Anti coagulation After Total Knee Arthtoplasty

[jthpac]

Good Morning Angels--

 

<br><br>     I recently switched jobs, ortho to ortho.  In my previous employment the majority of the docs used Warfarin, whereas in my new job we use Low Molecular Weight Heparin. I was wondering what are the majority of you are experiencing, as far as post op anti coagulation.    <br><br> Any and all additional comments are appreciated<br><br><br>Jim<br>

[jthpac]

I am not sure what I did wrong, but here is, hopefully, an easier version to read:

 

I recently switched jobs, ortho to ortho. In my previous employment the majority of the docs used Warfarin, whereas in my new job we use Low Molecular Weight Heparin. I was wondering what are the majority of you are experiencing, as far as post op anti coagulation.

 

Any and all additional comments are appreciated

 

Jim

[1ORTHOPA]

We use Warfarin for about 4 weeks on all total joints.

[wingedparasite]

We use warfarin as well, LMWH can cause the incision to bleed a tad more.

[smrtmom1]

We use Lovenox for 10 days, then we switch them to ASA 81mg for another 4-6 weeks.

 

My docs say the literature is pushing towards Lovenox. I am new, so I haven't read all the latest stuff.

 

Now that I see there is controversy, I will spend some time burried in my Up To Date and see what I can find.

[Razorback]

Lovenox or Fragmin x 14 days after hips and knees. No INR required to manage. We follow the platelets as well as the H & H with a CBC x 3 days post-op. Also use SCD's and TED hose immediately post-op.

[ventana]

Knees -

 

PI says lovenox 30mg BID NOT 40mg QD

 

 

don't do QD post knees (already had 2 DVT's QD)

[bradtPA]

I am treating a patient now who developed a clot post-op after being undertreated with 1 mg of coumadin (PT/INR I did was 1.1 at diagnosis).

[ATCPA??]

Our joint guys use Lovenox 30mg q12h x 14d for our knees, 40mg qday x 21 days for our hips. The drainage usually occurs in the patient's with poor protoplasm; ie the older demented patient's that are nutritionally deficient. They just sit there after surgery and drain and drain.

 

Another anti-coag question. Do you guys regularly use anticoagulation for surgery below the knee?

[1ORTHOPA]

Our joint guys use Lovenox 30mg q12h x 14d for our knees, 40mg qday x 21 days for our hips. The drainage usually occurs in the patient's with poor protoplasm; ie the older demented patient's that are nutritionally deficient. They just sit there after surgery and drain and drain.

 

Another anti-coag question. Do you guys regularly use anticoagulation for surgery below the knee?

 

If you mean things like ORIF's or tibial roddings, then the answer for us is no. Only on total joints for us.

[medictao]

I dont do TKA, since our practice is 98% trauma. But the 2 % is THA and for all major joints along with poly-trauma we use Lovenox 40 mg sq qd X 21 days.

[badtriangle]

Lovenox, 30 mg SQ, BID x 10 days, then 21 days ASA, 325 mg, QD

[Guest snoverdj]

I work for 10 general ortho MDs. For TKA: 1 strictly uses warfarin x 1 month; 2 use arixtra x 10 days then ASA 325 x 1 month; 2 use ASA 325 BID x 1 month; 5 use lovenox 40 x 10 - 14 days then ASA x 1 month.

 

For THA: the same in regards to warfarin, ASA and arixtra; the guys using lovenox tx for 1 month followed by ASA.

[maryfran123]

From the most recent CHEST guidelines for DVT proph in Ortho(4 wks of treatment):

http://chestjournal.chestpubs.org/content/126/3_suppl/338S.full#sec-27

 

 

<H3>Recommendations: Elective Knee Arthroplasty

 

3.2.1. For patients undergoing elective TKA, we recommend routine thromboprophylaxis using LMWH (at the usual high-risk dose), fondaparinux, or adjusted-dose VKA (target INR, 2.5; INR range, 2.0 to 3.0) [all Grade 1A].

Underlying values and preferences. We have not recommended fondaparinux over LMWH and VKA, or LMWH over VKA, because we place a relatively low value on the prevention of venographic thrombosis and a relatively high value on minimizing bleeding complications.

3.2.2. The optimal use of IPC is an alternative option to anticoagulant prophylaxis (Grade 1B).

3.2.3. We recommend against the use of any of the following as sole methods of thromboprophylaxis: aspirin (Grade 1A); LDUH (Grade 1A); or VFP (Grade 1B).

 

abbreviations: low-dose unfractionated heparin (LDUH), low molecular weight heparin (LMWH), or a vitamin K antagonist (VKA-i.e. coumadin) IPC--mechanical intermittent compression devices, VFA--foot pumps.

</H3>

[TheWanderer]

I'm just an EMT now but most of the total knees I transport out of the hospital to rehab are on Coumadin. Unfortunately, I couldn't tell you for how long or what dose with certainty.

[docrip]

We use Lovenox 40mg qd for 3wks.

Recently our hospitals changed to Fragmin. One of our docs had a patient that had severe problems with Fragmin, and demands Lovenox. Noted that either Lovenox or new hospital. I feel that the Fragmin allows the patient to bleed a little too much. No problem with the Lovenox for the past 3 yrs with TKAs.

[docrip]

We use Lovenox 40mg qd for 3wks.

Recently our hospitals changed to Fragmin. One of our docs had a patient that had severe problems with Fragmin, and demands Lovenox. Noted that either Lovenox or new hospital. I feel that the Fragmin allows the patient to bleed a little too much. No problem with the Lovenox for the past 3 yrs with TKAs.

 

Recent article in NEJM has leaned towards just using aspirin however!!

[mainiac]

We use Arixta x 3 days then Ecotrin x 30 days

[TraumawannabPAs]

I saw a patient the other day that had a total knee done and 12 hours post-op had a thrombolic CVA. He was then started on thrombolytics and developed a GI bleed and needed to be transfused. (just happy to clinically contribute with my own patient) :)

[mainiac]

Arixtra x 3 days then Ecotrin

[LIPPER]

seeing a lot of Xarelto 10mg QD x 12 days knee, 35days hip