LOTUS - Institute Of Haematology, Oncology and Bone Marrow Transplantation 


 

Newsletter Nov. 2014



Nov 17, 2014

Newsletter  Nov 2014                         Vol 5 issue 3  

Dear fellow Indians,

Let me wish you a very happy and prosperous Diwali and New Year. As always I thank you for your love and support to Lotus Hospital. I hope we give you even better services in years to come.

I present an interesting case of Deep Vein Thrombosis.

Case 1: 37 year old businessman was Replica Omega Watches diagnosed with DVT and admitted to another hospital. His relatives brought his file and investigations for second opinion.

He had pain in right leg for 7 days prior to presentation to his family physician. His physician saw him and gave him 3 days of NSAIDs. He felt better for 1 day and again went back with swelling in the same leg. He was referred to a hospital after Doppler done showed deep vein thrombosis. Doppler report revealed acute thrombosis in femoral veins (all deep veins were involved).

He was admitted in ICU (as happens many times!!)franck muller replica watches and he was thrombolysed. He was also started on low molecular weight heparin (Clexane). He was advised IVC filter (this is an umbrella like device which is inserted and fixed in the IVC so that the clot from deep veins of the lower limb cannot reach the pulmonary vessels and hence a pulmonary embolism is prevented). He developed headache and vomiting followed by ? seizure  after 2 days of thrombolysis and CT showed an 1.5 x2 cm intra cranial bleed.

He saw me after 14 days and in those days he underwent conservative management and on follow up scan 3 days after initial scan the lesion had not increased. He was started on warfarin 28 days after his initial presentation.

He was admitted again 8 months after his initial presentation with weakness and low haemoglobin. He was found to have malena and hence his had anemia(Hb was 5.4). On admission his INR (prothrombin time) was high at 6.2! (it should be in range of 2-2.5) and hence his risk of bleeding was high. He was managed with blood transfusion and IV iron and was discharged 5 days later. He was restarted on warfarin and then he saw me 1 month later for further advice.  When I saw him he was on Tab. Warf and Tab. Clopilet. He also had 4 colour doppler reports mentioning the percentage of clot remaining!!

What advice should I give him?

DVT is common disease and unfortunately the treatment depends by whom and where is it treated. In my last 5 years I have come across varied management patterns and little evidence based management, which has cause unnecessary discomfort and expense for our patients and their relatives. This case highlights some of the problems in managing DVT.

Questions raised in the case:

      1. Should DVT be thrombolysed?
          Only about 5-10% cases need thrombolysis. In case of “limb threatening” DVT it is useful. The risk of bleeding 
          is increased. We should remember that DVT is “venous clot” and NOT arterial like coronary artery disease. We should
          not thrombolyse DVT unless really indicated.
      

      2.How long should we should give warfarin?
          Most of the DVT or PE (Pulmonary Embolism) cases need 6 months of warfarin therapy. Below knee DVT need only
          months of DVT.  Our patient had GI bleed after 6 months, if we had stopped his warfarin at 6 months, it would        
           have been avoided.
     

     3.How frequently should we repeat colour Doppler?
         One should not do Doppler after initial diagnosis as they donot add to any clinical management. If the swelling  
         increases and you suspect a new clot, then only we should repeat the Doppler. This will save time of our already       
         busy sonologists.
   

    4. Do we need antiplatelet therapy (Aspirin or clopidrogel)? 
         I have often seen anti platelet prescribed with warfarin because of “clot”. This is not necessary. Platelets are
        not involved in venous clot (DVT) formation hence anti-platelet drugs are not to be given
     

    5Should IVC filter be prescribed to all patients with large and extensive DVT?
         IVC filter (described earlier) is often inserted after an extensive DVT (I have seen many cases where “insurance”
        patients were preferred!). There are very few indications of IVC filter insertion (i.e malignancy with DVT where   
        warfarin therapy cannot be given or a patient with thrombocytopenia where anticoagulation cannot be given etc)
     

    6.Almost all patients with DVT should have Grade 2 DVT stockings. Dietary advice should be given to all patients
        on warfarin (avoid green leafy vegetables, cauliflower, cabbage etc.). there is no difference between acitrom or
        warfarin
any one can be started.
    

    7.Thrombophilia profile (i.e tests carried out to find out why one gets thrombosis) is carried out in select patients to
         find out the cause, especially young patients and those with odd sites thrombosis.

         There must be many more questions regarding DVT. You may ask me in person.

Lotus Anticoagulation clinic:

We run an anticoagulation clinic where PT/INR is done on a fully automated coagulometer and advice regarding dose of warfarin is given. We are equipped to manage all DVT cases and complications of over- warfarin therapy.We strive hard to  provide evidence based management to all DVT patients.

 

 

 


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