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BCPS Exam > Critical Care: Preventing VTE > Flashcards

Critical Care: Preventing VTE Flashcards

1
Q

What are the two types of VTE?

A
  1. Deep vein thrombosis

2. Pulmonary embolism

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2
Q

What is the rate of deep vein thrombosis in critically illness?

A

8-40%

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3
Q

What is the rate of pulmonary embolism in critical illness?

A

Up to 12%

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4
Q

List 4 principal risk factors for VTE

A
  1. Traumatic causes
  2. Co-morbidites
  3. Patient characteristics
  4. Related to critical illness
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5
Q

List 3 traumatic risk factors of VTE

A
  1. Surgery
  2. Major trauma
  3. Lower extremity injury
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6
Q

List 5 co-morbidity risk factors of VTE

A
  1. Malignancy
  2. Sepsis
  3. Heart failure
  4. Respiratory failure
  5. Venous compression
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7
Q

List 3 patient characteristics risk factors of VTE

A
  1. Previous VTE
  2. Increasing age
  3. Pregnancy
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8
Q

List 3 critical illness-related riskf actors of VTE

A
  1. Immobility
  2. Central venous catheterization
  3. Critical illness
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9
Q

List two nonpharmacologic prevention of VTE

A
  1. Early mobility

2. Mechanical prophylaxis

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10
Q

List two types of mechanical prophylaxis

A
  1. Intermittent pneumatic compression

2. Graduated compression stockings

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11
Q

List two indications for mechanical prophylaxis of VTE

A
  1. Can be used in combination with pharmacologic treatment

2. Recommended for medical patients at risk of VTE who have a contraindication to pharmacologic anticoagulation

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12
Q

List four contraindications to pharmacologic anticoagulation

A
  1. Thrombocytopenia
  2. Severe coagulopathy
  3. Active bleeding
  4. Recent intracerebral hemorrhage
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13
Q

Recommendations for critically ill patients for VTE prevention come from what guidelines?

A
  1. American College of Chest Physicians, ninth edition

2. SSC provides identical recommendation

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14
Q

What is the recommendation for VTE prophylaxis?

A
  1. In critically ill patients
  2. Low-molecular-weight heparin or low-dose unfractionated heparic
  3. Over no prophylaxis.
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15
Q

What do the guidelines recommend for patients who are bleeding or at high risk for major bleeding?

A
  1. Mechanical thromboprophylaxis and

2. Start pharmacologic prophylaxis when the bleeding risk decreases.

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16
Q

List three pharmacologic options for prevention of venous thromboembolism

A
  1. Unfractionated heparin
  2. Low-molecular-weight-heparin
  3. Fondaparinux
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17
Q

What is the mechanism of unfractionated heparin?

A
  1. Factor Xa inhibition

2. Indirect thrombin inhibition

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18
Q

What is the mechanism of low-molecular-weight heparin?

A
  1. Factor Xa inhibition

2. Minor indirect thrombin inhibition

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19
Q

What is the mechanism of fondaparinux?

A
  1. Factor Xa inhibition
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20
Q

What is the prophylaxis dosing for unfractionated heparin?

A

5000 units SC two or three times daily

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21
Q

What is the prophylaxis dosing for low-molecular-weight heparin?

A
  1. Enoxaparin 40 mg SC

2. Dalteparin 5000 units SC daily

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22
Q

What is the prophylaxis dosing for fondaparinux?

A

2.5 mg SC daily

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23
Q

What are the adjustments for renal dysfunction with unfractionated heparin?

A

Unfractionated heparin does not require dose adjustments for renal dysfunction

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24
Q

What are the adjustments for renal dysfunction with low-molecular-weight heparin

A

CrCl less than 30 mL/min: enoxaparin 30 mg SC daily

25
Q

What is the dose adjustments for fondaparinux in renal dysfunction

A

Contraindicated for CrCl less than 30 mL/min

26
Q

Describe the cost of unfractionated heparin

A

Low cost

27
Q

Describe two versus there times daily administration of heparin for VTE prophylaxis

A
  1. Two meta-analysis have been completed on subjected.
  2. 2007 meta analysis showed no difference in efficacy, but higher risk of bleed in 3-times daily.
  3. 2011 meta analysis found no difference in efficacy or safety with either regimen.
28
Q

Describe the risk of heparin-induced thrombocytopenia (HIT) with prophylaxis unfractionated heparin

A

Risk of HIT lower than that of full anticoagulation doses

29
Q

Describe the therapeutic equivalency of LMWHs

A

all considered therapeutically equivalent

30
Q

Describe renal considerations of dalteparin

A

Dalteparin is renally elminated but can be considered in CrCl less than 30 ml/min because of low accumulation

31
Q

Describe risk of HIT with LMWH

A

Low risk of HIT

32
Q

Compare efficacy and safety of LMWH with heparin

A
  1. Largest trial of VTe prevention in critically ill patients,
  2. Dalteparin 5000 units once daily compared to heparin 5000 units twice daily
  3. Dalteparin better protection against PE, less HIT,
  4. Similar VTE protection, no difference in bleeding
33
Q

