26 - VTE Flashcards
VTE
Non-Pharmacologic Prophylaxis
Early stabilization of fractures
Active or passive:
Mobilization - post-OP day 1 / pain relief / PT
HYDRATION
Mechanical Prophylaxis
GCS = Graduated compression Stockings
IPC = Intermittent pneumatic Compression Devices
Padua Prediction Score
What Score / what is it used for?
Padua Predication Score
4+ = High risk for VTE
Used for:
VTE Prophylaxis in MEDICAL ILLNESS
3 Pts for:
Active Cancer / Previous VTE / Reduced Mobility / Known VTE cond.
ASH 2018 VTE Guidelines:
Prophylaxis for MEDICAL ILLNESS
Acutely Ill & Hospitilized
LMWH
Enoxaparin or Dalteparin
OVER
DOAC (betrixaban) & UFH (low dose heparin 5k)
- *Critically Ill:**
- *LMWH** > UFH
ASH 2018 VTE Guidelines:
Long Distance Travel >4 hours
Patient with:
Increased VTE Risk
Suggests using:
Graduated Compression Stockings (GCS)
or
Prophylactic LMWH
- if you cant use any of the ABOVE:*
- *Aspirin** > no prophylaxis at all
Caprini Score
What is score used for?
Estimates:
VTE RISK after GENERAL SURGERY
minor/major surgery / laparoscopic / open / elective arthroplasty
> 5 = HIGH RISK
Estimating
SURGICAL BLEEDING RISK
Risk Factors
Previous Major Bleeding
Severe Renal
Concomitant:
Antiplatelet Agent
Surgical Factors:
H/O or Difficult to control surgical bleeding during surgery
Neuraxial Anesthesia / Spinal Puncture
AC Warning for what?
+ Risk Factors
EPIDURAL** or **SPINAL HEMATOMA
may occur in pts on AC that are undergoing these procedures.
Risk Factors:
Indwelling epidural Catheters
concomitant: NSAIDs / Antiplatelets / ACs
H/o traumatic / repeated spinal punctures
H/o spinal deformity or spinal surgery
VTE Prophylaxis: Orthopedic Surgery
Hip Fracture Surgery (HFS)
Duration + Preferred Drug
same as hip/knee replacement
>10-14 Days
with:
LMWH
Enoxaparin 30mg q12
or 40mg QD
VTE Prophylaxis: Orthopedic Surgery
Hip or Knee Replacement (THA / TKA)
Duration + Preferred Drug
THA / TKA
>10-14 Days
with:
LMWH
12h Pre-op OR 12 POST-op
Enoxaparin 30mg q12
or 40mg QD
VTE Prophylaxis: Orthopedic Surgery
MAJOR Orthopedic Surgery
Duration + Preferred Drug
~35 Days
with DUAL prophylaxis:
Antithrombotic** + **IPC
Drug Recomendations for:
DVT PROPHYLAXIS
LMWH** & **Fondaparinux
> UFH or other agents
especially in:
High Risk surgical Patients = THA / TKA
Warfarin MAY be considered as alternative
when DELAYED prophylaxis is desired after THA / TKA
IVC Filter
Use
LAST LINE PROTECTION
can TRAP a blood clot –> heart / lungs
Reserved for patients at:
HIGHEST VTE RISK where OTHER prophylaxis can NOT be used
Clinical Presentation
DVT
S/Sx + Lab Tests + Diagnostic Tests
- *Leg Swelling / Pain / Warmth**
- *Palpable Cord** in affected leg
- *Homan’s Sign** = pain in BACK of knee when flexed
Lab Tests:
ELEVATED D-DIMER = product of fibrin degradation
Diagnostic Test:
- *VENOGRAPHY** = gold std for DVT diagnosis,
- BUT it can cause: ANAPHYLAXIS + NEPHROTOXICITY*
- *Compression Ultrasound CUS = most commonly used**
Clinical Presentation
PE
S/Sx + Lab Tests + Diagnostic Tests
- *Cough / Chest Pain+Tightness / SOB / Paliptation**
- *Blood Cough = Hemoptysis**
Tachypnea / Tachycardia / Diaphoresis
Lab Tests:
ELEVATED D-DIMER = product of fibrin degradation
Diagnostic Test:
- *PULMONARY ANGIOGRAPHY** = gold std for PE, but HIGH MORTALITY
- *CTPA =** most common use
- *V/Q Scan**
DVT DIAGNOSIS STEPS:
Suspected DVT -> Well’s Score > 2
Well’s Score > 2 = DVT LIKELY
VVV
Proximal CUS
(Compression Ultrasound)
VVV
If NEGATIVE CUS –> D-DIMER
VVV
if NEG D-DIMER –> FULL LEG CUS
DVT DIAGNOSIS STEPS:
Suspected DVT -> Well’s Score <2
Well’s Score < 2 = DVT* *UNLIKELY
VVV
D-DIMER –> Positive?
