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VTE Prophylaxis Focus on Prevention

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VTE Prophylaxis Focus on Prevention

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VTE Prophylaxis Focus on Prevention

  1. 1. VTE Prophylaxis Focus on Prevention
  2. 2. Deep vein thrombosis (DVT) forms in a vein of the leg. • Characterized by pain, swelling or tenderness of the leg, sometimes with redness and warmth Deep Vein Thrombosis
  3. 3. Pulmonary embolism Pulmonary embolism (PE) occurs when the blood clot breaks loose and travels to the lungs • Characterized by shortness of breath, sharp rib/chest pain and occasionally by hemoptysis, light-headedness, or collapse
  4. 4. Symptoms and Signs of DVT • Leg pain (90%) • Tenderness (85%) • Ankle edema (76%) • Calf swelling (42%) • Dilated veins (33%) • Dusky discoloration (30%) • Warmth • Redness DVT cannot be reliably diagnosed on the basis of history and physical exam, even in high-risk patients. Symptomatic DVT Most hospitalized patients with DVT will have NO SYMPTOMS or SIGNS!
  5. 5. Risk of VTE in Hospitalized Patients Geerts WT, et al. Chest 2008;358:381S-453S. 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 and Knee Arthroplasty, Hip Fracture Surgery 40-60 Major Trauma 40-80 Spinal Cord Injury 60-80 Critical Care Patients 10-80
  6. 6. Pulmonary Embolism Hospital Risk •Accounts for 10% of hospital deaths •In the UK, PE following DVT causes between 25,000 and 32,000 deaths each year1 International, cross- sectional audit of 35,000 inpatients at risk for VTE found:2 •only 59% of surgical patients and 40% of medical patients received recommended prophylaxis. 1. UK House of Commons Health Committee. HC 99. Published on 8 March 2005. 2. Cohen AT, et al. Lancet 2008;371:387-394.
  7. 7. Characterization of VTE events In the Worcester County, Mass VTE Study •60-70% of VTE events were considered to be provoked by: • Recent hospitalization (within 3 months) • Surgery • Trauma/fracture • Pregnancy 1. Spencer FA, et al. Arch Intern Med 2007;167:1471-5. 2. Spencer FA, et al. J Thromb Thrombolysis 2009;28:401-9. Risk for VTE increases with the number of risk factors and persists after hospital discharge.
  8. 8. Marco’s Story
  9. 9. Adapted from: Greer IA. Bailliere’s Clin Obstet Gynaecol 1997;11:403-30. The risk of DVT and PE is increased by several factors, including: Factors intrinsic to the patient Factors related to underlying disease or medical condition Factors introduced by medical or surgical treatment • Age • Obesity • Immobility • History of thrombosis • Thrombophilia • Varicose veins • Venous insufficiency • Pregnancy • Trauma • Heart failure/MI • Malignancy • Concomitant medication • Chemotherapy • Orthopaedic surgery • Major surgery • Caesarean section
  10. 10. 1. VTE is common in hospital patients 2. VTE is fatal (acutely and long-term) 3. VTE is preventable (safely and inexpensively) 4. Preventing VTE is the standard of care for almost all hospital patients in 2011 Slide courtesy of Dr. William Geerts. Rationale for Thromboprophylaxis
  11. 11. Adverse Consequences of VTE $Slide courtesy of Dr. William Geerts.
  12. 12. Key steps to ensure compliance with ROP: 1.Written policy/guideline 2.Identifies clients at risk & provides VTE prophylaxis 3.Establishes measures of success, uses information to make improvements 4.Provides information to health professionals (on risks & prevention measures)
  13. 13. Audrey’s Story Following a one week wait for surgery and the successful removal of a benign tumour – Audrey developed a PE. We are scared and worried about our surgery or primary reason for being in the hospital as it is. We rely on you to make us aware of any possible complications. For me, the blood clot was far scarier and worse than my brain tumour and operation. This experience with the blood clot has impacted my life. It was the scariest and worst experience I have ever had and it has left me fearful and anxious. “My plea to healthcare professionals: make sure you get people’s attention, and make sure they fully understand their risks and what can be done to prevent a blood clot.”
  14. 14. Guidelines for Prevention of VTE *Use clinical judgment to weigh the risk of venous thromboembolism versus the risk of bleeding.
  15. 15. Weight Dalteparin Dose Enoxaparin Dose Tinzaparin Dose <40 kg 2 500 U SC once daily 30 mg SC once daily 3 500 U SC once daily 40-100 kg 5 000 U SC once daily 40 mg SC once daily 4 500 U SC once daily 101-150 kg 5 000 U SC BID 40 mg SC BID 10 000 U SC once daily 151-200 kg 40 U/kg SC BID 0.4 mg/kg SC BID 14 000 U SC once daily Prevention of VTE in Hospitalized Patients: Summary of Good Practice eGFR >30 mL/min
  16. 16. In patients with impaired renal function (<30 mL/min): •Dalteparin: no dose adjustment is required. •Enoxaparin: a dosage adjustment is recommended since enoxaparin appears to accumulate in this patient group and may increase risk of bleeding. •Tinzaparin: no dose adjustment of tinzaparin at prophylaxis doses is needed in patients with impaired renal function1 , renal failure2,3 , or on hemodialysis2,3 . Use of LMWHs in Renal Impairment 1. Mahé O, et al.Thromb Haemost 2007;97:581-6. 2. PROTECT Investigators. N Engl J Med 2011;364:1305-14. 3. Nutescu EA, et al. Ann Pharmacother 2009;43:1064-83.
  17. 17. Contraindications to LMWHs:
  18. 18. Every in-patient w/o contraindication should be on VTE Prophylaxis

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