Vte, identification and management of patients at risk

Venous Thrombo-embolismVenous Thrombo-embolism
(VTE)(VTE)
Identification and Management of PatientsIdentification and Management of Patients
at Riskat Risk
Dr David Jesudemi
B.Sc., MBBS, MRCOG (Part 1), A.L.S.O Provider and Instructor
Registrar Obstetrics and Gynaecology
Habona General Hospital, Najran– Saudi Arabia
2017

Venous thromboembolic disease (VTE) is caused byVenous thromboembolic disease (VTE) is caused by
a blood clot developing in the venous system,a blood clot developing in the venous system,
usually in the deep veins (deep vein thrombosisusually in the deep veins (deep vein thrombosis
[DVT])[DVT])
If a portion or all of this blood clot detaches, it willIf a portion or all of this blood clot detaches, it will
travel through the venous system, through the hearttravel through the venous system, through the heart
and into the pulmonary arterial system where it willand into the pulmonary arterial system where it will
lodge.lodge.
This is a pulmonary embolus (PEThis is a pulmonary embolus (PE))
.

A dangerous and potentially deadly medical
condition
leading cause of death and disability worldwide
It is more common in pregnancy because pregnancy
is a pro-thrombotic state.
.
VTE= DVT + PEVTE= DVT + PE

Economic Burden ofEconomic Burden of
ThromboembolismThromboembolism
1010Million cases occur annually, most areMillion cases occur annually, most are
undocumentedundocumented
Diagnostic tests and treatment are costlyDiagnostic tests and treatment are costly
U.K, NHS spends 700 million pounds perU.K, NHS spends 700 million pounds per
yearyear
U.S spends $15.5 billion per yearU.S spends $15.5 billion per year
Australia loss of productive + treatment + lossAustralia loss of productive + treatment + loss
of well being costs $19.99 billion per yearof well being costs $19.99 billion per year

11in 4 people worldwide die of conditions caused byin 4 people worldwide die of conditions caused by
thrombosis (> deaths from AIDS + Breast CA+ MVAthrombosis (> deaths from AIDS + Breast CA+ MVA((

Venous Thrombo-embolism
StasisStasis
Activation of CoagulationActivation of Coagulation
Vessel DamageVessel Damage
Virchow's Triad

Clinical Presentation
pain and swelling of the leg, often starting in calf
Swelling and erythema over the affected area,
including ankle or foot
lower abdominal pain
mild pyrexia
increased white cell count

. Clinical assessment of VTE is not reliable for
diagnosis.
Less than 10% of patients with clinical signs of DVT
will have DVT confirmed.
Any patient with symptoms and signs suggestive of a
DVT should have objective testing performed as soon
as possible, and such women should be started on
treatment with low molecular weight heparin (LMWH)
until the diagnosis is excluded by objective testing.

DVT Investigations: LABDVT Investigations: LAB
 PT ,PTT , INRPT ,PTT , INR
 ESRESR
 D-dimer (not useful in pregnancy)D-dimer (not useful in pregnancy)
 ABGABG
 Protein C , S, Antithrombin IIIProtein C , S, Antithrombin III

DVT Investigations: UltrasoundDVT Investigations: Ultrasound
It is imperative to confirm the diagnosisIt is imperative to confirm the diagnosis
Compression or Duplex USS legCompression or Duplex USS leg

DVT Investigations: UltrasoundDVT Investigations: Ultrasound
 If ultrasound is negative and there is a low level ofIf ultrasound is negative and there is a low level of
clinical suspicion, anticoagulant treatment can beclinical suspicion, anticoagulant treatment can be
discontinued.discontinued.
 If ultrasound is negative and a high level ofIf ultrasound is negative and a high level of
clinical suspicion exists, anticoagulant treatmentclinical suspicion exists, anticoagulant treatment
should be discontinued but the ultrasound shouldshould be discontinued but the ultrasound should
be repeated on days 3 and 7be repeated on days 3 and 7

