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ETIOPATHOGENESIS

Abnormalities of flowAbnormalities of vessel wallHypercoagulability of bloodETIOPATHOGENESIS

Objectives/OutlineRationale for thromboprophylaxisSummary of the 7th ACCP thromboprophylaxis guidelinesImplementation strategies

Rationale for Thromboprophylaxis I. High prevalence of VTE in certain patient groups II. Adverse consequences of unprevented VTEIII. Efficacy, effectiveness and cost- effectiveness of thromboprophylaxis

Risk Factors for VTE Previous venous thromboembolism Increased age Surgery Trauma - major, local leg Immobilization - bedrest, stroke, paralysis Malignancy and its Rx (CTX, RTX, hormonal) Heart or respiratory failure Estrogen use, pregnancy, postpartum, SERMs Central venous lines Thrombophilic abnormalities

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Risk Factors for VTE Previous venous thromboembolism Increased age Surgery Trauma - major, local leg Immobilization - ? bedrest, stroke, paralysis Malignancy & its Rx (CTX, RTX, hormonal) Heart or respiratory failure Estrogen use, pregnancy, postpartum, SERMs Central venous lines Thrombophilic abnormalitiesMost hospitalized patients have at least one risk factor for VTE

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Some Basic Principles of Thromboprophylaxis Group prophylaxis rather than individual Mechanical prophylaxis only if high risk of bleeding No role for aspirin alone as DVT prophylaxis Epidural analgesia and anticoagulant thromboprophylaxis are compatible

7th ACCP Conference on Antithrombotic Therapy

DVT Prophylaxis: 3 Patient Groups Low risk Moderate risk High risk

Patient group: Age < 40 yearsMedical fully mobile, brief admissionSurgical procedure < 30 min, mobile, no additional risk factorsRecommendations: no specific prophylaxis mobilization

[Grade 1C] Low risk7th ACCP Conference on Antithrombotic Therapy

Patient group: Age between 40 60 years + minor surgery or age < 40 with risk factors Medical bedrest / sick Surgical major general, urologic, gynecologic proceduresEvidence:LDH ~ LMWHOptions: LDH [Grade 1A] 5000 bid LMWH [Grade 1A] 60, +/- risk factorsEvidence: 1. Venography: fondaparinux > LMWH > OVKA 2. Clinical: LMWH ~ OVKAOptions: LMWH [Grade 1A] > 3400 sc daily fondaparinux [Grade 1A] oral vitamin K antagonist (INR 2-3) [1A] LDH or LMWH + GCS or IPCStart: Postop (preop if HFS delayed)Duration: > 10 days (2-4 weeks)

7th ACCP Conference on Antithrombotic Therapy High risk

HIT with LDH or LMWH for ProphylaxisMartel Blood 2005;106:2710meta-analysis of 7 prospective studies comparing prophylactic LDH and LMWH Prophylactic anticoagulant HIT Heparin 41/1,730 (2.37 %) LMWH 1/1,762 (0.06 %)

* NNT=43

Routine Prophylaxis NOT Recommended: vascular surgery laparoscopic surgery knee arthroscopy spine surgery isolated lower extremity fractures long distance travel

7th ACCP Conference on Antithrombotic Therapy

Any additional risk factors will mandate consideration of thromboprophylaxis

Benefit:risk favors routine prophylaxisMajor orthopedic surgery (THR, TKR, HFS)Major traumaSpinal cord injuryMajor general, gyne, urologic surgeryMajor neurosurgeryMedical patients with additional risk factorsMost ICU patients

Benefit:risk favors routine prophylaxisMajor orthopedic surgery (THR, TKR, HFS)Major traumaSpinal cord injuryMajor general, gyne, urologic surgeryMajor neurosurgeryMedical patients with additional risk factorsMost ICU patientsBenefit:risk favors no prophylaxisSurgical patients: - brief procedure - fully mobile - no additional RFsMedical patients: - fully mobile - no additional RFsLong distance travel

Benefit:risk favors routine prophylaxisMajor orthopedic surgery (THR, TKR, HFS)Major traumaSpinal cord injuryMajor general, gyne, urologic surgeryMajor neurosurgeryMedical patients with additional risk factorsMost ICU patientsBenefit:risk uncertain- local practice or individual prophyl.Laparoscopic surgeryVascular surgeryCardiac surgeryElective spine surgeryArthroscopic surgeryBurnsIsolated lower extremity fracture

Benefit:risk favors no prophylaxis Surgical patients: - brief duration - fully mobile - no additional RFs Medical patients: - fully mobile - no additional RFs Long distance travel

