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SNI digital, innovations, and learning is pleased to present another in the series of Controversies in Spine Surgery with Nancy Epstein. This was given on March 10, 2024.
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And the title of this talk and this discussion isDefeanous Rambosius and
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Pulmonary Embolism and Prophylaxis in Spinals Neurosurgery. The paper is impressed and will appear in surgical neurology in the next one or two months
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Nancy Epstein is the professor of clinical neurosurgery at the School of Medicine at the State University of New York at Stony Brook, and she's the editor-in-chief of Surgical Neurology International.
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Nancy has had 40 years of experience in spine surgery as extensive publications on all aspects of spine disease and spine surgery and is a recognized
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expert around the world in this disease.
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Nancy Epstein is the professor of clinical neurosurgery at the School of Medicine at the State University of New York at Stony Brook. She's also editor-in-chief of Surgical Neurology International
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This has been a spine surgeon for over 40 years. as an extensive bibliography of publications on all aspects of spine disease and spine surgery and is recognized as a world authority in this area.
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Okay, today I'm gonna talk about deep venous thrombosis and pulmonary embolus, prophylaxis and spinal neurosurgery. It's really effectively going to be applicable to brain surgery and probably
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almost any other medical as well as surgical patient that you may encounter. I mean, I was interested in this because one thing I was really worried about is with all the pressure for prophylaxis,
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especially chemoprophylaxis, as neurosurgeons were worried about post-operative hematomas or complications or wounds falling apart and things like that. So I decided the best defense is to be on the
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offense and to look at the literature and see what I would find. So today, that's exactly what we're going to do. We're going to look at how See ya!
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How do we recognize something like this? It's very easy if you can see a leg that looks like this. You say, oh, well, that's DBT and the patient, you know, probably gonna have a PE. But if you
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look at two of these studies by Finn and Haynes, overall, there are about two million cases of DBT per year. But look at this staggering factor, 81 are asymptomatic. That patient may have a
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minimally elevated white count, a low grade fever. They may have some pain It could be even masquerading as abdominal pain, but they're not going to just jump out you with a label. There are 100,
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000 fatal pulmonary emboli per year. Now, that's neurosurgery. That's all surgery. That's all medicine. But again, the emphasis here is you want to catch DBT as well as see if there's a
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pulmonary embolus before it's too late.
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What we're going to find today's discussion is the best prophylaxis against phlebitis pulmonary embolus typically uses combined protocols. Now that can mean elastic stockings. It can mean
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compression stockings. And very importantly, it can be mini heparin or low molecular weight heparin. But again, what I'm gonna emphasize is each of these protocols has to be analyzed on a
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case-by-case basis because there may be major contraindications in your patient, not to use chemoprophylaxis. For example, you're not gonna put a patient where you had a very complex journal repair
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on mini heparin postoperatively unless you want that repair to fall apart. So anyway, an example of your compression stockings and here your low molecular weight heparin injections where typically
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the patients are taught how to do this.
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First of all, it's supposed to start on post-op day one and many of them are being sent home with us for the next month or so.
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Can I ask you a question, Nancy? Sure. If you give them, I'm just looking at your picture there. If you give them the low molecular weight happening into the subcutaneous tissue, does it take
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days to build a blood level
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or does it really get a blood level very quickly? It's a blood level very quickly. Usually the regime is every 12 hours, some regimes are every eight hours, often depends on the size and the
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weight of the patient, but let's say you're gonna bring a patient to surgery. You can have the less injection 12 hours before the surgery. Okay, good point. In Chibaro's study, this was 2018,
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they looked at or compared the compression stockings with low molecular weight heparin and about 3, 000 patients. And here you can see DBT 23, nearly 1 had a PE, but the best protocol was the
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combined protocol. They added the compression stockings plus the elastic stockings, plus the low molecular weight heparin in these patients Look how it lowered the DVT rate. from 23 down to 08, PE
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rate from
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09 to 018. So again, they concluded the best prophylaxis was a combination of all three, but as I'm going to emphasize again and again and again, you have to assess the comorbidities of each
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individual patient to determine which is the appropriate prophylaxis for that individual. So here's the outline for the lecture that I'm gonna give today. And during it, Jim asked me whatever, and
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we'll stop and discuss the different parameters. This is supposed to be an example, basically of a vein, and here is an embolus, and here you can see the embolus going further distally. But what
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we're going to look at in this DBT lecture is we're gonna look at the venous anatomy just briefly, discuss the frequency of flobitis and pulmonary embolus, look at the coagulation cascade, the
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symptoms of DBT and PE, risk factors associated with these, What are the appropriate diagnostic studies? What are the prophylactic regimens that are available out there? Some of which, by the way,
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cost you very little. In other words, if you are in a country where you don't have a lot of money to spend and you can't even afford the compression stockings, you've got the elastic stockings,
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use them. But in addition to that, try and get that patient out of bed day zero, the day of surgery, if at all possible, mobilize them as quickly as possible, hydrate that patient. Use all the
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conservative treatment and cheap modalities that you can use, rather than just sitting back and saying, Oh, well, we're gonna get a phlebitis because we can't afford the heparin. So we're gonna
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go over the prophylactic regimens and finally the best recommendations. Here's an example of the anatomy of the deep venous system. And I'm gonna show you how DVT can develop from below. And here,
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obviously here's the heart. So it can come from below the inferior vena cava or above the heart, the superior vena cava And here's how it starts. distally, you have in the calf veins, which very
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rarely embolize, but we're gonna go over that. Then you have the proximal veins, the right femoral vein, then you go up to the left externaliliac, the right externaliliac, and then superiorly,
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you've got the bilateral subclavian veins and the superior vena cava. These, the superior system contributes probably less than 5 of the DVT and PEs that you're gonna see the lower segment being the
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vast majority.
