DVT Prophylaxis in REHAB: A Tutorial on Guidelines

1. DVT Prophylaxis in REHAB:A Tutorial on Guidelines VCU/MCV Dept PM&R Version Date 1/20/03 Author: William Walker, MD

2. Define the Potential Adverse Events Associated With DVT: • PE, with resulting sequela including death • Extremity swelling, edema, pain with related functional impairment • Post-phlebitic syndrome

3. Define the Potential Risks of Anticoagulation Therapy: • GI bleeding • Local bleeding, especially at sites of recent trauma or surgery • Thrombocytopenia, with associated bleeding propensity

4. What Are Available Options for DVT Prophylaxis in Order of Efficacy?(Least  Most) • ASA • Foot pumps • Ted Hose (thigh high, well fitting) • SQ heparin 5,000 unit BID • Pneumatic leg pumps (if continuous) • “Aggressive” (LMWH at prophylaxis dose = coumadin at INR 2-3 range = Arixtra)

5. How Are High Risk (for DVT) Individuals Identified? • Use of standardized Risk assessment tool (See next slide) • Then stratify as follows: • Low Risk: < 2 factors • Moderate Risk: 2-4 risk factors • High Risk: > 5 risk factors OR TKR/THR OR Fracture of hip, femur, or tib-fib • Note: For surgery patients, the risk is also affected by factors related to the procedure itself

6. Age 40-60 years Age > 60 (count as 2 factors) History of DVT or PE (count as 5 factors) Malignancy Obesity (>120 % of IBW) Previous or present immobilization (>72hrs) Anticipated immobilization/bed confinement >72 hrs Major Surgery Paralysis Trauma Indwelling central venous catheter Crystalloid IV infusion (>5L/24hrs) Severe COPD Pregnancy, or post partum < 1 month Inflammatory bowel disease Severe sepsis Hypercoagulable state Nephrotic Syndrome Current or previous estrogen use w/in last 5 days Leg ulcers, edema, or stasis (varicose veins) History of MI History of CHF History of Stroke Risk Factors:

7. Who Should Receive this Risk Assessment • ALL Rehab admissions on N1 and N2 • If you did not DOCUMENT your risk assessment/plan, then it did not happen…so DVT risk should be a standard separate #’d problem in final part of H&P for EVERYONE • Distinguish and document if on coumadin for another purpose (ie high risk for DVT, prophylaxis in place while on coumadin for chronic afib)

8. How Should High Risk Patients Be Prophylaxed? • With aggresive prophylaxis: • LMWH at prophylaxis dose • OR Coumadin at INR 2-3 range • OR Arixtra • If above contraindicated, then consider: • IVC filter (prevents PE, not DVT) • Pneumatic compression > 23hr/day • Serial doppler surveillance

9. Who Needs Doppler to Exclude DVT? • High risk patients coming to rehab who did not receive definitive prophylaxis during acute care • Individuals with clinical signs or symptoms of DVT

10. What Absolute Contraindications to Anticoagulation Exist? • Hx of Heparin Induced Thrombocytopenia (for heparin only) • Platelet count < 15 x 109/L • Active GI bleed • Dissecting aneurysm • Congenital or contracted bleeding disorders

11. What Other Special Considerations for Anticoagulation Exist? • Discontinue use of LDUH or LMWH 12 hours prior to the placement/removal of a spinal catheter • Hold LDUH or LMWH for at least 2 hours after placement of removal of spinal catheter • Platelet count < 30 X 109/L • Status post brain, spinal, or ophthalmic surgery • Hemorrhagic stroke • Bacterial endocarditis • Diabetic retinopathy • Concomitant antiplatelet therapy

12. How Should These Considerations Be Handled? • Consultation, formally or informally, with relevant service (e.g. neurosurgery for recent brain surgery). • In most cases, neurosurgery at MCV permits aggressive prophylaxis after a week post-op brain or spinal surgery or a week post intracerebral bleed.

13. How Do We Modify This Approach After Elective TKA or THA at MCV? • Coumadin post-operatively is considered adequate prophylaxis even when INR sub-therapeutic (given long half-life). • Follow Orthopedic surgeon specific protocols for INR target, length of therapy, and outpatient monitoring in coumadinized patients.

14. How Is Major Bleeding Associated With Elevated INR Managed? • Stabilize patient and call consultant for stat transfer to acute hospital bed for aggressive treatment (i.e. FFP and Vitamin K 10 mg i.v.)

15. Guidelines for Elevated INRs in the Absence of Major Bleeding? • 3.1-5.0 (no bleeding): Omit one Warfarin dose and reduce maintenance dose slightly. • 3.1-5.0 (minor bleeding): Omit one Warfarin dose, reduce maintenance Warfarin dose, & give Vitamin K 1.0 mg p.o. • 5.1-9.0 (none/minor bleeding): Omit one Warfarin dose, reduce maintenance Warfarin dose, give Vitamin K 1.0-2.5 mg p.o., obtain next day INR. • >9.0 (none/minor): Omit one Warfarin dose, reduce maintenance Warfarin dose, give Vitamin K 2.5-5.0 mg p.o., obtain next day INR.