Thromboembolism Flashcards
in what situations would you use unfractionated heparin over LMWH?
- renal impairment
- in patients you want to reverse the effects/have short action (unfractionated heparin has shorter half life)
what anticoagulant is used in surgery for patients with lower limb immobilisation or pelvis fragility fractures?
what drug class is it?
fondaparinux
Xa inhibitor
how long in VTE prophylaxis in surgery?
what if major cancer surgery in abdomen?
what if spinal surgery?
- at least 7 days post surgery or until sufficent mobility
- major cancer in abdomen = 28 days
- spinal surgery = 30 days
what are the 3 VTE prophlyaxis plans for elective hip replacement surgery?
- LMWH for 10 days then 75mg aspirin for 28 days
- LMWH for 28 days + stockings until discharge
- Rivaroxaban
what are the 3 VTE prophlyaxis plans for elective knee replacement surgery?
- 75mg aspirin for 14 days
- LMWH for 14 days + stockings until discharge
- Rivaroxaban
are all pregnant women given VTE prophylaxis?
no - only those who are high risk
what VTE prophylaxis is given to women who have just given birth, had a miscarrige or termination of pregnancy in the past 6 weeks?
LMWH 6 - 8 hours after the event - contiune for minimum of 7 days
what 2 Xa inhibitors can be given for confirmed DVT/PE?
rivaroxaban or apixiabn
if rivaroxaban or apixaban are unsuitable what are the 2 alternative plans?
- LMWH for 5d followed by dabigatran or edoxaban
- LMWH + warfarin for at least 5 days or until INR is at least 2.0 for 2 consecutive readings followed by warfarin alone
how long is the treatment for distal DVT (calf)?
6 weeks
how long is the treatment for proximal DVT/PE?
at least 3 months (3 - 6 months in those with active cancer)
how long is the treatment for provoked DVT/PE?
stop at 3 months if provoking factor resolved
how long is the treatment for unprovoked DVT/PE?
3 months +
how long is the treatment for recurrent DVT/PE?
long term
in what situations do you aim for INR of 2.5 (+/- 0.5)?
VTEs, AF, cardioversion, MI, cardiomyopathy
in what situations do you aim for INR 3.5 (+/- 0.5)?
recurrent VTEs, or mechanical heart valves
what do you do if someone on warfarin has a major bleed?
stop warfarin
IV phytomenadione
dried prothrombin
what do you do with someone on warfarin has a minor bleed and INR >8?
stop warfarin
IV phytomenadione
what do you do with someone on warfarin has no bleeding but INR >8?
stop warfarin
PO phytomenadione
what do you do with someone on warfarin has bleeding and INR 5 - 8?
stop warfarin
IV phytomenadione
what do you do with someone on warfarin has no bleeding but INR 5 - 8?
with hold 1 - 2 doses of warfarin
when can you restart warfarin after someone has has a bleed/raised INR?
when INR less than 5
how does INR need to monitored in someone on warfarin?
every 1 - 2 days in early treatment
then every 12 weeks
whats the MHRA warning for warfarin?
skin necrosis and calciphylaxis (painful skin rash)
what vitamin is phytomenadione?
K1
can warfarin be used in pregnancy?
avoid in 1st and 3rd trimester as teratogenic
need contraception
what 4 interactions do you need to look out for with warfarin?
- vitamin K rich foods - these reduce the efficacy of warfarin (leafy greens)
- pomegranate and cranberry juice - increases INR
- Miconazole - increases INR
- CYP inducers/inhibitors
when do you need to stop and restart warfarin in minor surgery?
- surgery performed with and INR less than 2.5
- restart warfarin within 24 hours of procedure