DVT Investigations: FurtherDVT Investigations: Further
InvestigationsInvestigations
 Pelvic ultrasound with color Doppler - helpfulPelvic ultrasound with color Doppler - helpful
when thrombosis in the pelvic vessels is suspectedwhen thrombosis in the pelvic vessels is suspected
 Magnetic resonance venography/ConventionalMagnetic resonance venography/Conventional
contrast venography - when Doppler USS iscontrast venography - when Doppler USS is
negative and where there is a strong clinicalnegative and where there is a strong clinical
suspicion of iliac vein thrombosis. Contrast maysuspicion of iliac vein thrombosis. Contrast may
be used if repeated USS is inconclusive but therebe used if repeated USS is inconclusive but there
is a strong suggestion of DVT.is a strong suggestion of DVT.

TreatmentTreatment
The initial management of DVT involves:The initial management of DVT involves:
Elevation of the legElevation of the leg
Application of a graduated elastic compressionApplication of a graduated elastic compression
stocking (GECS) to the affected leg to help minimizestocking (GECS) to the affected leg to help minimize
the oedema.the oedema.
Early mobilization with compression stockings isEarly mobilization with compression stockings is
encouraged and does not encourage the clot toencouraged and does not encourage the clot to
detach and cause a PTE.detach and cause a PTE.
LMWH.LMWH.

Pulmonary Thrombembolism (PEPulmonary Thrombembolism (PE((
The symptoms and signs of pulmonary embolism include:The symptoms and signs of pulmonary embolism include:
sudden onset pleuritic chest painsudden onset pleuritic chest pain
Unexplained shortness of breathUnexplained shortness of breath
hemoptysishemoptysis
faintness or collapsefaintness or collapse
tachycardiatachycardia
tachypnoeatachypnoea
raised JVPraised JVP
chest may sound clearchest may sound clear
symptoms and signs associated with DVT.symptoms and signs associated with DVT.

ClinicalClinical
Clinical assessment of VTE is not reliable for diagnosis.Clinical assessment of VTE is not reliable for diagnosis.
Only 5% of Patients with clinical signs of pulmonaryOnly 5% of Patients with clinical signs of pulmonary
embolism will have pulmonary thromboembolus (PTE)embolism will have pulmonary thromboembolus (PTE)
confirmed.confirmed.
Any patient with symptoms and signs suggestive of a PTEAny patient with symptoms and signs suggestive of a PTE
should have objective testing performed as soon as possible.should have objective testing performed as soon as possible.
Such patient should be started on treatment with lowSuch patient should be started on treatment with low
molecular weight heparin (LMWH) until the diagnosis ismolecular weight heparin (LMWH) until the diagnosis is
excluded by objective testing.excluded by objective testing.

Non-Diagnostic InvestigationsNon-Diagnostic Investigations
 Oxygen saturation – resting hypoxiaOxygen saturation – resting hypoxia
 Arterial blood gas – respiratory alkalosis withArterial blood gas – respiratory alkalosis with
hypoxemiahypoxemia
 Chest X-ray – to exclude other pathologyChest X-ray – to exclude other pathology
 Electrocardiogram - may exclude a myocardialElectrocardiogram - may exclude a myocardial
infarction. Typically, there will be a sinusinfarction. Typically, there will be a sinus
tachycardia, RAD, RBBB or peaked p waves intachycardia, RAD, RBBB or peaked p waves in
Lead II. The 'S1T3Q3 pattern' is not often seen.Lead II. The 'S1T3Q3 pattern' is not often seen.

