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Dvt prophylaxis

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Dvt prophylaxis

  1. 1. Prophylaxis Pt. I DVT Prophylaxis in the SICUGabriel Brat, MSIII6/18/2007
  2. 2. Introduction• Importance of DVTs• Risk Factors• Methods of Prophylaxis• Recommendations• Compliance
  3. 3. Bundles• PE third most common cause of iatrogenic death.• 2001 AHRQ report emphasized 1A evidence• IHI 5 million lives campaign—VAP bundle
  4. 4. LE DUS for PE• 90% PE’s originate in lower extremity• 1st symptomatic DVT – Sensitivity 95%, specificity 96% – Increased sensitivity: • serial US at 5-7 days • combining with clinical suspicion
  5. 5. Lower Extremity Veins Iliac Deep Internal (Common) Saphenous Femoral (Superficial) Femoral Popliteal External SaphenousHauer. UCSF 2005
  6. 6. Risk Factors for DVTSurgeryTrauma (major or lower extremity)ImmobilityParesisMalignancyCancer therapy (hormonal, chemotherapy, or radiotherapy)Previous VTEIncreasing agePregnancy and the postpartum periodEstrogen-containing oral contraception or hormone replacement therapySelective estrogen receptor modulatorsAcute medical illnessHeart or respiratory failureInflammatory bowel diseaseNephrotic syndromeMyeloproliferative disordersParoxysmal nocturnal hemoglobinuriaObesitySmokingVaricose veinsCentral venous catheterizationInherited or acquired thrombophilia
  7. 7. Risk of DVT DVT Prevalence, Patient Group % 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, hip fracture surgery 40–60 Major trauma 40–80 Spinal cord injury 60–80 Critical care patients 10–80Geerts et al.Chest, 2004;126:338S
  8. 8. Inherited Hypercoagulability Prevalence Population DVT Prevalence Factor V Leiden 12-21%** 6% Prothrombin mut 6-8% 2% Protein C, S def 2-4% < 1% AT III def 1-2% <1% All Thrombophilia 24-37% 10% **OR 5.9 (CI 2-18) for breakthroughAlbrecht. Online 2007Baba Ahmed. Thromb Haemost 2007; 97: 171
  9. 9. Mechanical Prophylaxis
  10. 10. Overview Mechanical Compression • No convincing evidence of mortality value over placebo. Plantar vs. Calf • DVT in 21.0% plantar vs. 6.5% calf (p = 0.009). Knee-length vs. Thigh-length • Equivalent effect w improved compliance in KL group. Mechanical vs. Chemical • OR 0.46 (CI 0.16-1.29) for all heparin vs. mechanicalGregory et al. J Trauma 1999; 47:1
  11. 11. CompressionRoderick et al. HTA, 2005; 9
  12. 12. CompressionRoderick et al. HTA, 2005; 9
  13. 13. Chemical Prophylaxis
  14. 14. OverviewAspirin• Not recommended for DVT prophylaxis• Aspirin vs. LMWH • 63% RRR among 205 ortho pts LMWH vs. ASA. • Among hip trauma pts, 44% vs. 28% ASA vs. LMWHUFH and LMWH• UFH decreases incidence of DVT by 20% over placebo• LMWH decreases incidence of DVT by 30% over UFH.
  15. 15. Mechanism of Heparins Unfractionated heparin inactivates both Factor IIa and Xa LMWH has increased affinity for Factor Xa Fondiparinux is only a pentasaccharide sequenceWeitz. NEJM, 1997; 337:688
  16. 16. PharmokineticsTran and Lee. Ann Pharm 2003; 37: 1632.
  17. 17. LMWH vs. UFHDolovich, L. R. et al. Arch Intern Med 2000;160:181-188.
  18. 18. LMWH vs. UFH 2Dolovich, L. R. et al. Arch Intern Med 2000;160:181-188.
  19. 19. LMWH vs. UFH 3Dolovich, L. R. et al. Arch Intern Med 2000;160:181-188.
  20. 20. LMWH vs. UFH in TraumaAtia et al. Arch Intern Med 2001; 161: 10.
  21. 21. LMWH vs. UFH in Trauma • Double blind, RCT • 344 major trauma—no ICH • 1st dose within 36 hours of injury • No mechanical prophylaxis • 5000 U LDUH v. 30 mg enoxaparin BID • RRR DVT 30% for LMWH • Higher bleeding in LMWH, but not significantGeerts et al. NEJM 1996
  22. 22. Complication RatesLeonardi, M. J. et al. Arch Surg 2006;141:790-799.
