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DVT PROPHYLAXIS. SUNDIP PATEL 7 / 15 / 2009. BACKGROUND. D eep V ein T hrombosis is a common, yet preventable peri-operative complication Highest risk in critical care and spinal cord injury patients – 60-80% Post–General Surgery procedures: 15-40% Post-Ortho Procedures: 40-60%

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dvt prophylaxis

DVT PROPHYLAXIS

SUNDIP PATEL

7 / 15 / 2009

background
BACKGROUND
  • Deep Vein Thrombosis is a common, yet preventable peri-operative complication
  • Highest risk in critical care and spinal cord injury patients – 60-80%
  • Post–General Surgery procedures: 15-40%
  • Post-Ortho Procedures: 40-60%
  • Variable for Urologic cases
background1
BACKGROUND
  • Pulmonary Embolus
    • True Prevalance is unknown
    • W/O prophylaxis
      • Fatal PE in 0.2-.9% of ELECTIVE general surgery cases
      • Fatal PE in 0.1-2.0% of ELECTIVE hip
      • Fatal PE in 2.5-7.5% of Fractured Hip
virchow triad
VIRCHOW TRIAD
  • STASIS
    • From supine positioning and effects of anesthesia
  • HYPERCOAGULABILITY
    • Decreased clearance of the PROcoagulant
  • INTIMAL INJURY
    • Results from excessive vasodilation caused by vasoactive amines and anesthesia
  • Acting in concert, these 3 factors promote development of DVT in low-flow areas
risk factors
RISK FACTORS
  • AGE > 50
  • Hx of varicose veins
  • Hx of MI
  • Hx of Cancer
  • Hx of AFib
  • Hx of ISCHEMIC Stroke
  • Hx of DM
urologic risk
Urologic Risk
  • RISK Level for most UROLOGIC patients are considered

MODERATE

urologic risk1
UROLOGIC RISK
  • Risk of DVT w/o prophylaxis is 10 – 40%
  • RECS:
    • Low Molecular Weight Heparin (Lovenox)
    • Low Dose Unfractionated Heparin
    • Fondaparinux (ARIXTRA)
    • Also appropriate to use is
      • Graduated Compression Stockings
      • Intermittent Pneumatic Compression
      • Venous Foot Pumps
types of medical prophylaxis
Types of MEDICAL prophylaxis
  • ARIXTRA
    • Longer half-life than LMWH (17H v 4H)
    • Not for CKD pts
    • No monitoring
    • Single daily dosing
  • LMWH (lovenox)
    • Greater bioavailability
    • Longer duration
    • Little monitoring needed
    • HIT incidence less
  • LDUH
    • Easy administration
    • Cost Effective
    • Little monitoring needed
urologic procedures
UROLOGIC PROCEDURES
  • Transurethral – EARLY AMBULATION
    • IF HIGHER RISK, GCS OR IPC
  • Anti-incontinence and pelvic reconstructive surgery
    • Low risk – early ambulation
    • Mod risk – IPC or LMWH
    • Hi Risk – IPC + LDUH or LMWH
  • Urologic laparoscopic and/or robotically assisted - IPC
  • Open Procedures - IPC
contraindications
CONTRAINDICATIONS
  • ABSOLUTE
    • Active bleeding, PLT:20, neurosurgery, ocular surgery, intracranial bleeding w/in 10 days
  • RELATIVE
    • PLT:20-100, brain metastases, major abdominal surgery w/in past 2 days, GI bleeding or GU bleeding w/in past 14 days, infective endocarditis, malignant hypertension
prophylaxis options
PROPHYLAXIS OPTIONS
  • LMWH – 40mg SQ qd
  • LDUH – 5000u SQ B-TID
  • ARIXTRA – 2.5 SQ qd

NOT for patients with CrCl <30

For LOW RISK procedures and those with NO RISK FACTORS, no prophylaxis is required. ENCOURAGE AMBULATION EARLY AND FREQUENTLY

urologic recomendations
UROLOGIC RECOMENDATIONS
  • MAJOR, OPEN PROCEDURES
    • EITHER LMWH, LDUH, ARIXTRA (GRADE1A)
    • IF HIGH RISK OF BLEEDING, USE MECHANICAL METHODS UNTIL
  • LAPAROSCOPIC
    • IF previous dvt/pe, LMWH or LDUH, may also add IPC or GCS (Grade 1C)

ALL PATIENTS WITH HISTORY OF CANCER

summary
SUMMARY
  • ALL PATIENTS UNDERGOING ANY SURGERY SHOULD HAVE DVT PROPHYLAXIS
  • GCS AND EARLY AMBULATION SUFFICIENT IN MOST CASES
  • CONTINUE PROPHYLAXIS UNTIL AMBULATING
ad