Download Thrombophelebit prophylaxy

IN THE NAME OF
GOD
Prevention of Venous
Thromboembolism
Dr.Shirali
The prevention of VTE is the number one
strategy to improve patient safety in
hospitals according to the Agency for Health
Care Research and Quality.
Effective and safe prophylactic measures are
now available for most high risk patients and
numerous evidence-based guidelines have
been published for the prevention of VTE.
In spite of the availability of these guidelines
and the availability of safe and effective
prophylactic agents, numerous audits have
demonstrated that appropriate
thromboprophylaxis is not being offered to
examples:large numbers of surgical patients
Prophylaxis against DVT therefore should be
used in an effort to decrease the
incidence of PE. Each patient should be
assessed for thromboembolic risk .
Every hospital should develop a formal
active strategy for the prevention of VTE
in medical and surgical patients.This
should be in the form of a written
institution-wide thromboprophylaxis
policy endorsed by department heads .
There are two approaches to the prevention of
fatal PE :
Primary prophylaxis : Primary prophylaxis is carried
out using either drugs or physical methods that are
effective for preventing DVT.
Secondary prevention : Secondary prevention involves
the early detection and treatment of subclinical venous
thrombosis by screening postoperative patients with
objective tests that are sensitive for the presence of DVT.
However, no single screening method (eg, contrast
venography, ultrasonography, MRI venography) has
found universal acceptance for secondary prevention.
Accordingly, primary prophylaxis is preferred in
most clinical circumstances; it is more cost effective
than treatment of complications once they occur .
Secondary prevention with screening is reserved
for patients in whom primary prophylaxis is either
contraindicated or shown to be ineffective.
Surgical risk groups: The risk of postoperative VTE depends upon a number of
factors related to the surgical procedure
itself (degree of invasiveness, type and
duration of anaesthesia, requirement for
immobilization) , as well as a number of
patient-related adverse risk factors.
Stasis
Immobility
Congestive heart failure
Injury
Surgery (especially major orthopedic and pelvic)
Trauma
Thrombophilia
Cancer
Oral contraceptives
Hereditary states
RISK FACTORS FOR VTE — There are numerous risk
factors for the development of VTE in surgical patients, including
• the type and extent of surgery or trauma
• duration of hospital stay,
•immobility
• recent sepsis
•presence of a central venous access device
• pregnancy or the postpartum period
•Increasing age
•Prior VTE in patient or family members
•Presence of malignancy or obesity
•Presence of an inherited or acquired
hypercoagulable state
•One or more significant medical
comorbidities (eg, heart disease, infection,
inflammatory conditions, recent stroke)
2008 ACCP Guidelines have divided
patients undergoing surgical procedures
into :
1. low risk
2. moderate risk
3. high risk groups .
Low risk patients :
1. under the age of 40 +
2. no adverse patient-related or surgeryrelated risk factors +
3. general anaesthesia for less than 30
minutes.
Without prophylaxis their risk of DVTis
less than 1 percent and the risk of fatal PE
is less than 0.01 percent.
Moderate risk patients :
1- Include those undergoing minor surgery
who have additional risk factors. or
2- those age 40 to 60 who will require general
anaesthesia for more than 30 minutes and
have no additional adverse patient- or
surgery-related risk factors.
Without prophylaxis their risk of DVT is 2 to 4
percent and their risk of fatal PEis 0.1 to 0.4 percen.
High risk patients :
The high risk surgical group includes
those >60 years of age undergoing major
surgical procedures as well as those ages 40
to 60 with additional patient- or surgeryrelated risk factors .
Without prophylaxis the risk of DVTand
fatal PE in this group has been estimated to
be 4 to 8 percent and 0.4 to 1.0 percent,
respectively.
50-year-old woman scheduled to undergo
elective laparoscopic cholecystectomy
PMH notable for moderate COPD
No personal or family history of VTE
Medications: Spiriva®, albuterol
Stopped smoking 1 year ago
What should we recommend for
perioperative VTE prophylaxis in this
patient?
4
Reflects system adopted for all ACCP guidelines
The strength of any recommendation depends on two factors:
The trade-off between benefits, risks, costs, and level of confidence in
estimates of those benefits and risks
The quality of the evidence upon which the recommendations are based
If benefits do outweigh risks, and costs, a strong (Grade 1) recommendation
is used.
If there is less certainty about magnitude of benefits and risks, burdens, and
costs, a weak (Grade 2) recommendation is used.
Support for recommendations may come from high-quality, moderatequality, or low-quality evidence, labeled, respectively, A, B, and C.