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There are different rates of clot propagation for calf versus proximal DVTs. And what are these? The calf vein, the least likely to embolize to the lungs, the rate of a PE is about 11.
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And again, you're getting dopplers of the lower extremities. They tend to be more accurate below the knee than above the knee. And it's above the knees, theiliac, the pauptotel, the inferior
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vena cava, superior vena cava DVTs These are more likely to embolize to your lungs. and that can happen in up to 25 of cases. So you have to be aware of that difference and what studies you're
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gonna order and when and why. Do we know how many people with the
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blood clotting, with the habit and the calf say, I'll have it, do 85 or something like that have it already in the elax or? I think it's sort of the other way around that, well, the frequency
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overall of having the calf DVT is higher, significantly higher than the proximal because it's going to basically originate distally and typically go proximally. So I think it's like one to five or
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something like that. Five, in the calf to one that goes more proximally. Okay. Pulmonary embolism are basically clots that you're aware of that go from the pulmonary arteries and they go into the
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lungs.
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do we coagulate platelets and red cells? I'm not going to go into this in great detail. You know, here are your platelets, here are yourerythrocytes, and this is sort of the blood clot formation
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that you're looking at. It's start going to start with platelet coagulation next to red blood cells. It forms with the clotting factor, basically a fiber and plug at the site where there's been an
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injury, and this is what's then going to analyze. So the platelets and the red cells form a plug. You then have an activation of the clotting, a factor cascade, and the fiber and strands are
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going to strengthen the plug. So here your red cells, your platelets in the vein, they're going to form the thrombus and subsequently the embolus, and then it takes off and it goes more
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approximately
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The intrinsic and the extrinsic pathways are used to treat dbt really to determine the medications that are going to use. So Here is the intrinsic pathway, and this is where the extrinsic pathway.
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Intrinsic pathway, this is where heparin is going to function. Extrinsic pathway, you have a combination of pumidin, and also the aliquis, the zoraltos, the oral medications at this point that
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can act on avoiding progression towards the factor 10a.
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The symptoms of phlebitis and pulmonary embolus, okay, here you can have the swollen leg, leg tenderness, redness, focal warmth, leg pain. Again, 80 of the time you're not gonna see any of
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this. The symptoms and signs of the pulmonary embolus, it can be overt chest pain, inspiration, coughing up blood, shortness of breath, low grade fever, white count, tachycardia, confusion,
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low grade confusion, or it could be absolutely nothing. Sometimes you'll put on a pulse oximeter and you'll just get a real. start when you see how low the oxygenation might have fallen,
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especially it falls below 90 percent.
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In a gold-hobber study, American Journal of Cardiology 2010, the main point in this study is look at the risk factors for phlebitis pulmonary embolus, obesity, immobility, elder-aged cardiac
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disease, congestive heart failure, COPD, varicose veins, cancer, birth control, pills, pregnancy, major surgery, and hypercoagulation syndromes. So basically, when you see patients, too
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many, at least of my neurosurgical colleagues, I find, Jim, you may find this as well, they know nothing about overall medicine. They are so focused in neurosurgery that they look at the patient,
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they ignore the comorbidities, they make choices that are not the right choice for that patient, based on the attending comorbidities, and those patients are subsequently aware.
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Here is an example of one of the biggest problem is hypercoagulation syndromes are present in about 5 of your population. They can include factor five Leiden mutation, one of the most common, the
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antiphospholipid antibody syndromes, and other long-term deficiency syndromes. These are very important factors, especially when you're talking about long-term prophylaxis. When you look at the
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recommendations for
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prophylaxis, period, if a patient has had a first onset event,
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but it's unprovoked. That means the patient was not immobilized in a plane for 12 hours. They don't have a hypercoagulation syndrome. They don't have underlying cancer, et cetera. Maybe treatment
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is given for three to six months. And these days, one of the most common medications that's given is like an eloquis or a factor 10A inhibitor. But indefinite continuation of anticoagulation, That
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may be what's recommended and needed for your. patients with hypercoagulation syndromes. In fact, if you're about to do an elective operation on one of these patients, you have to be prepared and
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anticipate that you're going to have to start anticoagulation very, very quickly. Either that or put in an inferior vena cava filter in. Patients with persistent or recurrent or progressive DVT are
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going to need indefinite anticoagulation because if you stop the medication, it's just going to recur and those patients may have a fatal PE And then again, the ones with the major risk factors,
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the cancers, the morbid obesity, et cetera, and that list goes on. So can I stop here for a minute? So what you're telling me is in the universe of patients we're seeing,
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we take a sample out and we do surgery on them. We don't know much about their coagulation pattern because we just check their platelets or something like that. And but in that group, persistent or
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consistent number of people whose coagulation schemes are either abnormal or one or two standard deviations beyond the norm. And you don't know who those are. And so that's what comes up and
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surprises you. And it tells you, given the testing we had beforehand, we don't pick it up, we don't know. And I think it points to what you're gonna get to is recognize it early and treat it
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early Yes, recognize it early and try and prevent it early. In other words, yes, that patient with a hypercoagulation syndrome, you're gonna have to anticipate starting treatment within a day or
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two, or they're gonna be a guarantee to get disease. In the next slide, I'm going after patients who have a history of a prior DVT within the last five years. They're going to recur 20 of the time,
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if they've had a first event, or almost 30 of the time, if it's a second recurrence but the high-risk patients. fire histories of DVT. If there's a family history, you know, did any of your
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relatives previously undergo an operation and have a pulmonary embolus? This is actually one of the problems with the so-called initial intakes where now many physicians, especially in academic
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institutions, are given their requisite maybe 10 minutes, maybe 15 minutes. And lots
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of
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times as they're walking out the door, they'll say, Oh, by the way, and it's theOh, by the way, is that everybody's missing these days. And that's what could be lifesaving in terms of finding
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out what's going on in your history that could have would or should have been done. So, obviously, you can't start this before surgery, right? It would, it might make it too bloody at surgery.
