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Medical > Anticoagulation Guidelines > Flashcards

Anticoagulation Guidelines Flashcards

1
Q

Loading dose for Initiation of Vitamin K Antagonist Therapy

A
  • Sufficiently health patients > treated as outpatients
  • Initiating VKA thearpy with Warfarin 10 mg daily for the first 2 days
  • Followed by dosing based on INR measurements
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2
Q

Initiation Overlap for Heparin and VKA in patients with VTE

A

VKA therapy started on day 1 or 2 of LMWH or UFH

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3
Q

Monitoring frequency for VKAs

-patients with VKA therapy and consistently stable INRs

A

-testing every 12 weeks rather than every 4 weeks

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4
Q

Monitoring frequency for VKAs

-Single Out-of-Range INR (< 0.5 or supratherapeutic)

A

continue current dose and recheck within 1-2 weeks

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5
Q

Monitoring frequency for VKAs

-Bridging for Low INRs > single subtherapeutic INR value

A

routinely bridge with heparin

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6
Q

Health care providers who manage oral anticoagulation should do so in a systematic and coordinated fashion and include?

A
  • patient education
  • systematic INR testing
  • tracking
  • follow up
  • good patient communication of results and dosing decisions
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7
Q

VKA interactions to avoid

A
  • Cyclooxygenase-2-selective NSAIDs
  • Antibiotics (
  • Antiplatelet agents (except in situations where benefit is known or is highly likely to be greater than harm from bleeding)
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8
Q

VKA + Antiplatelet agents in which benefit outweighs risk

A
  • mechanical valves
  • ACS
  • Recent PCI with stents or CABG
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9
Q

Therapeutic INR range

A

2-3

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10
Q

Therapeutic INR range for high-risk groups (antiphospholipid syndrome or previous arterial or venous thromboembolism)

A

INR 2-3

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11
Q

Discontinuation of VKA therapy in those who are eligible

A

recommend abrupt vs. gradual tapering

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12
Q

VTE dosing for UFH (bolus, basal)

A 
80u/kg - bolus
15u/kg/h - basal
-or fixed dose:
bolus 5,000 u
basal 1,000 u/h
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13
Q

Cardiac or CVA dosing for UFH (bolus, basal)

A 
70 u/kg - bolus
15 u/kg/h - basal
-or fixed dose:
5,000 u
1,000 u/h
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14
Q

LMWH renal cutoff for dose reduction

A

-Cr. clearance < 30 mL/min

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15
Q

VTE treatment with Fondaparinux (Arixtra) weight cutoff for increased dosage

A

100 kg

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16
Q

Fondaparinux (Arixtra) dose for VTE

A

7.5 mg

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17
Q

Fondaparinux (Arixtra) dose for VTE with body weight > 100 kg

A

7.5 mg > 10 mg

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18
Q

VKA therapy with INR 4.5-10 with no evidence of bleeding

A

-No indication for Vitamin K

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19
Q

Indication for Vitamin K therapy in patients on VKA’s

A
  • INR > 10

- Oral Vitamin K

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20
Q

Treatment of VKA associated major bleeding

A
  • Rapid reversal with four-factor Prothrombin Complex Concentrate rather than plasma
  • Vitamin K (5-10 mg administered by slow IV injection)
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21
Q

VTE prophylaxis contraindications

A
  • high risk for major bleeding

- active bleeding

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22
Q

VTE mechanical thromboprophylaxis options

A
  • Graduated compression stockings (GCS)

- Intermittent pneumatic compression

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23
Q

US screening recommendations for critically ill patients

A

none, advise against

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24
Q

VTE prophylaxis recommendations in outpatients with cancer

A

-recommend against routine prophylaxis with LMWH, LDUH or VKAs

25
Q

Indication for VTE prophylaxis in cancer outpatients

A

Prophylactic dose LMWH or LDUH if:

  • solid tumors
  • additional risk factors for VTE
  • low risk of bleeding
26
Q

Additional risk factors for VTE in cancer outpatients

A
  • previous VTE
  • immobilization
  • hormonal therapy
  • angiogenesis inhibitors
  • thalidomide
  • lenalidomide
27
Q

Recommendations for routine prophylaxis in cancer outpatients with indwelling central venous catheters

A

-recommend against routine prophylaxis with LMWH, LDUH, or VKA’s

28
Q

Recommendations for VTE prophylaxis in chronically immobilized persons (at home or nursing home)

A

-recommend against routine prophylaxis with LMWH, LDUH, or VKA’s

29
Q

Risk factors for VTE

A
  • previous VTE
  • recent surgery or trauma
  • active malignancy
  • pregnancy
  • estrogen use
  • advanced age
  • limited mobility
  • severe obesity
  • known thrombophilic disorder
30
Q

Recommendations to prevent VTE in long distance travelers

A
  • frequent ambulation
  • calf muscle exercises
  • sitting in an aisle seat if feasible
31
Q

Recommendations for long distance travelers with increased risk of VTE

A

-properly fitted, below-knee GCS (providing 15-30 mm Hg of pressure at the ankle)

