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VTE Prevention In Action Interactive Case Scenarios

VTE Prevention In Action Interactive Case Scenarios. Dr Raj Patel. King’s Thrombosis Centre. Consultant Haematologist. raj.patel@kch.nhs.uk. Patient 1: Elective THR. 78 - year - old woman, osteoarthritis Elective THR BMI 31kg/m 2 , weight 93kg DVT post-partum.

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VTE Prevention In Action Interactive Case Scenarios

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  1. VTE Prevention In ActionInteractive Case Scenarios

  2. Dr Raj Patel King’s Thrombosis Centre Consultant Haematologist raj.patel@kch.nhs.uk

  3. Patient 1: Elective THR • 78-year-old woman, osteoarthritis • Elective THR • BMI 31kg/m2,weight 93kg • DVT post-partum

  4. Patient 1:VTE Risk Assessment

  5. Patient 1:Who performs VTE risk assessment (elective patient)?

  6. Patient 1:High Risk of VTE • Major orthopaedic procedure • Additional risk factors for VTE? • > 60 years old • Anticipated immobility 3 days • BMI above 30 kg/m2 • Previous VTE

  7. ACCP, 2008

  8. ACCP, 2008

  9. ACCP, 2008

  10. Patient 1: Treatment Is mechanical or pharmacological thromboprophylaxis contraindicated?

  11. Patient 1: Treatment choices-Mechanical Thromboprophylaxis

  12. Patient 1: Treatment choices-Pharmacological Thromboprophylaxis

  13. Patient 1:Other treatment choices?

  14. ACCP 2008: THR guidance • LMWH • (12hrs preop, 12-24hrs postop, 4-6hrs postop 50%) • Fondaparinux(2.5mg, 6-24hrs postop) • VKA • Mechanical device alone: only if bleeding risk high

  15. Value of Mechanical Thromboprophylaxis? • No bleeding (useful when bleeding risk high) • May enhance effectiveness of pharmacological thromboprophylaxis • Big variation in size/pressure/features • - many brands not assessed in trials • - fitting/compliance poor on wards • Fewer/smaller studies • - effect on reducing PE/death unknown • - less effective in high risk groups • - no study in medical inpatients

  16. ACCP 2008:Mechanical Thromboprophylaxis • Recommend primarily where bleeding risk high (1A) or as adjunct to pharmacological measure (2B) • Careful attention to proper use and compliance ‘optimal use’

  17. Prevention of DVT after general surgery (ACCP 2001)

  18. ACCP 2008: Aspirin 1.4.4 We recommend against the use of aspirin alone as thromboprophylaxis against VTE for any patient group (1A).

  19. Patient 1: Treatment • LMWH (preop) or oral agent (postop) once daily Plus • Graduated compression stockings and/or SCD

  20. Patient 1: Pharmacological Thromboprophylaxis –for how long?

  21. Patient 1: Pharmacological Thromboprophylaxis –for how long? ACCP: beyond 10 days, up to 35 days (1A)

  22. Epidurals ACCP: • insertion of spinal/epidural needle delayed 8-12 hrs following prophylactic heparin dose • removal scheduled just prior to next dose • following epidural removal, delay next doseby > 2 hrs • Dabigatran: not recommended

  23. Clinical presentation of HIT • Thrombocytopenia • Timing of thrombocytopenia • Thrombosis / other sequelae • oTher cause unlikely

  24. Patient 2: Gynaecological surgery • 63-year-old woman • Uterine carcinoma • Weight 135kg, BMI 38 kg/m2 • Abdominal hysterectomy

  25. Patient 2: VTE risk assessment • Major gynaecological procedure • Additional risk factors for VTE? • > 60 years old • Anticipated immobility 3 days • BMI 38 kg/m2 • Malignancy

  26. Patient 1: Treatment Is mechanical or pharmacological thromboprophylaxis contraindicated?

  27. Patient 2: Treatment choices-Mechanical Thromboprophylaxis

  28. Patient 2: Treatment choices-Pharmacological Thromboprophylaxis

  29. Patient 2:135 kg - What dose of LMWH

  30. Patient 2: Pharmacological Thromboprophylaxis – duration?

  31. Gynaecologic surgery guidance (ACCP 2008) • Minor procedureswithout ARFs: early ambulation only • Laparosopic procedures • -without ARFs: early ambulation • with ARFs: LMWH or LDUFH or IPC or GCS (1C) • Major procedures: • Benign disease: LMWH (1A) or LDUFH (1A) or IPC (1B) • Malignancy: consider LMWH 28 days • Bariatric surgery: higher doses LMWH or UFH suggested (2C)

  32. Patient 3: Neurosurgery and Spinal Procedures • 71-year-old woman • Elective spinal procedure (disc prolapse) • Smoker • Varicose veins • FV Leiden mutation heterozyous

  33. ACCP, 2008

  34. Patient 3:VTE Risk Assessment

  35. Patient 3: Risk Assessment for VTE • Major spinal procedure • Additional risk factors for VTE? • > 60 years old • Anticipated immobility 3 days • FV Leiden

  36. Patient 3: Treatment Is mechanical or pharmacological thromboprophylaxis contraindicated?

  37. Patient 3: Treatment choicesMechanical Thromboprophylaxis

  38. Patient 3: Treatment choicesPharmacological Thromboprophylaxis

  39. Patient 3: Pharmacological Thromboprophylaxis – duration?

  40. Elective spinal surgery guidance (ACCP 2008) • No ARFs: early ambulation (2C) • With ARFs: either • Post op LMWH (1B) • LDUFH (1B) • Periop IPC (1B) or GCS (2b) • With multiple ARFs: pharmacologic plus mechanical (2C)

  41. Defining the ComplexMedical Patient • . . . A patient you would give LMWH to, but for some reason you feel uncomfortable . . . • . . . A patient who would benefit from LMWH but may have a contraindication . . .

  42. Patient 4 • 74-year-old woman, 15-year history of type 2 diabetes • Peripheral neuropathy (feet), leg ulcers • BMI 33 kg/m2, 92kg • Admitted with unilateral lower limb cellulitis, immobility, high BMs • Treated with insulin, hydration and intravenous antibiotics

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