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Afsha NEW CV > VTE > Flashcards

VTE Flashcards

1
Q

what is VTE

A
  • blot clot forms in vein which partially or completely obstructs blood flow
  • includes DVT and PE
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2
Q

What is hospital acquired VTE

A

VTE occurs within 90 days of hospital admission

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3
Q

risk factors for VTE

A
  • surgery
  • trauma
  • significant immobility
  • malignancy
  • obesity
  • acquired or inherited hypercoaguable states
  • pregnant
  • postpartum
  • hormonal therapy - HRT or COC
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4
Q

most common form of VTE

A

DVT

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5
Q

DVT usually occurs in the following two areas ….. but can also affect other sites

A

deep veins of legs or pelvis

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6
Q

symptoms of DVT

A
  • unilateral localised pain
  • swelling
  • tenderness
  • skin changes
  • vein distention (swollen)
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7
Q

what is pulmonary embolism and how does it happen

A

commonly occurs when a thrombus, usually from a DVT, travels in blood (embolus) and obstructs blood flow to lungs causing respiratory dysfunction

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8
Q

symptoms of PE

A
  • chest pain
  • SOB
  • haemoptysis
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9
Q

what tool is used if DVT suspected

A

2-level DVT Wells Score is used to estimate clinical probability of DVT

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10
Q

When would the Wells score indicate DVT is likely

A

DVT likely if 2 points or more

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11
Q

When would the Wells score indicate that DVT is not likely

A

Wells score 1 point or less = DVT not likely

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12
Q

What is D dimer and what is the test

A
  • D dimer is a protein fragment that is made when a blood clot dissolves in the body
  • High D dimer test = may have a blood clot
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13
Q

risk of VTE on admission to hospital

A

all pt to undergo risk assessment to identify their risk of VTE and bleeding on admission

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14
Q

what are the two methods of thromboprophylaxis

A

mechanical
pharmacological

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15
Q

mechanical thromboprophylaxis - what is it and who would you offer it to (2 choices)

A
  • anti-embolism stockings that provide graduated compression and provide calf pressure of 14-15mmHg
  • these should be worn day and night until pt is sufficiently mobile
  • other choice is intermittent pneumatic compression
  • do not offer stockings to pt admitted with acute stroke, or if they have conditions e.g. PAD, peripheral neuropathy, severe leg oedema or local conditions (e.g. gangrene, dermatitis)
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16
Q

pharmacological prophylaxis
- when is it used in most cases
- when to give in pt who are at high risk of bleeding
- considerations for people receiving AC treatment

A
  • when using, in most cases, stat ASAP or within 14h admission
  • pt with RF for bleeding should only receive when their risk of VTE outweighs risk of bleeding (e.g. acute stroke, thrombocytopenia, acquired or untreated inherited bleeding disorders)
  • pt receiving AC treatment who are high risk VTE should be considered for prophylaxis if AC treatment interrupted (e.g. during peri-op period)
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17
Q

which anaesthesia should be used to reduce risk of VTE in surgical patients?

A

regional over GA if possible

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18
Q

which type of prophylaxis should be offered to pt with major trauma or undergoing cranial, abdominal, bariatric, thoracic, maxillofacial, ENT, cardiac or elective spinal surgery?

A
  • mechanical prophylaxis
  • e.g. anti-embolism stockings or intermittent pneumatic compression
  • choice of which depends on factors e.g. type of surgery, suitability for pt, their condition
  • continue prophylaxis until pt sufficiently mobile or discharged from hospital, or for for 30 days in spinal injury, elective spinal surgery or cranial surgery
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19
Q

which type of prophylaxis should be considered for pt undergoing general or orthopaedic surgery when risk of VTE outweighs bleeding risk?

A
  • pharmacological
  • choice depends on type of surgery’s suitability for pt, local policies
  • LMWH suitable in ALL types of general and orthopaedic surgery
  • unfractionated heparin preferred in pt with RI
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20
Q

…… is an option for pt undergoing abdominal, bariatric, thorax or cadmic surgery, or for pt with lower limb immobilisation or fragility fractures of pelvis, hip or proximal femur

A
  • fondaparinux sodium
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21
Q

which drug is preferred for pharmacological prophylaxis in pt with RI

way to remember - give the shorter one

A

unfractionated heparin

UFH is shorter bc 3 letters
LMWH longer

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22
Q

pharmacological prophylaxis in general surgery should usually continue for…

A

at least 7 days post op or until sufficiently mobile

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23
Q

how long should a pt receive pharmacological prophylaxis if they have had major cancer surgery in abdomen

A

28 days

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24
Q

how long should a pt receive pharmacological prophylaxis in pt who have had spinal surgery

A

30 days

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25
Q

when should mechanical prophylaxis with intermittent pneumatic compression be considered?

