Thromboembolism

Question 1

VTE risk assessment

Answer 1

VTE risk + Risk of Bleeding

Question 2

VTE prophylaxis options (2)

Answer 2

Mechanical VTE

Pharmacological VTE

Question 3

Pharmacological VTE prophylaxis

Answer 3

• Parental anticoagulation

- DOAC’s

Question 4

Duration of VTE prophylaxis
General Surgery
Major cancer
Knee hip replacement

Answer 4

Surgery: 5-7 days
Major cancer : 28 days
Knee hip replacement : extended duration

Question 5

Treatment of VTE step 1 and 2

- What the difference in renal pt

Answer 5

1) Low molecular weight heparin (LMWH) for at least 5 days / or until INR is 2
- Renal pt = unfractionated heparin

2) Oral anticoagulant
doc / warfarin

Question 6

What do you need to measure with unfractionated heparin

Answer 6

Activated partial thrombin time

Question 7

Which one would you use in pregnancy LMWH or unfractionated heparin

Answer 7

LMWH

Question 8

Which one has a shorter duration of action LMWH Unfractionated Heparin

Answer 8

Unfractionated heparin

Question 9

Why is LMWH a preferred choice

Answer 9

Lower risk of

• Osteoporosis
• Heparin induced thrombocytopenia

Question 10

Side effect of Heparin (4)

Answer 10

Haemorrhage
Hyperkalaemia
Heparin induced thrombocytopenia
Osteopetrosis

Question 11

Warfarin colours 
0.5mg
1mg 
3mg 
5mg

Answer 11

0.5mg = white
1mg = brown 
3mg = blue 
5mg = Pink

Question 12

Warfarin initial and mainitance dose

Answer 12

Initial = 5mg 
Maintenance = 3-9mg OD

Question 13

Target INR
VTE
Recurrent VTE

Answer 13

VTE / AF / Cardioversion / Mitral stenosis:/ MI 2.5

Recurrent VTE: 3.5

Question 14

Length of treatment in these scenarios:

Isolated calf DVT:
Provoked VTE:
Unprovoked DVT:

Answer 14

Isolated calf DVT: 6 weeks
Provoked VTE: 3 months
Unprovoked DVT: 3 months / long term

Question 15

MHRA alerts for warfarin (which alter INR results)

Answer 15

Direct acting antivirals can cause INR change
Over the counter Daktrain
Covid

Question 16

Side effect of warfarin and antidote

Answer 16

Bleeding , treatment Vitamin K

Calciphylaxis

Question 17

What to do in INR > 8.0 + (minor bleeding)

Answer 17

• Stop warfarin sodium;
• Give phytomenadione (vitamin K1) by slow intravenous injection;
• Repeat if INR still high after 24 hours
• Restart warfarin when INR <5.0

Question 18

What to do in Major bleeding

Answer 18

Stop Warfarin
IV Phytomenadione
Dried prothrombin complex

Question 19

What to do in INR > 8 ( + no bleeding)

Answer 19

• Stop warfarin sodium;
• Give phytomenadione (vitamin K1) by slow intravenous injection;
• Repeat if INR still high after 24 hours
• Restart warfarin when INR <5.0

Question 20

What to do in INR 5.0-8.0 + (minor bleeding)

Answer 20

• Omit warfarin
• give phytomenadione (vitamin K1) by slow intravenous injection;
• restart warfarin sodium when INR <5.0

Question 21

What to do in INR 5.0-8.0 + (no bleeding)

Answer 21

• withhold 1-2 warfarin doses
• Reduce maintenance dose
• Measure INR after 2-3 days

Question 22

What to do with warfarin for elective surgery

Answer 22

• Stop warfarin 5 dys before
• If INR greater than >1.5 give oral phytomenadione
• Restart warfarin the next day

Question 23

What to do with warfarin for emergency surgery

Answer 23

• Delay 6/12 hours

- No delay – give phytomenadione and dried prothrombin complex

Question 24

High risk of VTE in patients who take warfarin and are undergoing surgery , what would you do?

Answer 24

• If patient had VTE in the last three months

- Bridge patients with LMWH and stop 24 hours before surgery

Question 25

High risk of bleeding in patient who who take warfarin and are undergoing surgery , what would you do?

Answer 25

• Start LMWH 48 hours before surgery