DVT assessment & management Flashcards
- Venous thromboembolism (VTE) is?
- DVT has an annual incidence of about ? people
- Continuing or intrinsic risk factors include:
- Risk factors that temporarily raise the likelihood of DVT include:
- A disease that includes DVT & PE
DVT and PE are both forms of VTE, but they’re not the same thing
- 1/1000
- Previous VTE, Cancer, Increasing age, overweight or obese,
Male sex, HF, acquired/ familial thrombophilia.
Chronic low-grade injury to the vascular wall (e.g. vasculitis, hypoxia from venous stasis, or chemotherapy).
- Immobility,
Significant trauma or direct trauma to a vein (e.g. IV catheter),
Hormone treatment,
Pregnancy & the postpartum period,
Dehydration
- Typical signs & symptoms are:
- Other conditions which may present with similar signs & symptoms include:
- The ? should be used to assess the likelihood of DVT & inform further management.
- Pain & swelling in one leg (occasionally both legs).
Tenderness, changes to skin colour (red) & temperature, and vein distension, ulcer
- Physical trauma
Cardiovascular disorders such as superficial thrombophlebitis and post-thrombotic syndrome
Other conditions such as ruptured Baker’s cyst, cellulitis, and dependent oedema.
- two-level DVT Wells score
- For people who are likely to have DVT, management includes:
- Arranging referral for a proximal leg vein ultrasound scan to be carried out within 4 hours.
If a proximal leg vein ultrasound scan cannot be carried out within 4 hours of being requested, a blood sample should be taken for D-dimer testing; an interim 24-hour dose of a parenteral anticoagulant should be given; and a proximal leg vein ultrasound scan should be arranged (to be carried out within 24 hours of being requested).
For people who are unlikely to have DVT, a blood sample should be taken for D-dimer testing:
If the D-dimer test is positive, management options are as for people who are likely to have DVT.
If the D-dimer test is negative, an alternative diagnosis should be considered.
People with DVT require anticoagulant treatment in secondary care. On discharge they will require maintenance treatment with an oral anticoagulant drug for at least 3 months (provided there are no contraindications such as cancer or pregnancy) and compression stockings.
Explain the scoring sytem for a DVT
Prothrombotic factors in cancer include?
Tumor cells to produce and secrete procoagulant/fibrinolytic substances and inflammatory cytokines, and the physical interaction between tumor cell and blood (monocytes, platelets, neutrophils) or vascular cells. Other mechanisms of thrombus promotion in malignancy include nonspecific factors such as the generation of acute phase reactants and necrosis (i.e., inflammation), abnormal protein metabolism (i.e., paraproteinemia), and hemodynamic compromise (i.e., stasis). In addition, anticancer therapy (i.e., surgery/chemotherapy/hormone therapy) may significantly increase the risk of thromboembolic events by similar mechanisms, e.g., procoagulant release, endothelial damage, or stimulation of tissue factor production by host cells.
- Post-thrombotic syndrome:
- Superficial thrombophlebitis
- Migratory superficial thrombophlebitis is known as
A chronic venous hypertension causing limb pain, swelling, hyperpigmentation, dermatitis, ulcers, venous gangrene, and lipodermatosclerosis. It affects 20–40% of people after DVT of the lower limbs and can be debilitating with significant impact on quality of life.
- is a thrombosis and inflammation of superficial veins which presents as a painful induration with erythema, often in a linear or branching configuration forming cords.
- Trousseau’s syndrome:
pancreatic, gastric and lung cancer
lot is tender and the clot can be felt as a nodule under the skin
- Other conditions which may present with similar signs & symptoms include:
Physical trauma, e.g:
Calf muscle tear or strain.
Haematoma in the muscle.
Sprain/rupture of the Achilles tendon.
Fracture.
Cardiovascular disorders, e.g:
Superficial thrombophlebitis
Post-thrombotic syndrome
Venous obstruction or insufficiency, or external compression of major veins (e.g. by a fetus during pregnancy, or cancer).
Arteriovenous fistula and congenital vascular abnormalities.
Acute limb ischaemia.
Vasculitis.
Heart failure
Other conditions include:
Ruptured Baker’s cyst (a Baker’s cyst forms behind the knee from an out-pouching of the synovial membrane of the knee joint, and is a common complication of arthritis)
Cellulitis (commonly mistaken as DVT)
Dependent (stasis) oedema.
Lymphatic obstruction.
Septic arthritis.
Cirrhosis.
Nephrotic syndrome.
Compartment syndrome.
