(CHEST 1998; 114:119S-122S) unfathomable vein thrombosis (DVT) and pulmonary embolism (PE) are often met with complications following total hip or knee arthroplasty.

(CHEST 1998; 114:119S-122S)

unfathomable vein thrombosis (DVT) and pulmonary embolism (PE) are often met with complications following total hip or knee arthroplasty.[1,2] Despite the use of effective prophylaxis, many patients will still lay open asymptomatic DVT following joint arthroplasty that can be find outed reliably only by performing screening tests[13] transaction about the potential risk of PE from asymptomatic DVT has l clinicians to consider extending the duration of postoperative prophylaxis for up to 3 month or performing routine screening trials to diagnose asymptomatic venous thrombosis prior to hospital discharge.[1,4-7]

We performed a double-blind, randomized, controll trial in patients receiving postoperative warfarin prophylaxis following total hip or knee arthroplasty to evaluate whether the rates of following symptomatic DVT or PE are influenced at screening patients with compression ultrasonography to diagnose asymptomatic proximal DVT We also determined the rates of symptomatic venous thromboembolic and major bleeding complications occurring within 90 days of hospital discharge; this application of mind has been published in detail.[8]

METHODS

A double-blind, randomized, controll trial was guidanceed at the Victoria General Hospital, Halifax, Nova Scotia. Consecutive patients undergoing elective total hip or knee arthroplasty who received warfarin prophylaxis postoperatively and were within 48 to 72 h of wait fored hospital discharge were potentially eligible for the study

intelligent Vein Thrombosis Prophylaxis and Screening

Patients received 5 mg of sodium warfarin (Coumadin; Dupont Pharma; Mississauga, Ontario, Canada) in succession the night of surgery. The warfarin dose was adjusted to increase the international normalized ratio to greater than 17 from postoperative day 4 and then maintain it between 18 and 25 Warfarin prophylaxis was continued until hospital discharge. All patients were evaluated daily by way of the orthopedic medical staff through usual clinical practice.

Consenting eligible patients were randomized to be exposed to either bilateral screening compression ultrasonography or a sham transaction Patients were stratified by emblem of arthroplasty. Compression ultrasonography was performed using a high-resolution color duplex-Doppler scanner with an electronically focused linear array transducer (either 5- or 75-MHz probes). The entire proximal intricate venous system between the proximal for the use of all femoral vein and the trifurcation of the popliteal vein in the calf was evaluated for compressibility at 1-cm intervals. Compression ultrasound testing was considered positive if a vein or venous part was not fully compressible.[9] Patients whose compression ultrasound ordeals were positive underwent confirmatory venography of the involved leg using the way of Rabinov and Paulin.[10] In the occurrence that venography could not be performed or was judg inadequate because of nonvisualization of the suspected area of thrombosis, the positive compression ultrasound was considered a true-positive come Patients diagnosed with asymptomatic proximal DVT were treated with unfractionated IV heparin for 5 days, and warfarin was continued for 3 month with the dose adjusted to maintain the international normalized ratio between 20 and 30 The sham manner of proceeding was designed to mimic the technique of compression ultrasonography.

result Measures

The primary issue cluster in this study was defined a priori as the progress to maturity of one of the following after randomization: (1) symptomatic DVT involving the proximal venous combination of parts to form a whole confirmed by either compression ultrasound or venography; (2) symptomatic PE confirmed on ventilation perfusion lung scanning, pulmonary angiography, or autopsy; or (3) major bleeding after the institution of anticoagulant therapy for patients with asymptomatic DVT diagnosed on screening compression ultrasonography.

Follow-up of Exclud Patients

To maximize the generalizability of our cogitation findings, several subgroups of exclud patients who underwent elective joint arthroplasty were also followed for 90 days after hospital discharge for the disclosure of symptomatic venous thromboembolism. Patients exclud from this secondary analysis were those with metastatic cancer, those who had undergone joint arthroplasty within 3 month of a hip fracture, and those who had refused to give informed consent

Sample Size and Statistical Analysis

The principal analysis was a comparison of the rates of primary issue clusters in the two form into groupss The difference in these absolute rates, as well as the 95% confidence interval (CI) surrounding this difference, were calculated.

RESULTS

consideration Population

above the 27-month recruitment period, 1284 patients underwent total hip or knee arthroplasty at our institution. Three postoperative deaths occurr prior to the patients being guarded for study eligibility. A 72-year-old man with a history of ischemic heart disease died unexpectedly on the evening of his surgical procedure; no autopsy was performed. A other patient died from aspiration pneumonia and a third from gangrenous cholecystitis.

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