Diagnostic InvestigationsDiagnostic Investigations
 If compression ultrasonography confirms theIf compression ultrasonography confirms the
presence of DVT, no further investigation ispresence of DVT, no further investigation is
necessary and treatment for VTE should continue.necessary and treatment for VTE should continue.
 In patients with suspected PE without symptomsIn patients with suspected PE without symptoms
and signs of DVT:and signs of DVT:
 Ventilation/perfusion (V/Q) lung scan should beVentilation/perfusion (V/Q) lung scan should be
performed if the CXR is normalperformed if the CXR is normal
 Computerized tomography pulmonary angiogramComputerized tomography pulmonary angiogram
(CTPA) should be performed if the CXR is(CTPA) should be performed if the CXR is
abnormal.abnormal.

Diagnostic InvestigationsDiagnostic Investigations
 Anticoagulant treatment should be continued untilAnticoagulant treatment should be continued until
PE is definitively excluded.PE is definitively excluded.
 Echocardiogram - evidence of right atrial orEchocardiogram - evidence of right atrial or
ventricular dilatation or strain, may be helpful inventricular dilatation or strain, may be helpful in
the differential diagnosis of aortic dissectionthe differential diagnosis of aortic dissection
where there may be aortic regurgitationwhere there may be aortic regurgitation

Treatment of P.ETreatment of P.E
 Massive life threatening pulmonary embolus
with hemodynamic compromise – an acute
emergency:
1. Intravenous unfractionated heparin is the preferred1. Intravenous unfractionated heparin is the preferred
initial treatment in massive PE.initial treatment in massive PE.
2. Thrombolytic therapy – Tissue Plasminogen2. Thrombolytic therapy – Tissue Plasminogen
ActivatorActivator
3. Surgery. Pulmonary embolectomy is performed3. Surgery. Pulmonary embolectomy is performed
under cardiopulmonary bypass. If the patientunder cardiopulmonary bypass. If the patient
survives to theatre the results are excellent.survives to theatre the results are excellent.

Treatment of P.ETreatment of P.E
 Stable patients:
 Anti-coagulateAnti-coagulate
 Graduated elastic compression stockings (GECS)Graduated elastic compression stockings (GECS)
 Before treatment the following blood tests
should be taken:
 FBC
 coagulation screencoagulation screen
 renal and liver function as metabolism of heparinrenal and liver function as metabolism of heparin
may be affected if abnormal.may be affected if abnormal.

Thromboprohylaxis: Assessment ToolThromboprohylaxis: Assessment Tool
and Guidelinesand Guidelines
 VTE are often preventableVTE are often preventable
 Up to 60% of VTE occur during or after hospitalization,Up to 60% of VTE occur during or after hospitalization,
hence making it a leading preventable cause of hospitalhence making it a leading preventable cause of hospital
deathsdeaths
 Evidence based prevention strategies can stopEvidence based prevention strategies can stop
development of clots in “at-risk” individualsdevelopment of clots in “at-risk” individuals
 Use of VTE risk assessment tools/questionnaires to discernUse of VTE risk assessment tools/questionnaires to discern
a patient’s potential risks:a patient’s potential risks:
 Patient agePatient age
 Medical historyMedical history
 Specific lifestyle factorsSpecific lifestyle factors

 All patients admitted to the Habona General Hospital willAll patients admitted to the Habona General Hospital will
receive a VTE and bleeding risk assessment on admissionreceive a VTE and bleeding risk assessment on admission
 Responsibility of all clinical staff providing care toResponsibility of all clinical staff providing care to
patients who are at risk of VTE after admission to Habonapatients who are at risk of VTE after admission to Habona
General HospitalGeneral Hospital
 All medical and surgical units should develop and have aAll medical and surgical units should develop and have a
functional risk assessment tool:functional risk assessment tool:
1.1. Assess level of morbidityAssess level of morbidity
2.2. Thrombosis risk sectionThrombosis risk section
3.3. Bleeding risk sectionBleeding risk section
4.4. A prescription for thromboprohylaxisA prescription for thromboprohylaxis

