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Trombo-profilaxis en el paciente hospitalizado (no quirúrgico)

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Breve revisión sobre la trombo profilaxis en el paciente hospitalizado (no quirúrgico)

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Trombo-profilaxis en el paciente hospitalizado (no quirúrgico)

  1. 1. TROMBO-PROFILAXIS EN EL PACIENTE HOSPITALIZADO (NO QUIRÚRGICO) SEBASTIÁN TAMAYO O. ESTUDIANTE MEDICINA – CES.
  2. 2.  ¿Qué es trombo embolismo venoso?  ¿Qué es trombosis venosa profunda y trombo embolismo pulmonar?  ¿Cuáles son las manifestaciones de un TEV?  ¿Qué consecuencias puede traer un TEV?  ¿Cuál es la incidencia de TEV en los pacientes hospitalizados?  ¿Cuáles son los factores de riesgo para desarrollar TEV?  ¿A quién se le hace profilaxis anti TEV?  ¿Qué herramientas me ayudan a tomar esta decisión?  ¿Con qué fármacos se hace la profilaxis anti TEV?  ¿Cuánto tiempo se hace la profilaxis anti TEV?
  3. 3. ¿QUÉ ES UN TROMBO EMBOLISMO VENOSO?  Cuando se habla de trombo embolismo venoso (TEV) se hace referencia a 2 patologías: la trombosis venosa profunda (TVP) y el trombo embolismo pulmonar (TEP)
  4. 4. ¿CUÁLES SON LAS MANIFESTACIONES DE UN TROMBO EMBOLISMO VENOSO?  TVP: 1. AGUDOS: Edema, dolor, decoloración y en casos de TVP crónica ulceración de los miembros inferiores, flegmasia cerulea dolens y también puede ser asintomática. 2. SECUELAS: dolor permanente, edema, insuficiencia venosa y úlceras (síndrome post trombótico)  TEP: 1. AGUDOS: disnea, taquicardia, dolor torácico, derrame pleural, hipotensión, hipoxemia, muerte súbita y también puede ser asintomático. 2. SECUELAS: hipertensión pulmonar crónica
  5. 5. ¿QUÉ CONSECUENCIAS PUEDE TRAER UN TEV?  2/3 de los pacientes sintomáticos con TEV tienen TVP (sin TEP) y 1/3 tienen TEP.  En la TVP proximal (vena poplítea, femoral, o ilíacas) hasta un 50% de los casos se complica en TEP.  La mortalidad a 3 meses del TEP agudo es de 15-18%  La mortalidad a 1 año de la TVP recurrente es del 1,5%  El TEP causa 300.000 muertes al año en USA.
  6. 6. ¿CUÁL ES LA INCIDENCIA DE TEV EN LOS PACIENTES HOSPITALIZADOS?  En los pacientes que no reciben profilaxis anti-TEV es del 10-15%  2%-4.9% corresponden a la TVP proximal.  0,3%-1,5% corresponden al TEP
  7. 7. ¿CUÁLES SON LOS FACTORES DE RIESGO PARA DESARROLLAR UN TEV?  RECORDEMOS LA TRIADA DE VIRCHOW: ESTASIS, DAÑO ENDOTELIAL E HIPERCOAGULABILIDAD.  ESTASIS: ocurre cuando hay inmovilidad en los pacientes quirúrgicos o que tienen una condición médica la cual no les permite moverse.  DAÑO ENDOTELIAL: trauma, catéteres intravenosos, antineoplásicos, enfermedad de células falciformes.  HIPERCOAGULABILIDAD: síndrome antifosfolipídico, factor V de Leiden, mutaciones en el gen de protrombina deficiencia de proteína S.
  8. 8. ¿QUÉ HERRAMIENTAS BASADAS EN LA EVIDENCIA NOS SIRVEN PARA DETERMINAR EL RIESGO DE UN PACIENTE PARA DESARROLLAR TEV?  SCORE DE PADUA:
  9. 9. SCORE DE PADUA  Aprobado en las guías del American College of Chest Physicians (ACCP)  Se debe utilizar para saber a quien se le debe implementar la profilaxis anti TEV.  En los pacientes que tengan una puntuación igual o mayor a 4 se debe iniciar profilaxis anti TEV.
  10. 10. ¿CON QUÉ FÁRMACOS SE HACE LA PROFILAXIS ANTI TEV?  Se puede hacer con los siguientes: (vía subcutánea) 1. Heparina no fraccionada. 2. Heparina de bajo peso molecular.
  11. 11. HEPARINA NO FRACCIONADA (HNF)  Se une a la antitrombina III y aumenta la degradación de los factores Xa, IIa y IXa.  Dosis 5000U(1ml) SC cada 8-12 horas.  Reduce 60% el riesgo de TVP y 42% el riesgo de TEP comparada con el placebo.  No requiere ajuste de dosis en falla renal.  Se debe aplicar 2-3 veces / día  Las que más producen
