DVT Prophylaxis
Content
DVT Prophylaxis
Overview • • • • Risk factors What are the options Who gets what Guidelines
Virchows Triad • Stasis • Hypercoaguability • Endothelial Injury
Stasis
• • • • • • • • • • • Age >40 Immobility - bed bound, long hospital stay CHF Stroke Paralysis - paraplegic/paresis Spinal Cord injury Hyperviscosity Syndromes - Polycythemia Severe COPD Anesthesia >1hr Obesity Varicose Veins
Hypercoagulable State • • • • • • • • Cancer High estrogen states, OCP use Inflammatory Bowel Disease Nephrotic Syndrome Sepsis Smoking Pregnancy Thrombophilia
Endothelial Injury
• • • • Surgery Previous DVT Central lines Trauma
Options • Ambulation • Mechanical methods
– Compression Stockings – Intermittent pneumatic leg compression
• Pharmalogical agents
– UFH – LMWH (Enoxaparin)
Choosing the right prophylaxis • Encourage ambulation in every patient • Low risk: outpatient surgery, ambulatory
– Early ambulation should be sufficient
• Moderate risk: CHF, COPD, most patients
– UFH or LMWH
• High risk: Hip surgery, multiple trauma
– UFH or LMWH or Warfarin (INR 2-3)
Best available validated predictor
http://www.hematology.org/Publications/Hematologist/2011/6364.aspx
ACCP Guidelines, 9th Ed
1. Patients at Low Risk for DVT/PE Require NO Prophylaxis (1B) 2. Give Anticoagulant Prophylaxis to Patients at Elevated DVT-PE Risk, esp. the Critically Ill (1B) 3. For Patients who are Bleeding or at Risk for it, Use Leg Compression Devices Only (2C) 4. Some Outpatients With Cancer Should Take Daily Heparin Prophylaxis (2B) 5. High-Risk People On Long Plane Flights Should Walk, Consider Compression Stockings (2C) 6. People with Thrombophilia but no History of DVT/PE Should Not Take Anticoagulation Prophylaxis (1C)
References
• Anderson FA Jr. & Wheeler HB. Clin Chest Med 1995;16:235. • Venous Thromboembolism (VTE) Prevention in the Hospital: Transcript. June 2010. Agency for Healthcare Research and Quality, Rockville, MD. • Kahn SR et al. Prevention of VTE in Nonsurgical Patients. From: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. CHEST 2012;141 (suppl 2):e195S-e226S.
Overview • • • • Risk factors What are the options Who gets what Guidelines
Virchows Triad • Stasis • Hypercoaguability • Endothelial Injury
Stasis
• • • • • • • • • • • Age >40 Immobility - bed bound, long hospital stay CHF Stroke Paralysis - paraplegic/paresis Spinal Cord injury Hyperviscosity Syndromes - Polycythemia Severe COPD Anesthesia >1hr Obesity Varicose Veins
Hypercoagulable State • • • • • • • • Cancer High estrogen states, OCP use Inflammatory Bowel Disease Nephrotic Syndrome Sepsis Smoking Pregnancy Thrombophilia
Endothelial Injury
• • • • Surgery Previous DVT Central lines Trauma
Options • Ambulation • Mechanical methods
– Compression Stockings – Intermittent pneumatic leg compression
• Pharmalogical agents
– UFH – LMWH (Enoxaparin)
Choosing the right prophylaxis • Encourage ambulation in every patient • Low risk: outpatient surgery, ambulatory
– Early ambulation should be sufficient
• Moderate risk: CHF, COPD, most patients
– UFH or LMWH
• High risk: Hip surgery, multiple trauma
– UFH or LMWH or Warfarin (INR 2-3)
Best available validated predictor
http://www.hematology.org/Publications/Hematologist/2011/6364.aspx
ACCP Guidelines, 9th Ed
1. Patients at Low Risk for DVT/PE Require NO Prophylaxis (1B) 2. Give Anticoagulant Prophylaxis to Patients at Elevated DVT-PE Risk, esp. the Critically Ill (1B) 3. For Patients who are Bleeding or at Risk for it, Use Leg Compression Devices Only (2C) 4. Some Outpatients With Cancer Should Take Daily Heparin Prophylaxis (2B) 5. High-Risk People On Long Plane Flights Should Walk, Consider Compression Stockings (2C) 6. People with Thrombophilia but no History of DVT/PE Should Not Take Anticoagulation Prophylaxis (1C)
References
• Anderson FA Jr. & Wheeler HB. Clin Chest Med 1995;16:235. • Venous Thromboembolism (VTE) Prevention in the Hospital: Transcript. June 2010. Agency for Healthcare Research and Quality, Rockville, MD. • Kahn SR et al. Prevention of VTE in Nonsurgical Patients. From: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. CHEST 2012;141 (suppl 2):e195S-e226S.