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Am I right about that? Well, there are some patients who you could prophylactically put an IVC filter into. Okay You have a patient who is morbidly obese and you're going to be doing a
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thoracolumber instrument to take you nine hours. That's a patient where you could put a prophylactic IBC filter in or let's say you have that patient and they had a parrotic right leg and you got a
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Doppler study preoperatively and they have a DVT already. That may be a patient also he may require an IBC filter ahead of time. Now postoperatively you're still going to have to figure out when
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you're going to start something but you can figure out preoperatively who you're going to treat
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So these are the patients with recurrent DVT. What do they have in their histories? It was a proximal DVT. They have a history of cancer. They have hypercoagulation syndromes. Maybe they were
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treated previously for a DVT but they weren't treated long enough and there's a whole group of us out there who were doing preoperative dopplers on patients just prophylactically especially if there
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was a parisis or a paralysis of a leg or that would pick up a certain number of those patients with you. already present DVT that then had to be prevented with the, you know, filter, et cetera.
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And again, prevention, hydration, exercise, activity, et cetera. We diagnosed Doppler's basically with two major studies and there's the Doppler that measures the blood flow in the veins or the
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duplex ultrasound which visualizes the blood flow. But actually, how are we documenting pulmonary embolite? We're no longer using basically,
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you know, the nuclear studies around the world. This is a CTA study for diagnosing PEs and it was in 24 countries, 2023. And the CTA, and the CTA here is your pulmonary artery or pulmonary trunk
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and there's your pulmonary embolus.
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By the way, some of these patients that you suspect may have or you know already have a DVT, if you think that there is a chance that they have a PE, You can even preoperatively obtain some of
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these studies and determine. Does that patient surgery have to be delayed to treat that DVT and allow that clock to resolve before you even get started?
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The regimens for prophylaxis, they're multiple, they're complex, the elastic stockings, they're easy enough to put on, patient compliance can be a problem, the intermittent compression stockings.
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Well, that requires electricity. It also requires that you have the box. Now, the problem is sometimes you would come in in the morning, the compression stockings would be on the patient. There
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would be the box, but the box was not plugged into the wall. So they didn't have the benefit of the compression stockings working. The patient didn't have the benefit of having that kind of
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prevention or prophylaxis. So it takes a team of people to be on board in terms of making sure these are on. Also, if the patient gets up during the day to go for a walk, it's important to put
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them back on. How many times do you go past a patient's you know, room in the ICU. Oh, well, they're out of bed, they're sitting in a chair and they're left there for five or six hours. The
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compression stockings are not put back on, they're not plugged into the wall, they're just sitting ducks for our DVT. And then you have the mini heparins, and the low molecular weight heparins.
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These are more complicated with more risk and potential complications, but also typically greater efficacy, but instances where you just don't wanna use them, others where you really think you have
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to use them And then a whole bunch of literature on the combined regimens and the efficacy of using the combination of these. In fear of being a cave at filters have been around also for a long time.
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They tend to be underutilized, and they can have their own unique features and complications associated with them, and here sort of a figurative diagram of one. So how do the elastic stockings work?
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They reduce the risk of DBT, basically. It reduces the cross-sectional area Fast reviews flow. It reduces venous wall distension, and it can improve valve function. So in short, less pooling.
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You have to put the stockings on for them to be effective, but they can be effective against DBT. And again, if you're in a country where you don't have much in the way of resources, this is
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probably the cheapest way to try and help you reduce DBT, but if at all possible, get that patient out of bed, get them emulating, that's your best protection In 1986, Black et al. looked at
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pneumatic compression stockings in about 500 patients at Mass General in Boston, and they found that they could reduce the risk of phlebitis to about 23, but the risk of pulmonary embolus plate
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pretty much the same at 11, but they concluded that the intermittent compression stockings were pretty effective in terms of reducing DBT, but not pulmonary embolus. And here you can see,
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obviously, you know, quadriplegia and the patient with that severe. paralysis, you know, is going to have a DVT. You can prospectively do surveillance.
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And if you're going to choose to treat, this was a study that back in 1996, you compared the efficacy of elastic stockings and the intermittent compression stockings. By the way, look at the
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difference in rates of DVT as you would anticipate after brain surgery, 77 risk because they're much more immobilized, 15 risk of a spinal disease, but it's still pretty high and the incidence of
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PE was pretty much the same in both groups, so that's what you really want to try to avoid. But it was a helpful combination. Here in brain and spine tumor patients, what Carmen pointed out is
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that three out of four neurosurgeons in the US. only used mechanical prophylaxis, meaning the compression stockings and the elastic stockings, and they steered away from the US. anything having to
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do with the heparins because they're afraid of postoperative hematomas. Because obviously if you
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get a post-op hematoma acutely, perioperatively, post-operatively, you can have a paraplegic patient and that patient can die, obviously.