  23. 23. LMWH Advantages Disadvantages• Longer half life • Poor protamine• Improved efficacy response (60%)• Less heparin-induced • Variable effect w thrombocytopenia renal failure, obesity• Cost-effective for • Concern for trauma and gen surg bleeding
  24. 24. DVT Recommendations DVT, % PE, % Level of Risk Successful Prevention Strategies Calf Proximal Clinical Fatal Low risk 2 0.4 0.2 <0.01 Minor surgery in patients < 40 yr No specific prophylaxis; early and "aggressive" with no additional risk factors mobilization 10– 0.1– Moderate risk 20 2–4 1–2 0.4 Minor surgery in patients with risk factors LDUH (q12h), LMWH ( 3,400 U daily), GCS, or IPC 20– 0.4– High risk 40 4–8 2–4 1.0 Surgery in patients > 60 yr LDUH (q8h), LMWH (> 3,400 U daily), or IPC 40– Highest risk 80 10–20 4–10 0.2–5 Surgery in patients with multiple LMWH (> 3,400 U daily), fondaparinux, oral VKAs risk factors, Trauma, Ortho (INR, 2–3), or IPC/GCS + LDUH/LMWHGeerts et al. Chest, 2004; 126:338S
  25. 25. IVC Filters
  26. 26. IVCF Reasons for Use• Clot with active cerebral bleeding• Clot despite anticoagulation• Massive PE with chronically compromised pulmonary vasculature
  27. 27. IVCF Effectiveness Filter No filter p PE at day 12 1% 5% 0.03 PE at 2 years 3% 6% NS DVT at 2 years 21% 12% 0.02 Death 22% 21% NS Major bleed 9% 12% NSDeCousus et al. NEJM 1998; 338:409
  28. 28. Recommendations
  29. 29. DVT Recommendations DVT, % PE, % Level of Risk Successful Prevention Strategies Calf Proximal Clinical Fatal Low risk 2 0.4 0.2 <0.01 Minor surgery in patients < 40 yr No specific prophylaxis; early and "aggressive" with no additional risk factors mobilization 10– 0.1– Moderate risk 20 2–4 1–2 0.4 Minor surgery in patients with risk factors LDUH (q12h), LMWH ( 3,400 U daily), GCS, or IPC 20– 0.4– High risk 40 4–8 2–4 1.0 Surgery in patients > 60 yr LDUH (q8h), LMWH (> 3,400 U daily), or IPC 40– Highest risk 80 10–20 4–10 0.2–5 Surgery in patients with multiple LMWH (> 3,400 U daily), fondaparinux, oral VKAs risk factors, Trauma, Ortho (INR, 2–3), or IPC/GCS + LDUH/LMWHGeerts et al. Chest, 2004; 126:338S
  30. 30. Trauma RecsTrauma patients with at least one risk factor for VTE receive thromboprophylaxis, if possible (Grade 1A).In the absence of a major contraindication, LMWH prophylaxis starting as soon as it is considered safe to do so (Grade 1A).Mechanical prophylaxis with IPC be used if LMWH prophylaxis is delayed or if it is currently contraindicated due to active bleeding or a high risk for hemorrhage (Grade 1B).DUS screening in patients who are at high risk for VTE (eg, SCI, lower extremity or pelvic fracture, major head injury, or an indwelling femoral venous line, suboptimal prophylaxis) (Grade 1C).No use of IVCFs as primary prophylaxis in trauma patients (Grade 1C).Continuation of thromboprophylaxis until hospital discharge, including the period of inpatient rehabilitation (Grade 1C+).Continuing prophylaxis after hospital discharge in patients with major impaired mobility (Grade 2C).
  31. 31. ComplianceYu. Am J HP, 2007; 64: 69.
  32. 32. Causes for Poor Compliance Three fold increase in DVTs after 4 days in TICU.Nathens et al. J Trauma. 2007;62:557
  33. 33. Summary• DUS – Clinical suspicion + serial testing• Risk factors – Trauma and thrombophilia• Treatment – LMWH superior to UFH – Start early – Cost effective• Plans – Uptake poor at hospitals
  34. 34. Summary
  35. 35. Thank you.Thanks to pt. DW for worrying me about this issue every day for a week.
  36. 36. Clinical Probability of PE Leg swelling, tenderness 3 Pulse > 100 1.5 Immobilization, surgery 1.5 Prior DVT/PE 1.5 Hemoptysis 1 Cancer 1 No other more likely Dx 3 < 2 = Low probability 2-6 = Moderate > 6 = HighWells, Ann Intern Med 2001

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