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Year 3 - Preparation for Clinical Practise > VTE > Flashcards

VTE Flashcards

1
Q

When should a VTE assessment be carried out

A
  • be carried out on admission to hospital for all patients above 16 years old
  • ## should then be repeated 24 hours after admission or with change or condition
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2
Q

What are the major VTE risk factors

A
  • Cancer -r isa of VTE is 4x higher in cancer patients than in the general population
  • significant immobility - compared to normal activity, due to bed rest (>5 days) or hospitalisation, bed rest accounts for 28% of cases of confirmed PE
  • pregnancy - the risk of antenatal VTE is 4-5x higher in pregnant women than in non pregnant women of the same age
  • previous VTE - 30% of patients with a previous VTE have a recurrence in the next 10 years
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3
Q

What are the major VTE risk factors

A
  • Cancer - risk of VTE is 4x higher in cancer patients than in the general population
  • significant immobility - compared to normal activity, due to bed rest (>5 days) or hospitalisation, bed rest accounts for 28% of cases of confirmed PE
  • pregnancy - the risk of antenatal VTE is 4-5x higher in pregnant women than in non pregnant women of the same age
  • previous VTE - 30% of patients with a previous VTE have a recurrence in the next 10 years
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4
Q

Name some examples of low molecular weight heparin

A
  • enoxaparin
  • dalteparin
  • tinzaparin
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5
Q

How does low molecular heparin work

A
  • LMWH binds to antithrombin

- this inhibits activated factor X and therefore reduces the conversion of prothrombin to thrombin

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6
Q

How is LWMH given

A
  • given subcutaneously for VTE prophylaxis as a fixed dose
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7
Q

how can LWMH be reduced

A
  • protamine sulphate
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8
Q

what are the risks of LMWH

A
  • heparin induced thrombocytopenia (HIT)

- osteoporosis

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9
Q

what is the difference between LMWH and unfractionated heparin

A
  • unfractionated heparin has a higher molecular weight compared to LMWH
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10
Q

How does unfractionate heparin work

A
  • UFH binds to antithrombin to inactivate factor Xa and prevent the conversion of prothrombin to thrombin
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11
Q

What reverses unfractionate heparin

A
  • reversed by protamine sulphate
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12
Q

How does fondaparinux work

A
  • fondaparinux is a synthetic drug which binds with antithrombin to enhance factor Xa inhibition
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13
Q

Name some DOCAs

A
  • rivaroxaban
  • dabigatran
  • apixaban
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14
Q

How do apixaban and rivaroxaban work

A
  • these are oral selective direct factor Xa inhibitors - rivaroxaban can be used for prophylaxis in adults having hip or knee replacement surgery
  • apixaban can be used post hip or knee surgery
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15
Q

how does dabigatran work

A
  • dabigatran is converted to the active dabigatran by hydrolysis
  • it is a direct thrombin inhibitor
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16
Q

How is APPT affected by VTE prophylaxis

- Heparin

A
  • heparin can prolong APPT time

- dabigatran can prolong APPT but it does not coordinate with the concentration of dabigatran

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17
Q

How is prothrombin affected by VTE prophylaxis

A
  • Rivaroxaban can prolong PT/INR
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18
Q

What does PT measure

A
  • extrinsic and common coagulation pathway
19
Q

What does APPT measure

A

intrinsic and common coagulation pathway

20
Q

What does thrombin time measure

A
  • measures the conversion of fibrinogen to firkin by the action of thrombin
21
Q

What prolongs the thrombin time

A
  • Dabigatran and heparin
22
Q

What is Anti-FXa used to measure

A
  • this can be used to measure the activity of heparin or the factor Xa inhibitors int he plasma
23
Q

What is the downside of Anti-FXa

A
  • difficult to interpret in obese, malnourished and pregnant patients
24
Q

What should be avoided for VTE prophylaxis

A
  • apixaban, ribaroxaban - should be avoided if creatinine clearance is <15 mL/min
  • a dose reduction may be required if the creatinine clearance is <50mL/min
  • dabigatran - should be avoided if the creatinine clearance is <30 mL/min, a dose reduction may be required if the creatinine clearance is < 50mL/min
25
Q

