• Prophylaxis

• Diagnosis

• Treatment

Venous Thromboembolism Management

Spectrum of Venous Thromboembolism

Biologiconset Asymptomatic Symptomatic Outcome Death

Recovery

Disability

Primaryprophylaxis

Screening Clinical suspicion

Treatment

Management

“Pulmonary embolism remains the most common preventable cause of death in the hospital.”

Hull

1986

Venous Thrombosis ProphylaxisRisk Factor Equivalents

1 Factor

Age 40-59

Bed confinement >48 hrs

Varicose veins

Leg edema/ulcer/statis

Obesity (>20% ideal wt.)

MI (current)

CHF (current)

Severe COPD

Crystalliods (>5L/24 hrs)

Confining travel >4hrs

Pregnancy/postpartum (1 month)

Inflammatory bowel disease

Severe infection

Estrogen Rx

Operation >2 hrs

Venous Thrombosis Prophylaxis

Risk Factor Equivalents

2 Factors

Age > 60

Stroke (current)

Trauma

Pelvic operation

Joint replacement

Hip fracture

Malignancy

Pelvic/long bone fracture

Hypercoag. state

Hx DVT/PE

Spinal Cord Injury

3 Factors

Venous Thrombosis RiskWithout Prophylaxis

1-5%40-80%>6Highest

0.5-1.0%30-40%4-5High

0.1-0.5%10-30%2-3Moderate

<0.01%<10%0-1Low

PE DVT*Risk Factor

EquivalentsRisk

OutcomeRisk Profile

Modified from: Geerts W et al CHEST 2001

* Includes calf DVT

• Bioavailability of LMWH – Reduced HIT

• Fondaparinux results– 50% reduction VTE (ortho patients)– Reduced HIT

• Intermittent pneumatic compression– Mechanical venous velocity– Alters coagulation– More effective w/ GCS

Considerations / Observations Considerations / Observations VTE Prophylaxis

1. Prophylaxis is effective…Should be considered in all patients

2. Pharmacotherapy: consider renal function– LMWH (enoxaparin)– Fondaparinux

3. Mechanical methods– Stockings (8 -15 mm Hg) plus IPC– Risk of bleeding

– Combined w/pharmacoRx in high and highest risk patients

Considerations / Observations Considerations / Observations

VTE Prophylaxis

4. Caution with pharmacoRx in patients undergoing neuraxial anesthesia

5. Post-discharge prophylaxis should be considered in patients with continuing high risk

6. Aspirin alone as prophylaxis…

…NOT RECOMMENDED!

4. Caution with pharmacoRx in patients undergoing neuraxial anesthesia

5. Post-discharge prophylaxis should be considered in patients with continuing high risk

6. Aspirin alone as prophylaxis…

…NOT RECOMMENDED!

Considerations / Observations Considerations / Observations Considerations / Observations Considerations / Observations VTE Prophylaxis VTE Prophylaxis

VTE Prophylaxis VTE Prophylaxis

Recommendations Recommendations Recommendations Recommendations

RiskRisk RecommendationRecommendation

Ambulation (all pts)Ambulation (all pts)

IPC/GCS or,

UFH 5000 SQ q 12 hrs or,

Enoxaparin 40mg SQ daily

IPC/GCS or,

UFH 5000 SQ q 12 hrs or,

Enoxaparin 40mg SQ daily

IPC/GCS plus…

UFH 5000U SQ q 8 hrs; or

Enoxaparin 40 mg SQ daily or

Enoxaparin 30mg SQ q 12 hrs

Fondaparinux 2.5 mg SQ daily

IPC/GCS plus…

UFH 5000U SQ q 8 hrs; or

Enoxaparin 40 mg SQ daily or

Enoxaparin 30mg SQ q 12 hrs

Fondaparinux 2.5 mg SQ daily

IPC/GCS plus…

UFH 5000 SQ q 8 hrs

Enoxaparin 40mg SQ daily

Enoxaparin 30mg SQ q 12 hrs

IPC/GCS plus…

UFH 5000 SQ q 8 hrs

Enoxaparin 40mg SQ daily

Enoxaparin 30mg SQ q 12 hrs

Low (0-1)Low (0-1)

Moderate (2-3)

Moderate (2-3)

High (4-5)High (4-5)

Highest(>6)

Highest(>6)