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I had looked in 2005 at 100 of my own patients having a one-level corepectomy infusion. Typically, let's say a C4 to six or a C5 to seven. And at that point I was using the acress grafts and ABC
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plates. These operations took on average about three and a half hours. And
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I was getting these patients out of bed day zero. Nobody was staying in bed. There was one patient at a DVT about six days postoperatively. And we did a hyper-quagulation workup that ended up being
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positive. This, by the way, shows you that the patients are not always going to be in the hospital when they develop that DVT In fact, it's much more frequent that they're outside the hospital.
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When these episodes occur, if they call the office and they say I'm symptomatic ABC or D, bring them in, get them studied and don't just push everything off to the next day. Some of them have to
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come through your emergency room to get those Doppler's done.
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Can I interrupt?
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Does this mean that, you know, does this mean that, obviously what you're telling me is, I've got a group of patients I'm operating on There's maybe two, three percent that they're going to get a
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DBT.
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There's even if they get it, it's still going to go to the lungs. No matter what I do, one out of a hundred is still going to have a pulmonary embolus, which is not a mild problem. So now you've
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got that complication in surgery. Obviously prevention becomes the key notice. One is you got to get a good history or do some tests ahead of time And we don't do very well at that. And now after,
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on day one after surgery, do you do ultrasounds of the legs? Besides obviously getting them out of bed, you're gonna get to that. But do you anticipate all this? Is there some things you can do
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to prevent it like getting ultrasounds every day or something like that? Is that reasonable? Yeah, well, I actually ordered Doppler studies, post-op day one. And usually before the patients were
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discharged and we picked up numbers of these DVTs, but believe it or not, the response of the department was they didn't want to know about it.
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It just prolonged the length of stay. And I was saying, well, what about the safety and health of the patient? Doesn't that come first? Well, you would think that that would be or should be the
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case. That's not always the case.
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In this instance, it was interesting, the patient had the underlying, you know, hypercoagulation syndrome and there was nobody else in the family who had had that. history. So we couldn't have
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anticipated that necessarily. But it's one of the reasons why you get a call from that patient post-op. They have a low-grade fever. They may have a feeling of some chest discomfort. They may be
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coughing. Something is a rye. There's nothing better than bringing that patient in to look at the patient. Look at them, evaluate them. If you're not going to do it, at least send them to their
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medical physician to have them take a look at them. And if they see their medical physician and they think that there might be a DVT, you want to make sure that that doppler is done that day, that
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afternoon, not just put off for the next day, because the patient could have a fatal PE between those times and I've seen that happen.
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Okay, thank you. So you've got to be, you've got to have a high index of suspicion is what you're saying. Yes, and your responsibility for that patient doesn't end once you get that patient out
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the door I mean, how many times do we see? ourselves, any of our colleagues, you know, if you can get the patient out the door, then it's somebody else's problem. Well, the answer is it's
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still your problem, at least for the next 90 days. It's your primary problem. And you have to be, especially in this day and age where the internists have no time, the PCPs have no time, nobody
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has any time to see anybody in the office anymore practically, you have to still be that patient's position and listen to the complaints Don't just have your secondary tertiary staff deal with these
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patients, your nurse practitioners, your PAs, your medical assistants. Too often you look at medical legal charts and guess who the only person who was to contact and dealt with these patients.
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Medical assistants. I can see the system as it's evolving, is going to go to tell some nurse practitioner to go see them and they won't even look at it. That's right, that's right And they won't
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put a hand on them. They'll just diagnose it over the phone. So listen, this is a preventable disaster that's waiting to happen and the disease is terrible.
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So either get them out of bed as fast as you can, or you've got to get started on something to treat this disease and prevent it. That's right, that's right. And that takes enough personnel in the
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correct unit to do that. Yeah, there isn't. I mean, many of us had arguments where our post-op ACDFs, you know, one level ACDF, no reason that patient should be in monitored unit. I put them
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in monitored unit every time. Why? Because the nursing ratio was one to two, one to three. They'd get them out of bed. They had that pulse oximeter on. I thought that they were more carefully
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monitored and protected in that setting, rather than just being tossed out on the floor where, you know, it might be one nurse to 20 or 30 patients, you know, especially when that other person
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didn't come in. Very good recommendation that'll often be ignored.
