Treatment and Prophylaxis of VTE

Question 1

For initial VTE treatment what should patients be given

Answer 1

Rapid-acting anticoagulant

Question 2

During warfarin initiation what should be overlapped with it, for how long, what parameters should be met

Answer 2

Injectable anticoagulants, 5 days and until the patient’s INR is greater than or equal to 2 for at least 24 hours

Question 3

T/F: As long at the VTE and PE is uncomplicated patients can be treated outpatient

Answer 3

True

Question 4

How long should VTE treatment be, when would it be longer

Answer 4

3 months, VTE reccurence and major bleeding

Question 5

What are the deep veins in the body

Answer 5

Inferior vena cava, Iliac vein, Femoral vein, popliteal vein, anterior tibial vein

Question 6

What are upper extremity DVT

Answer 6

thrombosis of the brachial, axillary, subclavian, and internal jugular veins

Question 7

What usually cause the upper extremeity DVTs

Answer 7

Central venous catheter, Implantable cardiac defibrallator, cardiac pacemakers or other foreign implants

Question 8

What are the three categories that can cause DVTs

Answer 8

Blood stasis, vascular injury, hypercoaguability

Question 9

What are early methods of prophylaxis for VTE

Answer 9

Active or passive mobilization, Adequate hydration

Question 10

What are two types of mechanical prophylaxis of VTEs

Answer 10

Graduated compression stockings, Intermittent pneumatic compression devices

Question 11

Where is the most pressure in graduated compression stockings

Answer 11

At the ankles, decreases going up

Question 12

How long should intermittent pneumatic compression devices be attached

Answer 12

At least 18 hours

Question 13

What are the pharmacological choices for VTE prophylaxis is brought for medical illness

Answer 13

Heparin, LMWH, Fondaparinux, Betrixban

Question 14

What is an appropriate Heparin dose for VTE prophylaxis, LMWH, Fondaparinux

Answer 14

5000 units SC every 8-12 hours, Enoxaparin 40 mg SC daily or 30 mg SC every 12 hours, Dalepartin 2500-5000 units SC daily, 2.5 mg SC daily

Question 15

Which VTE prophylaxis pharmacologic agent can be taken by mouth, what is the correct dose

Answer 15

Betrixiban 160 mg once then 80 mg daily

Question 16

According to the Padua Prediction Score what has the highest risk factor (3)

Answer 16

Active cancer, Previous VTE (with exclusion to superficial vein thrombosis), Reduced mobility, already known thrombillic conditions

Question 17

What score on the Padua constitutes a high risk for VTE, low risk

Answer 17

4 or more, 3 or less

Question 18

What do the 2018 ASH guidelines recommend for VTE prophylaxis

Answer 18

LMWH over DOACs for acute medically ill patients

Question 19

T/F: For VTE prophylaxis LMWH should be used alone in inpatient prophylaxis without continuing therapy after discharge

Answer 19

True

Question 20

For Critically ill patients what should be given for VTE prophylaxis

Answer 20

Heparin or LMWH

Question 21

For acutely and critically ill patients what is the hirearchy and options for VTE prophylaxis

Answer 21

Patients should receive pharmacological prophylaxis over mechanical prophylaxis, patients should receive only one type of prophylaxis at a time, pneumatic compression devices or compression stockings are the only to recommended mechanical prophylaxis

Question 22

What is the VTE prophylaxis recommendation for flying longer than 4 hours and no risk factors present

Answer 22

Nothing

Question 23

What is the VTE prophylaxis recommendation for flying longer than 4 hours with risk factors

Answer 23

Graduated compression stockings or prophylactic LMWH

Question 24

What is the VTE prophylaxis recommendation for flying longer than 4 hours with risk factors and the patient cannot recieve a graduated compression stocking or prophylactic LMWH

Answer 24

Aspirin

Question 25

What can be used to estimate VTE risk after general surgery, what are the categories

Answer 25

Caprini Score/ very low (0 to 1), low (2), moderate (3 to 4), high (greater than or equal to 5)

Question 26

What are known risk factors for surgical bleeding

Answer 26

Previous major bleeding, severe renal failure, concomitant antiplatelet agent, extensive surgical dissection and revision surgery