Describe a role of fondaparinux in VTE prophylaxis

A

can be safe in patients with a history of HIT

34
Q

Describe reversal of fondaparinux

A

Data on reversal of fondaparinux is lacking

35
Q

Describe evidence of fondaparinux in critically ill patients

A

Limited data in critically ill patients

36
Q

List three direct oral anticoagulants which have been studied in VTE prophylaxis of critically ill patients

A
  1. Rivaroxaban
  2. Apixaban
  3. Betrixaban
37
Q

Describe evidence for VTE prophylaxis in critically ill patients for rivaroxaban

A
  1. Rivaroxaban compared to enoxaparin in acutely ill medical patients needing hospitalization,
  2. Cardiogenic or septic shock with need for vasopressors excluded,
  3. Same efficacy at day 10, but higher risk of bleeding in rivaroxaban group.
38
Q

Describe evidence for VTE prophylaxis in critically ill patients for apixaban

A
  1. Apixaban compared to enoxaparin in acutely ill medical patients needing hospitalization,
  2. Septic shock excluded from trial,
  3. Same efficacy, but higher bleeding rate in apixaban.
39
Q

Describe the APEX trial

A
  1. Compared Betrixaban to enoxaparin for VTE prophylaxis in medically ill patients,
  2. Significantly reduced VTE events,
  3. No increase in bleeding rates.
  4. Safety and efficacy in critically ill patients is still unclear.
40
Q

List three special populations with other considerations for VTE prophylaxis in critical care

A
  1. Impaired kidney function
  2. Overweight or underweight
  3. Major traumatic injuries
41
Q

Describe a consideration for LMWH in impaired kidney function

A
  1. If estimated CrCl is less than 30 ml/min, LMWH dose is usually necessary.
  2. Dalteparin can be used because it has minimal renal metabolism.
  3. If CrCl is less than 20 ml/min or the patient requires dialysis, dosing information is limited for LMWH.
  4. Anti-Xa monitoring may not be reliable in patients undergoing dialysis.
42
Q

Describe consideration for fondaparinux in renal impairment

A

Fondaparinux is contraindicated in CrCl less than 30 ml/min

43
Q

Describe consideration for unfractionated heparin in renal impairment

A

Low-dose unfractionated heparin is minimally renally eliminated and is safe to use in patients with reduced kidney function

44
Q

What is the consideration for overweight/underweight adults patients in VTE prophylaxis?

A

Expert opinion only:

  1. increase unfractionated heparin dose and LMWH prophylaxis dose if BMI is greater than 40-kg/m2
  2. Peak (4 hours post dose) anti-Xa of 0.2-0.4 IU/mL is recommended
45
Q

What is the BMI greater than 40 prophylaxis dose of heparin?

A

7500 units

46
Q

What is the BMI greater than 40 prophylaxis dose of LMWH?

A

Increase by 30-100%

47
Q

What is the consideration for VTE prophylaxis for patients admitted with major traumatic injuries?

A

Enoxaparin 30 mg every 12 hours is more effective than other regimens

48
Q

Why is there a common consideration for antithrombotic therapy and regional anesthesia?

A

Critically ill patients have their spinal meninges accessed for:

  1. Therapeutic (epidural anesthesia, lumbar drains)
  2. Diagnostic (lumbar puncture)
49
Q

What is the risk for antithrombotic therapy and spinal access?

A

The combination of antithrombotic medications and spinal meninges access is associated with an elevated risk of spinal or epidural hematoma, which can lead to ischemia and paralysis

50
Q

What society has guidelines for antithrombotic herapy and regional anesthesia?

A

The American Society of Regional Anesthesia and Pain Medicine

51
Q

What are the American Society of Regional Anesthesia and Pain Medicine recommendations for heparin?

A
  1. No contraindication to low-dose unfractionated heparin at daily doses less than 10,000 units (i.e. 5000 BID)
  2. Unknown whether SQ heparin at doses greater than 10,000 (i.e. 5000 units every 8 hours) carry higher risk.
  3. If patients receiving SQ heparin at doses greater than 10,000 units daily, enhanced monitoring for neurologic deficits should occur.
52
Q

What are the American Society of Regional Anesthesia and Pain Medicine recommendations for LMWH?

A
  1. Timing of needle placement

2. Removal of needle

53
Q

When should needle placement occur for patients receiving LMWH?

A

10-12 hours after the last LMWH dose (longer in patients with renal disease)

54
Q

Indwelling catheters should be removed before initiation of ____ LMWH postoperatively, but can be maintained for ____ regimens.

A

Indwelling catheters should be removed before initaition of twice-daily LMWH postoperatively, but can be maintained for patients on once-daily regimens.

55
Q

The first dose of LMWH should be at least ___ hours after indwelling catheter removal

A

2 hours

56
Q

Indwelling catheter remoavl should be at least ____ hours after the last LMWH dose (longer in patients with renal disease)

A

10-12 hours

57
Q

What is the american society of regional anesthesia and pain medicine recommendation for fondaparinux?

A

Because of a lack of data and early clinical trial data, the use of fondaparinux should be avoided

58
Q

What is the american society of regional anesthesia and pain medicine recommendation for DOAC?

A

Because of differences in half-life and elimination, there are specific recommendations regarding regional anesthesia

BCPS Exam (34 decks)

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