Prevention Of Venous Thromboembolism Final

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international guidelines onvenous thromboembolism prenetion in critical care patients

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  • Prevention Of Venous Thromboembolism Final

    1. 1. Guidelines for Prevention of Venous Thromboembolism in Critical Care Patients D. Sandesc “ Victor Babes” University of Medicine and Pharmacy, Timisoara
    2. 2. Guidelines for Prevention of Venous Thromboembolism in Critical Care Patients <ul><li>Main sources. General recommendation s </li></ul><ul><li>VTE prevention in the ICU </li></ul><ul><li>VTE prevention guidelines in s evere sepsis </li></ul><ul><li>VTE prevention in politrauma </li></ul><ul><li>VTE prevention in burn patients </li></ul>
    3. 3. Evidence-Based Clinical Practice Guidelines of the American College of Chest Physicians (8th Edition) *William H. Geerts, David Bergqvist, Graham F. Pineo, John A. Heit, Charles M. Samama, Michael R. Lassen and Clifford W. Colwell Chest 2008;133;381-453 DOI 10.1378/chest.08-0656 http :// chestjournal.org / cgi /content/abstract/133/6_ suppl /381S Downloaded from chestjournal.org on June 25, 2008 Prevention of Venous Thromboembolism
    4. 4. Prevention and treatment of Venous Thromboembolism <ul><li>International Consensus Statement (Guidelines according to scientific evidence) </li></ul><ul><li>Int.Angiol 2006, 25:101-161 </li></ul><ul><li>Nicolaides AN, Fareed J, Kakkav AK, et. al. </li></ul>
    5. 7. Annual mortality due to VTE in Europe (25 countries) <ul><li>Mortality due to VTE 1 </li></ul><ul><ul><li>in hospital 261,477 </li></ul></ul><ul><ul><li>ambulatory 108,535 </li></ul></ul><ul><li>Combined mortality due to : </li></ul><ul><ul><li>AIDS 5,860 2 </li></ul></ul><ul><ul><li>Breast cancer 86,831 2 </li></ul></ul><ul><ul><li>Prostate cancer 63,636 2 </li></ul></ul><ul><ul><li>Traffic accidents 53,599 2 </li></ul></ul>1 Cohen AT. Presented at the 5th Annual Congress of the European Federation of Internal Medicine; 2005. 2 Eurostat statistics on health and safety 2001. Available from: http://epp.eurostat.cec.eu.int. 209,926
    6. 8. The majority of the postoperative episodes of VTE are undetectable 10 – 20% symptomatic 80 – 90% asymptomatic
    7. 9. Postoperative prophylaxis of the fatal PE using low dose unfractioned Heparin (Kakkar , Lancet , 1975) Number of patients with fatal PE p < 0.005 16 2 0 2 4 6 8 10 12 14 16 18 Control NFH Kakkar VV, et al. Lancet . 19 75 ;2: 45 Low doses of UFH save 7 lives each 1,000 patients who have undergone surgery. PE = Pulmonary Embolism; UFH = Unfractioned Heparin (N = 2,076) (N = 2,045)
    8. 10. Risk Factors for VTE (1) <ul><li>Surgery </li></ul><ul><li>Trauma (major trauma or lo w er extremity injury) </li></ul><ul><li>Cancer (active or occult) </li></ul><ul><li>Cancer therapy (hormonal, chemot h erapy, angiogenesis inhibitors, radiot h erapy) </li></ul><ul><li>Previous VTE </li></ul><ul><li>Venous compression (tumor, h a ematoma, arterial abnormality) </li></ul><ul><li>Increasing age </li></ul><ul><li>Pregnancy and the postpartum period </li></ul><ul><li>Estrogen-containing oral contraceptives or hormone replacement therapy </li></ul>
    9. 11. Risk Factors for VTE (2) <ul><li>Selective estrogen receptor modulators </li></ul><ul><li>Erythropoiesis-stimulating agents </li></ul><ul><li>Acute medical illness </li></ul><ul><li>Inflammatory bowel disease </li></ul><ul><li>Inherited or acquired thrombophilia </li></ul><ul><li>Nephrotic syndrome </li></ul><ul><li>Myeloproliferative disorders </li></ul><ul><li>Paroxysmal nocturnal hemoglobinuria </li></ul><ul><li>Obesity </li></ul>