  12. 12. HEPARINAS DE BAJO PESO MOLECULAR (HBPM)  Se unen a la antitrombina III y aumenta la degradación del factor Xa.  Dosis enoxaparina en pacientes sin falla renal: 20-40mg una vez al día (1mg/kg/día)  Dosis dalteparina: 200UI/kg/día una vez al día.  Eficacia similar a las HNF, en algunas series es superior que la HNF para prevenir la TVP.  Se aplica una vez al día  Causan menos TIH  A largo plazo son más económicas que la HNF ya que producen menos TIH.  Todas requieren ajuste en falla renal excepto la dalteparina (si se usa por periodos cortos).
  13. 13. FONDAPARINUX  Inhibidor del factor Xa.  Requiere ajuste en falla renal.  Se aplica una vez al día.  NO está aprobado por la FDA en trombo profilaxis en el paciente no quirúrgico.  SI está aprobada por la FDA en la trombo profilaxis del paciente con cirugía ortopédica.  Es el anticoagulante de elección cuando se presenta TIH.
  14. 14. CUALES NO USAR 1. Warfarina: No se usa ya que su actividad anticoagulante inicia a los 5 días de empezado el régimen. Además es poco predecible y tiene muchas interacciones. 2. Aspirina. 3. Inhibidores directos de la trombina (se usan en profilaxis en cirugía de reemplazo de cadera o rodilla) 4. Inhibidores directos del factor Xa (se usan en profilaxis en cirugía de reemplazo de cadera o rodilla)
  15. 15. ¿EN QUÉ PACIENTES INICIO PROFILAXIS ANTI TEV?  Pacientes con score de Padua mayor o igual a 4.  Pacientes oncológicos.  Pacientes mayores de 40 años, con movilidad reducida durante 3 días o más.  Mayores de 40 años que tengan al menos un factor de riesgo (ver diapositiva #8)
  16. 16. TROMBO PROFILAXIS EN FALLA RENAL  No usar HBPM  No usar fondaparinux.  Excepto dalteparina que se puede usar por cortos periodos y enoxaparina con dosis ajustada y monitoreo de niveles del factor Xa si están disponibles)
  17. 17. ¿CUÁNTO TIEMPO DEBE DURAR LA PROFILAXIS ANTI TEV?  El riesgo de TEV persiste 90 días luego del alta hospitalaria.  Todos los estudios han sido con ciclos de 6-14 días.  La profilaxis extendida está bien estudiada en los pacientes quirúrgicos pero no en los no quirúrgicos.  Se retiran una vez se de el paciente se de alta.
  18. 18. RECOMENDACIONES DE TROMBO PROFILAXIS EN PACIENTES NO QUIRURGICOS (GUÍAS CHEST/ACCP 2012 9TH ED)
  19. 19.  2.3. For acutely ill hospitalized medical patients at increased risk of thrombosis, we recommend anticoagulant thromboprophylaxis with low-molecular-weight heparin [LMWH], low-dose unfractionated heparin (LDUH) bid, LDUH tid, or fondaparinux(Grade 1B).  2.4. For acutely ill hospitalized medical patients at low risk of thrombosis, we recommend against the use of pharmacologic prophylaxis or mechanical prophylaxis (Grade 1B).  2.7.1. For acutely ill hospitalized medical patients who are bleeding or at high risk for bleeding, we recommend against anticoagulant thromboprophylaxis (Grade 1B).  2.7.2. For acutely ill hospitalized medical patients at increased risk of thrombosis who are bleeding or at high risk for major bleeding, we suggest the optimal use of mechanical thromboprophylaxis with graduated compression stockings (GCS) (Grade 2C) or intermittent pneumatic compression (IPC) (Grade 2C), rather than no mechanical thromboprophylaxis. When bleeding risk decreases, and if VTE risk persists, we suggest that pharmacologic thromboprophylaxis be substituted for mechanical thromboprophylaxis (Grade 2B).
  20. 20.  2.8. In acutely ill hospitalized medical patients who receive an initial course of thromboprophylaxis, we suggest against extending the duration of thromboprophylaxis beyond the period of patient immobilization or acute hospital stay (Grade 2B).  3.2. In critically ill patients, we suggest against routine ultrasound screening for DVT(Grade 2C).  3.4.3. For critically ill patients, we suggest using LMWH or LDUH thromboprophylaxis over no prophylaxis (Grade 2C).  3.4.4. For critically ill patients who are bleeding, or are at high risk for major bleeding, we suggest mechanical thromboprophylaxis with GCS (Grade 2C) or IPC(Grade 2C) until the bleeding risk decreases, rather than no mechanical thromboprophylaxis. When bleeding risk decreases, we suggest that pharmacologic thromboprophylaxis be substituted for mechanical thromboprophylaxis (Grade 2C).

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