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and it's not financially expedient, which is the other problem. Okay, terrific. So much better. I also looked at 100 patients having multi-level front and back procedures, 360 procedures. These
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were mostly patients with ossification of the posterior longitudinal ligament. And this was in 2005. And here's your classic example of OPLL, where you're doing a multi-level perpectomy infusion,
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then you're turning them over and doing a posterior fusion. And what did I find in these patients? These were average nine-hour procedures By the way, in the beginning, these were sometimes 13 and
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14-hour procedures. Sometimes there were also CSF leaks that one had to deal with, and that required wound parrotneal and lumboparotneal shunts, which many of my colleagues didn't know how to do
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and didn't know how to treat. Seven had DVTs and two had PEs, and the two PEs were the ones with theiliac vein DVTs. This group has to be very carefully monitored. This is a group that's also
29:21
typically, they were wearing a halo earlier in the course, and then they were wearing a complex cervical. thoracic orthosis. But getting these patients out of bed mobilized, it takes an entire
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team to do that several times a day, not just the ones today. And that's the safest thing for those patients and not sending that to the floor. If you go back to that one slide, what that tells
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you is almost one out of 10 patients if your prolonged surgery are in this category. Yes, yes And you have to be vigilant and it's often extremely silent. You know, if you're just going to say,
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well, but you know, I'll look at the patient who's high risk, you know, the heavy patient, you know, the one who has some kind of underlying cancer diagnosis, that's great. But you have to
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look at the risk factors and the other patients as well. And the fact that the immobility is one of the biggest factors of all, and that could be a problem. This is a group, by the way, because
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Because their pre-operative deficits are often very severe. Very operative Doppler studies may signal to you that that patient has an underlying DVT and therefore you will know that you're going to
30:32
have to treat that patient post-op much less put in a filter so that when they're prone or supine for long periods of time, they don't throw an embolus in the middle of surgery. So if I'm adding up
30:43
the risk of surgery, now I got a one out of ten chance of having the patient get a DVT, then let's say he's got a low parisis from retraction on a nerve root. Now I've got that as a complication
30:54
That's another 3 or something of surgery or more. I mean you keep adding up these complication rates, that's why you're getting trouble. Yes, yes. On the other hand, these, this group of
31:06
patients with LPLO had the most severe cervical myelodic alopathy. In other words, they had preoperative amores, and here's your CAT scan. By the way, on the CAT scan, you see this vertebral
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body, you see this vertebral body. You see this black area here, and then you see the hyperdense area behind it. a double layer sign, meaning if you go anteriorly in this patient, you're going
31:28
to get a massive CSF lead because it's going to be no dura. So what you try and do is you try and go anteriorly, you do whatever corpusctomy you're going to do, realign them and then try and put
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them into a
31:40
lordotic position post-op so that, uh, and fuse them from behind so that you can take the pressure off their cord. So now he's got a CSF lead after surgery. You want to put a drain in or at least
31:51
put them down in bed or something like that. You know, you just increased your risk and your problems considerably. Well, actually, and that's such an important factor because you're talking now,
32:03
we're going to talk about low dose or low molecular low molecular weight heparin. You do not, on a patient with a complex CSF lead repair, you do not want to put these patients on your low
32:16
molecular weight heparins or their repairs are going to fall apart. I go to conferences all the time and they're just saying, you know, I'm saying, aren't you taking this into account? Oh, no,
32:26
patient's gonna be fine. I said, well, no, patient's not gonna be fine. So here is your, you know, example of thrombosis, subcutaneous heparin, low dose mini heparin, 5, 000 units sub-Q,
32:38
Q12, others will say it has to be Q8H. Sometimes it depends on the patient factors, you know, are they heavier individuals, et cetera, low molecular weight heparin, same kind of thing And here
32:49
are the other regimes that you have. What's important is the heparins do not break down the clot. It allows the body to reabsorb these clots and it inhibits the further growth and propagation of
33:03
that clot, okay? So that's important to remember. By the way, because of your comment this morning, I just thought I'd look at this. This was from the Canadian Journal of Pharmacology 2009 and
33:15
Thompson basically, he's got the Delta parin and actually part and all these other. and basically the maximum dose that you're gonna have for these patients taken every day. And again, you're
33:26
gonna have various factors that may change the doses given, especially the weight of the patient in question. Clocks looked at the incidence of decreasing DVTPE after surgery using multi-modes
33:40
prophylaxis. And this is the important point here. The 992 patients where they use compressive devices, that's mechanical prophylaxis, with the chemoprophylaxis, those patients did the best. The
33:54
rate of DVT was much lower in these patients, 1 versus the 27 you're seeing over there, okay? Number of patients was pretty comparable. Incidents of PE, pretty much the same, incidents
34:08
interesting of the
34:11
epidural hematoma frequency was the same in both groups with or without the use of a mini-heparin derivative.
34:19
go into this thinking, oh, well, you know, it's only the patients on the mini heparin or the low molecular weight heparin or we're gonna have the clots. Well, that happens not to be the case,
34:29
which is good because it just shows you that the recommendation becomes to use the compressive devices and very much seriously consider using the chemoprophylaxis because the data out there show again,
34:43
the risk of the epidural hematomas postop, pretty much the same even with or without the chemoprophylaxis And that's, remember, I showed you earlier on the paper from the early '90s that was
34:54
talking about, well, three out of four neurosurgeons are still just using a mechanical prophylaxis. So in this day and age, you really have to think about whether or not there are enough cons not
35:06
to use chemoprophylaxis in these patients and again, when.
35:11
That was a great slide. That's really, now I've got DVD down to 1.
35:18
which is great. And the PE down to half percent. I mean, now we're getting, it's not gone, but it's a lot better.