VVV
Proximal CUS
VVV
Negative CUS –> Full Leg CUS
DVT DIAGNOSIS STEPS:
Suspected PE -> Well’s Score > 4
PE needs is GREATER THAN 4 (5+)
(DVT is 2+)
Well’s Score > 4 = PE LIKELY
VVV
Imaging:
CTPA** or **V/Q** or **Pulmonary Angiography
VVV
If NEGATIVE CUS –> D-DIMER
VVV
if NEG D-DIMER –> FULL LEG CUS
DVT DIAGNOSIS STEPS:
Suspected PE -> Well’s Score < 4
4 or Less
Well’s Score < 4 = PE* *UNLIKELY
VVV
D-DIMER
VVV
If POSITIVE –> CTPA** or **V/Q
VTE TREATMENT + PREVENTION
ORAL ONLY OPTIONS
- *RIVAROXABAN**
- *15mg BID x 21 Days** –> 20mg QD
APIXABAN
10mg BID x 7 days –> 5mg BID
VV
2.5mg BID AFTER 6 months
VTE TREATMENT + PREVENTION
SWITCH OPTION
UFH / LMWH / FONDA
SC x 5 DAYS
VVV
DABIGATRAN 150mg BID
or
EDOXABAN 60mg QD
VTE TREATMENT + PREVENTION
BRIDGING / OVERLAP
Warfarin QD
+overlapped w/+
UFH/LMWH/Fonda
+5 days AND INR > 2
ENOXAPARIN DOSING
LMWH
for
Treatment of VTE
ENOXAPARIN
1mg/kg** **SC q12
Or
1.5mg/kg SC qd
- Enoxaparin for PREVENTION of PE is:*
- *40 mg QD** or 30mg q12
FONDAPARINUX
Dosing for VTE Treatment
FONDA = WEIGHT BASED
- *<50kg**
- *5mg SC q24**
- *50-100kg**
- *7.5mg SC q24**
- *>100 kg**
- *10mg SC q24**
Monitoring for DOACs
RENAL FUNCTION
Baseline & After
CBC = Varies
LFT = Anually
- *CrCl > 60**
- *q6-12 months**
- *CrCl 30-59** or Age >75 or Drug Interactions
- *q6 months**
- *CrCl 15-30_ or _Fluctuating CrCl**
- *q 3 months**
Monitoring for DOACs
- *CBC**
- *Baseline & After**
Renal Fxn = Varies
LFT = Anually
ANNUAL CBC Check
for most patients
Low Baseline Hgb/HCt** or **Age >75** or **Drug Interactions
1 month after TX
then q6 months or More if indicated
2015 ACCP Recommendations:
DVT / PE
TREATMENT DURATION
3 MONTHS
at least
Long Term Consequences of VTE
PTS = POST-THROMBOTIC SYNDROME
Develops in 1/2 of all patients who get a LEG DVT
Edema / Ulcers / Venouc Ectasia
Risk Factors:
Proximal DVT / Recurrent VTE in same leg / Obesity
DVT symptoms > 1 month / Poor AC control
CTEPH = Chronic Thromboembolic Pulmonary HTN
SOB / Tiredness / Depression
Diagnosis: Right Heart cath / Pulmonary angiography
Treatment: Long-term AC / PTE
Surgical Interruption
How long to hold DOACs?
> 2 Half Lives for low bleeding risk surgeries
4-5 half lives for HIGH bleeding risk surgeries
When can we start DOAC’s
from WARFARIN?
Warfarin –> DOAC
- *Rivaroxaban**
- *INR < 3**
- *Apixaban** + Dabigatran
- *INR <2**
Edoxaban INR
< 2.5
When can we start DOACs
from UFH / LMWH parenteral?
Parenteral –> DOAC
UFH = when infusion d/c
LMWH = when NEXT LMWH dose is DUE
VTE TREATMENT
if
CrCl < 30ml/min
UFH for 5 days
OVERLAP with:
Warfarin** + **INR > 2
VTE Prophylaxis:
Orthopedic Surgery
Which drugs are NOT INDICATED for certain surgeries?
HFS = Hip Fracture
NO DOACS
Dabigatran / Apixaban / Rivaroxaban
= NO INDICATION
- *TKA = Total Knee Arthoplasty**
- *Dabigatran only** not indicated