Management of suspected DVT
Warfarin/rivaroxaban
treatment is usually continued for at least 3 months, but duration may be longer depending on whether the DVT was unprovoked or provoked
(INR) target of 2.5, keeping within the range of 2.0–3.0 for warfarin
rivaroxaban needs no monitoring or dose adjustments
Ensure that people with unprovoked DVT are investigated for the possibility of an undiagnosed cancer
A physical examination (guided by the person’s full history).
CXR
Blood tests (full blood count, serum calcium, and liver function tests).
Urinalysis.
Investigations for cancer with an abdomino-pelvic CT scan (and a mammogram for women) should be considered in all people aged over 40 years of age with a first unprovoked DVT who do not have signs or symptoms of cancer based on initial investigation.
Ensure that people with unprovoked DVT have been offered thrombophilia testing
Testing for antiphospholipid antibodies should be considered in people who have had unprovoked DVT.
Testing for hereditary thrombophilia should be considered in people who have had unprovoked DVT and who have a first-degree relative who has had DVT.
Advise the person:
To engage in regular walking exercise after they are discharged from hospital (unless a specialist advises against this).
That the affected leg should be elevated when sitting.
That extended travel, or travel by aeroplane, should be delayed until at least 2 weeks after starting anticoagulant treatment.
Rivaroxiban
- MOA
- Indications
- Direct inhibitor of activated factor X (factor Xa)
black triangle drug, still under intensive post-marketing surveillance by the Medicines and Healthcare products Regulatory Agency (MHRA).
- Prophylaxis of VTE following knee replacement surgery
PO for adult: 10 mg once daily for 2 wks, to be started 6–10 hrs after surgery.
Prophylaxis of VTE following hip replacement surgery
PO for adult: 10 mg once daily for 5 wks, to be started 6–10 hrs after surgery.
Initial treatment of DVT, Initial treatment of PE
PO adult: Initially 15 mg twice daily for 21 days, to be taken with food.
Continued treatment of deep-vein thrombosis (following initial treatment),
Continued treatment of pulmonary embolism (following initial treatment),
Prophylaxis of recurrent deep-vein thrombosis,
Prophylaxis of recurrent pulmonary embolism
PO adult: 20 mg once daily, to be taken with food
Prophylaxis of stroke and systemic embolism in patients with non-valvular atrial fibrillation and with at least one of the following risk factors: congestive heart failure, hypertension, previous stroke or transient ischaemic attack, age ≥ 75 years, or diabetes mellitus
PO adult: 20 mg once daily, to be taken with food.
Prophylaxis of atherothrombotic events following an ACS with elevated cardiac biomarkers (in combination with aspirin alone or aspirin and clopidogrel)
PO adult: 2.5 mg twice daily usual duration 12 months.
rivaroxiban
- s/e
- pregnancy/breastfeeding
- Common or very common
Anaemia; asthenia; constipation; diarrhoea; dizziness; fever; gastrointestinal discomfort; haemorrhage; headache; hypotension; menorrhagia; nausea; oedema; pain in extremity; post procedural anaemia; renal impairment; skin reactions; vomiting; wound complications
- avoid
when does PE classically occur?
10-12 days post op
patient straining at stool
venous pressure waves during straining causes thrmobus to fractire and embolise (grastrucnemius and soleus contract and narrow the lumen og the veins)
surgery prothrombotic state
How can a post op DVT be prevented?
- Pre-operative mobilisation - maintain mobility as close as possible to the time of surgery
- Postoperative mobilisation – mobilise as soon as possible after surgery
- Graduated compression stockings (GCS), also called anti-embolism stockings (AES)
- Intraoperative intermittent calf compression
- Maintain hydration
- Stop pro-thrombotic drugs (such as the COCP)
What are the thromboprophylaxis guidelines on general, endocrine and vascular surgery
- warfarin vs
- In all patients whose warfarin has been stopped?
- Drugs potentiating warfarin
- or a Direct Oral Anticoagulant (DOAC e.g. dabigatran, rivaroxaban, apixaban, edoxaban)
- 5 days before surgery, the INR should be measured on the day before surgery, allowing correction with oral phytomenadione (vitamin K) if it is greater than or equal to 1.5 (suggested dose 2mg).
home for the 5 days before surgery. The last dose of warfarin should be taken on the evening of day -6. LMWH is started on the morning of day -3 and is continued until day -1 (i.e. 24 hours before surgery). If the surgery poses a high risk of bleeding, this final dose of LMWH on day -1 should only be half the full anticoagulant dose
1st Trimester: Teratogenic
3rd Trimester: Brain Haem