35:28
Yes. And again, you know, vigilance, having it, having surgeons aware, I once wrote a paper that I don't think anybody ever read except myself who wrote it. It was calling, called how much
35:40
medicine does a spine surgeon need to know to better care for and treat, you know, spinal patients. And I think it was a real sleeper and, you know, probably nobody ever read it, but it's
35:51
talking about, you know, selection of patients that acute my patient within six months, you're not going to operate on them. They've had a new stent. You're not going to stop that aspirin and
36:02
plavics for at least a year, really. Sometimes it might be half a year if you can get a special dispensation, but just knowing enough medicine to protect your patients is critical you can't just
36:14
have blinders. This is one of the best papers I've So I was chubaro at all in World Neurosurgery 2018, and the best regimen they concluded, elastic stockings, plus the intermittent compression
36:27
stockings, plus the low molecular weight heparin. And then compared it to the previous study of elastic stockings with the low molecular weight heparin, but adding the intermittent compression
36:37
stockings was better. DVT, lower rates, 08 versus 23. The incidence of PE was lower, 018 versus
36:46
09 So the best regimen in this study was to use all three together. And it really doesn't cost you much, and it's not much of a hassle to add the compression stockings to your elastic stockings and
36:60
then use your low molecular weight heparin. So I thought this was pretty cute. These two women, damn, it sure feels good to get those compression stockings on. By the way, if you would go to the
37:10
patient's bedside, I remember at one of the Friday's spine conference. I said, well, you know, just turn the patient over and look at their wound, you know, I don't care if you just go up to
37:21
the patient in YouTube bubblegum with five minutes, you know, talk to them, you know, examine them, do something hands-on, you know, roll them over. What does that wound look like? You know,
37:30
make sure those compression stockings are on their legs andor the elastic stockings, and they couldn't believe. They said, Oh, well, you know, you just have your, you know, PA or your medical
37:41
student or whoever it is, look at them And the answer is no. You are still responsible. You are still so cold, the captain of the ship, and your ship is definitely going to sink if you don't
37:52
remain vigilant, actually. This is a study from 2023 talking about, again, advocating for using multiple regimes, and what did they found? They found that the chemoprophylaxis lowered the rate
38:05
of DVT There was only one bleed in this group, and they recommended the intermittent compression stockings. Early immobilization, best post-op day zero, not just day one, and adding the
38:17
chemoprophylaxis post-op day one. So now you've really attacked the argument which I was thinking about is, well, I didn't want to start it
38:31
on low molecular weight tepron, because I just don't want a chance of having bleeding. When can I start it? What you're saying from all these studies, is you can start it right away, in that the
38:44
chance of having a problem is extremely low. That's exactly correct. And if during the time you have them there, in other words, what's the biggest thing that they're doing these days? Operate on
38:58
the patient, send them home. Right. Nobody's keeping them to watch them. They go home, they don't get out of bed, they come in with a flagrant DVT, PE, wound, et cetera I mean, this is one
39:11
of the biggest problems that you have is Post-operative surveillance is just going out the window because all people are caring about is getting them out the door.
39:22
And this should not be the case for your complex surgical procedures. You're certainly your instrument at Lumbar Fusion as well. You read these series, post-op day one, 23 hours stay. Some of
39:36
them just don't even have that 23 hours stay. And some of them are
39:40
sent home and they have a cardio pulmonary arrest from an acute PE that nobody bothered to look at or figure out. We'll go back there one minute. I think one of the questions people are gonna say,
39:52
look, I've had this extensive operation. I don't want to put him on anything in a coagulant 'cause he's gonna be bleeding. Well, if you have a drain in place and they're draining a lot, then
40:05
you're probably gonna want to hold off starting any chemoprophylaxis in that patient You're going to want to also question. is there a CSF leak that I've missed, especially if the volume is in the
40:19
hundreds, and the hundreds and the hundreds and the hundreds, and it's not slowing down. So not only can you say, well, I'm gonna not use any chemoprophylaxis here because the patient's bleeding
40:31
a lot. Number one, you've gotta take all the blood parameters, et cetera, into account. When you were operating in the patient, what was your blood loss? Did you have to give plate list? Did
40:40
you have to give clotting factors, et cetera? But also, is there an underlying CSF leak here that I've completely missed? And is that why the volume of fluid is so huge?
40:51
If I start them on low molecular chemoprophylaxis, in my excuses, well, I don't wanna have any more bleeding after surgery, what you've just shown us is that's not true. That's correct. That's
41:04
not true. And if you've got other complicating factors, if you, if you, I always, my friend, I've surprised a lot of residents. And their knowledge of coagulation
41:18
and how you coagulate and keep a dry field. Well, the answer to that was I put a bag on the end of the table or something like that and then let the blood flow out.
41:28
Obviously you've asked for higher risks in post-operative clot and not with that because you don't want to give him a prophylaxis. You're going to get a P on top of that. You're just asking for
41:39
trouble
41:42
Right. And, you know, again, you have to take one step back and say, well, was the operation that I did an open procedure or one of these minimally invasive procedures? Did I really see that I
41:56
didn't get a CSF leak? Did I really take out the disc?
42:01
How am I going to recognize if this patient is really neurologically worsening? Well, you have to examine them post-operatively to determine that So often these patients are sent to, you know, a
42:12
recovery room. And the nurse is going to be discharging them later, much less maybe in an anesthesia resident. And nobody's going to neurologically examine the patient's to see, you know, do they
42:22
have a post-op hematomy before they leave the door? Then they're leaning in favor often of not putting in a drain because they don't want them to go home with the drain and they don't want to end up
42:33
having to transfer them for an in-hospital stay because that's a bad mark against the record. So if I'm in a country or if I'm in a part of whatever I am, I don't have access to chemoprophylaxis,
42:46
you're going to get to that, but obviously you got them out of bed. If I, in other words, you don't have to be in a country with money to get chemoprophylaxis. These drugs, low molecular weight,
42:56
a dextran or whatever it is or heparin, you can, that's available everywhere in the world, should be, right? Yes, pretty much. And if it's not, then you've got to be more acutely aware and do
43:08
what you're going to tell us next Right, right.
43:13
IVC filters, well, 80 of trauma patients, especially, are going to develop a
43:21
DVT. The indications for filters vary. If you have just done a very complex drill repair, let's say the patient has a hypercoagulation syndrome, you are going to want to avoid your low molecular
43:34
weight heparin, because you're afraid your drill repair is going to fall apart.
