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.
Risk factors: surgery, trauma, significant immobility, malignancy, obesity, acquired/inherited hypercoagulable states, pregnancy and the postpartum period, and hormonal therapy (COC/HRT).
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.
Symptoms of DVT/PE
DVT
Unilateral localised pain,
swelling,
tenderness,
skin changes,
and/or vein distension.
PE
chest pain,
shortness of breath,
and/or haemoptysis (blood cough)
VTE prophylaxis
NON-Pharmacological / Mechanical
Anti embolism stocking - make Calf pressure 14 to 15 mmHg. Worn day and night till when patient is mobile.
Don’t give stocking to ppl 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 patient has risk factors that cause them to need VTE prophylaxis, their VTE risk needs to outweigh bleeding risk.
Ppl on anticoagulant with high risk should be given prophylaxis if anticoagulation is interrupted.
Surgical patients
Use regional anaesthesia over general anaesthesia to reduce VTE risk.
Mechanical given in most types of surgery.
Pharmacological considered in general or orthopaedic surgery and 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.
Mechanical Intermittent Pneumatic compression is ALT 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
- Rivoroxaban
ALT apixaban or Dabigatran
IF drugs contraindicated use anit embolism stocking till discharge.
ELECTIVE KNEE REPLACEMENT:
- Low dose Aspirin 14 days. OR
- LMWH 14 days + Stockings. OR
- Rivoroxaban.
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 pharmacological prophylaxis.
1st line - LMWH (dalteparin, enoxaparin etc). ALT fondaparinux. Minimum 7 days.
RENAL impairment - UFH or LMWH (dose adjusted)
Mechanical done when pharmacological contraindicated untill patient 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 another DVT or post thrombotic syndrome
Mechanical interventions only used sometimes (surgeries)
Pharmacological
B4 giving check contras patient pref etc DO BASELINE blood tests (FBC, renal and hepatic function, prothrombin time and activated partial thromboplastin time)
CONFIRMED DVT/PE
1st line -Apixaban or Rivoroxaban
ALT - LMWH at least 5 days THEN Dabigatran or edoxaban 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 of 15 - 50 ml/min + confirmed VTE offer one of:
- Apixaban
- Rivaroxaban;
- LMWH for min 5 days THEN dabigatran (if Crcl 30 or +) or edoxaban
- LMWH or UFH together with a vit K antagonist for at least 5 days or when INR is at least 2.0 for consecutive readings, THEN vit K antagonist ALONE.
Duration of anticoagulation treatment and long-term anticoagulation for secondary prevention
Confirmed VTE should be offered anticoagulation for at least 3 months (3 to 6 in active cancer). Discuss with patient pref etc.
Consider stopping anticoagulation after 3 months (3-6 active cancer) after provoked VTE if provoking factor is gone and course was uncomplicated.
Alert patient of what to look out for in case of another VTE.
Consider continuing after 3 months (6 active cancer) for unprovoked VTE.
Discuss with patient and see bleeding/VTE risk.
For long-term, continue on intial anticoagulant unless issues arise or patient prefer change switch to apixaban.
Consider aspirin if they decline continued anticoagulation.
Patients on long term review each year health and VTE/Bleeding risk.
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 untill VTE risk is gone or 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 women if sus VTE.
B4 starting drugs do baseline blood tests (FBC, coagulation screen, U&E, LFT)
LMWH ASAP for sus VTE until excluded and continue if confirmed VTE.
Extreme body weight <50 or >90 kg or complicating factor (renal impairment) measure peak anit Xa activity.
DVT use stocking also
Women with hemorrhage risk (bleeding risk) use IV UFH timm risk factor for haemorrhage gone.
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.