The phrase “we recommend” is used for strong recommendations (Grade 1A,
1B, 1C) and “we suggest” for weak recommendations (Grade 2A, 2B,
2C).
Targets one or two legs of Virchow’s triad:
Mechanical prophylaxis (stasis)
Elastic compression stockings
Intermittent pneumatic compression devices
Pharmacological prophylaxis (hypercoagulability)
Unfractionated heparin
Low-molecular-weight heparins
Fondaparinux
Aspirin (?) .
Targets one or two legs of Virchow’s triad:
Mechanical prophylaxis (stasis)
Elastic compression stockings
Intermittent pneumatic compression devices
Perioperative Management of
Antithrombotic Therapy in
Nonorthopedic Surgical Patients
----Antithrombotic Therapy and Prevention of Thrombosis, 9th
ed: American College of Chest Physicians Evidence-Based
Clinical Practice Guidelines
Copyright: American College of Chest Physicians 2012©
1- For general and abdominal-pelvic
surgery patients at very low risk for
VTE (0.5%;Rogers score,7; Caprini
score, 0), we recommend that no
specific pharmacologic (Grade 1B) or
mechanical (Grade 2C) prophylaxis be
used other than early ambulation.
2. For general and abdominal-pelvic surgery patients at low risk for VTE
( 1.5%; Rogers score, 7-10; Caprini
score, 1-2), we suggest mechanical
prophylaxis, preferably with intermittent pneumatic compression (IPC),
over no prophylaxis (Grade 2C) .
3. For general and abdominal-pelvic sur-gery
patients at moderate risk for VTE ( 3.0%;
Rogers score, . 10; Caprini score, 3-4) who are
not at high risk for major bleeding complications, we suggest LMWH (Grade 2B ), LDUH
(Grade 2B) , or mechanical prophylaxis, preferably with IPC (Grade 2C) , over no prophylaxis.
4. For general and abdominal-pelvic surgery patients at moderate risk for VTE
(3.0%;Rogers score, 10; Caprini score, 3-4)
who are at high risk for major bleeding
complications or those in whom the
consequences of bleeding are thought to be
particularly severe, we suggest mechanical
prophylaxis, preferably with IPC, over no
prophylaxis (Grade 2C) .
5. For general and abdominal-pelvic surgery patients
at high risk for VTE ( 6.0%;Caprini score, 5) who
are not at high risk for major bleeding complications,
we recommend pharmacologic prophylaxis with
LMWH (Grade 1B) or LDUH (Grade 1B) over no
prophylaxis.
We suggest that mechanical prophylaxis with elastic
stockings or IPC should be added to pharmacologic
prophylaxis (Grade 2C) .
6. For high-VTE-risk patients undergoing
abdominal or pelvic surgery for cancer who
are not otherwise at high risk for major bleeding complications, we recommend extendedduration pharmacologic prophylaxis (4 weeks)
with LMWH over limited-duration
prophylaxis (Grade 1B)
7. For high-VTE-risk general and abdominalpelvic surgery patients who are at high risk for
major bleeding complications or those in
whom the consequences of bleeding are
thought to be particularly severe, we suggest
use of mechanical prophylaxis, preferably
with IPC, over no prophylaxis until the risk of
bleeding diminishes and pharmacologic
prophylaxis may be initiated (Grade 2C) .
8. For general and abdominal-pelvic surgery
patients at high risk for VTE (6%; Caprini
score, 5) in whom both LMWH and unfractionated heparin are contraindicated or
unavailable and who are not at high risk for
major bleeding complications, we suggest lowdose aspirin (Grade 2C) , fondaparinux (Grade
2C) , or mechanical prophylaxis, preferably
with IPC (Grade 2C) , over no prophylaxis.
9. For general and abdominal-pelvic surgery
patients, we suggest that an inferior vena cava
(IVC) filter should not be used for primary VTE
prevention (Grade 2C) .
10. For general and abdominal-pelvic surgery
patients, we suggest that periodic surveillance
with venous compression ultrasound (VCU)
should not be performed (Grade 2C) .
Timing of commencement of prophylaxis :
Prophylaxis is ideally started either before or shortly
after surgery and continued at least until the patient
is fully ambulatory . The administration of
thromboprophylaxis in close proximity to surgery
has been shown to enhance its efficacy in a
systematic review that compared prophylaxis with
LMW heparin versus warfarin .
In general, LMW heparin has been shown to be superior to
UFH or warfarin but inferior to fondaparinux in terms of
efficacy, with similar bleeding rates in patients undergoing
total hip or total knee replacement surgery.
