VTE - DVT & PE Flashcards
What is it?
VTE includes PE and DVT. It is basically a blood clot in a vein that partially/fully blocks the blood flow.
Hospital VTE happens within 90 days of hospital admission.
DVT - usually happens in legs or pelvis.
PE - clot usually travels from DVT and obstructs blood flow to lungs.
MUST do VTE risk assessment if patient is in hospital.
Also a bleeding risk as VTE prophylaxis/treatment increases risk of bleeding.
Overview of pathways on phone
PTs at high risk of VTE (EXAM Q)
Surgery,
Trauma,
Significant immobility,
Malignancy,
Obesity,
Acquired/inherited hypercoagulable states,
Pregnancy and the postpartum period,
Hormonal therapy (COC/HRT),
>60
Hx of VTE
Dehydration
Symptoms of DVT/PE
DVT
Unilateral localised pain,
swelling,
tenderness,
skin changes,
and/or vein distension
Warm on touch
PE
chest pain,
shortness of breath,
and/or haemoptysis (blood cough)
VTE prophylaxis
NON-Pharmacological / Mechanical
- Anti embolism stocking - make Calf pressure 14-15 mmHg. Worn day and night till when patient is mobile.
AVOID stocking in PTs with acute stroke or conditions like peripheral arterial disease, peripheral neuropathy, severe leg oedema, or local conditions.
- Foot impulse device
- Intermittent Pneumatic compression.
Pharmacological
Should start ASAP or within 14hrs of admission.
- If PTs NEED VTE prophylaxis. VTE risk needs to outweigh bleeding risk.
PTs on anticoagulant with high risk should be given prophylaxis if anticoagulation is interrupted.
PROPHYLAXIS PATHWAYS
Surgical patients
Use regional anaesthesia over general anaesthesia - reduces VTE risk.
Mechanical given in most types of surgery (continue till patient mobile or discharged)
Pharmacological considered in general/orthopaedic surgery + when VTE risk outweighs bleeding risk.
DRUGS:
LMWH suitable for all but UFH preferred in renal impairment.
ALT fondaparinux.
TIME:
general surgery - 7 day POST OP OR when mobility is back.
28 days after major cancer surgery in stomach and 30 for spine surgery.
ALT Mechanical Intermittent Pneumatic compression when others contraindicated in ppl with major trauma/lower surgery.
ELECTIVE HIP REPLACEMENT:
- LMWH 10 days THEN low dose aspirin 28 days. OR
- LMWH 28 days +Stocking till discharge. OR
- Rivaroxaban ALT apixaban or Dabigatran
IF drugs contraindicated use anti embolism stocking till discharge.
ELECTIVE KNEE REPLACEMENT:
- Low dose Aspirin 14 days. OR
- LMWH 14 days + Stockings. OR
- Rivaroxaban ALT apixaban or Dabigatran.
IF drugs contraindicated use Intermittent Pneumatic compression till mobile.
Medical patients
Acutely ill patients with high risk of VTE should be given drug prophylaxis
1st line - LMWH (Dalteparin, enoxaparin etc). ALT fondaparinux. Minimum 7 days.
RENAL impairment - UFH or LMWH (dose adjusted)
Mechanical when pharmacological contraindicated until PT is mobile.
Acute stroke - Intermittent Pneumatic compression should be considered start with 3 days of stroke and continue for 30 days until patient is mobile or discharge.
VTE treatment
Non pharmacological
To manage symptoms after DVT elastic graduated compression Stockings.
- not given to prevent or post thrombotic syndrome
Mechanical interventions only used sometimes (surgeries)
Pharmacological
B4 giving check contras, patient pref, DO BASELINE blood tests (FBC, renal and hepatic function, prothrombin time & activated partial thromboplastin time)
- Offer interim anticoagulant for PTs who investigation can’t be done or results can’t be gained in time.
CONFIRMED DVT/PE: (R.A.L.E.D)
1st line - Rivaroxaban or Apixaban
ALT
- LMWH at least 5 days THEN Edoxaban or Dabigatran
OR
- LMWH with Vit k antagonist at least 5 days or when INR is at least 2 in consecutive readings THEN Vit K antagonist ALONE.
RENALLY impaired treatment
Approx. CrCl 15-50 ml/min + confirmed VTE offer one of:
Same as above
BUT to use dabigatran (CrCl must be 30/+) or
For LMWH and Vit K option (last 1) can chose LMWH or UFH.
VTE in pregnancy
Prophylaxis
Consider LMWH during hospital admission for women who VTE risk outweighs bleeding risk and is pregnant but not in active labour or given birth or had miscarriage or abortion past 6 weeks.
Continue until VTE risk is gone/discharge.
But women who gave birth, miscarriage or abortion during past 6 weeks should start LMWH 4-8 hrs after event for 7 days unless unsuitable.
Mechanical can also be given ie stocking or compression.
Treatment
Refer immediately pregnant or given birth in past 6 weeks if sus VTE.
- B4 starting drugs do baseline blood tests (FBC, coagulation screen, U&E, LFT)
LMWH ASAP for sus VTE until excluded.
Continue if confirmed VTE.
- HIT pregnant women - Refer to specialist
NOTE:
- LMWH preferred - dont cross placenta and lower risk of osteoporosis an HIT (hep indu thro).
- LMWH eliminated FASTER in pregnancy so DOSE adjustment needed.
- Extreme body weight <50 or >90 kg or complicating factor (renal impairment) routinely measure peak anti Xa activity.
DVT use elastic stocking too - reduces symptoms
Women with haemorrhage risk (bleeding risk) use IV UFH until risk factor for haemorrhage resolved.
ALT specialist.
Extracorporeal circuits/ Haemorrhage
E circuits:
UFH used in maintenance in cardiopulmonary bypass and haemodialysis.
HAEMORRHAGE
if occurs withdraw UFH or LMWH BUT if rapid reversal required use protamine sulfate.
Duration of Treatments (EXAM Q)
Confirmed proximal VTE:
Anticoagulation at least 3 months (3 to 6 in active cancer).
- {Proximal (located in femoral-thigh, illia-abdomen veins)}
Provoked VTE:
3months (3-6 active cancer)
- Can stop after 3 months if provoking factor is gone and course was uncomplicated.
- Alert patient of what to look out for in case of another VTE.
Unprovoked VTE:
Can continue >3 months (>6 active cancer).
- Discuss with patient and see bleeding/VTE risk.
For long-term, continue on initial anticoagulant unless issues arise or patient prefer change
- Switch to Apixaban.
Consider aspirin if they decline continued anticoagulation.
Patients on long term Anticoagulation/Aspirin review each year health and VTE/Bleeding risk.
Side effects of Anticoagulants
Most common AE - Bleeding/ Haemorrhage.
Withdraw from LMWH or Heparin if haemorrhage occurs.
PROTAMINE sulfate - Antidote to reverse Heparin effects. (Only partially reverses effects of LMWH)
