VTE Prophylaxis Flashcards
What is a major risk factor for VTE? what do 60% of VTE cases occur from
Current or recent hospitalization
Which patients are 70-80% of fatal PE’s occur in
non-surgical/surgical
non-surgical
How much can anticoagulant prophylaxis reduce the incidence of VTE by?
60%
What is the specific standard to meet for anticoagulation prophylaxis
Medical and surgical clients at risk of VTE that are 18+
What are the steps for individual based assessment for prophylaxis? (3)
- Estimate the individual’s risk of developing VTE
- Estimate the individual’s risk of bleeding
- Determine the appropriate mix of prophylactic methods
- early ambulation
- mechanical (GCS, IPC)
- pharmacologic
What are the steps for group based assessment for prophylaxis?
- use a standardized order set for all patients within a particular group or service
- encouraged by the canadian patient saety initiative CPSI
What are the 2 tools used to estimate the risk of developing VTE
- Statistically validated risk stratification tool
- Modified caprini model - Clinical gestalt (pattern recognition)
- using clinical experience to recognize patient characteristics/circumstances and making decisions based on them
For estimating the risk of bleeding, what consists of a major bleed risk? (4)
- Fatal bleeding
- symptomatic bleeding into a critical area/organ (blood in urine/stool, tender abdomen)
- bleeding that causes a drop in Hemoglobin of 20g/L
- requiring at least 2 units of blood
T/F Bleeding risk scores properly validated for use in surgical patient
False
What are ABSOLUTE contraindications for anticoagulant thromboprophylaxis? (4)
- active bleed
- clinically-important bleeding
- platelets under 30 x 10^9
- major bleeding disorder (hemophilia)
What are Relative contraindications for anticoagulant thromboprophylaxis? (3)
- recent intracranial hemorrhage
- recent perispinal bleeding
- recent high bleeding risk surgery (cardiac, spinal, intracranial, major trauma)
Recent = 1-3 months
What are the appropriate mix of prophylactic methods (3)
- early ambulation
- mechanical (GCS, IPC)
- pharmacologic
What is the effectiveness of early ambulation alone? Benefits? Harms?
No evidence
- immobility is a risk factor so it makes sense to remove it
Benefits:
- decreased length of stay for certain conditions
- improved functional status for older ppl
Harm
- risk of falling if not supervised/assisted or ambulate too early
What is the mechanical method machine called? explain it
Intermittent pneumatic compression (IPC)
- inflatable wraps around leg (just calf or full leg)
- pressure + deflation helps venous return to heart
- helping skeletal pump + valvular pump in the veins (Since veins don’t have muscle in their walls)
Intermittent pneumatic compression (IPC) Effectiveness/harm?
Effectiveness
- reduces the risk of DVT by 55% and PE by 50% compared to no IPC prophylaxis
Harms:
- Discomfort beneath the cuff
- Skin breakdown (avoid in leg ulcers or peripheral artery disease
- nerve damage (rare)
Mechanical method: graduated compression stockings
Effectiveness?
Harms
Effectiveness
- effective for reducing risk of DVT, unsure about PE
- More evidence in surgical patients
Harms
- similar to IPC (discomfort, skin breakdown, nerve damage)
- may worsen arterial blood flow in patients with peripheral artery disease
- possible allergy to material
Disadvantage
- miscellaneous (must be properly fitted by a professional)
Compare efficacy of UFH, LMWH, and fondaparinux
LWMH similar to fondaparinus
- more effective than low dose UFH
LWMH is generally preferred except for? (2)
- Use UFH is renal impairment CrCl <20-30 ml/min or if cost is an issue
- Use Fondaparinux if patient has a history of HIT (can cross react with HIT antibodies in a patient w a history of HIT)
What are the harms for pharmacological therapy? UFH? LWMH?
- all increase the risk of major bleeding
- UFH may cause HIT (heparin induced thrombocytopenia)
- LWMH may cross react with HIT antibodies in a patient w a history of HIT
When do you start thromboprophylaxis? For who?
Non-orthopedic surgery patients
- start 0-2 hours before surgery or 0-12 hours after
What is the duration for VTE prophylaxis?
Moderate-high risk for VTE
- until hospital discharge at least
Major abdominal-pelvic cancer surgery:
- up to 30 days
Who are candidates for mechanical prophylaxis?
All Patients with ABSOLUTE contraindications and most with relative contraindications
Who would benefit from a specialist assessment (eg. thrombosis team)
Patients with a high risk of VTE and a relative contraindication
What does group-based assessment imply?
Adv
Disadv
Implies that low risk patients can still get prophylaxis
Adv
- easy to do (check boxes on sheet)
- systematic (requires clinician to acknowledge)
Disadv
- may lead to overtreatment of low risk patients (possible harm, usually isn’t very harmful)
What do the evidence say about prophylaxis in:
Long-term care/nursing home
No sufficient evidence to use it, associated with harm
- DO NOT USE
What do the evidence say about prophylaxis in:
Cancer-related
YES give only if:
- high risk outpatient for VTE
- no risk factors for bleeding
- no drug interactions
What do the evidence say about prophylaxis in:
Long distance air travel
In patients with increased VTE risk
- recent surgery
- history of VTE
- postpartum women
- active malignancy
OR ≥2 risk factors -> Combinations of the previous with 1. HRT, 2. obesity or 3. pregnancy
- use stockings or LWMH for flight 4 hours or longer
- start 1 hour before flight
Compression stockings are not as efficacious as LWMH for PE
If you want to minimize risk of VTE event: use ?
If you want to minimize risk of bleeding: use ?
If you want to minimize risk of VTE event: use LMWH
If you want to minimize risk of bleeding: use Stockings
