Prevention of venous thromboembolism.
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Anticoagulants↗
Biomedical subjects
G J Merli
Publications and source records attributed to G J Merli.
Outpatient anticoagulation issues for the primary care physician.
Increasingly, primary care providers are caring for patients who require anticoagulation. In this article the indications for, complications of, and methods of dosing and monitoring warfarin in the outpatient setting are reviewed. Heparin use among ambulatory patients also is discussed.
Ambulatory Care↗
The outpatient with unilateral leg swelling.
Approaching the patient with unilateral leg swelling presents a challenge to the physician in ambulatory practice. Contributing to the difficulty is the lack of studies that have assessed a population of patients presenting with unilateral leg swelling. The purpose of this article is to discuss unilateral leg swelling with respect to the chronicity of the presentation and the most common differential diagnoses based on a review of the current literature and personal clinical experience.
Ambulatory Care↗
Update. Deep vein thrombosis and pulmonary embolism prophylaxis in orthopedic surgery.
Deep vein thrombosis and pulmonary embolism continue to be controversial areas for prophylaxis in orthopedic surgery. This patient population continues to have the highest incidence of deep vein thrombosis and pulmonary embolism when inappropriately or not prophylaxis for this complication. This article reviews the current modalities for prophylaxis with respect to their safety and efficacy. In addition, the new modalities of low molecular weight heparin and arteriovenous impulse system are presented.
Anticoagulants↗
Medical consultation in the patient with multiple trauma.
Medical consultation is frequently requested to assist the trauma team in the management of the patient with multiple traumatic injuries. Four areas are commonly encountered as problems for management in this patient population. In this article, myocardial contusion, stress ulceration, seizure prophylaxis, and deep vein thrombosis prevention are addressed with respect to incidence, assessment, and management.
Contusions↗
Etiology, incidence, and prevention of deep vein thrombosis in acute spinal cord injury.
This article provides a critical review of the literature on the etiology, incidence, and prevention of deep-vein thrombosis in acute spinal cord injured patients. Stasis and hypercoagulability are the two major factors contributing to the development of thrombosis in this patient population. This has been supported by studies that demonstrate an impaired venous return from the lower extremities and abnormal coagulation factors, which predispose to thrombogenesis. The incidence of deep vein thrombosis secondary to the above etiologies varies from 49% to 100% in the first 12 weeks with the first 2 weeks having the highest rate following acute injury. This high rate of complication has led to numerous studies to identify the most effective regimens of prophylaxis. Studies using noninvasive testing and venography in acute spinal cord injury have supported two approaches for preventing deep-vein thrombosis. Single agent pharmacologic therapy with adjusted dose heparin is effective but does carry some risk of bleeding. Combination therapy with external pneumatic compression sleeves plus either aspirin/dipyridamole or low-dose heparin and electrical stimulation plus low-dose heparin have significantly reduced the incidence of deep vein thrombosis. The duration of prophylaxis with the above modalities has varied between 8 and 12 weeks following acute injury. Further large scale studies are required in this high-risk population to better delineate the incidence of deep vein thrombosis and pulmonary embolism, to identify the best modalities, and to define the duration of treatment for the prevention of these complications.(ABSTRACT TRUNCATED AT 250 WORDS)
Acute Disease↗
What's new for the medical consultant.
The role of the medical consultant caring for the surgical patient has evolved over the last 20 years as numerous books and articles have contributed to the knowledge base of this field. Consultants used to merely "clear" patients for surgery. Now, guidelines based on data are available to direct many perioperative management decisions. The consultant is responsible for knowing the ever-growing body of literature and for conducting himself or herself according to accepted guidelines for consultation.
Diagnostic Tests, Routine↗
Approaching the surgical patient. Role of the medical consultant.
Medical consultants will no longer "clear patients" but will "prepare them" for surgery instead. They will be required to possess the expertise in assessing a patient's risk for surgery, managing perioperative medications, caring for postoperative complications, maintaining appropriate conduct in the role as consultant, and recording accurate documentation of level of service for third party reimbursement.
Humans↗
Mechanical plus pharmacological prophylaxis for deep vein thrombosis in acute spinal cord injury.
This pilot study assessed the effectiveness of external pneumatic compression (EPC) with gradient elastic stockings (GES) and low dose heparin (LDH) in the prevention of deep vein thrombosis (DVT) in acute spinal cord injured (SCI) patients in the first 14 days following injury. Twenty-one consecutive patients within 48 hrs of injury with acute C2 through T12 motor complete or nonfunctional motor incomplete spinal cord lesions were enrolled. 125 I fibrinogen scanning was performed daily. A positive scan was confirmed by venography. Thrombosis was demonstrated in 1/19 patients. A control group from a previous study confirmed thrombosis in 6/17 patients (p = 0.04). Comparison of extent of thrombosis demonstrated a reduction in the treated group (p = 0.02). This pilot study demonstrates that EPC with GES plus LDH may be an effective prophylactic regimen in these patients.
