VTE prophylaxis simplified focus on prevention.ppt

VTE prophylaxis and guidelines on prevention

1. VTE Prophylaxis
Focus on Prevention

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. 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. 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. 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. 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 year
1
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. 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
num
ber of risk factors and
persists after hospital discharge.

8. Marco’s Story

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. 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. Adverse Consequences of VTE
$
Slide courtesy of Dr. William Geerts.

13. 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)

14. 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.”

15. Guidelines for
Prevention of VTE
*Use clinical judgment to weigh the risk of venous thromboembolism versus the risk of bleeding.

16. 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 kg5 000 U SCBID40 mg SC BID 10 000 U SC
once daily
151-200 kg40 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

17. 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 thispatient
group and may increase risk of bleeding.
•Tinzaparin: no dose adjustment of tinzaparin at
prophylaxis doses is needed in patients with impaired
renal function
1
, renal failure
2,3
, or on hemodialysis
2,3
.
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.

18. Contraindications to LMWHs:

19. Every in-patient w/o
contraindication
should be on
VTE Prophylaxis