DEEP VEIN

THROMBOSIS
PATIENT’S IDENTITY
 Name : Mrs. S
 Age : 58 y.o.
 MR : 049115
 Admitted : November 24th , 2015
HISTORY TAKING
 Chief complaint
Swelling on the right leg
 Present illness history
Occurs since one week ago, the patient
complained of right leg slowly beginning to swell
with pain and cramps. No cyanosis, patients can
still feel if his feet touched. No SOB, no DOE, no
orthopnea and no Paroxysmal Nocturnal Dyspnea.
HISTORY TAKING
 Past medical history
2010 patient were diagnosed with hypertension
and regularly control with drugs.
History of heart disease denied.
History DM denied
History of malignant diseases: Carcinoma Cervix
History of the same disease in the family does not
exist.
RISK FACTOR
 Aging
 Malignancy
PHYSICAL EXAMINATION
 General state :
Moderate illness/well nourished/ conscious
 Vital status
Blood Pressure : 130/80 mmHg
Pulse Rate : 90 bpm (regular)
Respiratory Rate : 20 tpm
Temperature : 36,5 0C (axilla)
BW : 50kg
BH : 151cm
IMT : 21.91
PHYSICAL EXAMINATION
 Head: anemic (-) icteric (-)
 Neck : JVP R+1 cmH2O (300)
 Chest :
Inspection : symmetry left = right
Palpation : mass (-), no tenderness
Percussion : sonor left = right
Auscultation : vesicular, ronchi -/- wheezing -/-
PHYSICAL EXAMINATION
 Cor :
Inspection : ictus cordis not visible
Palpation : ictus cordis not palpable, thrill (-)
Percussion :
dull, Upper border 2nd ICS linea parasternalis sinistra,
Right border 4th ICS linea parasternalis dextra, Left
border 5th ICS linea medioclavicularis sinistra
Auscultation: heart sound I/II pure, regular, murmur (-)
PHYSICAL EXAMINATION
 Abdomen :
Inspection : flat, follows breath movement
Auscultation: peristaltic (+), normal
Palpation : liver and spleen not palpable
Percussion : tympani

 Extremities :
Swelling on the right leg with pain
Pitting Edema
Warm(+)
Homan’s sign positif
LABORATORIUM (November, 1 st , 2015 )
HEMATOLOGY RESULT NORMAL VALUE

WBC 19,29 x 103 /mm3 4.0-10.0 x 103

RBC 3,96 x 106/mm3 4.0-6.0x106

HGB 10,5 g/dL 12-16

MCH 21,5 pg 26,5-33,5

MCHC 31,7 gr/dL 31,5-35

HCT 31,4 37-48

PLT 486 x 103/mm3 150-400 x 103

Ureum 54 10-50 md/dL

Creatinin 1,2 <1.3

Na 137 136-145 mmol/l

K 4,1 3.5-5.1 mmol/l

Cl 110 97-111 mmol/l

PT 17,4 10-14 detik

INR 1,45 -

APTT 36,5 22.0-30.0 detik

D Dimer 3,98 < 0,5

ELECTROCARDIOGRAPHY
(November 1st 2015)
Rhythm: Sinus rhytme
Frequence: 76 bpm
Axis: normoaxis
P wave: 0.04 sec
P-R interval: 0.1 sec
QRS interval: 0.1 sec
ST segment: normal
Conclusion : Sinus rhytme, normoaxis, heart rate 76 bpm.

ECG NORMAL
Echovascular
 Blood flow from
distal to proximal is
not flowing well with
thrombus in
Common Femoral
Vein and Right
Popliteal vein.
 CONCLUSION:
Deep Vein
Thrombosis
 Resume
 Women 58 yo came with Edema on right leg occurs since one
week ago, the right leg slowly beginning to swell, pain(+) and
cramps(+). History of hypertension(+) on treatment,
Malignancy(+): Carcinoma Cervix. Physical examination on
lower extremities: Edema on the right leg, warmt(+). Homan’s
sign(+). Risk factor: Carcinoma Cervix, Well’s Score: +2
 Laboratory finding: WBC: 19,29, PLT: 429000 , PT: 17,4, APTT:
36,5, INR: 1.45, D-Dimer: 3,98.
 Echo vascular: Blood flow from distal to proximal is not flowing
well with thrombus in Common Femoral Vein and Right Popliteal
vein
DIAGNOSIS
Deep Vein Thrombosis
TREATMENT
IVFD NaCl 0.9% 500cc/24h/intravena