A
  • when pharmacological prophylaxis is contraindicated in pt undergoing lower limb amputation, or those with major trauma or fragility fractures of pelvis, hip or proximal femur
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26
Q

pt undergoing elective hip replacement should be given thrombopropjhylaxis with
- 3 main options
- 3 alternatives

A
  • either LMWH for 10 days, followed by low dose aspirin for a further 28 days
  • or LMWH for 28 days in combo with anti-embolism stockings until discharged,
  • or rivaroxaban
  • alternatives: apixaban or dabigatran
  • alternative is pharmacological prophylaxis contraindicated: anti embolism stockings until pt is mobile
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27
Q

Patients undergoing an elective knee replacement should be given thromboprophylaxis …. (3 options and 3 alt) w

A
  • Low-dose aspirin for 14 days
  • LMWH for 14 days in combination with anti-embolism stockings until discharge
  • rivaroxaban.

if these options are unsuitable,
apixaban or dabigatran etexilate can be considered as alternatives.

If pharmacological CI intermittent pneumatic compression can be used until the patient is mobile.

28
Q

rivaroxaban dose for prophylaxis of VTE following hip or kneee replacement therapy

A
  • knee: 10mg OD for 2 weeks, to be stated 6-10h after surgery
  • hip: 10mg OD for 5 weeks to be started 6-10h after surgery
29
Q

acutely ill medical patients who are at high risk of VTE should be offered which type of prophylaxis? and what is first line treatment? what is treatment in pt with RI?

A

pharmacological
- 1st line: either LMWH or fondaparinux (alt) for minimum 7 days
- RI: either LMWH or unfractionated heparin, adjust dose as necessary

30
Q

acutely ill medical patients who are at high risk of VTE should be offered pharmacological prophylaxis. but if this is contraindicated, what should you do

A

consider mechanical prophylaxis and continue use until pt sufficiently mobile

31
Q

prophylaxis for pt admitted with acute stroke. how long should it be continued for. what is unsuitable

A
  • mechanical prophylaxis with intermittent pneumatic compression
  • anti-embolism stockings unsuitable!!
  • start within 3 days of acute stroke and continue for 30 days, or until sufficiently mobile, or discharged
32
Q

what is unsuitable in acute stroke

A

anti embolism stockings

33
Q

thromboprophylaxis in pregnancy - who should be considered for pharmacological prophylaxis with LMWH during hospital admission

A
  • all pregnant women (not in active labour), or women who have given birth, had a miscarriage or termination of pregnancy during the past 6 weeks, with a risk of VTE that outweighs the bleeding risk
34
Q

in pregnant women, prophylaxis should be continued until…

A
  • no longer a risk of VTE or until discharge from hospital
35
Q

women who have given birth, has a miscarriage or termination during the past 6 weeks, should start thromboporphylaxis with…. for how long?

A

with LMWH 4-8h after the event (unless contraindicated) for a minimum of 7 days

36
Q

pregnancy: additional mechanical prophylaxis (state which one is first line) should be considered for women who are likely to be immobilised or have significantly reduced mobility and should be continued until ….

A
  • continue until the woman is sufficiently mobile or discharged from hospital
  • 1st line: intermittent pneumatic compression, alt is anti embolism stocking
37
Q

what to do if someone has suspected PE and signs of haemodynamic instability, also state some signs of haemodyanmic instability

A
  • immediately refer for hospital admission
  • signs of haemodynamic instability include pallor, tachycardia, hypotension, shock, collapse
38
Q

non drug treatment for VTE treatment

A
  • elasticated graduation compression stockings may be used to manage leg symptoms after DVT
  • they are not recommended to prevent post-thrombotic syndrome or VTE recurrence after a DVT
  • mechanical interventions (e.g. inferior vena coal filters or percutaneous mechanism thrombectomy) can be considered in certain pt
39
Q

diagnostic investigations cannot be completed or results cannot be obtained within the required timeframe for a pt. what do. you do

A

offer interim therapeutic AC
if possible, choice of interim AC should be one that can be continued if proximal DVT and/or PE confirmed

40
Q

when starting treatment with AC, carry out the following baseline bloods

A

FBC
renal and hepatic function
prothrombin time
activated partial thromboplastin time

41
Q

Pt has confirmed proximal DVT or PE. which ACs would you offer? what if they are unsuitable?