Adolescent↗
Deep vein thrombosis in spinal cord injury. Summary and recommendations.
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Anticoagulants↗
Management of deep vein thrombosis in spinal cord injury.
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Acute Disease↗
Prophylaxis for deep vein thrombosis and pulmonary embolism in the geriatric patient undergoing surgery.
The difficulty surrounding guidelines for the prophylaxis of deep vein thrombosis (DVT) and pulmonary embolism (PE) stems from the willingness to accept some degree of DVT in the calf, with the resultant lower risk of fatal PE, versus the risk of bleeding from a more effective prophylaxis that prevents DVT. This article reviews the etiology, risk factors, methods of prophylaxis, incidence of DVT/PE in various surgeries, and guidelines for DVT/PE prophylaxis.
Adult↗
Lymphedema of the lower extremities: evaluation by microcolloidal imaging.
Contrast lymphangiography has been the traditional radiographic method for imaging the lymphatic system of the lower extremities. Because of the difficulty in performing the procedure and its potential side effects, radionuclide lymphangiography is a safe and reliable alternative. Technetium-99m labeled to antimony trisulfide colloid was used in nine patients presenting with lymphedema of the lower extremities. The procedure was relatively simple to perform, and no adverse effects were noted.
Abdomen↗
Deep vein thrombosis: prophylaxis in acute spinal cord injured patients.
The purpose of this prospective, randomized study was to evaluate the efficacy of low-dose heparin, alone or in combination with electric stimulation, in the prevention of deep vein thrombosis (DVT) in C2 to T11 motor complete and incomplete-preserved motor, nonfunctional spinal cord injured patients. The tibialis anterior and gastrocnemius-soleus muscle groups were stimulated bilaterally, using 50 microsecond pulses given at 10Hz with a four-second "on" and an eight-second "off" cycle for 23 hours daily over a 28-day period. Forty-eight patients, less than two weeks after injury, were randomly assigned to saline placebo (n = 17), low-dose heparin (5,000U, subcutaneous every eight hours) (n = 16), and low-dose heparin plus electric stimulation (n = 15). A normal 125-I fibrinogen scan and impedance plethysmography were required for entry into the study. Surveillance for DVT was evaluated by daily 125-I fibrinogen scanning. Venography was performed to confirm a positive impedance plethysmography and/or 125-I fibrinogen scanning tests for two consecutive days and at the completion of the study. The incidence of DVT was 8 of 17 in the placebo group, 8 of 16 in the low-dose heparin group, and 1 of 15 in the electric stimulation plus low-dose heparin group. The use of electric stimulation plus low-dose heparin significantly (p less than 0.05) decreased the incidence of DVT compared to the other treatments.
Electric Stimulation Therapy↗
Dihydroergotamine/heparin in the prevention of deep-vein thrombosis after total hip replacement. A controlled, prospective, randomized multicenter trial.
In a randomized, double-blind, placebo-controlled multicenter trial, the efficacy and safety of dihydroergotamine mesylate/heparin sodium as a prophylactic agent for deep-vein thrombosis were evaluated in 148 patients who were forty years old or more and who underwent total hip replacement. The incidence of venographically proved postoperative deep-vein thrombosis was 52 per cent in the placebo group and 25 per cent in the dihydroergotamine mesylate/heparin sodium group (p = 0.002). Proximal thrombi developed in only 5 per cent and extensive thrombi, in only 10 per cent of the patients who received dihydroergotamine mesylate/heparin sodium. In contrast, proximal thrombi and extensive thrombi developed in 19 and 25 per cent, respectively, of the patients in the placebo group (p less than 0.05). Adverse reactions in the two groups did not differ significantly: in the treatment group they consisted primarily of hematoma at the site of injection (9 per cent), hematoma at the wound (5 per cent), and excessive postoperative bleeding, and in the placebo group there was hematoma at the site of injection (3 per cent). It was concluded that the combination agent dihydroergotamine mesylate/heparin sodium was effective and safe prophylaxis against deep-vein thrombosis for the patients who underwent total hip replacement in this study.
Adult↗
The medical consultant.
This article reviews the historical development of the medical consultant. The major articles that have set the foundation for this art are reviewed. Future directions and a mnemonic for successful consultations are presented.
Consultants↗
Prophylaxis for deep vein thrombosis and pulmonary embolism in the surgical patient.
This article reviews the pathophysiology for the development of deep vein thrombosis and pulmonary embolism in the surgical patient. Patients are stratified into risk groups based on predisposing criteria for the development of thrombosis. Seven modalities of prophylaxis are reviewed with respect to appropriate application. Five major types of surgery are described assessing incidence and prophylaxis of choice. The final section deals with the special consideration of patients with thrombotic disease undergoing surgery.
Humans↗
Preoperative management of the surgical patient with neurologic disease.
This article reviews neurologic problems that have been categorized into two groups: parenchymal and vascular disease. Each disease has a brief summary of key clinical points, followed by recommended management strategies. The neurologic diseases most frequently encountered by the medical consultant are presented.
Humans↗