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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


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