 Emergency department and Gynae ER physicians shouldEmergency department and Gynae ER physicians should
commence risk assessment and prophylaxis when thecommence risk assessment and prophylaxis when the
patient will not be seen by the in-patient team/ consultantpatient will not be seen by the in-patient team/ consultant
until the next dayuntil the next day
 Prior to a planned surgeryPrior to a planned surgery
 Patient VTE risk assessment forms part of the patientsPatient VTE risk assessment forms part of the patients
medical clerking and admission process.medical clerking and admission process.
 The patient must be reassessed in 24 hours or earlier if theThe patient must be reassessed in 24 hours or earlier if the
patient’s diagnosis changes and as an ongoing plan of carepatient’s diagnosis changes and as an ongoing plan of care
 All VTE risk assessments completed by non- medical staff,All VTE risk assessments completed by non- medical staff,
eg pre-operative settings, must have a senior medicaleg pre-operative settings, must have a senior medical
review ON the day of their admissionreview ON the day of their admission

 Regard medical patients as being at increased risk of VTERegard medical patients as being at increased risk of VTE
if they:if they:
I.I. Have had or are expected to have significantly reducedHave had or are expected to have significantly reduced
mobility for three (3) days or more, ormobility for three (3) days or more, or
II.II. Are expected to have on-going reduced mobility relative toAre expected to have on-going reduced mobility relative to
their normal state and have one or more of the risk factorstheir normal state and have one or more of the risk factors
 Regard surgical patients and patients with trauma as beingRegard surgical patients and patients with trauma as being
at increased risk of VTE if they meet one of the followingat increased risk of VTE if they meet one of the following
criteriacriteria
I.I. Surgical procedure with a total anesthetic and surgical timeSurgical procedure with a total anesthetic and surgical time
of more than 90 minutes, or 60 minutes if the surgeryof more than 90 minutes, or 60 minutes if the surgery
involves the pelvis or lower limbinvolves the pelvis or lower limb

I.I. Acute surgical admission with inflammatory or intra-Acute surgical admission with inflammatory or intra-
abdominal conditionabdominal condition
II.II. Expected significant reduction in mobilityExpected significant reduction in mobility
III.III. Assess all patients for risk of bleeding before offeringAssess all patients for risk of bleeding before offering
pharmacological VTE prophylaxispharmacological VTE prophylaxis
IV.IV. Do not offer pharmacological VTE prophylaxis toDo not offer pharmacological VTE prophylaxis to
patients with any of the risk factors for bleeding unlesspatients with any of the risk factors for bleeding unless
the risk of VTE outweighs the risk of bleedingthe risk of VTE outweighs the risk of bleeding

 Do not allow patients to become dehydrated unlessDo not allow patients to become dehydrated unless
clinically indicatedclinically indicated
 Encourage patients to mobilize as soon as possibleEncourage patients to mobilize as soon as possible
 Do not regard aspirin or other antiplatelet agents asDo not regard aspirin or other antiplatelet agents as
adequate prophylaxis for VTEadequate prophylaxis for VTE
 Consider offering temporary inferior vena cava filters toConsider offering temporary inferior vena cava filters to
patients who are at very high risk of VTE (such patientspatients who are at very high risk of VTE (such patients
with a previous VTE event or an active malignancy) andwith a previous VTE event or an active malignancy) and
for whom mechanical and pharmacological VTEfor whom mechanical and pharmacological VTE
prophylaxis are indicatedprophylaxis are indicated
 Patients and their families or carers should be offeredPatients and their families or carers should be offered
verbal and written information before starting VTEverbal and written information before starting VTE
prophylaxis and as part of their discharge processprophylaxis and as part of their discharge process

 Clinicians prescribing VTE prophylaxis must be aware ofClinicians prescribing VTE prophylaxis must be aware of
additional factors associated in specific patient groups:additional factors associated in specific patient groups:
 StrokeStroke
 OncologyOncology
 Palliative carePalliative care
 Existing antiplatelet or anti-coagulant therapyExisting antiplatelet or anti-coagulant therapy
 Patients who are receiving full anticoagulantPatients who are receiving full anticoagulant
 Patients provided with anti-embolic stockings should havePatients provided with anti-embolic stockings should have
them fitted and monitoredthem fitted and monitored
 Patients taking vitamin KPatients taking vitamin K