43:38
More of an obesity. Preoperatively, these may be patients that you're going to put the filter into, because you're afraid your low molecular weight heparin, and pair the drill repair.
43:50
The clot that's going to form to try and make that a successful repair is going to lice and disappear.
44:03
So, your intrinsic reparative process is going to be interrupted. And those repairs are often going to fall apart. I gotcha.
44:16
Okay. Prior or persistent phlebitis or pulmonary embolus, a patient who is paralyzed, the incidence of DVT is going to be huge, long-term immobilization in the future in that paralyzed patient,
44:27
hypercoagulation syndromes. So, here are the different types of filters And this is basically what it looks like on an AP view. Sometimes, by the way, you may be doing AP in lateral lecturers on
44:39
a patient and you
44:47
say, Wait a minute. You never told me you had a filter in place. Oh, yeah, Doc. I had this, you know, 15 years ago, or whatever, okay, well, the fact that you have a filter in place can
44:50
increase what's called the inferior vena cava syndrome, which I'm going to get to very shortly. But originally, we had greenfield filters. Greenfield filters, by the way, couldn't be removed But
45:01
the newer ones are. In other words, a few months after the surgery, usually three to four, I'll show you a series where it was seven months, you want to take these filters out so that they don't
45:13
sit there as a coagulation nightis. This
45:18
is just an example of what the trapeze filter is going to look like. It traps the clots. The clots can migrate though around these filters so that you can actually develop a DVT that starts, you
45:30
know, in your calves, going to Eligveins, and then goes all the way up your inferior vena cava up to the filter so you clog the whole thing up, you can develop swelling in the lower extremities,
45:42
you can end up rupturing the inferior vena cava with this, and these are patients that may require embolectomies.
45:49
So this is what you have to look for if you've put in an IVC filter and again, you want to make sure whether or not you can end up taking that filter out.
46:00
years ago where there was a patient with a circumferential operation, 360 degree surgery, and the patient developed a DVT post-op. I didn't want to anticoagulate this guy because I was afraid that
46:14
he might get a post-op hematoma.
46:17
One of these filters, brand new, retrievable kind of filter was placed. It embolized to that patient's pulmonary artery. Was causing all kinds of arrhythmias So I
46:31
basically said, look, let's put the patient in the ICU. Let's try and watch that patient for a week so that I'm not worried about him becoming quite a collegiate from a post-op hematoma so that you
46:43
don't have to fully heparinize him to take this out of his pulmonary artery. So a
46:50
week later, they operated, split his chest open. I was there watching. They took out the inferior vena cava filter and the patient ended up fine. And these are not just simple, make sure that
47:03
people putting them in have some experience using them as well as retrieving them, because there are all kinds of retrieval devices. Usually they go from above to try and retrieve these. And I had
47:14
used these, I placed these patients in four patients who developed DVT after lumbar laminectomies and instrumented fusions. By the way, the DVTs were two to six days post-op One patient was
47:27
morbidly obese, one had progressive DVT and PEs, actually the other three did, and one actually had a PE around the filter and had a hypercoagulation syndrome. But in this study, 2023, 380 IVC
47:40
filters replaced,
47:42
62 were retrieved after seven months. A lot of studies is going to be higher than that, and it's usually within a shorter period of time because the longer the time before you try and retrieve it,
47:53
the more difficult it is to retrieve In this case, 92 of the retrievals were routine, they could do it successfully. 8 were more complicated and only in one patient was there was a minor adverse
48:05
event, but no really difficult problem with that. And here, this is the IBC filter retrieval, removals, you go from above, you go from below, you sneer this, you sneer that. This is where
48:17
your interventional radiologists come into play and some of us have some colleagues who are just phenomenal interventionalists and these are really life-saving procedures to be done by the ones who
48:30
hopefully have the experience doing them. Oh,
48:34
that's fine. So, if you look at this in conclusion, in Arnold's study in chess 2001, he talked about missed opportunities for prevention of venous thromboembolism. And this is what I'm gonna show
48:49
you. He said, look, it's the failure to follow the guidelines of the American College of Chess Physicians, the most common reasons for failure of prophylaxis I mean, anybody could guess. this is
49:01
the kind of thing you can have an open discussion with. Maybe Dr. Ashwarp might want to give us an answer to that if he's just joined us before I give him an answer. But I'll show you the answer
49:11
anyway. None was used. None. No elastic compression stockings, no intermittent compression stockings. None. Okay, inadequate duration of treatment or prophylaxis. And the last is the incorrect
49:27
type of prophylaxis being used. In other words, that patient with the hypercoragulation syndrome, elastic stocking, intermittent compression stockings, they're not going to do the trick. And
49:37
you're going to have to start something very early postoperatively. It's going to be best to use the combined prophylaxis regimes if your patient can tolerate it. It lowered the rate of DVT in this
49:50
one series to 08 and PE to less than 2. So the
49:55
conclusion is that the best prophylaxis against DBT combines you. protocols, the elastic stockings, the compression stockings, and your low molecular weight heparin regimes, as we showed you in
50:08
the beginning of today's talk. Let me ask you this. One thing,
50:14
you've talked about it, we've talked about, what about early ambulation? Critical. The earlier you can ambulate, the better off you're going to be In terms of, as soon as they're awake and alert,
50:29
we were doing this in the recovery room, if possible. Just get them up, get them walking, taking a few steps, also repeating it every hour, if you could, requires personnel to do that,
50:45
especially in a post-operative care unit, where they may be overwhelmed by the number of patients coming in and out. But that is the best, It's the cheapest factor, it's the most protective factor,
50:56
it's the best factor.