    10. 12. Specific risk factors for VTE in the ICU <ul><li>Central vascular acces s </li></ul><ul><li>Mechanical ventilation </li></ul><ul><li>Muscular paralysis </li></ul><ul><li>Extrarenal epuration techniques </li></ul><ul><li>Prolonged immobilisation </li></ul>
    11. 13. Approximate Risks of DVT in Hospitalized Patients* * Rates based on objective diagnostic screening for asymptomatic DVT in patients not receiving thromboprophylaxis Patient Group DVT Prevalence, % Medical patients 10-20 General surgery 15-40 Major gynecologic surgery 15-40 Major urologic surgery 15-40 Neurosurgery 15-40 Stroke 20-50 Hip or knee arthroplasty, HFS 40-60 Major trauma 40-80 SCI 60-80 Critical care patients 10-80
    12. 14. Levels of Thromboemboli c Risk and Recommended Thromboprophylaxis in Hospital ized Patients *
    13. 15. Hospital Thromboprophylaxis Policy <ul><li>For every general hospital, active strategy that addresses the prevention of VTE is to be developed (Grade 1A) . </li></ul><ul><li>Local strategy, in form of a written, institution-wide thromboprophylaxis policy (Grade 1C) . </li></ul><ul><li>T he use of strategies shown to increase thromboprophylaxis adherence, including the use of computer decision support systems (Grade 1A), preprinted orders (Grade 1B) , and periodic audit and feedback (Grade 1C) . Passive methods such as distribution of educational materials or educational meetings are not recommended as sole strategies to increase adherence to thromboprophylaxis (Grade 1B) . </li></ul>
    14. 16. Mechanical Methods of Thromboprophylaxis <ul><li>Recommended primarily in patients at high risk of bleeding (Grade 1A) , or possibly as an adjunct to anticoagulant-based thromboprophylaxis (Grade 2A). </li></ul><ul><li>Careful attention to be directed towards ensuring the proper use of, and optimal adherence with, these methods (Grade 1A). </li></ul><ul><li>GCS : Gradual Compression Stockings </li></ul><ul><li>IPC : Intermitent Pneumatic Compression </li></ul>
    15. 17. Aspirin as Thromboprophylaxis <ul><li>We recommend against the use of aspirin alone as prophylaxis against VTE for any patient group (Grade 1A) </li></ul>
    16. 18. Anticoagulant dosing <ul><li>We recommend that clinicians follow the manufacturer suggested dosing guidelines (Grade 1C) </li></ul><ul><li>We recommend renal function to be considered when making decisions about the use and/or dose of LMWH, fondaparinux and other antithrombotic drugs (Grade 1A) </li></ul><ul><li>*LMWH= Low Molecular Weight Heparin </li></ul><ul><li>*LDUH= Low Dose Unfractioned Heparin </li></ul>
    17. 19. Use of Antithrombotic Drugs for Prophylaxis in Patients with Renal Impairment 1 Clexane ® -Lovenox ® prescribing information. sanofi-aventis. 2 Fragmin ® prescribing information. Pfizer. 3 Innohep ® prescribing information. Pharmion. 4 Arixtra ® prescribing information. GlaxoSmithKline. Moderate (Cl Cr 30–50 mL/min) and mild renal impairment (Cl Cr 50–80 mL/min) Severe renal impairment (Cl Cr < 30 mL/min) Enoxaparin 1 No adjustment needed “ dose to be adjusted ” Dose is being specified. Dalteparin 2 No information available “ To be used with precaution” Dose is not being specified. Tinzaparin 3 No information available “ To be used with precaution” Dose is not being specified. Fondaparinux Used with precaution in moderate renal impairment “ Contraindicated”
    18. 20. Thromboprophylaxis and body weight 1 Clexane ® -Lovenox ® prescribing information. Sanofi-aventis. 2 Fragmin ® prescribing information. Pfizer. 3 Innohep ® prescribing information. Pharmion. 4 Arixtra ® prescribing information. GlaxoSmithKline. Men < 57 kg and Women < 45 kg) Obese (IMC 30–48 kg/m 2 ) Enoxaparin 1 No adjustment needed No adjustment needed Dalteparin 2 No information available No information available Tinzaparin 3 No information available No information available Fondaparinux “ Not if < 50 kg No information available
