Download Venous Thromboembolism Prophylaxis for Inpatients

Venous Thromboembolism Prophylaxis
for Medical Inpatients
Heather Hofmann, rev. 4/18/14
DSR2 Mini Lecture
Objectives
• Recognize that VTE carries high morbidity and mortality
• Determine VTE risk for nonsurgical inpatient
• Select VTE prophylaxis for the non-surgical inpatient
Background
VTE
Venous Thromboembolism
DVT
Deep vein thrombosis
PE
Pulmonary embolism
Most medical inpatients are at risk for VTE.
– 25% of all VTE cases occur in the hospital
– 50-75% occur on medicine
– 5-10% of inpatient mortality are due to PE
Heparin ppx
– does NOT decrease inpatient mortality risk
– DOES decrease PE incidence
Determine Prophylaxis
VTE risk
Low
Patient
admitted
Bleeding risk
Early
ambulation
Determine
risk of VTE
Moderate
Or High
Low
Anticoagulant
prophylaxis
High
Intermittent
pneumatic
compression
Determine
bleeding risk
Determine Prophylaxis
VTE Risk Stratification
Low
If all 3:
< 40yo
Mobile
No VTE risk factors (next slide)
Moderate All other patients.
High
ICU patients.
Bleeding Risk Stratification
Low
Moderate
High
Limited validated definitions; can
determine “IMPROVE” risk
Active GI bleed
Bleed (GI, CVA…) < 3mos ago
Platelets < 50K
Risk Factors for VTE
•
•
•
•
•
•
•
•
•
Obesity: BMI > 30
Smoking
Immobility
Malignancy
Previous VTE
Presence of central venous catheter
Inherited or acquired hypercoagulable states
Oral contraceptives/Hormone replacement therapy/tamoxifen
Admission diagnosis of:
– Congestive heart failure (NYHA III/VI)
– Acute COPD exacerbation
– Acute infectious disease or sepsis
– Acute myocardial infarction
– Stroke with lower limb paralysis
– Inflammatory bowel disease*
Non-Pharmacologic Prophylaxis
• AMBULATION
– Use if low VTE risk!
• MECHANICAL
– Use if moderate-high VTE risk but high bleeding risk
– Intermittent pneumatic compression (/SCDs/Sequentials)
• Contraindicated in leg ischemia from PVD
– Options ineffective in prevention of VTE:
• Graduated compression stockings
• Venous foot pumps
Pharmacological VTE Prophylaxis
Medication
Dose
Heparin
Unfractionated (UFH)
5,000 units SQ q8h
5,000 units SQ q12h if elderly
Enoxaparin (Lovenox)
Low Molecular Weight
(LMWH)
30-40mg SQ daily
Contraindicated if CrCl < 30 mL/min
What VTE prophylaxis would you use?
62 yo F is admitted for community acquired pneumonia.
No prior history of VTE, bleeding, hepatic, or renal failure.
Her platelet count is 200.
VTE Risk?
Moderate
Bleeding Risk?
Low
VTE PPx:
UFH or LMWH
What VTE prophylaxis would you use?
35 yo M is admitted for acute gout. He is ambulatory. He has no
prior VTE, GI bleed, thrombophilia, or malignancy. BMI 23. His
platelet count is 240.
VTE Risk?
Low
Bleeding Risk?
Low
VTE PPx:
Early ambulation
What VTE prophylaxis would you use?
21 yo F admitted to ICU for DKA from poor insulin compliance.
She is ambulatory. She has no prior VTE, GI bleed, thrombophilia,
or malignancy. Platelet count is 300.
VTE Risk?
High
Bleeding Risk?
Low
VTE PPx:
UFH or LMWH
What VTE prophylaxis would you use?
65 yo F is admitted for treatment of an active malignancy. CrCl is
20 ml/min. She has a history of prior VTE but no history of
bleeding, hepatic failure. Her platelet count is 250.
VTE Risk?
Moderate
Bleeding Risk?
Low
VTE PPx:
UFH
Determine Prophylaxis
VTE risk
Low
Patient
admitted
Bleeding risk
Early
ambulation
Determine
risk of VTE
Moderate
Or High
Low
Anticoagulant
prophylaxis
High
Intermittent
pneumatic
compression
Determine
bleeding risk
Determine Prophylaxis
VTE Risk Stratification
Low
If all 3:
< 40yo
Mobile
No VTE risk factors (next slide)
Moderate All other patients.
High
ICU patients.
Bleeding Risk Stratification
Low
Moderate
High
Limited validated definitions; can
determine “IMPROVE” risk
Active GI bleed
Bleed (GI, CVA…) < 3mos ago
Platelets < 50K
Summary
• Recognize VTE risk in all hospitalized patients.
• Assess VTE risk with every admission
• Use pharmacologic prophylaxis for patients with moderate to
high risk of VTE
• If pharmacologic prophylaxis is contraindicated due to high
risk of bleeding, use ICD’s; do not use compression
stockings.
• AMBULATION for all at low risk of VTE.
References
Guyatt GH, et al. Executive Summary : Antithrombotic Therapy and Prevention of Thrombosis, 9th ed:
American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141;7S-47S.
Francis, CW. Prophylaxis for Thromboembolism in Hospitalized Medical Patients. N Engl J Med
2007;356:1438-44.
Pineo GF. Prevention of venous thromboembolic disease in medical patients. UpToDate, Mar 2012.
Qaseem A, et al. Venous Thromboembolism Prophylaxis in Hospitalized Patients: A Clinical Practice
Guideline From the American College of Physicians. Ann Intern Med. 2011;155:625-632.
Decousus, H., Tapson, V. F., Bergmann, J.-F., Chong, B. H., Froehlich, J. B., Kakkar, A. K., … IMPROVE
Investigators. (2011). Factors at admission associated with bleeding risk in medical patients: findings from the
IMPROVE investigators. Chest, 139(1), 69–79. doi:10.1378/chest.09-3081
Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis
after stroke (CLOTS trial 1): a multicentre, randomised controlled trial. (2009). The Lancet, 373(9679), 1958–
1965. doi:10.1016/S0140-6736(09)60941-7