Sat., 10/16/10 Pelvis & Spine, Paper #80, 3:53 pm OTA-2010
Sequential Duplex Ultrasound Screening for Deep Venous Thrombosis in Asymptomatic Patients with Acetabular and Pelvic Fractures Treated Operatively
Berton R. Moed, MD; John R. Miller, BS;
St. Louis University School of Medicine, St. Louis, Missouri, USA
Purpose: The timing of ultrasound screening for the diagnosis of proximal deep vein thrombosis (DVT) in asymptomatic trauma patients has been inconsistently described (eg, within 3 days of hospital admission or in the 24 hours before discharge from the hospital, etc). The purpose of this study was to examine the utility of sequential scans obtained preoperatively and before hospital discharge in asymptomatic patients with acetabular and/or pelvic fractures treated operatively.
Methods: In 2003, a screening protocol for DVT was begun for asymptomatic patients with acetabular and/or pelvic fractures treated operatively. Duplex ultrasound screening was employed, along with color flow and spectral techniques. No attempt was made to assess the pelvic veins. Scans were to be obtained the evening before or the morning of surgery and then the day before planned discharge from the hospital. Preoperative patients whose screening studies were positive for proximal DVT were to receive an inferior vena cava filter. Postoperative patients whose studies were positive were to have anticoagulation. A protocol for DVT prophylaxis was also instituted. Of 334 sequential patients, 105 were excluded due to a breach of protocol (no preoperative and/or postoperative study), the insertion of a prophylactic inferior vena cava, or the occurrence of a symptomatic pulmonary embolism (PE) or DVT prior to preoperative scanning. Therefore, 229 patients were available for study.
Results: There were 35 patients (15%) with a proximal asymptomatic DVT. 16 (7%) were diagnosed preoperatively and received an inferior vena cava filter. 19 (8%) were diagnosed postoperatively and received therapeutic anticoagulation. In addition, two patients (1%) had a postoperative symptomatic PE diagnosed the day following surgery. In both of these patients, a postoperative ultrasound was subsequently obtained and was interpreted as negative for DVT. Fatal PE did not occur.
Conclusions: Sequential ultrasound scanning for DVT according to a set protocol appears to be an improvement over the use of a single preoperative or a single postoperative (prehospital discharge) scan. Preoperative scanning decreases the risk of operating on a patient with an asymptomatic DVT; the predischarge scan decreases the risk of sending a patient home with an untreated DVT. Therefore, we recommend obtaining sequential scans preoperatively and before hospital discharge in these high-risk asymptomatic patients with operatively treated acetabular and/or pelvic fractures. However, patients may remain at risk for PE propagating from an undiagnosed pelvic vein thrombosis. If magnetic resonance venography (MRV) is to be used to detect asymptomatic pelvic DVT, the findings of this study suggest that MRV should be performed in a similar sequential fashion.
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• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant.