vte prevention in action interactive case scenarios
DESCRIPTION
VTE Prevention In Action Interactive Case Scenarios. Dr Raj Patel. King’s Thrombosis Centre. Consultant Haematologist. [email protected]. Patient 1: Elective THR. 78 - year - old woman, osteoarthritis Elective THR BMI 31kg/m 2 , weight 93kg DVT post-partum. - PowerPoint PPT PresentationTRANSCRIPT
VTE Prevention In Action
Interactive Case Scenarios
Patient 1: Elective THR
• 78-year-old woman, osteoarthritis
• Elective THR
• BMI 31kg/m2, weight 93kg• DVT post-partum
Patient 1:VTE Risk Assessment
0
4
71
1. Low risk of VTE
2. 2: Moderate risk of VTE
3. 3: High risk of VTE
Patient 1:Who performs VTE risk assessment (elective patient)?
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0
1
1
2
0
0
1. At surgical pre-assessment clinic by nurse
2. At surgical pre-assessment clinic by anaesthetist
3. At surgical pre-assessment clinic by surgeon
4. On day of admission by nurse
5. On day of admission by junior doctor
6. On day of admission by anaesthetist
7. Other (eg ward pharmacist)
Patient 1:High Risk of VTE
• Major orthopaedic procedure
• Additional risk factors for VTE?– > 60 years old – Anticipated immobility 3 days– BMI above 30 kg/m2
– Previous VTE
ACCP, 2008
ACCP, 2008
ACCP, 2008
Patient 1: Treatment
Is mechanical or pharmacological
thromboprophylaxis contraindicated?
Patient 1: Treatment choices-Mechanical Thromboprophylaxis
0
10
1
3
59
1. None
2. Full-length Anti-Embolism Stockings only
3. Knee-length Class II Graduated Compression Stockings only
4. Sequential Compression Device only
5. Anti-Embolism Stocking plus Sequential Compression Device
Patient 1: Treatment choices-Pharmacological Thromboprophylaxis
0
41
7
8
23
1. None (mechanical device only)
2. LMWH commencing before or after surgery
3. Fondaparinux
4. Dabigatran
5. Rivaroxaban
Patient 1:Other treatment choices?
1
2
5
59
1. Tranexamic acid
2. Aspirin
3. Warfarin
4. None of the above
ACCP 2008: THR guidance
•LMWH
(12hrs preop, 12-24hrs postop, 4-6hrs postop 50%)
•Fondaparinux (2.5mg, 6-24hrs postop)
•VKA
•Mechanical device alone: only if bleeding risk high
Value of Mechanical Thromboprophylaxis?
•No bleeding (useful when bleeding risk high)
•May enhance effectiveness of pharmacological thromboprophylaxis
•Big variation in size/pressure/features
- many brands not assessed in trials
- fitting/compliance poor on wards
•Fewer/smaller studies
- effect on reducing PE/death unknown
- less effective in high risk groups
- no study in medical inpatients
ACCP 2008:Mechanical Thromboprophylaxis
• Recommend primarily where bleeding risk high (1A) or as adjunct to pharmacological measure (2B)
• Careful attention to proper use and compliance ‘optimal use’
RegimenRegimen No. trialsNo. trials No. No. patientspatients
No. DVT No. DVT patientspatients
Incidence Incidence %%
Risk Risk reduction reduction
%%
ControlsControls 5454 43104310 10841084 2525 ----
AspirinAspirin 55 372372 7676 2020 2020
StockingsStockings 33 196196 2828 1414 4444
Low-dose Low-dose heparinheparin
4747 1033910339 784784 88 6868
LMWHLMWH 2121 93649364 595595 66 7676
IPCIPC 22 132132 44 33 8888
Prevention of DVT after general surgery Prevention of DVT after general surgery (ACCP 2001)(ACCP 2001)
ACCP 2008: Aspirin
1.4.4 We recommend against the use of aspirin alone as thromboprophylaxis against VTE for any patient group (1A).
Patient 1: Treatment
• LMWH (preop) or oral agent (postop) once daily
Plus
• Graduated compression stockings and/or SCD
Patient 1: Pharmacological Thromboprophylaxis –for how long?
1
1
23
57
1. None given
2. Until hospital discharge
3. 10 post-op days
4. 28-35 post-op days
ACCP: beyond 10 days, up to 35 days (1A)
Patient 1:Pharmacological Thromboprophylaxis –for how long?
Epidurals
ACCP: – insertion of spinal/epidural needle delayed
8-12 hrs following prophylactic heparin dose– removal scheduled just prior to next dose– following epidural removal, delay next dose
by > 2 hrs
• Dabigatran: not recommended
Clinical presentation of Clinical presentation of HITHIT
• ThrombocytopeniaThrombocytopenia• Timing of thrombocytopeniaTiming of thrombocytopenia• Thrombosis / other sequelaeThrombosis / other sequelae• oTher cause unlikelyoTher cause unlikely
Patient 2: Gynaecological surgery
• 63-year-old woman
• Uterine carcinoma
• Weight 135kg, BMI 38 kg/m2
• Abdominal hysterectomy
Patient 2: VTE risk assessment
• Major gynaecological procedure
• Additional risk factors for VTE?– > 60 years old – Anticipated immobility 3 days– BMI 38 kg/m2
– Malignancy
Patient 1: Treatment
Is mechanical or pharmacological
thromboprophylaxis contraindicated?
Patient 2: Treatment choices-Mechanical Thromboprophylaxis
2
9
3
3
49
15
1. None
2. Anti-Embolism Stockings only
3. Class II Graduated Compression Stockings only
4. Sequential Compression Device only
5. Anti-embolism stocking plus Sequential Compression
6. Class II Graduated Compression Stockings plus Sequential Compression
Patient 2: Treatment choices-Pharmacological Thromboprophylaxis
1
69
1
7
2
1. None (mechanical device only)
2. Prophylactic LMWH
3. Dabigatran
4. Rivaroxaban
5. Warfarin (INR 2-3) post-op
Patient 2: 135 kg - What dose of LMWH
23
16
33
3
1. : Standard once daily dose (e.g. enoxaparin 40mg daily)
2. : Increased dose once daily (e.g. enoxaparin 60-80mg daily)
3. : Standard dose, increased frequency (eg enoxaparin 40mg twice daily)
4. : Increased frequency and dose (eg enoxaparin 60mg twice daily)
Patient 2: Pharmacological Thromboprophylaxis – duration?
0
9
18
43
8
1. None given
2. Until discharge
3. 10 post-op days
4. 28-35 days
5. Until in remission
Gynaecologic surgery guidance (ACCP 2008)
•Minor procedures without ARFs: early ambulation only
•Laparosopic procedures
- without ARFs: early ambulation
-with ARFs: LMWH or LDUFH or IPC or GCS (1C)
•Major procedures:
-Benign disease: LMWH (1A) or LDUFH (1A) or IPC (1B)
-Malignancy: consider LMWH 28 days
•Bariatric surgery: higher doses LMWH or UFH suggested (2C)
Patient 3: Neurosurgery and Spinal Procedures
• 71-year-old woman
• Elective spinal procedure (disc prolapse)
• Smoker
• Varicose veins
• FV Leiden mutation heterozyous
ACCP, 2008
Patient 3:VTE Risk Assessment
0
18
51
1. Low risk of VTE
2. Moderate of VTE
3. High risk of VTE
Patient 3: Risk Assessment for VTE
• Major spinal procedure
• Additional risk factors for VTE?– > 60 years old – Anticipated immobility 3 days– FV Leiden
Patient 3: Treatment
Is mechanical or pharmacological
thromboprophylaxis contraindicated?
Patient 3: Treatment choicesMechanical Thromboprophylaxis
0
2
2
3
68
1. None
2. Anti-Embolism Stockings only
3. Class II Graduated Compression Stockings only
4. Sequential Compression Device only
5. Anti-embolism stocking plus Sequential Compression
Patient 3: Treatment choicesPharmacological Thromboprophylaxis
27
41
0
1
1
1. None: mechanical device only
2. LMWH
3. Dabigatran
4. Rivaroxaban
5. Warfarin post-op
Patient 3: Pharmacological Thromboprophylaxis – duration?
9
20
20
25
1. None given
2. Until discharge
3. 10 post-op days
4. 28-35 days
Elective spinal surgery guidance (ACCP 2008)
•No ARFs: early ambulation (2C)
•With ARFs: either
•Post op LMWH (1B)
•LDUFH (1B)
•Periop IPC (1B) or GCS (2b)
•With multiple ARFs: pharmacologic plus mechanical (2C)
Defining the ComplexMedical Patient
• . . . A patient you would give LMWH to, but for some reason you feel uncomfortable . . .
• . . . A patient who would benefit from LMWH but may have a contraindication . . .
Patient 4
• 74-year-old woman, 15-year history of type 2 diabetes
• Peripheral neuropathy (feet), leg ulcers
• BMI 33 kg/m2, 92kg
• Admitted with unilateral lower limb cellulitis, immobility, high BMs
• Treated with insulin, hydration and intravenous antibiotics
Patient 4:VTE Risk Assessment
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69
1. Low risk of VTE
2. High risk of VTE
Patient 4: Treatment
Is mechanical or pharmacological
thromboprophylaxis contraindicated?
Patient 4: Treatment choicesMechanical Thromboprophylaxis
55
5
1
6
1
0
1. None
2. Anti-Embolism Stockings only
3. Class II Graduated Compression Stockings only
4. Sequential Compression Device only
5. Anti-embolism stocking plus Sequential Compression
6. Class II Graduated Compression Stockings plus Sequential Compression
Patient 4: Treatment choicesPharmacological Thromboprophylaxis
62
12
1
1
2
1. Prophylactic dose LMWH
2. Low dose unfractionated heparin
3. Dabigatran
4. Rivaroxaban
5. Warfarin
Patient 4: Risk Assessment for VTE
• > 40 years old with acute medical illness and reduced mobility?– Yes
• Additional risk factors– age > 70 years– infection– BMI 33 kg/m2
KCH guidelines for medical thromboprophylaxis
Patient 4: Pharmacological Thromboprophylaxis –for how long?
0
32
13
12
16
1. None given
2. Until discharged
3. 10 days
4. 28-35 days
5. Until fully mobile
Clear Benefits of Thromboprophylaxis over
Placebo
MEDENOX1 63% Placebo
Enoxaparin 40 mg
PREVENT2 49% Placebo
Dalteparin
ARTEMIS3 47% Placebo
Fondaparinux
14.9*
5.5
Study RRR Thromboprophylaxis Patients with VTE (%)
5.0*
2.8
10.5†
5.6
*VTE at day 14; †VTE at day 15.
P<0.001
P=0.0015
P=0.029
RRR
63%
45%
47%
Primary Efficacy Endpoints: Implications for Clinical Practice
MEDENOX1 Distal and proximal 63%venographic DVT+ symptomatic VTE+ fatal PE
PREVENT2 Compression 45%ultrasonographic DVT+ symptomatic VTE+ fatal PE
ARTEMIS3 Distal and proximal 47%venographic DVT+ symptomatic VTE+ fatal PE
Trial VTE RRR NNTNumber needed to treat – justifies
thromboprophylaxis
10
45
20
Patient 4
• 74-year-old woman, 15-year history of type 2 diabetes, diet controlled
• Peripheral neuropathy (feet), leg ulcers• BMI 33kg/m2
• Admitted with unilateral lower limb cellulitis, immobility, and high BMs
• Treated with insulin, hydration and intravenous antibiotics
Patient 4:Platelet count 110x109/L (Not bleeding)
10
39
12
5
1. Withhold LMWH
2. Prophylactic dose LMWH (eg enoxaparin 40mg)
3. reduced dose LMWH (eg enoxaparin 20mg)
4. UFH
Patient 4:Platelet count 110x109/L (Not bleeding)
• Mild asymptomatic thrombocytopenia
• Seek haematology advice?
• No adjustment in prophylaxis
Patient 4:Platelet count 20x109/L (Not bleeding)
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1
9
7
1. withhold LMWH
2. prophylactic dose LMWH (eg enoxaparin 40mg)
3. reduced dose LMWH (eg enoxaparin 20mg)
4. UFH
Patient 4:Platelet count 20x109/L (not bleeding)
• Significant unexplained thrombocytopenia
• Seek haematology advice
• Withhold LMWH
Patient 4
• 74-year-old woman, 15-year history of type 2 diabetes, diet controlled
• Peripheral neuropathy (feet), leg ulcers• BMI 33kg/m2
• Admitted with unilateral lower limb cellulitis, immobility, and high BMs
• Treated with insulin, hydration and intravenous antibiotics
Patient 4:Creatinine 156 micromol/L (60–120)CC 40mls/min
11
32
14
11
3
1. omit LMWH
2. standard dose LMWH (eg enoxaparin 40mg)
3. reduced dose LMWH (eg enoxaparin 20mg)
4. UFH 5000u twice daily
5. UFH 5000u three times daily
Patient 4:Drug monitoring required?