The use of the enoxaparin differs between regions :
In North America, enoxaparin is commonly used in the dose of
30 mg twice daily starting 12 to 24 hours postoperatively.
In Europe, enoxaparin at a dose of 40 mg is started 12 hours
preoperatively and is then given once daily.
Other LMW Heparin preparations have usually been given in a
once daily dosage, starting postoperatively.
Extended prophylaxis : As the result of
shortened hospital length of stay, many patients will
require out-of-hospital prophylaxis. This is
particularly true after total hip replacement, where
the evidence is that patients require 28 to 35 days of
prophylaxis with LMW heparin, rather than 7 to 10
days . Although warfarin is effective in extended
prophylaxis, the incidence of major bleeding was
higher than that seen with LMW heparin .
Patients undergoing cancer
surgery or major abdominal
surgery also benefit from
extended prophylaxis.
A meta-analysis in patients undergoing cancer
surgery concluded that there was no difference
between LMW heparin and UFH in terms of
efficacy, DVT location, or bleeding
complications .
Low dose unfractionated heparin : Low
dose subcutaneous unfractionated heparin
(UFH) for prophylaxis of VTE is usually
given in a dose of 5000 units two hours
preoperatively and then every 8 to 12
hours postoperatively (ie, either twice or
three times daily).
In addition to its relatively low side effect
profile, low dose UFH has the advantage that
it is relatively inexpensive, easily
administered, and anticoagulant monitoring is
not required.
However, the platelet count should be
monitored regularly in all patients receiving
low dose UFH to detect the development of
heparin-induced thrombocytopenia .
Low molecular weight heparin : A number
of low molecular weight heparin (LMW
Heparin) preparations are available. These
drugs have the advantage that they can be
given subcutaneously once or twice daily at a
constant dose without laboratory monitoring.
In addition, there is a lower incidence of
heparin-induced thrombocytopenia than with
UFH.
Fondaparinux has been evaluated in the prevention of VTE in
patients undergoing orthopedic surgery, general surgery, and in
hospitalized medical patients. Fondaparinux 2.5 mg once/day by
subcutaneous injection has been compared with the enoxaparin 40
mg once daily starting 12 hours preoperatively in patients
undergoing total hip or total knee replacement, with enoxaparin 30
mg twice daily in patients undergoing total hip replacement, and
with enoxaparin 40 mg daily in patients suffering hip fracture .In a
2002 meta-analysis of four available trials, it was concluded that the
efficacy of fondaparinux was superior to that of enoxaparin .
In these studies, major bleeding occurred more
frequently in fondaparinux-treated subjects, but there
was not an increase in bleeding leading to death or reoperation or bleeding into a critical organ with
fondaparinux compared with enoxaparin.
Most of the patients who bled had their initial
fondaparinux injection less than eight hours
postoperatively.
Oral anticoagulation : Oral anticoagulation with
vitamin K antagonists (VKA) such as warfarin can be
commenced preoperatively, at the time of surgery, or
postoperatively for the prevention of VTE .
However, therapy started at the time of surgery or in
the early postoperative period may not prevent small
venous thrombi from forming because the
anticoagulant effect of the VKAs is not achieved until
the third or fourth day of treatment .
Nonetheless, warfarin appears to effectively inhibit
extension of such thrombi if present, thereby
preventing clinically important VTE. Because of its
delayed onset of action along with bleeding rates
similar to those seen with LMW heparin, warfarin has
been favored as a thromboprophylactic agent by
orthopedic surgeons in the United States.
Venous Thromboembolism
(VTE) in Patients with
Cancer
The risk of VTE including
(DVT) and (PE) is increased
several-fold in patients with
cancer. Hospitalized patients with
cancer and those receiving active
therapy seem to be at the
greatest risk for development of
VTE. In a population-based study,
cancer was associated with a 4.1fold greater risk of thrombosis,
whereas the use of chemotherapy
increased the risk 6.5-fold.
Risk Factors for VTE
in Patients With
Malignant Disease
Patient-related factors
Older age
Race (higher in African Americans; lower in
Asian-Pacific Islanders)
Comorbid conditions (obesity, infection,
renal disease, pulmonary disease, arterial
thromboembolism)
Prior history of VTE
Elevated prechemotherapy platelet count
Heritable prothrombotic mutations
Cancer-related factors
Primary site of cancer (GI, brain, lung,
gynecologic, renal, hematologic)
Initial 3-6 months after diagnosis
Current metastatic disease
Treatment-related factors
Recent major surgery
Current hospitalization
Active chemotherapy
Active hormonal therapy
Current or recent antiangiogenic therapy
(thalidomide, lenalidomide, bevacizumab)
Current erythropoiesis-stimulating agents
Presence of central venous catheters
SHOULD HOSPITALIZED
PATIENTS WITH
CANCER RECEIVE
ANTICOAGULATION FOR
VTE PROPHYLAXIS ?
