Treatment and Prophylaxis of VTE Flashcards
For initial VTE treatment what should patients be given
Rapid-acting anticoagulant
During warfarin initiation what should be overlapped with it, for how long, what parameters should be met
Injectable anticoagulants, 5 days and until the patient’s INR is greater than or equal to 2 for at least 24 hours
T/F: As long at the VTE and PE is uncomplicated patients can be treated outpatient
True
How long should VTE treatment be, when would it be longer
3 months, VTE reccurence and major bleeding
What are the deep veins in the body
Inferior vena cava, Iliac vein, Femoral vein, popliteal vein, anterior tibial vein
What are upper extremity DVT
thrombosis of the brachial, axillary, subclavian, and internal jugular veins
What usually cause the upper extremeity DVTs
Central venous catheter, Implantable cardiac defibrallator, cardiac pacemakers or other foreign implants
What are the three categories that can cause DVTs
Blood stasis, vascular injury, hypercoaguability
What are early methods of prophylaxis for VTE
Active or passive mobilization, Adequate hydration
What are two types of mechanical prophylaxis of VTEs
Graduated compression stockings, Intermittent pneumatic compression devices
Where is the most pressure in graduated compression stockings
At the ankles, decreases going up
How long should intermittent pneumatic compression devices be attached
At least 18 hours
What are the pharmacological choices for VTE prophylaxis is brought for medical illness
Heparin, LMWH, Fondaparinux, Betrixban
What is an appropriate Heparin dose for VTE prophylaxis, LMWH, Fondaparinux
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
Which VTE prophylaxis pharmacologic agent can be taken by mouth, what is the correct dose
Betrixiban 160 mg once then 80 mg daily
According to the Padua Prediction Score what has the highest risk factor (3)
Active cancer, Previous VTE (with exclusion to superficial vein thrombosis), Reduced mobility, already known thrombillic conditions
What score on the Padua constitutes a high risk for VTE, low risk
4 or more, 3 or less
What do the 2018 ASH guidelines recommend for VTE prophylaxis
LMWH over DOACs for acute medically ill patients
T/F: For VTE prophylaxis LMWH should be used alone in inpatient prophylaxis without continuing therapy after discharge
True
For Critically ill patients what should be given for VTE prophylaxis
Heparin or LMWH
For acutely and critically ill patients what is the hirearchy and options for VTE prophylaxis
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
What is the VTE prophylaxis recommendation for flying longer than 4 hours and no risk factors present
Nothing
What is the VTE prophylaxis recommendation for flying longer than 4 hours with risk factors
Graduated compression stockings or prophylactic LMWH
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
Aspirin
What can be used to estimate VTE risk after general surgery, what are the categories
Caprini Score/ very low (0 to 1), low (2), moderate (3 to 4), high (greater than or equal to 5)
What are known risk factors for surgical bleeding
Previous major bleeding, severe renal failure, concomitant antiplatelet agent, extensive surgical dissection and revision surgery
T/F: Spinal/epidural hematomas may occur in patients on anticoagulation that are receiving neuraxial anastethia or undergoing spinal puncture
True
When are the risks for bleeding highest after orthapedic surgery
First 7 to 14 day, after 35 days
What is the VTE prophylaxis for hip or knee replacement
Minimum of 10-14 days LMWH is preferred (can use fondaparinox, DOACs except Betrixiban, Heparin, wafarin and aspirin)
What is the VTE prophylaxis for hip fracture surgery
Minimum of 10-14 days LMWH is preferred ( can use fondaparinox, DOACs except Betrixiban, Heparin, warfarin and aspirin)
What is the VTE prophylaxis if a patient is having major orthopedic surgery, how long
Dual prophylaxis with antithrombotics and IPC during hospital, possibly up to 35 days
T/F: For Total Hip Arthroplasty, Total Knee Arthroplasty, and Hip Fracture Surgery the VTE prophylaxis dose for the injectables is mostly the same
True
What are the lower ranges when using INR for VTE prophylaxis regarding orthopedic surgery
1.8-2.2
What is the only type of surgery that Dabigatran is recommended for use in, what dose
110 mg once then 220 mg daily
What is the only of surgery that Apixaban and Rivaroxaban are not indicated for
Hip Fracture Surgery
If a patient is receiving LMWH as thrombophylaxis when should they get it
12 hour or more before the operation or 12 hours or more after the operation
What is the order for using injectable anticoagulants for surgery prophylaxis, what is the best option if the kidney function is bad
LMWH, Fondaparinox, Heparin/ Heparin
What is a permenant solution for not getting a blood clot in the lungs, how long should they be in the vessel
IVC filters, 6 months
What are symptoms of DVT, what labratory test help determine
Leg swelling, pain, or warmth, elevated D-dimer
If a patient comes in with VTE and has severe cadiopulmonary compromise or high risk of limb loss what should be given
Heparin or LMWH
If a patient come in with VTE and has active bleeding or a contraindication to an anticoagulant
Place IVC filter, initiate anticoagulation when bleeding or contraindication resolves
What are the outpatient VTE treatments
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
What is the dosing of enoxaparin for TREATMENTof VTE
1 mg/kg SC every 12 hours OR 1.5mg/kg SC every 24 hours
T/F: ACCP guidelines suggest Warfarin over DOACs
False: DOACs (dabigatran, rivaroxaban, apixaban or edoxaban) is suggested over warfarin
How long should clots be treated
3 months
What are consequences of postthrombotic syndrome
Hyperpigmentation, venous ulcer, venous ectasia, edema
When is warfarin stopped for someone going into surgery why, what may be given instead but what is the cavieat
5 days, lower INR to 1.5, LMWH but the last dose must be 24-36 hours prior to the procedure
How long should DOACs be held before a major surgery
A minimum of 1 day for low risk, 2-3 days for high risk
When is it okay to switch Warfarin to Rivaroxaban, Apixaban
INR should be less than 3, INR less than 2