    19. 21. Guidelines for Prevention of Venous Thromboembolism in Critical Care Patients <ul><li>Main sources. General recommendation s </li></ul><ul><li>VTE prevention in the ICU </li></ul><ul><li>VTE prevention in s evere sepsis </li></ul><ul><li>VTE prevention in politrauma </li></ul><ul><li>VTE prevention in burn patients </li></ul>
    20. 22. Critical Care (1) <ul><li>P atients admitted to a critical care unit : </li></ul><ul><li>- recommend ed routine assessment for VTE risk and routine thromboprophylaxis (Grade 1A). </li></ul><ul><li>For critical care patients who are at moderate risk for VTE ( eg, medically ill or postoperative general surgery patients) : </li></ul><ul><li>- LMWH or LDUH thromboprophylaxis (Grade 1A) . </li></ul>
    21. 23. Critical Care (2) <ul><li>C ritical care patients who are at higher risk ( eg, following major trauma or orthopedic surgery ) : </li></ul><ul><li>- LMWH thromboprophylaxis (Grade 1A). </li></ul><ul><li>C ritical care patients who are at high risk for bleeding : </li></ul><ul><li>- recommend ed the optimal use of mechanical thromboprophylaxis at least until the bleeding risk decreases (Grade 1A). When the high bleeding risk decreases, pharmacologic thromboprophylaxis is recommend ed to be substituted for or added to the mechanical thromboprophylaxis ( Grade 1C) . </li></ul>
    22. 24. Guidelines for Prevention of Venous Thromboembolism in Critical Care Patients <ul><li>Main sources. General recommendation s </li></ul><ul><li>VTE prevention in the ICU </li></ul><ul><li>VTE prevention guidelines in s evere sepsis </li></ul><ul><li>VTE prevention in politrauma </li></ul><ul><li>VTE prevention in burn patients </li></ul>
    23. 25. VTE prevention in severe sepsis ( Surviving Sepsis Campaign 2008 ) <ul><li>“… a) L ow-dose unfractionated heparin (UFH) administered twice or three times per day; or b) D aily low-molecular weight heparin (LMWH) unless there are contraindications (i.e., thrombocytopenia, </li></ul><ul><li>If c ontraindication for heparin use : mechanical prophylactic device, unless contraindicated (grade 1A). </li></ul><ul><li>V ery high-risk patients ( history of DVT, trauma, or orthopedic surgery ) : a combination of pharmacologic and mechanical therapy to be used unless contraindicated or not practical (grade 2C). </li></ul><ul><li>P atients at very high risk : LMWH to be used rather than UFH as LMWH is proven superior in other high-risk patients (grade 2C). </li></ul>
    24. 26. Guidelines for Prevention of Venous Thromboembolism in Critical Care Patients <ul><li>Main sources. General recommendations </li></ul><ul><li>VTE prevention in the ICU </li></ul><ul><li>VTE prevention guidelines in s evere sepsis </li></ul><ul><li>VTE prevention in trauma </li></ul><ul><li>VTE prevention in burn patients </li></ul>
    25. 27. Trauma (1) <ul><li>For all major trauma patients : </li></ul><ul><li>- recommend ed : routine thromboprophylaxis if possible (Grade 1A). </li></ul><ul><li>For major trauma patients in the absence of a major contraindication : </li></ul><ul><li>- LMWH thromboprophylaxis starting as soon as it is considered safe to do so (Grade 1A) </li></ul><ul><li>- An acceptable alternative is the combination of LMWH and the optimal use of a mechanical method of thromboprophylaxis (Grade 1B). </li></ul><ul><li>If LMWH thromboprophylaxis is contraindicated due to active bleeding or high risk for clinically important bleeding : </li></ul><ul><li>- Mechanical thromboprophylaxis with IPC or GCS alone (Grade 1B). When the high bleeding risk decreases, we recommend pharmacologic thromboprophylaxis to be substituted for or added to the mechanical thromboprophylaxis (Grade 1C). </li></ul>
