22. DVT Flashcards
Name risks for DVT (Pre-test probability (clinical suspicion)) (3)
- Virchow’s Triad
- Acquired
- Hereditary
Chez des patients présentant une forte probabilité de maladie thrombotique (p. ex., caillot important dans la jambe, embolie pulmonaire soupçonnée), est-ce qu’il faut attendre les résultats pour commencer un tx ?
Non
Commencez un traitement anticoagulant si les tests sont retardés.
Chez les patients dont la TVP a été diagnostiquée, utilisez un anticoagulant oral de façon adéquate. C’est quoi les précautions ?
- Commencez rapidement
- Surveillez les interactions médicamenteuses
- Surveillez les valeurs de laboratoire et ajustez les doses au besoin
- Cessez la warfarine au besoin
- Éduquez le patient
Évoquez la possibilité d’une ____ sous-jacente chez les patients atteints d’une TVP, surtout quand elle est inattendue.
Évoquez la possibilité d’une coagulopathie sous-jacente chez les patients atteints d’une TVP, surtout quand elle est inattendue.
Utilisez les ___ chez certains patients, afin de prévenir et de traiter un syndrome postphlébitique.
bas de contention
Name Virchow’s Triad
- une lésion pariétale
- stase veineuse
- un facteur hémostasique d’hypercoagulabilité.
Name acquired risks for DVT (9)
- Prior thromboembolism
- Recent major surgery
- Trauma
- Immobilization
- Antiphospholipid antibodies
- Malignancy
- Pregnancy
- Oral contraceptives
- Myeloproliferative disorders
Name hereditary risks for DVT (4)
- Thrombophilie par mutation du facteur V
- Mutations du gène de la prothrombine
- Déficit en protéine S ou C
- Déficit en antithrombine
Describe : Wells Score
+1 point for each of the following
* Paralysis, paresis or recent orthopedic casting of lower extremity
* Bedridden >3 days recently or major surgery within 4 weeks
* Localized tenderness of the deep veins
* Swelling of entire leg
* Calf swelling 3 cm greater than other leg (measured 10 cm below the tibial tuberosity)
* Pitting edema greater in the symptomatic leg
* Non-varicose collateral superficial veins
* Active cancer or cancer treated within 6 months
* Previously documented DVT
-2 points for alternative diagnosis at least as likely as DVT (Baker’s cyst, cellulitis, muscle damage, superficial vein thrombosis, post-thrombotic syndrome, inguinal lymphadenopathy, extrinsic venous compression)
Score <2 = 6% DVT, ≥2 = 28% DVT
Name risks of Upper extremity DVT (3)
- Cathéter veineux central
- recent pacemaker
- malignancy
Descrbe D-dimer use
DVT involve which veins ?
- 70 à 80 % des TVP touchent les veines proximales à l’échographie, le plus souvent la veine poplitée et la veine fémorale superficielle.
- 20 à 30 % des TVP sont isolé dans les veines du mollet : le tibial antérieur, péronier et veines tibiales postérieures
Patients with moderate-high suspicion of DVT (unless high risk of bleed) should start what?
anticoagulation before diagnosis
How long to use anticoagulate?
- Anticoagulate for initial 3 months
- consider indefinite in unprovoked and cancer (and low risk bleeding):
Name anticoagulation options (3)
-
LMWH or IV heparin (5000 units bolus then 20 units/kg/hr target aPTT 2-3x control aPTT) overlap with warfarin for minimum 5 days and INR >2 for minimum 2 days
__
DOAC - Apixaban 10mg PO BID x 1 week, then 5mg PO BID (can decrease to 2.5mg PO BID after 6 months)
- Rivaroxaban 15mg PO BID x 3 weeks then 20mg PO daily (can decrease to 10mg PO daily after 6 months)
- Note: Dabigatran and Edoxaban require 5-10 day initial treatment bridge with LMWH
__ - Subcutaneous LMWH (eg. Dalteparin 100 U/kg SC daily or Enoxaparin 1.5mg/kg SC daily) or IV heparin x 5-10 days, then dabigatran 150mg PO BID
- LMWH x 1 month then DOAC or warfarin
Consider Warfarin when? (6)
- Fibrillation auriculaire valvulaire A
- ClCr < 30
- Syndrome des antiphospholipides
- Poids > 120 kg
- Pont gastrique
- Insuffisance hépatique
LMWH preferred in what patients ?
- Cancer and in Pregnancy : advantages include fixed/simple-dosing and lower Heparin-Induced Thrombocytopenia
- There is some evidence that apixaban can be used as an alternative for patient with cancer who do not want injections (but avoid in upper GI malignancy due to increased rate of bleeding)
Only consider Aspirin in DVT tx when?
those who are adverse to long-term anticoagulation (32% reduction of recurrent VTE vs 82% when on oral anticoagulants)
Isolated distal DVT anticoagulation when?
- only if symptomatic and risk factors for extension (severe symptoms, >5cm in length, multiple deep veins, close to popliteal veins, no reversible risk factor, previous VTE, in-patient, positive D-dimer)
- progression on imaging
Superficial vein thrombosis can be treated with what?
with topical/oral NSAIDs for symptoms, if >5cm consider low-intermediate dose LMWH
Urgent surgical intervention for what?
phlegmasia cerulea dolens (phlébite bleue) (extensive thrombosis which can cause irreversible ischemia, necrosis, gangrene)
When to do prophylaxis for DVT (2)
- Arthroplastie de la hanche/du genou, fracture de la hanche = 14 à 35 jours
- Traumatisme orthopédique majeur, chirurgie rachidienne compliquée, fracture isolée sous le genou, amputation L/E, alitement = jusqu’à la sortie
Describe signs of : Post-thrombotic syndrome (PTS) (10)
Signs of chronic venous insufficiency (usually 6 months) after a DVT
* extremity pain
* heaviness
* cramps
* paresthesias
* pruritus
* venous dilation
* edema
* pigmentation
* skin changes
* venous ulcers
Name risks for Post-thrombotic syndrome (PTS) (4)
- Personnes âgées, obésité
- Tabagisme
- Insuffisance veineuse primaire, varices
- TVP proximale, thrombus résiduel après traitement, TVP récidivante, anticoagulation inadéquate
Describe tx : Post-thrombotic syndrome (PTS) (4)
(similar to chronic venous disease)
* Smoking cessation, weight loss if obesity
* Elevation
* Exercise training
* Compression stockings/bandages (30-40mmHg) or Compression device
Describe prevention : Post-thrombotic syndrome (PTS) (3)
If at risk of PTS, consider compression stockings
* start within two weeks of diagnosis
* after anticoagulation started
* and continue for two years
Name hypercoagulable states / cases (7)
- Cancer
- Pregnancy
- Meds (Hormonal)
- IBD
- Congstive Heart Failure
- Nephrotic
- Inherited
When to test for thrombophilia ? (3)
- Family hx
- Young
- Multiple / recurrent
Describe upper arm DVT dx
CONSTANS score : 1 point each for
* Central line or pacemaker
* Localized pain
* Unilateral edema
* Minus 1 point if other dx at least as plausible
-1 or 0 = 12% and with negative D-dimer rules out arm DVT
1 = 20%
2-3 = 70%
How to tx if testing is delayed ?
- 1 dose of oral Xa Inhibitor (Apixaban, Rivaroxaban)
- OR dose of LMWH or IV heparin
What tx is safe in pregnancy / breast-chest-feeding ?
How long to treat DVT ?
- > = 3 months (DVT = 3 letters so 3 months)
- Unprovoked DVT = lifelong