Question 27

T/F: Spinal/epidural hematomas may occur in patients on anticoagulation that are receiving neuraxial anastethia or undergoing spinal puncture

Answer 27

True

Question 28

When are the risks for bleeding highest after orthapedic surgery

Answer 28

First 7 to 14 day, after 35 days

Question 29

What is the VTE prophylaxis for hip or knee replacement

Answer 29

Minimum of 10-14 days LMWH is preferred (can use fondaparinox, DOACs except Betrixiban, Heparin, wafarin and aspirin)

Question 30

What is the VTE prophylaxis for hip fracture surgery

Answer 30

Minimum of 10-14 days LMWH is preferred ( can use fondaparinox, DOACs except Betrixiban, Heparin, warfarin and aspirin)

Question 31

What is the VTE prophylaxis if a patient is having major orthopedic surgery, how long

Answer 31

Dual prophylaxis with antithrombotics and IPC during hospital, possibly up to 35 days

Question 32

T/F: For Total Hip Arthroplasty, Total Knee Arthroplasty, and Hip Fracture Surgery the VTE prophylaxis dose for the injectables is mostly the same

Answer 32

True

Question 33

What are the lower ranges when using INR for VTE prophylaxis regarding orthopedic surgery

Answer 33

1.8-2.2

Question 34

What is the only type of surgery that Dabigatran is recommended for use in, what dose

Answer 34

110 mg once then 220 mg daily

Question 35

What is the only of surgery that Apixaban and Rivaroxaban are not indicated for

Answer 35

Hip Fracture Surgery

Question 36

If a patient is receiving LMWH as thrombophylaxis when should they get it

Answer 36

12 hour or more before the operation or 12 hours or more after the operation

Question 37

What is the order for using injectable anticoagulants for surgery prophylaxis, what is the best option if the kidney function is bad

Answer 37

LMWH, Fondaparinox, Heparin/ Heparin

Question 38

What is a permenant solution for not getting a blood clot in the lungs, how long should they be in the vessel

Answer 38

IVC filters, 6 months

Question 39

What are symptoms of DVT, what labratory test help determine

Answer 39

Leg swelling, pain, or warmth, elevated D-dimer

Question 40

If a patient comes in with VTE and has severe cadiopulmonary compromise or high risk of limb loss what should be given

Answer 40

Heparin or LMWH

Question 41

If a patient come in with VTE and has active bleeding or a contraindication to an anticoagulant

Answer 41

Place IVC filter, initiate anticoagulation when bleeding or contraindication resolves

Question 42

What are the outpatient VTE treatments

Answer 42

Rivaroxaban 15mg BID for 21 days THEN 20 mg daily, Apixiban 10 mg BID for 7 days THEN 5 mg BID for up to 90 days THEN 2.5 mg BID, LMWH/fondaparinux for 5 days then SWITCH to dabigatran or edoxaban, LMWH/fondaparinux OVERLAPPED with warfarin for at least 5 days AND the INR is greater than 2 then dose adjust to 2-3 range

Question 43

What is the dosing of enoxaparin for TREATMENTof VTE

Answer 43

1 mg/kg SC every 12 hours OR 1.5mg/kg SC every 24 hours

Question 44

T/F: ACCP guidelines suggest Warfarin over DOACs

Answer 44

False: DOACs (dabigatran, rivaroxaban, apixaban or edoxaban) is suggested over warfarin

Question 45

How long should clots be treated

Answer 45

3 months

Question 46

What are consequences of postthrombotic syndrome

Answer 46

Hyperpigmentation, venous ulcer, venous ectasia, edema

Question 47

When is warfarin stopped for someone going into surgery why, what may be given instead but what is the cavieat

Answer 47

5 days, lower INR to 1.5, LMWH but the last dose must be 24-36 hours prior to the procedure

Question 48

How long should DOACs be held before a major surgery

Answer 48

A minimum of 1 day for low risk, 2-3 days for high risk

Question 49

When is it okay to switch Warfarin to Rivaroxaban, Apixaban

Answer 49

INR should be less than 3, INR less than 2