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Prophylaxis Pt. I DVT Prophylaxis in the SICU Gabriel Brat, MSIII 6/18/2007

DVT Prophylaxis.ppt

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  • Prophylaxis Pt. IDVT Prophylaxis in the SICUGabriel Brat, MSIII6/18/2007

  • IntroductionImportance of DVTsRisk FactorsMethods of ProphylaxisRecommendationsCompliance

  • BundlesPE third most common cause of iatrogenic death.2001 AHRQ report emphasized 1A evidenceIHI 5 million lives campaignVAP bundle

  • LE DUS for PE90% PEs originate in lower extremity1st symptomatic DVTSensitivity 95%, specificity 96%Increased sensitivity:serial US at 5-7 dayscombining with clinical suspicion

  • Lower Extremity Veins

    Iliac(Superficial)FemoralDeep (Common) FemoralExternal SaphenousInternal SaphenousPoplitealHauer. UCSF 2005

  • Risk Factors for DVTSurgeryTrauma (major or lower extremity)ImmobilityParesisMalignancyCancer therapy (hormonal, chemotherapy, or radiotherapy)Previous VTEIncreasing agePregnancy and the postpartum periodEstrogen-containing oral contraception or hormone replacement therapySelective estrogen receptor modulatorsAcute medical illnessHeart or respiratory failureInflammatory bowel diseaseNephrotic syndromeMyeloproliferative disordersParoxysmal nocturnal hemoglobinuriaObesitySmokingVaricose veinsCentral venous catheterizationInherited or acquired thrombophilia

  • Risk of DVTGeerts et al.Chest, 2004;126:338S

    Patient GroupDVT Prevalence, %

    Medical patients1020General surgery1540Major gynecologic surgery1540Major urologic surgery1540Neurosurgery1540Stroke2050Hip or knee arthroplasty, hip fracture surgery4060Major trauma4080Spinal cord injury6080Critical care patients1080

  • Inherited Hypercoagulability

    **OR 5.9 (CI 2-18) for breakthroughAlbrecht. Online 2007Baba Ahmed. Thromb Haemost 2007; 97: 171

    Prevalence DVT

    Population

    Prevalence

    Factor V Leiden

    12-21%**

    6%

    Prothrombin mut

    6-8%

    2%

    Protein C, S def

    2-4%

    < 1%

    AT III def

    1-2%

  • Mechanical Prophylaxis

  • OverviewMechanical CompressionNo convincing evidence of mortality value over placebo.Plantar vs. Calf DVT in 21.0% plantar vs. 6.5% calf (p = 0.009).Knee-length vs. Thigh-lengthEquivalent effect w improved compliance in KL group.Mechanical vs. ChemicalOR 0.46 (CI 0.16-1.29) for all heparin vs. mechanical

    Gregory et al. J Trauma 1999; 47:1

  • CompressionRoderick et al. HTA, 2005; 9

  • CompressionRoderick et al. HTA, 2005; 9

  • Chemical Prophylaxis

  • OverviewAspirinNot recommended for DVT prophylaxisAspirin vs. LMWH63% RRR among 205 ortho pts LMWH vs. ASA.Among hip trauma pts, 44% vs. 28% ASA vs. LMWHUFH and LMWH UFH decreases incidence of DVT by 20% over placebo LMWH decreases incidence of DVT by 30% over UFH.

  • Mechanism of HeparinsWeitz. NEJM, 1997; 337:688Unfractionated heparin inactivates both Factor IIa and XaLMWH has increased affinity for Factor Xa

    Fondiparinux is only a pentasaccharide sequence

  • PharmokineticsTran and Lee. Ann Pharm 2003; 37: 1632.

  • Dolovich, L. R. et al. Arch Intern Med 2000;160:181-188.LMWH vs. UFH

  • Dolovich, L. R. et al. Arch Intern Med 2000;160:181-188.LMWH vs. UFH 2

  • Dolovich, L. R. et al. Arch Intern Med 2000;160:181-188.LMWH vs. UFH 3

  • Atia et al. Arch Intern Med 2001; 161: 10.LMWH vs. UFH in Trauma

  • LMWH vs. UFH in TraumaGeerts et al. NEJM 1996Double blind, RCT 344 major traumano ICH 1st dose within 36 hours of injury No mechanical prophylaxis 5000 U LDUH v. 30 mg enoxaparin BID RRR DVT 30% for LMWH Higher bleeding in LMWH, but not significant

