LOTUS - Institute Of Haematology, Oncology and Bone Marrow Transplantation 


 

Newslettter Vol 8 issue 1, January 2017



Feb 1, 2017

 

                                                                                                             Newslettter  Vol 8  issue 1,  January 2017

Dear friends ,colleagues and seniors,

I wish you a very happy and prosperous new year 2017. I once again take this opportunity to thank you all for the support to Lotus hospital since last 6 years. I am glad to tell you all that we have successfully completed 31 bone marrow transplants to date at Lotus hospital.

In this issue I will discuss a pertinent problem in management of venous thrombosis.

Case 1:  

 47 year old male reported to his treating physician with pain in his left leg. He had no particular swelling, no sign of obvious inflammation. He was given pain killers and ask to see the physician in 5 days. Patient went back to his physician a month later with increasing pain and swelling and was then diagnosed with Deep vein thrombosis home decor ideas. The clot extended from external iliac vein to femoral vein. There was no clot in Inferior vena cava. In view of the major thrombosis he was referred to a cardiologist.

He was seen and asked to get admitted with an explanation that he would need thrombolysis and placement of IVC filter (this is like a small umbrella made out of special material which is placed in the inferior vena cava so that the clot from lowerlimb does not reach the pulmonary vasculature hence preventing pulmonary embolism) with a budget of 1.46 lakhs (patient was a primary school teacher)

Patient went to see his local family doctor at Patanjali health centre. The doctor in the centre referred the patient to me for a second opinion. He had pain and swelling. No breathlessness. In his colour Doppler report the clot was of subacute nature.

What advice do I give this gentle man?

A] What his is ideal management?

B]Does he need thrombolysis?

C] Does he need IVC filter?

D]How many days admission is required if at all?

E]Does he need an antiplatelet drug also?

F] Does he routinely need statins?

I started him on low molecular weight heparin and oral anticoagulation with warfarin. He was not ready for admission (ideally in a large DVT one needs admission for atleast 3-4 days to monitor for pulmonary embolism )

I advised him that he does not need thrombolysis and he also does not need IVC filter.

   Indications of IVC filter in DVT?

 A] Acute DVT where anticoagulation therapy is contraindicated (e.g immediately post major surgery,     

     cancer where platelets are low, DVT in a patient who has active bleeding and hence                                                                        

     anticoagulation is contraindicated etc.)

B] Recurrent DVT  inspite of adequate anticoagulation.

C] Extensive DVT with impending embolism i. e clot extending in IVC .

Just an extensive DVT alone does not merit an IVC filter insertion.

What are the problems with IVC filter?

A]Everyone is excited to insert a filter but we forget to remove it?? A persistent filter can be a site of                       

     a new clot and then the patient can get bilateral DVT?

B]Most of the cases IVC filter insertion is a temporary measure.

C]Cost involved is huge and patient and family can be worried unnecessarily (unless it is an insurance  

    patient or Jeevandai Patient!)

Thrombolysis ?

 I have come across many cases chopard happy diamonds clone watches of acute DVT where thrombolysis was carried out. In my opinion we think “any clot should be thrombolysed”, but we should remember that DVT is a venous clot unlike coronary syndrome or stroke where it is an arterial clot.

It is indicated only in extensive acute DVT where it is “limb threatening” or a case of PE where hypotension is present.

I have seen atleast 6 cases where after thrombolysis (because of clot dislodgement )the patient developed acute PE???

 

                                                          


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