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7
3
16
4
0
1. no
2. APTR
3. anti-Xa level 1hr post dose
4. anti-Xa level 3-4hrs post dose
5. anti-Xa level pre-dose (trough level)
6. INR
Patient 4:
Mild renal impairment
ACCP:
- consider renal function with LMWH
- elderly, diabetics, high bleeding risk
Patient 4:Mild renal impairment
ACCP options:
-avoid drugs which bioaccumulate
-lower dose
-monitor drug level or anticoagulant effect
1. UFH
2. LMWH reduced dose
3. LMWH standard dose with anti-Xa monitoring if prolonged use
Patient 4
• 74-year-old woman, 15-year history of type 2 diabetes
• Peripheral neuropathy (feet), leg ulcers• BMI 33kg/m2
• Admitted with unilateral lower limb cellulitis, immobility, and high BMs
• Treated with insulin, hydration and intravenous antibiotics
Patient 4:Creatinine 256 micromol/L (60–120)CC <20mls/min
12
1
26
27
4
1. omit LMWH
2. standard dose LMWH (eg enoxaparin 40mg)
3. reduced dose LMWH (eg enoxaparin 20mg)
4. UFH 5000u twice daily
5. UFH 5000u three times daily
Patient 4 :Drug monitoring required?
2
3
0
1
1. No
2. APTR
3. INR
4. anti-Xa level 3-4hrs post dose
Patient 4: Severe renal impairment options:
-avoid drugs which bioaccumulate -lower dose-monitor drug level or anticoagulant effect
UFH
Patient 4: BMI=16 kg/m2
• 74-year-old woman, 15-year history of type 2 diabetes, diet controlled
• Peripheral neuropathy (feet), leg ulcers
• BMI 16 kg/m2
• Admitted with unilateral lower limb cellulitis, immobility, and high BMs
• Treated with insulin, hydration and intravenous antibiotics
Patient 4: BMI=16 kg/m2
• Very low body weight patient
• Would you change LMWH prophylaxis?
Patient 4: BMI=16 kg/m2
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0
0
1. Give LMWH standard prophylactic dose
2. Give LMWH standard prophylactic dose and monitor anti-Xa
3. Reduce LMWH dose
4. UFH 5000u twice daily
5. No heparin
Patient 4 : very elderly
• 98-year-old woman, 15-year history of type 2 diabetes, diet controlled
• Peripheral neuropathy (feet), leg ulcers
• BMI 33kg/m2
• Admitted with unilateral lower limb cellulitis, immobility, and high BMs
• Treated with insulin, hydration and intravenous antibiotics
Patient 4 : very elderly
• Would you change LMWH prophylaxis?
Patient 4 : very elderly
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0
24
0
5
3
1. Continue LMWH
2. Increase LMWH dose
3. Reduce LMWH dose
4. UFH 5000u three times daily
5. UFH 5000u twice daily
6. Stop heparin
Patient 5
• 66-year-old man admitted with acute exacerbation of COPD
KCH guidelines for medical thromboprophylaxis
Patient 5: Risk Assessment for VTE
• > 40 years old with acute medical illness and reduced mobility?– yes
• Additional risk factors– respiratory disease/acute infectious
disease
• Is pharmacological thromboprophylaxis contraindicated?– no
Patient 5: Treatment
• LMWH: enoxaparin 40 mg s.c. daily
• AES
Patient 5: Very urgent arterial blood gas
– would you change LMWH prophylaxis?
Patient 5 :Very Urgent Arterial Blood Gas
4
25
2
4
3
1. Reduce LMWH dose
2. Continue LMWH and press long/hard
3. UFH
4. Stop heparin altogether
5. Delay procedure for 12-24hrs following last LMWH dose
Patient 5:Needs non-urgent Central Venous Line
– would you change LMWH treatment?
Patient 5: Non-Urgent Central Venous Line
3
1
9
2
44
1. Reduce LMWH dose
2. UFH 5000u three times daily
3. Continue LMWH and press long/hard
4. Stop heparin altogether
5. Delay procedure for 12-24hrs following last LMWH dose
Patient 5:Ultrasound guided liver biopsy
– would you change LMWH prophylaxis?
Patient 5:Ultrasound guided liver biopsy
4
1
2
18
47
1. Reduce LMWH dose
2. UFH 5000u three times daily
3. Continue LMWH
4. Stop heparin altogether
5. Delay procedure for 24hrs following last LMWH dose
Patient 5: HIT?
• 6 days after admission his platelet count falls to 70x109/L and the next day is 30x109/L
• You are asked if this is ‘heparin-induced thrombocytopenia’
Patient 5: Falling platelets, HIT?
1
0
71
1
1. UFH infusion
2. Increase LMWH dose to prevent thrombosis
3. Stop all heparins and seek urgent haematology opinion
4. Transfuse platelets to prevent bleeding