What should be avoided for VTE prophylaxis in kidney damage

A
  • apixaban, ribaroxaban - should be avoided if creatinine clearance is <15 mL/min
  • a dose reduction may be required if the creatinine clearance is <50mL/min
  • dabigatran - should be avoided if the creatinine clearance is <30 mL/min, a dose reduction may be required if the creatinine clearance is < 50mL/min
26
Q

How do anti-embolic stockings work

A
  • compress the muscles in the calves to improve venous return
  • they are fitted to size
  • should be placed below the knees to promote maximal calf compression
27
Q

How to intermittent pneumatic compression device work (IPC)

A
  • an air pump inflates and deflates the sleeves to improve venous return in the lower limb
  • mimicking the natural venous return when the leg muscles contract
  • used for immobile patients
28
Q

Who should not have anti embolism stockings

A
  • severe leg oedema
  • allergy to material
  • suspected or proven peripheral arterial disease
  • peripheral arterial bypass grafting
  • peripheral neuropathy or other causes of sensory impairment
  • any conditions where stockings may cause damage such as fragile skin or dermatitis
  • major limb deformity or unusual leg size or shape preventing correct fit
29
Q

describe when VTE stockings can be used

A
  • should be worn day and night until a patient has no longer reduced mobility
  • removed daily to check skin integrity
  • may not be suitable for all patients
  • can be given to pregnant women
30
Q

What should you check pre prescription for VTE prophylaxis

A
  • patients weight
  • full blood count
  • clotting screen
  • kidney function
  • liver function
31
Q

what are the absolute contraindications to VTE prophylaxis

A
  • active bleeding
  • hypersensitivity to the drug
  • newly diagnosed heparin induced thrombocytopenia
32
Q

What are the relative contraindications to VTE prophylaxis

A
  • known bleeding disorder
  • platelets < 50x109/L
  • peptic ulcer disease and/or oesophageal varices
  • Severe hypertension
  • Severe renal failure
  • recent cerebral haemorrhage
  • coagulopathy
  • major trauma or recent neurosurgery or eye surgery
  • past history of HIT
  • spinal or epidural anaesthesia
33
Q

describe what makes up a wells score

A
  • clinical signs and symptoms of a DVT = 3
  • an alternate diagnosis is less likely than PE = 3
  • heart rate >100 beats per minute = 1.5
  • heart rate is >100bpm = 1.5
  • immobilisation for more than 3 days or surgery in the previous 4 weeks = 1.5
  • previous DVT/PE = 1.5
  • Haemoptysis = 1
  • malignancy (on treatment, treated in the last 6 months or palliative) = 1
34
Q

What does the wells score have to be higher than in order to cause a PE

A
  • if greater than 4 = PE likely

- if less than 4 = PE unlikely

35
Q

What do you do if a PE is unlikely

A

D dimer

  • if D dimer negative consider an alternative diagnosis
  • If D dimer positive consider a CPTA
36
Q

What do you do if a PE is likely

A
  • Immediate CTPA
37
Q

What do you do if a CTPA cannot be performed

A
  • interim LMWH whilst waiting for one

- might be a state dose or written regular if there is a longer delay

38
Q

What can be found on an ECG with a PE

A
  • Sinus tachycardia
  • right ventricular strain pattens - T wave inversion in V1-V4 and inferior leads
  • right bundle branch block
  • right axis deviation
  • S1Q1T3 pattern - Deep S wave in lead 1, Q wave in III, and inverted T wave in III - sign of acute cor pulmonale
39
Q

What is an embolus

A
  • an embolus is any intravascular material that has migrated from its original location to block another vessel
40
Q

What is Virchow’s triad

A
  • three factors that can lead to thrombus formation
41
Q

What makes up Virchow’s triad

A
  • venous stasis
  • trauma
  • hypercoagulability
42
Q

What is an unstable PE

A
  • hypotensive (systolic blood pressure <90mmHg)
  • have a drop in the SBP of 40mmhg from baseline for 15 minutes
  • require inotropes for management of their hypotension
43
Q

how should an unstable PE be measured

A
  • thrombolysis
44
Q

name the types of thrombolysis used in an unstable PE

A
  • surgical embolectomy
  • catheter directed Treatment
  • venous filter

Year 3 - Preparation for Clinical Practise (33 decks)

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