good slide dvt

ETIOPATHOGENESIS

• Abnormalities of flow• Abnormalities of vessel wall• Hypercoagulability of blood

ETIOPATHOGENESIS

Objectives/Outline Rationale for thromboprophylaxis

Summary of the 7th ACCP thromboprophylaxis guidelines

Implementation strategies

Rationale for Thromboprophylaxis

I. High prevalence of VTE in certain patient groups

II. Adverse consequences of unprevented VTE

III. Efficacy, effectiveness and cost- effectiveness of thromboprophylaxis

Risk Factors for VTE¨ Previous venous thromboembolism¨ Increased age¨ Surgery¨ Trauma - major, local leg¨ Immobilization - bedrest, stroke, paralysis¨ Malignancy and its Rx (CTX, RTX, hormonal)¨ Heart or respiratory failure¨ Estrogen use, pregnancy, postpartum, SERMs¨ Central venous lines ¨ Thrombophilic abnormalities

Risk Factors for VTE¨ Previous venous thromboembolism¨ Increased age¨ Surgery¨ Trauma - major, local leg¨ Immobilization - ? bedrest, stroke, paralysis¨ Malignancy & its Rx (CTX, RTX, hormonal)¨ Heart or respiratory failure¨ Estrogen use, pregnancy, postpartum, SERMs¨ Central venous lines ¨ Thrombophilic abnormalitiesMost hospitalized patients have at

least one risk factor for VTE

Some Basic Principles of Thromboprophylaxis

• Group prophylaxis rather than individual

• Mechanical prophylaxis only if high risk of bleeding

• No role for aspirin alone as DVT prophylaxis

• Epidural analgesia and anticoagulant thromboprophylaxis are compatible

7th ACCP Conference on Antithrombotic Therapy

DVT Prophylaxis: 3 Patient Groups

Low risk

Moderate risk

High risk

Patient group: Age < 40 years

Medical – fully mobile, brief admission

Surgical – procedure < 30 min, mobile,

no additional risk factors

Recommendations: no specific prophylaxis

mobilization [Grade 1C]

Low risk7th ACCP Conference on Antithrombotic Therapy

Patient group: Age between 40 – 60 years + minor surgery or age < 40 with risk factors Medical – bedrest / sick Surgical – major general, urologic,

gynecologic procedures

Evidence: LDH ~ LMWHOptions: LDH [Grade 1A] 5000 bid

LMWH [Grade 1A] <= 3400 u once daily TEDS, IPC (high bleeding risk) [1C+]

Start: as soon as possibleDuration: until discharge (not “ambulation”)

Moderate risk7th ACCP Conference on Antithrombotic Therapy

Patient group: Major orthopedics (THR, TKA, HFS) Age 40 – 60 years with major surgery (G +U)

Minor surgery, Age > 60, +/- risk factors

Evidence: 1. Venography: fondaparinux > LMWH > OVKA 2. Clinical: LMWH ~ OVKAOptions: LMWH [Grade 1A] > 3400 sc daily

fondaparinux [Grade 1A] oral vitamin K antagonist (INR 2-3) [1A] LDH or LMWH + GCS or IPC

Start: Postop (preop if HFS delayed)

Duration: > 10 days (2-4 weeks)


High risk

HIT with LDH or LMWH for Prophylaxis

Martel – Blood 2005;106:2710

• meta-analysis of 7 prospective studies comparing prophylactic LDH and LMWH

Prophylactic anticoagulant HIT

Heparin 41/1,730 (2.37 %)

LMWH 1/1,762 (0.06 %)

* NNT=43

Routine Prophylaxis NOT Recommended:• vascular surgery• laparoscopic surgery• knee arthroscopy• spine surgery• isolated lower extremity fractures• long distance travel


Any additional risk factors will mandate consideration of thromboprophylaxis

Benefit:risk favors routine prophylaxis

• Major orthopedic surgery (THR, TKR, HFS)• Major trauma• Spinal cord injury• Major general, gyne, urologic surgery• Major neurosurgery• Medical patients with additional risk factors• Most ICU patients



Benefit:risk favors no prophylaxis

• Surgical patients: - brief procedure - fully mobile - no additional RFs• Medical patients: - fully mobile - no additional RFs• Long distance travel



Benefit:risk uncertain- local practice or

individual prophyl.