    26. 28. Trauma (2) <ul><li>T rauma patients : </li></ul><ul><li>- not recommend ed : the use of an IVC filter as thromboprophylaxis (Grade 1C) . </li></ul><ul><li>For major trauma patients : </li></ul><ul><li>- recommend ed : the continuation of thromboprophylaxis until hospital discharge (Grade 1C). For trauma patients with impaired mobility who undergo inpatient rehabilitation, we suggest continuing thromboprophylaxis with LMWH or a VKA (target INR, 2.5; range, 2.0 to 3.0) (Grade 2C). </li></ul>
    27. 29. Acute Spinal Cord Injury (1) <ul><li>For all patients with acute SCI : </li></ul><ul><li>- routine thromboprophylaxis recommended (Grade 1A). </li></ul><ul><li>- thromboprophylaxis with LMWH, commenced once primary hemostasis is evident (Grade 1B) . Alternatives include the combined use of IPC and either LDUH (Grade 1B) or LWMH (Grade 1C). </li></ul><ul><li>SCI with high bleeding risk : </li></ul><ul><li>- recommend ed : the optimal use of IPC and/or GCS (Grade 1A) . When the high bleeding risk decreases, we recommend pharmacologic thromboprophylaxis to be substituted for or added to the mechanical thromboprophylaxis (Grade 1C) . </li></ul>
    28. 30. Acute Spinal Cord Injury (2) <ul><li>For patients with an incomplete SCI associated with evidence of a spinal hematoma on CT or MRI : </li></ul><ul><li>- mechanical thromboprophylaxis instead of anticoagulant thromboprophylaxis at least for the first few days after injury (Grade 1C). </li></ul><ul><li>Following acute SCI : </li></ul><ul><li>- recommended against: the use of LDUH alone (Grade 1A). </li></ul><ul><li>For patients with SCI : </li></ul><ul><li>- recommended against: the use of an IVC filter as thromboprophylaxis (Grade 1C) . </li></ul><ul><li>For patients undergoing rehabilitation following acute SCI : </li></ul><ul><li>- recommend ed : the continuation of LMWH thromboprophylaxis or conversion to an oral VKA (INR target, 2.5; range, 2.0 to 3.0) (Grade 1C). </li></ul>
    29. 31. Guidelines for Prevention of Venous Thromboembolism in Critical Care Patients <ul><li>Main sources. General recommendations </li></ul><ul><li>VTE prevention in the ICU </li></ul><ul><li>VTE prevention guidelines in s evere sepsis </li></ul><ul><li>VTE prevention in politrauma </li></ul><ul><li>VTE prevention in burn patients </li></ul>
    30. 32. Burns <ul><li>B urn patients who have additional risk factors for VTE, including one or more of the following: advanced age, morbid obesity, extensive or lower-extremity burns, concomitant lower-extremity trauma, use of a femoral venous catheter, and/or prolonged immobility : </li></ul><ul><li>- recommend ed : routine thromboprophylaxis if possible (Grade 1A). </li></ul><ul><li>- recommend ed : the use of either LMWH or LDUH, starting as soon as it is considered safe to do so (Grade 1C). </li></ul><ul><li>B urn patients who have a high bleeding risk : </li></ul><ul><li>- recommend ed : mechanical thromboprophylaxis with GCS and/or IPC until the bleeding risk decreases (Grade 1A). </li></ul>
    31. 33. VTE prevention in critical patients-conclusions <ul><li>VTE - major public health problem </li></ul><ul><li>VTE - avoidable disease ! </li></ul><ul><li>VTE in ICU – special category , needs individual , dynamic evaluation </li></ul><ul><li>VTE prevention in special populations (renal failure ,extreme weights, etc): use the products with adapted doses </li></ul><ul><li>Institutional and national strategy necessary </li></ul>

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