A

either apixaban or rivaroxaban

if unsuitable, offer either

LMWH for at least 5 days followed by dabigatran or edoxaban

or

LMWH concurrently with vit k antagonist for at least 5 days or until INR at least 2.0 for 2 consecutive readings, followed by vit K antagonist on its own

42
Q

The use of unfractionated heparin with a vit K antagonist to treat a confirmed proximal DVT or PE is not routinely recommended unless the pt has

A

RI
established renal failure
increased risk bleeding

43
Q

how long should pt with confirmed proximal DVT or PE should be offered AC treatment for?

A

at least 3 months (3-6 moths if active cancer)

discuss benefits and risks of continuing beyond this with pt

44
Q

when can you consider stopping AC treatment after provoked DVT or PE if the provoking factor no longer present and clinical course has been uncomplicated

A

Consider stopping AC treatment 3 months (3-6 months for those with active cancer)

45
Q

For pt with an unprovoked DVTE or PE consider continuing AC treatment …

A

beyond 3 months (beyond 6 months for active cancer)

discuss with pt their pref and risks of VTE recurrence and bleeding
if low bleeding risk, the benefits of continuing AC are likely to outweigh the risks

46
Q

AC treatment can affect the following 2 tests

A

hereditary thrombophillia
antiphospholipid antibodies

47
Q

can you use predictive risk tools e.g. HASBLED

A

can be considered to assess whether long term AC is appropriate, but relying on them solely is not recommended

48
Q

for people who decline continued AC treatment, consider the unlicensed use of

A

aspirin

49
Q

Women with suspected DVT and/or PE who are pregnant or have given brith during the past 6 weeks should be

A

referred immediately to hosp for assessment and management

50
Q

VTE suspected in pregnancy. What needs to be started immediately

A

LMWH starts immediately for suspected VTE until it is excluded
Continue as maintenance in pt with confirmed DVT or PE

51
Q

vte in pregnancy - routine monitoring of peak anti-Xa activity is recommended for the following women on LMWH

A
  • extremes of body weight (under 50kg or 90kg or more)
  • complicating factors e.g. RI, recurrent VTE
52
Q

in the initial management of DVT in pregnancy, also use this non drug treatment

A

elastic graduated compression stockings should be applied on the affected leg as an additional treatment to manage symptoms such as pain and swelling

53
Q

what should you do in women considered to be high risk of haemorrhage and in whom continued heparin treatment is essential (pregnancy)

A

treat with IV unfractionated heparin until the risk factors for haemorrhage have resolves

54
Q

if VTE occurs at term what should you consider using

A

IV unfractionated heparin

55
Q

pregnant woman has develoepd heparin-induced thrombocytopeonia or is heparin allergic. what to do?

A

manage with alt AC under specialsit advice

56
Q

what is used in the maintenance of extracorporeal circuits in cardiopulmonary bypass and haemodialysis

A

unfractionated heparin

57
Q

what to do if haemorrhage occurs whilst pt on heparin for VTE

A

usually sufficient to withdraw unfractionated or LMWH ,

if rapid reversal of the effects of heparin is required, protamine sulfate is a specific antidote

58
Q

use of protamine sulphate as a specific antidote for unfractionated vs LMWH

A

only partially reverses effects of LMWH!

59
Q

what heparin is preferred in pregnancy

A

LMWH

60
Q

what heparin is preferred in RI

A

UFH

61
Q

what to do if haemorrhage occurs whilst on heparin

A

If haemorrhage occurs it is usually sufficient to withdraw UFH or LMWH , but if rapid reversal of the effects of the heparin is required, protamine sulfate is a specific antidote (but only partially reverses the effects of LMWH).

62
Q

what to do if heparin induced thrombocytopenia occurs

A

If heparin-induced thrombocytopenia is strongly suspected or confirmed, the heparin should be stopped and an alternative anticoagulant, such as danaparoid, should be given. Ensure platelet counts return to normal range in those who require warfarin.

63
Q

heparin induced thrombocytopenia is more likely with

A

UFH

64
Q

what electrolyte disturbance can occur with heparin

A

hyperkalaemia

Inhibition of aldosterone secretion by UFH or LMWH or can result in hyperkalaemia; patients with DM, chronic renal failure, acidosis, raised plasma potassium or those taking potassium-sparing drugs seem to be more susceptible. The risk appears to increase with duration of therapy.

65
Q

monitoring for heparins

A

Platelet counts should be measured just before treatment with unfractionated or low molecular weight heparin, and regular monitoring of platelet counts may be required if given for longer than 4 days (heparin induced thrombocytopenia)

Plasma-potassium concentration should be measured in patients at risk of hyperkalaemia before starting the heparin and monitored regularly thereafter, particularly if treatment is to be continued for longer than 7 days.

Afsha NEW CV (40 decks)

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