Thromboprohylaxis: TypesThromboprohylaxis: Types
 Mechanical VTE ProphylaxisMechanical VTE Prophylaxis
1.1. Graduated Elastic Compression stockings (thigh or kneeGraduated Elastic Compression stockings (thigh or knee
length)length)
 The mechanism of action of GECS is uncertain, but theyThe mechanism of action of GECS is uncertain, but they
may act by preventing over-distension of the leg veins,may act by preventing over-distension of the leg veins,
thus preventing endothelial damage with subsequentthus preventing endothelial damage with subsequent
activation of the coagulation systemactivation of the coagulation system
 Thigh length stockings are usually used in pregnancyThigh length stockings are usually used in pregnancy
compared to below-knee stockings in the non-pregnant.compared to below-knee stockings in the non-pregnant.
 They are available in standard, large and extra-large sizesThey are available in standard, large and extra-large sizes
based on ankle and thigh circumference.based on ankle and thigh circumference.

 Contraindications to use of GECS:Contraindications to use of GECS:
 arterial diseasearterial disease
 gangrenous conditions and peripheral vascular diseasegangrenous conditions and peripheral vascular disease
 absent foot pulsesabsent foot pulses
 intermittent claudicationintermittent claudication
 femoro-popliteal bypass graftsfemoro-popliteal bypass grafts
 peripheral neuropathyperipheral neuropathy
 pulmonary oedemapulmonary oedema
 cellulitis.cellulitis.

 Use with caution in cases of:Use with caution in cases of:
 extreme leg deformityextreme leg deformity
 fragile skinfragile skin
 pressure ulcerspressure ulcers
 dermatitisdermatitis
 lower limb oedemalower limb oedema
 diabetes.diabetes.

1.1. GECSGECS
2.2. Foot impulse devices and Intermittent pneumaticFoot impulse devices and Intermittent pneumatic
compression devices (thigh or knee length)compression devices (thigh or knee length)
3.3. Inferior Vena Cava filtersInferior Vena Cava filters

 Pharmacologic ProphylaxisPharmacologic Prophylaxis
1.1. Low molecular weight heparinLow molecular weight heparin
2.2. Unfractionated heparinUnfractionated heparin
3.3. WarfarinWarfarin

STEP 1: Assess Risk for VTESTEP 1: Assess Risk for VTE
 Critically and Acutely ill Medical Patients (Padua score)Critically and Acutely ill Medical Patients (Padua score)
 StrokeStroke

 Surgical Patients (Padua score)Surgical Patients (Padua score)
 StrokeStroke

 Obstetric Patients (RCOG)Obstetric Patients (RCOG)
 StrokeStroke

STEP 2: Assess Risk of BleedingSTEP 2: Assess Risk of Bleeding
 StrokeStroke

STEP 3: Order Prophylaxis as perSTEP 3: Order Prophylaxis as per
recognized guidelinesrecognized guidelines
 StrokeStroke

 VTE does not discriminateVTE does not discriminate
 Affects anyone regardless of age, ethnicity or raceAffects anyone regardless of age, ethnicity or race
 Can occur without any warning signsCan occur without any warning signs
 Can go unrecognized and undiagnosedCan go unrecognized and undiagnosed
 Are you at risk?!Are you at risk?!

Thromboprohylaxis: Patient’s RightsThromboprohylaxis: Patient’s Rights
 If you are admitted to a hospital and don’t receive a VTEIf you are admitted to a hospital and don’t receive a VTE
assessment:assessment:
BE PROACTIVE – ASK FOR ONE!BE PROACTIVE – ASK FOR ONE!

Thromboprohylaxis: Patient’s RightsThromboprohylaxis: Patient’s Rights

Vte, identification and management of patients at risk

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