1. Hospitalized patients who have active malignancy with acute
medical illness or reduced mobility should receive pharmacologic
thromboprophylaxis in the absence of bleeding or other
contraindications.
2. Hospitalized patients who have active malignancy without
additional risk factors may be considered for pharmacologic
thromboprophylaxis in the absence of bleeding or other
contraindications.
3. Data are inadequate to support routine thromboprophylaxis in
patients admitted for minor procedures or short chemotherapy
infusion, or in patients undergoing stem cell/ bone marrow
transplantation.
Pharmacologic Prophylaxis in
Hospitalized medical patients
Unfractionated heparin 5,000 U q8h
Dalteparin 5,000 U qd
Enoxaparin40 mg qd
Fondaparinux 2.5 mg qd
Duration for medical patients is for the length of hospital stay or
is fully ambulatory.
Unfractionated heparin 5,000 U every 12 hours has also been
used but appears to be less effective;
SHOULD AMBULATORY
PATIENTS WITH CANCER
RECEIVE ANTICOAGULATION
FOR VTE PROPHYLAXIS
DURING SYSTEMIC
CHEMOTHERAPY?
1. Routine pharmacologic prophylaxis is not
recommended in cancer outpatients.
2. Based on limited RCT data, clinicians may consider LMWH
prophylaxis on a case-by-case basis in highly selected outpatients with
solid tumors receiving chemotherapy. Consideration of such therapy
should be accompanied by a discussion with the patient about the
uncertainty concerning benefits and harms, as well as dose and duration
of prophylaxis in this setting.
3. Patients with multiple myeloma receiving thalidomide- or
lenalidomide-based regimens with chemotherapy and/or dexamethasone
should receive pharmacologic thromboprophylaxis with either aspirin or
LMWH for lower-risk patients and LMWH for higher-risk patients
SHOULD PATIENTS WITH
CANCER UNDERGOING
SURGERY RECEIVE
PERIOPERATIVE
VTE PROPHYLAXIS?
1. All patients with malignant disease undergoing major surgical
intervention should be considered for pharmacologic
thromboprophylaxis with either UFH or LMWH unless
contraindicated because of active bleeding or a high bleeding risk.
2. Prophylaxis should be commenced preoperatively.
3. Mechanical methods may be added to pharmacologic
thromboprophylaxis, but should not be used as monotherapy for
VTE prevention unless pharmacologic methods are contraindicated
because of active bleeding or high bleeding risk.
4. A combined regimen of pharmacologic and mechanical prophylaxis
may improve efficacy, especially in the highest-risk patients.
5. Pharmacologic thromboprophylaxis for patients undergoing major
surgery for cancer should be continued for at least 7-10 days.
Extended prophylaxis with LMWH for up to 4 weeks
postoperatively should be considered for patients undergoing
major abdominal or pelvic surgery for cancer who have high-risk
features such as restricted mobility, obesity, history of VTE, or
with additional risk factors .In lower risk surgical settings, the
decision on appropriate duration of thromboprophylaxis should be
made on a case-by-case basis considering the individual patient.
Surgical patients
Unfractionated heparin 5,000 U 2-4 h pre-op and q8h
thereafter or 5,000 U 10-12 h preop and 5,000 U qd
thereafter
Dalteparin 2,500 U 2-4 h pre-op and 5,000 U qd
thereafter or 5,000 U 10-12 h pre-op and 5,000 U qd
thereafter
Enoxaparin 20 mg 2-4h pre-op and 40 mg qd thereafter or
40 mg 10-12 hr pre-op and 40 mg qd thereafter
Fondaparinux 2.5 mg qd beginning 6-8h post-op
All doses are given as subcutaneous injections except as
indicated, When neuraxial anesthesia or analgesia is
planned, prophylactic doses of once-daily LMWH should
NOT be given within 10 – 12 h prior to the
procedure/instrumentation (including epidural catheter
removal). After the surgery, the first dose of LMWH can
be given 6 – 8 h postoperatively. After catheter removal,
the first dose of LMWH can be given no earlier than 2
h afterwards. Clinicians should refer to their institutional
and the American Society of Regional Anesthesia
Guidelines for more information.
for surgical patients, prophylaxis
should be continued for at least 7-10
days. Extended prophylaxis for up to 4
weeks should be considered for highrisk patients.