  • Leonardi, M. J. et al. Arch Surg 2006;141:790-799.Complication Rates

  • LMWHAdvantagesLonger half lifeImproved efficacyLess heparin-induced thrombocytopeniaCost-effective for trauma and gen surgDisadvantagesPoor protamine response (60%)Variable effect w renal failure, obesityConcern for bleeding

  • DVT RecommendationsGeerts et al. Chest, 2004; 126:338S

  • IVC Filters

  • IVCF Reasons for UseClot with active cerebral bleedingClot despite anticoagulationMassive PE with chronically compromised pulmonary vasculature

  • IVCF EffectivenessFilterNo filter pPE at day 121%5%0.03PE at 2 years3%6%NSDVT at 2 years21%12%0.02Death22%21%NSMajor bleed9%12%NS

    DeCousus et al. NEJM 1998; 338:409

  • Recommendations

  • DVT RecommendationsGeerts et al. Chest, 2004; 126:338S

  • Trauma RecsTrauma patients with at least one risk factor for VTE receive thromboprophylaxis, if possible (Grade 1A). In the absence of a major contraindication, LMWH prophylaxis starting as soon as it is considered safe to do so (Grade 1A). Mechanical prophylaxis with IPC be used if LMWH prophylaxis is delayed or if it is currently contraindicated due to active bleeding or a high risk for hemorrhage (Grade 1B).

    DUS screening in patients who are at high risk for VTE (eg, SCI, lower extremity or pelvic fracture, major head injury, or an indwelling femoral venous line, suboptimal prophylaxis) (Grade 1C).

    No use of IVCFs as primary prophylaxis in trauma patients (Grade 1C).

    Continuation of thromboprophylaxis until hospital discharge, including the period of inpatient rehabilitation (Grade 1C+).

    Continuing prophylaxis after hospital discharge in patients with major impaired mobility (Grade 2C).

  • ComplianceYu. Am J HP, 2007; 64: 69.

  • Causes for Poor ComplianceNathens et al. J Trauma. 2007;62:557Three fold increase in DVTs after 4 days in TICU.

  • SummaryDUS Clinical suspicion + serial testingRisk factors Trauma and thrombophiliaTreatmentLMWH superior to UFHStart early Cost effectivePlans Uptake poor at hospitals

  • Summary

  • Thank you.Thanks to pt. DW for worrying me about this issue every day for a week.

  • Clinical Probability of PEWells, Ann Intern Med 2001Leg swelling, tenderness3Pulse > 1001.5Immobilization, surgery1.5Prior DVT/PE1.5Hemoptysis1Cancer1No other more likely Dx3

    < 2 = Low probability 2-6 = Moderate > 6 = High

    90%. AND studies show that 40% patients presenting with PE who have NO leg symptoms have a DVT if you look for it.Dx = noncompressibility of a deep veinSerial US if sx persist: identify 1-2% w/ DVT missed on initial study.50% prox DVTs embolize to lung. 20% calf vein DVTs embolize to prox veins, meaning that only 10% cause PE. In trauma pts, 1/3 to of dvts are proximal.