50:59
Okay, I do. And again, yeah. Yeah, go ahead. But a simple axis is to use all three if you can, but I can't emphasize enough, you have to analyze the pros and the cons for these regimes,
51:10
especially the low molecular weight heparin, on a case-by-case basis. What was the operation that was done? What would the risks be for this patient re-bleeding? If I put them on low molecular
51:21
weight heparin, if I just did a complex dural repair and I'm just gonna go over that and over that and over it again, this is not gonna be the patient they're gonna use the low molecular weight
51:30
heparin on. If that patient has a hyper-coagulation syndrome and their cousin developed a DVT and died of a PE within a short period of time, et cetera, that's the patient where you're going to
51:40
want to be very vigilant and start them on something as soon as possible and get them up and out of bed and get them going as soon as possible. And one of the things when you've got the references up
51:51
there,
51:53
I wanna ask you another question we talked about early ambulation, Now I've got to see it, I'm gonna ask you another question. We talked about early ambulation. Now I've got a CSF leak at surgery.
52:05
I put them down in bed. I put it right, I put a drain in to get this thing going and so forth. If you put them on the low molecular weight anticoagulation, the clot won't really form well as you
52:18
were talking to about it. So now everything is more complicated. You can't use the prophylaxis you want The patient's in bed from another problem. Well, if I just open the door and seal it after
52:31
seal it well after surgery, how long do I have to wait before I started just without having a problem? Okay. Well, I think the main thing is the changes that have occurred in dural closure
52:44
techniques. This actually might be a good topic for one of our other discussions.
52:49
Number one, if you have a dural leak And certainly if you're doing it. minimally invasive, endoscopic, whatever it is, do that patient a favor, open them up, do a real repair. You can do a
53:03
primary sutured repair if there is enough dura to close. Use a muscle patch graft to make that water tight. Sometimes that's difficult, sometimes that's complicated. Actually, I wrote a paper
53:18
with a colleague, Mark Golnick, about using anchor sutures on the surrounding bone that can help you do this. You're also going to want to use intermittent sutures. I do 70 cortex because the
53:32
suture is bigger or fatter than the needle that you're using, the 70 needle. In addition, you're going to want to put microdural staples between those interrupted sutures. Don't use a running
53:46
suture, even though of the articles that say, Oh, running sutures, the same is interrupted, they're not.
53:51
And, very importantly, these days you have not only Durgin, which is microfibular collagen, but you also have different fiber and sealants. I used to seal, not Duroseal, Duroseal, can form a
54:04
big glom. It's this big, gluey green stuff. It's FDA proof of this use. But then you use, after you've done your Dural Repair, you've got your sutures, you've got your microdural staples, you
54:16
might have sewn on a patch graft, do not use them on a fat graft. It's not gonna work It's gonna shrink. It's not gonna effectively, you know, block it, do your Valsava Maneuver, make sure that
54:27
that's as water tight as possible. Use your microfibular collagen, your dorogen, and then create, like a sandwich almost of, you use a layer of your microfibular collagen. First, putting down a
54:41
layer of fiber and sealant, microfibular collagen, followed by the final layer of the fiber and sealant. So, and over that, you can put in a drain.
54:51
With the improved techniques for repairing the dura, many of these patients these days, we do not leave flat for 24 or 48 hours like we used to. We just start getting them up. Now, it might
55:06
depend on the complexity of the repair in some cases, but that's the way they're no longer treated, typically with the 48 hours, head down 10 degrees to Della Burg, et cetera. So that may be the
55:18
safest thing to do in patients I'll inject a personal note here. I was found to
55:25
have colon cancer. They took me to surgery to operate on me. And it's known with certain cancers that you get elevated coagulation factors. About a week or so after surgery, I developed, and I
55:37
was getting up and so I developed multiple pulmonary emboli. Yeah. And so they put me on some anticoagulation and so forth. We tried to come off three months later and had another small spell So
55:50
they put me on it. My brother, I wound up with a hyperniform in the kidney. I was kind of passed it off a little bit. He didn't know about that. He was just having some symptoms. He didn't want
56:01
to have him followed up. Got to the hospital hospital. I had a massive PE and died. Oh, no. So this is not a benign disease. But you get it. It's not. It's not insignificant. So I think the
56:16
point is that everybody tends to ignore it or let the nurse see it Or maybe the physician's assistant who doesn't know what they're looking for. You're just asking for trouble. Yeah. No, I mean,
56:28
I can actually remember a patient like I just remember now. 360 front to back flip flop post-op day one. Shortness of breath, hypoxia, everything else. CTA PE protocol. Big, big saddle emblis.
56:42
And actually we managed to stabilize her. But we had to anticoagulate her and it was, you know, post-op day one up day one, but there was absolutely no choice in that case.
56:52
Vigilance is critical, but you can only be vigilant if you're actually seeing the patient or they're calling you. Because these days, as I said, all they're interested in is getting the patient
57:05
out of the hospital. And once they're out of the hospital, they're often not sophisticated enough to realize that something bad is going on. Which is probably one of the reasons why if you're gonna
57:18
discharge patients early, have a schedule of bringing them back routinely a day or two or three later, just to make sure that you are surveilling what's going on with them. You do not want this
57:30
problem and you can do things to prevent it and get yourself down below the 1 like you showed in the statistics. Yeah, yeah. Okay, terrific job. Appreciate it very much, really. Excellent.
57:44
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57:58
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