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ICU > Venous Thromboembolism > Flashcards

Venous Thromboembolism Flashcards

1
Q

What is the cause done VTE after major surgery?

A

Thromboplastin release

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2
Q

What are the medical conditions with the highest risk of VTE?

A

Right heart failure
Stroke with lower extremity weakness
Cancer

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3
Q

What is responsible for the variable anticoagulant effect of heparin?

A

Plasma protein levels

Heparin binds these, macrophage, and endothelial cells. This messes with its bioavailability

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4
Q

What is the MOA of unfractionated heparin?

A

Bind to antithrombin III and this complex inactivates factor 2a (thrombin) and Xa

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5
Q

What is the standard dosing of LDUH?

A

5,000 units q8 or q 12

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6
Q

What are the advantages of LMWH?

A
  1. More potent anticoagulant
  2. More predictable effect
  3. Longer duration of action (doesn’t bind endothelial cells or macrophage)
  4. Reduced binding of platelets (lower risk of HIT)
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7
Q

What is the disadvantage of LMWH?

A

Cleared renally

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8
Q

What type of surgeries is LMWH superior to LDUH for?

A

Major orthopedic surgery

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9
Q

What is the dosage of enoxaparin in obese patients?

A

0.5 mg/kg

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10
Q

What are the advantages of dalteparin over lovenox?

A

Given only once daily in higher doses

Can be continued without dose reduction in renal failure

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11
Q

How long should you hold LMWH before an epidural?

A

If twice a day dosing - 12 hours

If once a day dosing - 24 hours

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12
Q

How long do you wait after an epidural to restart LMWH?

A

2 hours

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13
Q

How do graded compression stockings work?

A

Create a gradient of external pressure to force venous outflow of the legs

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14
Q

Can graded compression stockings be used alone for thromboprophylaxis?

A

No

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15
Q

Can intermittent pneumatic compressions be used alone?

A

Yes

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16
Q

What are the clinical symptoms of PE?

A

Tachypnea, tachycardia, hypoxemia, dypsnea

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17
Q

What is the principal method for finding venous thrombosis in the leg?

A

Compression us

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18
Q

What technique can be used as adjunct for identifying thrombosis?

A

Color Doppler US

19
Q

What is the test of choice for an upper extremity clot?

A

Venous US

20
Q

What can be missed in a CTA?

A

Smaller, segmental clots

21
Q

How do you manage a PE?

A

Bolus of IV heparin

22
Q

What is the target PTT?

A

46-70 seconds

23
Q

What is the target PTT ratio test?

A

1.5-2.5

24
Q

When does HIT appear?

A

5-10 days afte the initiation of heparin therapy

25
Q

What can reverse heparin?

A

Protamine sulfate

26
Q

How much protamine would you give?

A

1 mg covers 100 units
If been running for 30 minutes - do 0.5 mg per 100 units
If been running for more than 2 hours - do 0.27-0.375 mg per 100

27
Q

How would you dose protamine for a continuous heparin infusion?

A

Use the heparin dose that ran over last 2 hours and give 1 mg per 100

28
Q

What does protamine cause?

A

Bradycardia
Hypotension
Hypersensitivity (ask about fish products)

29
Q

How can use asses the effectiveness of protamine?

A

Get activated PTT 5-15 minutes after administration

30
Q

How can you avoid Brady and hypotension when giving protamine?

A

Give it slowly over 10 minutes

31
Q

What is the therapeutic dose of LMWH for a PE?

A

1 mg/kg q 12 h

32
Q

How do you monitor the effect of LMWH?

A

Anti-Xa levels

33
Q

What is the desired range of anti-Xa for clot?

A

0.6-1 unit/ml if twice a day dosing

Over 1 if once a day

34
Q

Why is continuous heparin infusion the treatment modality if choice for PE?

A

Rapid acting
Easily reversible
Doesn’t require dose adjustment in renal patients

35
Q

What is the initial dose of warfarin?

A

5-10 mg for first 2 days

36
Q

What is the standard thrombolytic regimen?

A

Alteplase 100 mg infused over 2 hours

37
Q

What is the goal thrombolytic therapy for a PE?

A

Limit clot extension
Does not break up existing clot
Can reduce right heart strain

38
Q

What are the indications for thrombolytic therapy?

A

Hemodynamic deterioration and RV dysfunction

39
Q

What are the indications for an IVC filter?

A

Absolute contraindication to anti coagulation
PE during full anticoag
A large free-floating thrombus
Limited cardiopulmonary reserve

40
Q

What is the shape and name of the filter used?

A

Greenfield filter, looks like a bad mitten birdie

Allows it to fill without compromising the lumen of the IVC

41
Q

How are IVC filters inserted?

A

Percutaneously through the IJ or femoral vein

42
Q

Where in the IVC is it placed?

A

Below the renal veins

43
Q

What are the risk factors for VTE.

A 
Surgery
Trauma
Malignancy
Estrogen drugs
EPO
Acute medical illness
Prior hx
Obesity
Pregnancy
Sepsis
Vasopressors
Platelet transfusions 
Immobility

ICU (17 decks)

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