920 likes | 1.08k Views
VTE Prevention In Action Interactive Case Scenarios. Dr Raj Patel. King’s Thrombosis Centre. Consultant Haematologist. raj.patel@kch.nhs.uk. Patient 1: Elective THR. 78 - year - old woman, osteoarthritis Elective THR BMI 31kg/m 2 , weight 93kg DVT post-partum.
E N D
Dr Raj Patel King’s Thrombosis Centre Consultant Haematologist raj.patel@kch.nhs.uk
Patient 1: Elective THR • 78-year-old woman, osteoarthritis • Elective THR • BMI 31kg/m2,weight 93kg • DVT post-partum
Patient 1:Who performs VTE risk assessment (elective patient)?
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
Patient 1: Treatment Is mechanical or pharmacological thromboprophylaxis contraindicated?
Patient 1: Treatment choices-Pharmacological Thromboprophylaxis
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’
Prevention of DVT after general surgery (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?
Patient 1: Pharmacological Thromboprophylaxis –for how long? ACCP: beyond 10 days, up to 35 days (1A)
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 doseby > 2 hrs • Dabigatran: not recommended
Clinical presentation of HIT • Thrombocytopenia • Timing of thrombocytopenia • Thrombosis / other sequelae • oTher 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-Pharmacological Thromboprophylaxis
Gynaecologic surgery guidance (ACCP 2008) • Minor procedureswithout 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
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 choicesPharmacological Thromboprophylaxis
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