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PubMed1981

Comparative influences of epidural and general anaesthesia on deep venous thrombosis and pulmonary embolism after total hip replacement.

In an investigation on deep venous thrombosis and pulmonary embolism, where neither dextran nor antithrombotic drug prophylaxis were employed, 30 patients undergoing total hip replacement were randomly allotted to one of two groups receiving either epidural or general anaesthesia. The epidural group (n = 15) was given 0.5% bupivacaine with epinephrine (5 micrograms/ml) and this was prolonged into the postoperative period for pain relief. The general anaesthesia group (n = 15) was operated on under artificial ventilation with nitrous oxide/oxygen via an endotracheal tube and intravenously administered fentanyl and pancuronium bromide. In this group of patients narcotic analgesics (ketobemidone) were given intramuscularly on demand for pain relief postoperatively. The frequency of deep venous thrombosis involving the femoral veins, as observed at phlebography, was significantly lower in patients receiving continuous epidural block (3 of 15; 20%), than in those receiving general anaesthesia and parenteral analgesics postoperatively (11 of 15; 73%). Further, the frequency of pulmonary embolism, as determined by pulmonary perfusion lung scanning, was lower in patients receiving continuous epidural block (2 of 15) than in the general anaesthesia group (7 of 15). Possible explanations for these findings are discussed, including a hyperkinetic lower limb blood flow and lower fibrinolysis inhibition activity in patients given epidural block. Lower blood transfusion requirements in patients given epidural block might also play a role, as well as a "stabilizing" effect of local anaesthetics on platelets, leukocytes and endothelial cells.

Anesthesia, Epidural↗
PubMed1986

Diagnosis of deep venous thrombosis and pulmonary embolism. The tests and their limitations.

Pulmonary embolism and venous thrombosis are ubiquitous diseases with significant morbidity and mortality and for which successful although risky treatments are available. Accurate diagnosis is therefore necessary and requires testing beyond the physical examination and history. The number of tests proposed over the years compared with the number in current use attests to the problems with the methods. The more definitive tests are also more invasive, riskier, and more expensive. Individual experience in performance and interpretation of the available tests is of great importance in achieving accurate results, and thus the best scheme for investigation of the patient varies from institution to institution. The most accepted and practiced scheme would involve contrast venography as the initial and final test for suspected venous thrombosis, and pulmonary perfusion imaging (with use of chest radiography in all instances and ventilation imaging in most instances) as the screening test for pulmonary embolism, followed by pulmonary angiography when the scan is not definitive or the clinical picture is divergent from the scan results.

Blood Gas Analysis↗
PubMed2005

Diagnosis of deep vein thrombosis and pulmonary embolism in pregnancy: a systematic review.

INTRODUCTION: Diagnosing deep vein thrombosis (DVT) and pulmonary embolism (PE) in pregnancy is challenging. Many of the common diagnostic tests, including compression ultrasonography (CUS), ventilation-perfusion scintigraphy (VQ scan) and helical computed tomography (hCT) that have been extensively investigated in non-pregnant patients, have not been appropriately validated in pregnancy. Extrapolating results of diagnostic studies of DVT and PE in non-pregnant patients to those who are pregnant may not be correct because during pregnancy, physiologic and anatomic changes may affect diagnostic test results, presentation and natural history of VTE. METHODS: We performed a systematic analysis of published studies addressing accurate diagnostic testing for DVT and PE in pregnancy to determine the accuracy of these tests in pregnancy. RESULTS: Our initial search yielded 530 articles of which four remained for inclusion, three studies investigating diagnostic testing in patients with a clinical suspicion of DVT or PE and one study in patients with a clinical suspicion of PE. CONCLUSIONS: From our systematic analysis of published studies investigating diagnostic testing for a clinical suspicion of DVT in pregnancy we conclude that; (i) two studies support withholding anticoagulant therapy in pregnant women with a clinical suspicion of DVT and normal results on serial IPG (impedance plethysmography), however, IPG is no longer used; (ii) one study demonstrated that a normal CUS at presentation combined with a normal D-dimer test or an abnormal D-dimer test combined with normal serial CUS appears promising for safely excluding DVT in pregnant patients, but too few patients were included in this pilot-study to draw firm conclusions; and (iii) one study investigated pregnant patients with a clinical suspicion of PE and this study concluded that in patients with normal or non-diagnostic VQ scans, withholding anticoagulant therapy might be safe, but this needs confirmation in larger studies. Recommendations on diagnostic testing of pregnant patients with a clinically suspected DVT or PE are provided.

Female↗
PubMed2003

Diagnostic approaches to suspected deep vein thrombosis and pulmonary embolism.

The present paper aims at reviewing our present knowledge on the diagnosis of deep vein thrombosis and pulmonary embolism with a particular emphasis on clinically suspected outpatients. The various contemporary diagnostic tools (including clinical probability assessment, fibrin D-Dimer measurement, venous compression ultrasonography, ventilation/perfusion lung scintigraphy, helical CT scan, and echocardiography) are presented and rational sequential strategies are discussed in their various aspects, including validation in outcome studies, and cost-effectiveness analyses.