• Laparoscopic surgery• Vascular surgery• Cardiac surgery• Elective spine surgery• Arthroscopic surgery• Burns• Isolated lower extremity fracture

Benefit:risk favors no prophylaxis

• Surgical patients: - brief duration - fully mobile - no additional RFs• Medical patients: - fully mobile - no additional RFs• Long distance travel

Thromboprophylaxis Use in Practice 1992-2002

Prophylaxis Patient Group Studies Patients Use (any)

Orthopedic surgery 4 20,216 90 % (57-98)

General surgery 7 2,473 73 % (38-98)

Critical care 14 3,654 69 % (33-100)

Gynecology 1 456 66 %

Medical patients 5 1,010 23 % (14-62)

Recommended VTE Prophylaxis Strategies in Surgical Settings

Indication Prevention Strategy

General Surgery UFH 5,000 units q 8h, 1st dose 2h preoperatively, continued for 7 days or LMWH once daily

Cancer Surgery Enoxaparin 40 mg daily or equivalent, 1st dose 10-14h preoperatively if possible, for 28 days

UFH = unfractionated heparinLMWH = low molecular weight heparin

Recommended VTE Prophylaxis Strategies in Surgical Settings (cont.)


Total Hip Replacement

Enoxaparin 40 mg daily or equivalent, beginning preoperative evening, continuing out-of-hospital for 21-28 days

Enoxaparin 30 mg BID or equivalent, 1st dose 12-24h postoperatively, until hospital discharge

Dalteparin 2,500 units ≥ 4h post-op, then 5,000 units daily until hospital discharge or for 35 days



Total Hip Replacement (cont.)

Fondaparinux 2.5 mg 4-8h post-op, then ≥ 12h after 1st dose, then daily for 5-9 daysWarfarin daily, 1st dose 7.5 mg 24-48h preoperatively, adjusted to target INR of 2.0-3.0

Warfarin daily, 1st dose 5 mg preoperative evening, adjusted to target INR of 2.0-3.0 and continued 4-6 weeks


Indication Prevention StrategyTotal Knee Replacement

Enoxaparin 30 mg BID or equivalent, beginning 12-24h postoperatively, continued for an average of 9 days

Fondaparinux 2.5 mg, 1st dose 4-8h postoperatively, 2nd dose ≥ 12h after 1st dose, then daily for 5-9 days

Hip Fracture Surgery

Fondaparinux 2.5 mg, 1st dose 4-8h postoperatively, 2nd dose ≥ 12h after 1st dose, then daily for 5-9 days. If surgery is delayed > 24-48h after admission, give 1st dose 10-14h preoperatively


Indication Prevention StrategyNeurosurgery Enoxaparin 40 mg daily or equivalent, 1st

dose ≤ 24h postoperatively, continued until hospital discharge, plus GCS

Craniotomy for Brain Tumor

Enoxaparin 40 mg daily or UFH 5,000 units BID, 1st dose on 1st postoperative morning, continued until hospital discharge, plus GCS/IPC, plus predischarge venous ultrasonography

GCS = graduated compression stockingsIPC = intermittent pneumatic compression devices

Duration of ProphylaxisRecommendations for extending the duration of

prophylaxis in high-risk scenarios:

Geerts WH, et al. Chest. 2004;126(suppl 3):338S-400S.

Cancer surgery 28 days postoperativelyTotal hip replacement and hip fracture repair

28-35 days postoperatively

Trauma Throughout inpatient rehabilitation and after discharge in patients with significantly impaired mobility

Objectives/Outline Rationale for thromboprophylaxis

Summary of the 7th ACCP thromboprophylaxis guidelines

Implementation strategies

Strategies to Improve Thromboprophylaxis Success

• Excellent quality guidelines• National body endorsement• Hospital accreditation (JCAHO)• Pay for performance (CMS)• Local written policy (care pathway) for the hospital / program / patient care unit• Pharmacist responsibility• Pre-printed orders • Computerized orders

Take-Home Points• Know the common VTE risk factors• Assess VTE risk for each hospitalized patient

individually• Become familiar with the various VTE prophylaxis

regimens for different at-risk patient groups• Apply the current ACCP guidelines to prevent

VTE in hospitalized patients

Prevention of VTE: Summary

1. Thromboprophylaxis is indicated for most hospitalized patients

2. But is under-utilized

3. Not ASA; mechanical rarely; warfarin scary

4. Chest 2004;126(suppl):338S-400S

5. Systems approach / hospital policy

6. Keep it simple, routine: Pre-printed orders

Just do it!

Thank you

http://webmm.ahrq.gov

Bill Geerts, MD, FRCPC, FCCPUniversity of Toronto

http://webmm.ahrq.gov/

good slide dvt

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