Vte prophylaxis

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Vte prophylaxis

  1. 1. UNIVERSAL VTE PROPHYLAXIS
  2. 2. PREVIOUS VTE AND / OR THROMBOPHILIA
  3. 3. y y y y lmwh R I S K F A C T O R S Y SCORE OF 3 OR HIGHER CONSIDER @ LEAST 7 DAYS OF LMWH LOVENOX +SCD 1 Weight < 50 kg = 20 mg Lovenox/ Q 24 Weight 50–90 kg = 40 mg Lovenox/ Q 24 Weight 91–130 kg = 60 mg Lovenox/ Q 24 Weight 131–170 kg = 80 mg Lovenox/ Q 24 Weight > 170 kg = 0.6 mg/kg/day H eparin PRE -operative dose 5000 – no sooner than 1 hour prior to spinal or epidural / SCD PLACED PRIOR TO SPINAL Lovenox administration 8-12 hours after c/s and no sooner than 2 hours after removal of epidural catheter
  4. 4. VTE Risk factors Defined <ul><li>BMI >/=40 (based on 1 st trimester weight or prepregnancy weight) </li></ul><ul><li>Gross varicose veins = symptomatic, above the knee or associated with phlebitis/edema/skin changes </li></ul><ul><li>MEDICAL COMORBIDITIES :heart failure or severe lung disease, SLE, cancer, inflammatory conditions (inflammatory bowel disease or inflammatory polyarthropathy), nephrotic syndrome (proteinuria >3 g/day), sickle cell disease, intravenous drug user </li></ul><ul><li>Immobility or clinically significant reduced mobility = ≥ 3 days </li></ul><ul><li>long-distance travel = > 4 hours </li></ul><ul><li>Systemic infection (requiring antibiotics or admission to hospital) (e.g., pneumonia, pyelonephritis, postpartum wound infection) </li></ul><ul><li>surgery during pregnancy OR after delivery e.g. appendectomy OR P ostpartum tubal ligation </li></ul><ul><li>OHSS = ovarian hyperstimulation syndrome, </li></ul><ul><li>PPH = postpartum hemorrhage, (>1 liter ) or requiring transfusion </li></ul>
  5. 5. Contraindications to Low-molecular-weight Heparin (LMWH) <ul><li>LMWH should be avoided, discontinued or postponed in women who are at risk of bleeding after careful consideration of the balance of risks of bleeding and clotting. </li></ul><ul><li>RISK FACTORS FOR BLEEDING ARE: </li></ul><ul><li>Women with active antenatal or postpartum bleeding </li></ul><ul><li>Women considered at increased risk of major hemorrhage (such as placenta previa) </li></ul><ul><li>Women with a bleeding diathesis, such as von Willebrand's disease, hemophilia or acquired coagulopathy </li></ul><ul><li>Women with thrombocytopenia (platelet count less than 75 x 10 9 ) </li></ul><ul><li>Acute stroke in the last 4 weeks (ischaemic or haemorrhagic) </li></ul><ul><li>Severe renal disease (glomerular filtration rate less than 30 mL/minute/1.73 m 2 ) </li></ul><ul><li>Severe liver disease (prothrombin time above normal range or known hepatic or esophageal varices) </li></ul><ul><li>Uncontrolled hypertension (blood pressure greater than 200 mmHg systolic or greater than 120 mmHg diastolic) </li></ul>
  6. 6. EPIDURAL OR SPINAL PRE-OPERATIVE ASRA GUIDELINES <ul><li>Due to less risk of spinal hematoma with prophylactic UFH compared to LMWH ; RIVERSIDE recommends 5000 units of heparin pre-operatively </li></ul><ul><li>TWO regimens available for timing of pre-operative UFH administration </li></ul><ul><li>UNFRACTIONATED PROPHYLACTIC HEPARIN </li></ul><ul><li>THE RISK OF NEURAXIAL BLEEDING MAY BE REDUCED BY DELAY OF PRE-OPERATIVE HEPARIN INJECTION UNTIL AFTER THE BLOCK IS PLACED. </li></ul><ul><li>IF HEPARIN IS ADMIMISTERED PRIOR TO PLACEMENT OF SPINALOR EPIDURAL ; PLACEMENT OF THE SPINAL NEEDLE should be delayed for at least one hour duration after the pre-operative 5000 units of heparin </li></ul><ul><li>LOVENOX or LMWH </li></ul><ul><li>Regional anesthesia is contraindicated in patients less than 24 hours from their last dose of therapeutic LMWH ( 1/mg /kg Lovenox q 12 hrs OR 1.5 mg / kg Lovenox /24 hours ). </li></ul><ul><li>For prophylactic once daily injection Lovenox , regional anesthesia can be placed 10 to 12 hours’ after the last dose of Lovenox . </li></ul>Regional anesthesia & pain medicine 2010; 35: 102
  7. 7. EPIDURAL OR SPINAL POST-OPERATIVE ASRA GUIDELINES <ul><li>Single daily dosing thromboprophylaxis with Lovenox. No additional hemostasis altering drugs should be administered owing to additive effects ( NSAIDS) </li></ul><ul><li>The first postoperative lmwh prophylactic dose should be administered no sooner than 6 hours postoperatively and ideally 8-12 hours postoperatively ( based on balance between individual risk for vte / post –operative bleeding ). </li></ul><ul><li>If an indwelling catheter is in place it should be removed 10-12 hours after the last dose of LMWH. Subsequent LMWH dosing should occur a minimum of 2 hours after catheter removal. </li></ul><ul><li>The second post-operative dose should occur no sooner than 24 hours after the first post-operative dose </li></ul>Regional anesthesia & pain medicine 2010; 35: 102
  8. 8. EPIDURAL OR SPINAL POST-OPERATIVE ASRA GUIDELINES TWICE DAILY DOSING <ul><li>TWICE DAILY DOSING WITH LMWH is associated with increased risk for spinal hematoma </li></ul><ul><li>The first dose of LMWH should be administered no earlier than 24 hours post-operatively, regardless of anesthetic technique, and only if adequate surgical hemostasis is present. </li></ul><ul><li>If an indwelling catheter is present it must be removed prior to the first postoperative LMWH dose, and the first dose should be delayed for 2 hours after catheter removal. </li></ul>Regional anesthesia & pain medicine 2010; 35: 102

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