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PDAT5 CV > 26 - VTE > Flashcards

26 - VTE Flashcards

1
Q

VTE
Non-Pharmacologic Prophylaxis

A

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

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2
Q

Padua Prediction Score

What Score / what is it used for?

A

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.

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3
Q

ASH 2018 VTE Guidelines:
Prophylaxis for MEDICAL ILLNESS

Acutely Ill & Hospitilized

A

LMWH
Enoxaparin or Dalteparin
OVER
DOAC (betrixaban) & UFH (low dose heparin 5k)

  • *Critically Ill:**
  • *LMWH** > UFH
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4
Q

ASH 2018 VTE Guidelines:
Long Distance Travel >4 hours

Patient with:
Increased VTE Risk

A

Suggests using:
Graduated Compression Stockings (GCS)
or
Prophylactic LMWH

  • if you cant use any of the ABOVE:*
  • *Aspirin** > no prophylaxis at all
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5
Q

Caprini Score

What is score used for?

A

Estimates:
VTE RISK after GENERAL SURGERY
minor/major surgery / laparoscopic / open / elective arthroplasty

> 5 = HIGH RISK

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6
Q

Estimating
SURGICAL BLEEDING RISK

Risk Factors

A

Previous Major Bleeding

Severe Renal

Concomitant:
Antiplatelet Agent

Surgical Factors:
H/O or Difficult to control surgical bleeding during surgery

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7
Q

Neuraxial Anesthesia / Spinal Puncture

AC Warning for what?
+ Risk Factors

A

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

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8
Q

VTE Prophylaxis: Orthopedic Surgery
Hip Fracture Surgery (HFS)

Duration + Preferred Drug

A

same as hip/knee replacement
>10-14 Days
with:
LMWH

Enoxaparin 30mg q12
or 40mg QD

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9
Q

VTE Prophylaxis: Orthopedic Surgery
Hip or Knee Replacement (THA / TKA)

Duration + Preferred Drug

A

THA / TKA
>10-14 Days
with:
LMWH
12h Pre-op OR 12 POST-op

Enoxaparin 30mg q12
or 40mg QD

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10
Q

VTE Prophylaxis: Orthopedic Surgery
MAJOR Orthopedic Surgery

Duration + Preferred Drug

A

~35 Days
with DUAL prophylaxis:
Antithrombotic** + **IPC

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11
Q

Drug Recomendations for:
DVT PROPHYLAXIS

A

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

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12
Q

IVC Filter

Use

A

LAST LINE PROTECTION
can TRAP a blood clot –> heart / lungs

Reserved for patients at:
HIGHEST VTE RISK where OTHER prophylaxis can NOT be used

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13
Q

Clinical Presentation
DVT

S/Sx + Lab Tests + Diagnostic Tests

A
  • *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**
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14
Q

Clinical Presentation
PE

S/Sx + Lab Tests + Diagnostic Tests

A
  • *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**
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15
Q

DVT DIAGNOSIS STEPS:

Suspected DVT -> Well’s Score > 2

A

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

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16
Q

DVT DIAGNOSIS STEPS:

Suspected DVT -> Well’s Score <2

A

Well’s Score < 2 = DVT* *UNLIKELY
VVV
D-DIMER –> Positive?
VVV
Proximal CUS
VVV
Negative CUS –> Full Leg CUS

17
Q

DVT DIAGNOSIS STEPS:

Suspected PE -> Well’s Score > 4

PE needs is GREATER THAN 4 (5+)
(DVT is 2+)

A

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

18
Q

DVT DIAGNOSIS STEPS:

Suspected PE -> Well’s Score < 4
4 or Less

A

Well’s Score < 4 = PE* *UNLIKELY
VVV
D-DIMER
VVV
If POSITIVE –> CTPA** or **V/Q

19
Q

VTE TREATMENT + PREVENTION

ORAL ONLY OPTIONS

A
  • *RIVAROXABAN**
  • *15mg BID x 21 Days** –> 20mg QD

APIXABAN
10mg BID x 7 days –> 5mg BID
VV
2.5mg BID AFTER 6 months

20
Q

VTE TREATMENT + PREVENTION

SWITCH OPTION

A

UFH / LMWH / FONDA
SC x 5 DAYS
VVV
DABIGATRAN 150mg BID
or
EDOXABAN 60mg QD

21
Q

VTE TREATMENT + PREVENTION

BRIDGING / OVERLAP

A

Warfarin QD
+overlapped w/+
UFH/LMWH/Fonda
+5 days AND INR > 2

22
Q

ENOXAPARIN DOSING
LMWH
for
Treatment of VTE

A

ENOXAPARIN

1mg/kg** **SC q12
Or
1.5mg/kg SC qd

  • Enoxaparin for PREVENTION of PE is:*
  • *40 mg QD** or 30mg q12
23
Q

FONDAPARINUX

Dosing for VTE Treatment

A

FONDA = WEIGHT BASED

  • *<50kg**
  • *5mg SC q24**
  • *50-100kg**
  • *7.5mg SC q24**
  • *>100 kg**
  • *10mg SC q24**
24
Q

Monitoring for DOACs

RENAL FUNCTION
Baseline & After

CBC = Varies

LFT = Anually

A
  • *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**
25
Q

Monitoring for DOACs

  • *CBC**
  • *Baseline & After**

Renal Fxn = Varies

LFT = Anually

A

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

26
Q

2015 ACCP Recommendations:
DVT / PE
TREATMENT DURATION

A

3 MONTHS
at least

27
Q

Long Term Consequences of VTE

A

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

28
Q

Surgical Interruption

How long to hold DOACs?

A

> 2 Half Lives for low bleeding risk surgeries

4-5 half lives for HIGH bleeding risk surgeries

29
Q

When can we start DOAC’s

from WARFARIN?

A

Warfarin –> DOAC

  • *Rivaroxaban**
  • *INR < 3**
  • *Apixaban** + Dabigatran
  • *INR <2**

Edoxaban INR
< 2.5

30
Q

When can we start DOACs

from UFH / LMWH parenteral?

A

Parenteral –> DOAC

UFH = when infusion d/c

LMWH = when NEXT LMWH dose is DUE

31
Q

VTE TREATMENT
if
CrCl < 30ml/min

A

UFH for 5 days
OVERLAP with:
Warfarin** + **INR > 2

32
Q

VTE Prophylaxis:
Orthopedic Surgery

Which drugs are NOT INDICATED for certain surgeries?

A

HFS = Hip Fracture
NO DOACS
Dabigatran / Apixaban / Rivaroxaban
= NO INDICATION

  • *TKA = Total Knee Arthoplasty**
  • *Dabigatran only** not indicated

PDAT5 CV (30 decks)

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