE
 
I don't do nuthin. No blood thinners after flatfoot. Used to do maybe a full aspirin for 2 weeks. Now nothing. Everything is fine. No literature to support anything. This is assuming they have no history I pretty much do thigh tourniquet for everything, 250. Never ankle tourniquet sometimes calf at 200. No pneumatic device on contra limb at my hospital.
 
heybrother said:
1. How much discussion did you have with them before the surgery about the risk of a DVT/PE? This is an interesting subject to me ie. how do you discuss with a patient the likelihood/severity of an unlikely event that can have a high severity.
2. Now that you've had the complication - after the fact - have you discovered any relevant information that would have changed your original treatment plan not to put them on a blood thinner? ie. the patient tells you now "oh btw, I've had a blood clot before".
3. Did you let them remove the boot during the day, at night etc?

My suspicion is - you are just very unlucky.
Click to expand...
Yes the. Numbers caught up with you. Ambulatory and still got one. Bad luck.
 
Even if you get a DVT on a post op patient, you’re only really in trouble if you don’t recognize and make the dx. They get treated with some xarelto and that’s it.

I don’t anticoagulate anyone without risk factors, and even then I’ll only anticoagulate if they are going to be NWB for an extended period of time. I don’t really use tourniquets for much any more. Just did a flatfoot this morning with no tourniquet.

I think I’ve had 1 DVT in the last 7-8 years. It was diagnosed and treated without any issues. There is no literature to support routine prophylaxis, I don’t really worry about it any more.
 
heybrother said:
1. How much discussion did you have with them before the surgery about the risk of a DVT/PE? This is an interesting subject to me ie. how do you discuss with a patient the likelihood/severity of an unlikely event that can have a high severity.
2. Now that you've had the complication - after the fact - have you discovered any relevant information that would have changed your original treatment plan not to put them on a blood thinner? ie. the patient tells you now "oh btw, I've had a blood clot before".
3. Did you let them remove the boot during the day, at night etc?

My suspicion is - you are just very unlucky.
Click to expand...

1. I spend about 3-5 minutes during preop visit discussing the signs and symptoms. This is why the patient recognized it right away and got to the ER.

2. The patient is already on anticoagultion that she didn’t even stop for surgery. So I didn’t really think I needed to do anything additional

3. She took boot off while in the couch and for bed…

From all these responses I do think this was purely bad luck. But in the end nothing bad happened because she recognized it and went the ER for prompt treatment.
 
PMG03470 said:
1. I spend about 3-5 minutes during preop visit discussing the signs and symptoms. This is why the patient recognized it right away and got to the ER.

2. The patient is already on anticoagultion that she didn’t even stop for surgery. So I didn’t really think I needed to do anything additional

3. She took boot off while in the couch and for bed…

From all these responses I do think this was purely bad luck. But in the end nothing bad happened because she recognized it and went the ER for prompt treatment.
Click to expand...
Already on anticoag, already ambulatory, already explained risks, caught it early on- you did everything right.

No literature to support. Have seen 1 dose lovenox after big surgeries, ASA 325mg is popular but again- no significant findings in literature
 
Do you guys anticoagulate non op fractures when you boot or cast them? And if so do you still anticoag wbat w cam boot?
 
PMG03470 said:
To break away from all the posts speaking about the profession and its flaws I would like to start a discussion on anticoagulation protocols. If anyone is willing to share I am interested in hearing what everyone’s personal protocols are.

I recently had an ambulatory patient develop a PE and I am considering changing how I do things. For background the patient had a 1st MPJ fusion and 2nd PIPJ fusion and were ambulatory starting day of surgery in CAM walker. I did not anticoagluate in any way.

Let’s make this educational!
Click to expand...

I agree that post-op anticoagulation is generally not indicated (without a history or risk factors) for F&A surgery. But PICA actually disagrees. That’s because of the large payouts on a small number of cases. But documentation on the discussion of risks and being diligent and responsive to signs and symptoms will most likely save you in a lawsuit, but it doesn’t mean you won’t get sued should it happen.
 
dtrack22 said:
Even if you get a DVT on a post op patient, you’re only really in trouble if you don’t recognize and make the dx. They get treated with some xarelto and that’s it.

I don’t anticoagulate anyone without risk factors, and even then I’ll only anticoagulate if they are going to be NWB for an extended period of time. I don’t really use tourniquets for much any more. Just did a flatfoot this morning with no tourniquet.

I think I’ve had 1 DVT in the last 7-8 years. It was diagnosed and treated without any issues. There is no literature to support routine prophylaxis, I don’t really worry about it any more.
Click to expand...
When you all operate without tourniquet, what do you do for blood control, or are all your surgeries just wet/clean as you go. I understand for amputations and things but I mean for the bigger ones
 
Echoing what has been said previously, there's no good evidence I've seen for requiring prophylaxis. My residency hospital wanted to enact a required prophylaxis for all LE surgery and I did a deep dive at the time and there was no good info. It was anecdotal or didn't show much benefit one way or another and the risks associated with prophylaxis often outweighed the benefit. So yeah, outside of prior history, fracture on birth control, etc then I don't do anything. You do enough surgery and you'll get one occasionally. Recognize and treat.
 
Homo sapien said:
When you all operate without tourniquet, what do you do for blood control, or are all your surgeries just wet/clean as you go. I understand for amputations and things but I mean for the bigger ones
Click to expand...

Local with epi and bovie. I don’t use tourniquets on most ankle fusions, I don’t use them on any medial/lateral/posterior ankle fracture. Did inflate for a bit on a recent anterior approach pilon. Don’t use them on Achilles work or gastrocs, lateral ankle stabs, peroneal repairs. Ankle scopes and complex Charcot TTC type procedures are about the only cases I universally use a tourniquet.
 
Homo sapien said:
When you all operate without tourniquet, what do you do for blood control, or are all your surgeries just wet/clean as you go. I understand for amputations and things but I mean for the bigger ones
Click to expand...
To be clear, operate without tourniquet is not equal to not having tourniquet on at all (for me).
I always have one on the ankle / calf / thigh... even if 99% sure I won't use it.

I just use 50/50 lido epi + lido plain (makes 1 : 200,000) and inject mid-met or proximal. That has plenty of EBM for not having issues.
You could just use the lido epi 1:100k out of the bottle, but that's a fair risk if you ever lost a toe or had issues.

I sometimes use esmarch for amps (around hindfoot/ankle for TMA, ray amp, etc).

I use tourniquet infrequently for the mid portion of the surgery (joint fusion, tendon repair, osteotomy + fixation whatever). The epi wears off after about an hour, or some ppl just bleed a lot. But yeah, in general, I use cuff virtually never on Achilles, bunions, hammertoes, ankle fx, etc. Other stuff is variable. You never know when you get those ppl with varicose veins, highly vascular ("TRT"), supplements that make them bleed a lot, etc. I've done rearfoot fusions without cuff inflation and also inflated for Weils sometimes. It's variable. When you use a cuff, it's always good to let down cuff for closure, though... you see the bleeders and can tie or buzz them, and it minimizes hematomas.

I think the ppl who use tourniquet from before incision until bandage is complete for all F&A surgery are crazy... time waste, nerve pain, crushes blood vessels, higher risk of rebound hyperperfusion edema/pain, wastes OR time, etc. It should not be standard of care anymore.
 
I rarely use tourniquet. Have it on “just in case” but rarely need to pump it up.

Aspirin 81mg PO QD for CYA… erm I mean DVT prophylaxis 🥸
 
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