32
Q

Recommendations for patients with asymptomatic thrombophilia (without a previous history of VTE)

A

-recommend against the long-term daily use of mechanical or pharmacologic thromboprophylaxis to prevent DVT

33
Q

General and abdominal-pelvic surgery in patients at very low risk for VTE (< 0.5%; Rogers score < 7, Caprini score 0)

A
  • Early ambulation

- No specific pharmacologic or mechanical prophylaxis

34
Q
  • General and abdominal-pelvic surgery

- low risk VTE (1.5%; Rogers score 7-10; Caprini score)

A

-mechanical prophylaxis with intermittent pneumatic compression devices

35
Q

General and abdominal-pelvic surgery

-Moderate risk for VTE (3.0%; Rogers score > 10; Caprini score 3-4)

A
  • LMWH or LDUH (if not at high risk for major bleeding complications)
  • IPCs (if major bleeding complications)
36
Q

General and abdominal-pelvic surgery

  • High risk for VTE (6.0%; Rogers Caprini score > 5)
  • Not at high risk for major bleeding complications
A

-Pharmacologic prophylaxis > LMWH or LDUH
and
-Mechanical prophylaxis >
elastic stockings or IPC’s

37
Q

General and abdominal-pelvic surgery patients

-IVC filter indications

A

not used for primary VTE prevention

38
Q

General and abdominal-pelvic surgery patients

-periodic surveillance with venous compression US

A

-should not be performed

39
Q

Cardiac surgery patients with an uncomplicated postoperative course

A

-mechanical prophylaxis (preferably IPC > no prophylaxis or pharmacologic prophylaxis)

40
Q

Cardiac surgery patients

-hospital course prolonged by one or more nonhemorrhagic surgical complications

A 
mechanical prophylaxis
\+
pharmacologic prophylaxis (LDUH or LMWH)
41
Q

Thoracic surgery patients

  • moderate risk for VTE
  • not at high risk for perioperative bleeding
A

-LDUH or
-LMWH or
-mechanical prophylaxis (IPC)
all > no prophylaxis

42
Q

Thoracic surgery patients

  • high risk for VTE
  • not high risk for perioperative bleeding
A 
Pharmacologic prophylaxis (LDUH or LMWH)
\+
Mechanical prophylaxis (IPC or elastic stockings)
43
Q

Thoracic surgery patients

-high risk for major bleeding

A

-mechanical prophylaxis

44
Q

Craniotomy

A

mechanical prophylaxis > none

45
Q

Craniotomy

-high risk for VTE (craniotomy for malignant disease)

A 
mechanical prophylaxis
\+
pharmacologic prophylaxis (once adequate hemostasis is established and risk of bleeding decreases)
46
Q

Spinal surgery

A

mechanical prophylaxis

47
Q

Spinal surgery

-high risk for VTE (malignant disease or those undergoing surgery with a combined anterior-posterior approach)

A 
mechanical prophylaxis
\+
pharmacologic prophylaxis (once adequate hemostasis is established and risk of bleeding decreases)
48
Q

Major Orthopedic surgery (total hip arthroplasty (THA), total knee arthroplasty (TKA), hip fracture surgery (HFS))

A

Minimum 10-14 days
-LMWH, fondaparinux, apixaban, dabigatran, rivaroxaban, LDUH, adjusted dose VKA, ASA or intermittent pneumatic compression device (IPCD)

(*one panel member believed ASA should not be included)

49
Q

IPCD requirements

A
  • capable of recording and reporting proper wear time on a daily basis for inpatients and outpatients
  • efforts should be made to achieve 18 h of daily compliance
50
Q

Major orthopedic surgery (THA, TKA, HFS)
+
receiving LMWH as thromboprophylaxis
timetable to start pre- and post-procedure prophylaxis

A

-LMWH > 12 hours pre- or post-operatively

51
Q

Major orthopedic surgery duration of thromboprophylaxis in the outpatient setting

52
Q

Major orthopedic surgery thromboprophylaxis recommendations during hospital stay

A

Dual prophylaxis

  • antithrombotic agent
  • IPCD
53
Q

Major orthopedic surgery
+
Increased risk of bleeding
thromboprophylaxis recommendations

A

-IPCD or no prophylaxis rather than pharmacologic treatment

54
Q

Major orthopedic surgery
+
decline/uncooperative with injections or IPCD
thromboprophylaxis recomendations

A

Apixaban or Dabigatran

alternatively rivaroxaban or adjusted-dose VKA if apixaban or dabigatran are unavailable

55
Q

Major orthopedic rusgery
+
Increased bleeding risk or contraindications to both pharmacologic and mechanical thromboprophylaxis

IVC placement recommendations

A

No use of IVC filter < No prophylaxis

56
Q

Following major orthopedic surgery
+
Screening for DVT with Doppler before hospital discharge

A

Not recommended

57
Q

Isolated lower-leg injuries distal to the knee

requiring leg immobilization

A

-No pharmacologic prophylaxis

58
Q

Knee arthroscopy without history of prior VTE

A

No prophylaxis

59
Q

Interruption of VKA before surgery timetable

A

discontinue 5 days prior to sugery

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