    Study has shown that PCPs misinterpret US results diagnosing superficial femoral clot as unimportant. Most studies of VTE and its prevention have used sensitive diagnostic tests to detect DVT. The majority of the thrombi diagnosed by these screening tests were confined to the calf, were clinically silent, and remained so without any adverse consequences.22232425 However, approximately 10 to 20% of calf thrombi do extend to the proximal veins,222627282930 and, particularly in patients undergoing major surgery involving the hip, isolated femoral vein DVT is common.31323334 There is also a strong association between asymptomatic DVT and the subsequent development of symptomatic VTE.223536373839404142 For example, one study42 found that among critical care patients with asymptomatic DVT detected by screening DUS there was a significantly greater rate of PE development during their index hospitalization compared to those patients without silent DVT (11.5% vs 0%, respectively; p = 0.01). Furthermore, the in-hospital case-fatality rate of VTE is 12%,12 and the data suggest a case-fatality rate at 1 year of 29 to 34%.1243 If you look for a source Among all pts with clot, 24-37% have thrombophilia, vs. 10% of the general pop (w/ clot, 80% of all comers have a cause acquired or genetic)FV Leiden - 5-6% of Whites, rare in Asian, AA. Causes resistance to protein C.Lifetime risk of clot increased 2.2X (vs. Pro C, S 7-8X)inc risk by 4-10 in heterozygotesProthrombin mutation: leads to PT levels 30% higher than controlsHomocystein - due to genetic abnormality most commonly of MTHFR enzyme, or deficiency of B6, B12, or folic acidAbout 1/3 w/ SLE have ACLA and 1/3 have LAHalf w/ SLE and APS will clotAlso, elevated F8 level >150% nl, linked to blood group other than 0, presumed genetic50-60% of inherited thrombophilia is due to FV Leiden or the Prothrombin mutationAmong 205 patients undergoing hip or knee arthroplasty, who were randomized to receive aspirin or the LMWH ardeparin, the relative reduction in the risk of VTE with the use of LMWH over aspirin was 63% (p < 0.001).157 The RRRs for DVT and proximal DVT in patients who have received prophylaxis with a VFP plus aspirin over that with aspirin alone following total knee arthroplasty (TKA) were 32% and > 95%, respectively (p < 0.001 for both comparisons).156 Among hip fracture surgery (HFS) patients who were randomized to receive either aspirin or danaparoid, a low-molecular-weight heparinoid, VTE was detected in 44% and 28% of the patients, respectively (p = 0.028).158 We commonly use US as a diagnostic test for DVT, but how good is it as a diagnostic test for PE? 90%. AND studies show that 40% patients presenting with PE who have NO leg symptoms have a DVT if you look for it.Dx = noncompressibility of a deep veinSerial US if sx persist: identify 1-2% w/ DVT missed on initial study.We commonly use US as a diagnostic test for DVT, but how good is it as a diagnostic test for PE? 90%. AND studies show that 40% patients presenting with PE who have NO leg symptoms have a DVT if you look for it.Dx = noncompressibility of a deep veinSerial US if sx persist: identify 1-2% w/ DVT missed on initial study.Among 205 patients undergoing hip or knee arthroplasty, who were randomized to receive aspirin or the LMWH ardeparin, the relative reduction in the risk of VTE with the use of LMWH over aspirin was 63% (p < 0.001).157 The RRRs for DVT and proximal DVT in patients who have received prophylaxis with a VFP plus aspirin over that with aspirin alone following total knee arthroplasty (TKA) were 32% and > 95%, respectively (p < 0.001 for both comparisons).156 Among hip fracture surgery (HFS) patients who were randomized to receive either aspirin or danaparoid, a low-molecular-weight heparinoid, VTE was detected in 44% and 28% of the patients, respectively (p = 0.028).158 Enoxaparin has 10a to 2a ratio of 3.8, which is highest.Most difference found because of dalteparin and nadroparin. Made by: Pfizer and Sanofi. Lovenox is Sanofi as well.Bleeding among general surgery. No study in trauma patients of bleeding complications.GFR < 30, decrease dose to weight based from 1 mg/kg SQ bid to qd, for prevention 30 qd. Not FDA approved for HD pts.Weight limit enoxaparin 144 kg. The incremental cost of enoxaparin relative to UH was C$90, and the incremental effectiveness was 0.085DVTs averted and -0.13 LYG. This resulted in an incremental cost-effectiveness ratio of C$1,059 per DVTaverted, and the conclusion that UH is the dominant strategy in terms of LYG. UH remained the dominant strategy in terms of life years independent ofthe parameter estimates because of increased bleeding in the LMWH. Shorr 2001, CCM. DVT with LDH was 14.7%, that LMWH resulted in a relative risk reduction of DVT of 50%, but that enoxaparin nearly quadrupled the risk of bleeding. Despite the higher costs of enoxaparin, this tactic yielded a net savings of $391.23 per DVT prevented.

    Value of risk stratification.Low risk = ambulatory surgeryHigh risk: elderly, ortho, cancer, or multiple other risks400 patients with proximal DVT, 50% with PE. Also repeated to show equivalence

    Low risk = ambulatory surgeryHigh risk: elderly, ortho, cancer, or multiple other risksHospital admissions on or after January 1, 2001, and concluded by March 31, 2005, were included if they met any of the following conditions as defined in the ACCP Consensus Conference on Antithrombotic Therapy guidelinesExponential increase DVT diagnosis after 4 days. 3 times risk of finding DVT if waiting more 4 days. Logistic regression shows LE injury improves use.