Algorithms↗
PubMed2005

Deep venous thrombosis and pulmonary embolism after knee arthroscopy in athletes carrying the thrombophilic factor lupus anticoagulant.

In patients undergoing arthroscopic knee surgery, deep venous thrombosis and pulmonary embolism are rare and there is not clear indication as to the necessity of thromboprophylactic treatment in these patients. However, the role of coagulation disorders in thrombotic events following arthroscopy is unknown. We report 2 cases of massive deep venous thrombosis and pulmonary embolism after knee arthroscopy in athletes carrying the thrombophilic factor lupus anticoagulant, but with no personal or familial history of thrombotic diseases. A few days after the arthroscopic intervention, both patients presented with deep venous thrombosis and 1 developed a severe pulmonary embolism. Blood examination showed that both athletes were lupus anticoagulant-positive. This is the first description of an association between venous thromboembolism, knee arthroscopy, and a prothrombotic condition. This report suggests that screening for hypercoagulability might be useful in athletes undergoing even minimally invasive orthopaedic surgery and that in cases of venous thromboembolism after knee arthroscopy, a prothrombotic disorder should be suspected.

Adult↗
PubMed2005

Delays in diagnosis of deep vein thrombosis and pulmonary embolism.

PURPOSES: To investigate delays in the diagnosis of deep vein thrombosis (DVT) and pulmonary embolism (PE). SUBJECTS AND METHODS: We prospectively identified 1,152 patients in whom DVT or PE had been diagnosed at 70 North American medical centers. We recorded demographic characteristics and dates of symptom onset, initial medical evaluation, and confirmatory diagnostic tests. RESULTS: We identified substantial numbers of patients for whom there were delays in the diagnosis of DVT, PE, or both. For acute DVT, 170 of 808 patients (21%) received diagnoses > 1 week after symptom onset, and 40 of 808 patients (5%) received diagnoses > 3 weeks after symptom onset. On average, 80% of the delay in diagnosis of DVT occurred between symptom onset and medical evaluation. Acute PE was diagnosed in 59 of 344 patients (17%) > 1 week after symptom onset, and in 17 of 344 patients (5%) > 3 weeks after the onset of symptoms. Delays in the diagnosis of PE represented both delays in seeking medical attention (mean, 3 days; upper limit of 95% confidence interval [CI], 12 days); and delays from the first medical evaluation to diagnosis (mean, 2 days; upper limit of 95% CI, 9 days). CONCLUSIONS: Although the majority of patients with DVT and PE seek medical attention and receive diagnoses promptly after symptom onset, substantial delays exist in the diagnosis of DVT and PE for many patients. There is a need to develop and test strategies that reduce delays in diagnosis.

Aged↗
PubMed1997

Clinical evaluation of an immunoturbidimetric D-dimer assay in the diagnostic procedure of deep vein thrombosis and pulmonary embolism.

We investigated 128 patients with suspected deep vein thrombosis and 26 patients with suspected pulmonary embolism. Plasma cross-linked fibrin degradation products were measured instantly by a new rapid and fully quantitative immunoturbidimetric assay (Boehringer Mannheim) which recognizes the D-dimer epitope by antibody-coated latex particles. Diagnosis of deep vein thrombosis was established by either ascending venography (n = 105) or colour duplex ultrasound (n = 8), whereas for the exclusion of deep vein thrombosis only venography was accepted. The sensitivity/specificity for the diagnosis of deep vein thrombosis was 98%/44%. Patients with suspected pulmonary embolism were examined by pulmonary angiography (n = 19) or perfusion lung scanning alone (n = 6), if sufficient. One pulmonary embolism was diagnosed at post-mortem examination. For pulmonary embolism, sensitivity/specificity was 100%/50%. These findings indicate that the new immunoturbidimetric technique is as reliable as former ELISA methods and allows to rule out thromboembolic disorders. D-dimers showed a correlation to the extent of the deep vein thrombosis, proximal thrombosis producing higher D-dimer levels. Patients presenting immediately after the onset of symptoms were found to have higher D-dimers than patients examined after a few days. A quantitative D-dimer measurement thus seems to provide precious additional information of the duration and the extent of thromboembolic disease.

Adult↗
PubMed1984

Acyl-enzymes as thrombolytic agents in dog models of venous thrombosis and pulmonary embolism.

A quantitative model of venous thrombosis in the beagle dog is described. The model was adapted to permit ageing of isolated experimental clots in vivo. A model of acute pulmonary embolism in this species is also described. In the venous thrombosis model, infusion of streptokinase (SK) or SK-activated human plasmin gave significant lysis but bolus doses of SK. plasmin complex were ineffective. Active site anisoylated derivatives of SK. plasminogen complex, SK-activated plasmin and activator-free plasmin were all active when given as bolus doses in both models. At lytic doses, the acyl-enzymes caused fewer side-effects attributable to plasminaemia than the corresponding unmodified enzymes.

Animals↗