Thromboprophylaxis Use in Practice 1992-2002 Prophylaxis Patient Group Studies Patients Use (any) Orthopedic surgery 4 20,216 90 % (57-98) General surgery 7 2,473 73 % (38-98) Critical care 14 3,654 69 % (33-100) Gynecology 1 456 66 % Medical patients 5 1,010 23 % (14-62)

Recommended VTE Prophylaxis Strategies in Surgical SettingsIndicationPrevention StrategyGeneral SurgeryUFH 5,000 units q 8h, 1st dose 2h preoperatively, continued for 7 days or LMWH once dailyCancer SurgeryEnoxaparin 40 mg daily or equivalent, 1st dose 10-14h preoperatively if possible, for 28 days

UFH = unfractionated heparinLMWH = low molecular weight heparin

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Recommended VTE Prophylaxis Strategies in Surgical Settings (cont.)IndicationPrevention StrategyTotal Hip ReplacementEnoxaparin 40 mg daily or equivalent, beginning preoperative evening, continuing out-of-hospital for 21-28 daysEnoxaparin 30 mg BID or equivalent, 1st dose 12-24h postoperatively, until hospital dischargeDalteparin 2,500 units 4h post-op, then 5,000 units daily until hospital discharge or for 35 days

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Recommended VTE Prophylaxis Strategies in Surgical Settings (cont.)IndicationPrevention StrategyTotal Hip Replacement (cont.)Fondaparinux 2.5 mg 4-8h post-op, then 12h after 1st dose, then daily for 5-9 daysWarfarin daily, 1st dose 7.5 mg 24-48h preoperatively, adjusted to target INR of 2.0-3.0Warfarin daily, 1st dose 5 mg preoperative evening, adjusted to target INR of 2.0-3.0 and continued 4-6 weeks

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Recommended VTE Prophylaxis Strategies in Surgical Settings (cont.)IndicationPrevention StrategyTotal Knee ReplacementEnoxaparin 30 mg BID or equivalent, beginning 12-24h postoperatively, continued for an average of 9 daysFondaparinux 2.5 mg, 1st dose 4-8h postoperatively, 2nd dose 12h after 1st dose, then daily for 5-9 daysHip Fracture SurgeryFondaparinux 2.5 mg, 1st dose 4-8h postoperatively, 2nd dose 12h after 1st dose, then daily for 5-9 days. If surgery is delayed > 24-48h after admission, give 1st dose 10-14h preoperatively

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Recommended VTE Prophylaxis Strategies in Surgical Settings (cont.)IndicationPrevention StrategyNeurosurgeryEnoxaparin 40 mg daily or equivalent, 1st dose 24h postoperatively, continued until hospital discharge, plus GCSCraniotomy for Brain TumorEnoxaparin 40 mg daily or UFH 5,000 units BID, 1st dose on 1st postoperative morning, continued until hospital discharge, plus GCS/IPC, plus predischarge venous ultrasonography

GCS = graduated compression stockingsIPC = intermittent pneumatic compression devices

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Duration of ProphylaxisRecommendations for extending the duration of prophylaxis in high-risk scenarios:Geerts WH, et al. Chest. 2004;126(suppl 3):338S-400S.

Cancer surgery28 days postoperativelyTotal hip replacement and hip fracture repair28-35 days postoperativelyTraumaThroughout inpatient rehabilitation and after discharge in patients with significantly impaired mobility

2413. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126(suppl 3):338S-400S. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15383478

Objectives/OutlineRationale for thromboprophylaxisSummary of the 7th ACCP thromboprophylaxis guidelinesImplementation strategies

Strategies to Improve Thromboprophylaxis Success Excellent quality guidelines National body endorsement Hospital accreditation (JCAHO) Pay for performance (CMS) Local written policy (care pathway) for the hospital / program / patient care unit Pharmacist responsibility Pre-printed orders Computerized orders

Take-Home PointsKnow the common VTE risk factorsAssess VTE risk for each hospitalized patient individuallyBecome familiar with the various VTE prophylaxis regimens for different at-risk patient groupsApply the current ACCP guidelines to prevent VTE in hospitalized patients

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Prevention of VTE: SummaryThromboprophylaxis is indicated for most hospitalized patientsBut is under-utilizedNot ASA; mechanical rarely; warfarin scaryChest 2004;126(suppl):338S-400SSystems approach / hospital policyKeep it simple, routine: Pre-printed ordersJust do it!

Thank you

http://webmm.ahrq.govBill Geerts, MD, FRCPC, FCCPUniversity of Toronto