Alpentin 100 mg/24h/oral

Simarc 2 mg/24h/oral

MST 15 mg/24h/oral
DISCUSSION
DEFINITION
 Deep vein thrombosis (DVT) refers to
the formation of one or more blood clots
in one of the body’s large veins, most
commonly in the lower limbs. The clot
can cause partial or complete blocking
of circulation in the vein
ANATOMY OF DEEP AND
SUPERFICIAL VEINS
ETIOLOGY / RISK FACTOR
PATHOGENESIS
 Three mechanisms are involved in
the pathogenesis of venous
thrombosis (Virchow’s triad), they
are:
venous stasis,
injury to the venous wall,
hypercoagulable states.
CLINICAL FEATURES
 A DVT most commonly develops in a deep vein
below the knee in the calf. Typical DVT
symptoms include:
Pain and tenderness of the calf.
Swelling of the calf.
Colour and temperature changes of the calf. Blood
that would normally go through the blocked vein is
diverted to outer veins. The calf may then become
warm and red.
Sometimes there are no symptoms and a DVT is only
diagnosed if a complication occurs, such as a
pulmonary embolus.
Edema, principally unilateral, is the most
specific symptom.
Leg pain occurs in 50% of patients, but
this is entirely nonspecific. Pain can
occur on dorsoflexion of the foot
(Homans sign).
Pratt's sign: Squeezing of posterior calf
elicits pain.
DIAGNOSIS
 Well score
 D-Dimer
 D-Dimer, a byproduct of fibrin degradation that can be

measured in a peripheral blood sample, is highly sensitive

for the diagnosis of DVT and/or acute PE.
 Because D-dimer may also be elevated in many other

conditions (such as cancer, inflammation, infection and

necrosis), a positive test result is not specific for DVT.
 Thus, a normal D-dimer value can help exclude the

presence of DVT, but an elevated level does not confirm

the diagnosis.
 Venous compression duplex
that is 95% sensitive for the diagnosis of
symptomatic DVT in a proximal vein but
only.
This technique uses real-time ultrasound
scanning to image the vein and pulsed
Doppler ultrasound to assess blood flow
within it.
Criteria used for diagnosis of DVT with
duplex ultrasonography include the inability
to compress the vein with direct pressure,
direct visualization of the thrombus, and
absence of blood flow within the vessel.
ALGORITHMA OF DIAGNOSIS
TREATMENT
 The aim of treatment of VTE is to reduce
morbidity and mortality.
 This is achieved by optimal therapy to
prevent thrombus extension and
embolisation.
 The mainstay of therapy is
pharmacological.
 Adjunct therapies include mechanical
devices like filters and stents.
INITIAL TREATMENT OF DVT
 In clinically suspected DVT, treatment with UFH or
LMWH should be given until the diagnosis is
excluded by objective testing
 The regimen for the administration of iv UFH is as
follows
 Baseline APTT, PT, FBC, renal profile, liver function test
and thrombophilia screen
 Initial dose of iv bolus UFH 80 IU/kg followed by
maintenance infusion at 18 IU/kg/hr.
 Check APTT at 6, 12 and 24 hours. The target APTT ratio
is 1.5 to 2.5. This must be achieved in the first 24 hours
and maintained thereafter.
 Start warfarin therapy at 5 mg on the first 2 days.
Thereafter adjust daily dose according to INR.
 Check platelet count from day 3 till the end of second
week.
 Discontinue heparin once target INR (2.0 - 4.0) is
achieved on 2 consecutive days.
MANAGEMENT OF IV
UFH
Initial dose 80 IU/kg bolus, then 18
IU/kg/hr
APTT < 35 s (<1.2x control) 80 IU/kg bolus, then increase
rate by 4 IU/kg/hr
APTT 35 to 45 s (1.2 to 1.5x 40 IU/kg bolus, then increase
control) Infusion rate by 2 IU/kg/hr

APTT 46 to 70 s (1.5 to 2.3x No change

control)

APTT 71 to 90 s (2.3 to 3x Decrease infusion rate by 2

control) IU/kg/hr
APTT >90 s (>3x control) Hold infusion for 1 hour, then
decrease
Infusion rate by 3 IU/kg/hr
SUBCUTANEOUS UFH
 effective alternative to intravenous UFH for the
initial management of DVT
 The regimen for the administration of
subcutaneous, UFH includes an
 Initially, intravenous bolus of 5000 IU followed by
subcutaneous injections of 15,000 to 20,000 IU 12 hourly
 This is monitored by the APTT with the mid-interval APTT
maintained between 1.5-2.5 times the control
LMWH recommended
LMWH recommended Treatment
Enoxaparin (Clexane) 1 mg/kg twice
daily
Nadroparin (Fraxiparine) 0.1 ml/kg twice
daily

Nadroparin (Fraxiparine 0.1 ml/kg once

Forte) daily
Tinzaparine (Innohep) 175 units/kg once
daily
MAINTENANCE TREATMENT
OF DVT
 Following initial heparinisation in patients with
DVT, maintenance of anticoagulation with oral
anticoagulants is recommended
 Following discharge-followed up within a week
with a repeat INR.
 If the INR remains within therapeutic range, the
same dose is maintained and the next follow-up
will be 2 weeks later
 More frequent visits are required if therapeutic INR
is not achieved
DURATION OF
THERAPY
Time Event

3 to 6 months first event with reversible or

time-limited risk factor (Surgery,
trauma, immobility, oestrogen
use)
= 6 months idiopathic VTE, first event

12 months to lifetime - anticardiolipin antibody

- first event with cancer - antithrombin deficiency
- recurrent event, idiopathic or
until resolved with thrombophilia
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