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DVT PROPHYLAXIS

DVT PROPHYLAXIS. SUNDIP PATEL 7 / 15 / 2009. BACKGROUND. D eep V ein T hrombosis is a common, yet preventable peri-operative complication Highest risk in critical care and spinal cord injury patients – 60-80% Post–General Surgery procedures: 15-40% Post-Ortho Procedures: 40-60%

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DVT PROPHYLAXIS

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  1. DVT PROPHYLAXIS SUNDIP PATEL 7 / 15 / 2009

  2. BACKGROUND • Deep Vein Thrombosis is a common, yet preventable peri-operative complication • Highest risk in critical care and spinal cord injury patients – 60-80% • Post–General Surgery procedures: 15-40% • Post-Ortho Procedures: 40-60% • Variable for Urologic cases

  3. BACKGROUND • Pulmonary Embolus • True Prevalance is unknown • W/O prophylaxis • Fatal PE in 0.2-.9% of ELECTIVE general surgery cases • Fatal PE in 0.1-2.0% of ELECTIVE hip • Fatal PE in 2.5-7.5% of Fractured Hip

  4. VIRCHOW TRIAD • STASIS • From supine positioning and effects of anesthesia • HYPERCOAGULABILITY • Decreased clearance of the PROcoagulant • INTIMAL INJURY • Results from excessive vasodilation caused by vasoactive amines and anesthesia • Acting in concert, these 3 factors promote development of DVT in low-flow areas

  5. RISK FACTORS • AGE > 50 • Hx of varicose veins • Hx of MI • Hx of Cancer • Hx of AFib • Hx of ISCHEMIC Stroke • Hx of DM

  6. Urologic Risk • RISK Level for most UROLOGIC patients are considered MODERATE

  7. UROLOGIC RISK • Risk of DVT w/o prophylaxis is 10 – 40% • RECS: • Low Molecular Weight Heparin (Lovenox) • Low Dose Unfractionated Heparin • Fondaparinux (ARIXTRA) • Also appropriate to use is • Graduated Compression Stockings • Intermittent Pneumatic Compression • Venous Foot Pumps

  8. Types of MEDICAL prophylaxis • ARIXTRA • Longer half-life than LMWH (17H v 4H) • Not for CKD pts • No monitoring • Single daily dosing • LMWH (lovenox) • Greater bioavailability • Longer duration • Little monitoring needed • HIT incidence less • LDUH • Easy administration • Cost Effective • Little monitoring needed

  9. UROLOGIC PROCEDURES • Transurethral – EARLY AMBULATION • IF HIGHER RISK, GCS OR IPC • Anti-incontinence and pelvic reconstructive surgery • Low risk – early ambulation • Mod risk – IPC or LMWH • Hi Risk – IPC + LDUH or LMWH • Urologic laparoscopic and/or robotically assisted - IPC • Open Procedures - IPC

  10. CONTRAINDICATIONS • ABSOLUTE • Active bleeding, PLT:20, neurosurgery, ocular surgery, intracranial bleeding w/in 10 days • RELATIVE • PLT:20-100, brain metastases, major abdominal surgery w/in past 2 days, GI bleeding or GU bleeding w/in past 14 days, infective endocarditis, malignant hypertension

  11. PROPHYLAXIS OPTIONS • LMWH – 40mg SQ qd • LDUH – 5000u SQ B-TID • ARIXTRA – 2.5 SQ qd NOT for patients with CrCl <30 For LOW RISK procedures and those with NO RISK FACTORS, no prophylaxis is required. ENCOURAGE AMBULATION EARLY AND FREQUENTLY

  12. UROLOGIC RECOMENDATIONS • MAJOR, OPEN PROCEDURES • EITHER LMWH, LDUH, ARIXTRA (GRADE1A) • IF HIGH RISK OF BLEEDING, USE MECHANICAL METHODS UNTIL • LAPAROSCOPIC • IF previous dvt/pe, LMWH or LDUH, may also add IPC or GCS (Grade 1C) ALL PATIENTS WITH HISTORY OF CANCER

  13. SUMMARY • ALL PATIENTS UNDERGOING ANY SURGERY SHOULD HAVE DVT PROPHYLAXIS • GCS AND EARLY AMBULATION SUFFICIENT IN MOST CASES • CONTINUE PROPHYLAXIS UNTIL AMBULATING

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