VTE ProphylaxisFocus on Prevention

Deep vein thrombosis (DVT) forms in a vein of the leg.

• Characterized by pain, swelling or tenderness of the leg, sometimes with redness and warmth

Deep Vein Thrombosis

Pulmonary embolism

Pulmonary embolism (PE) occurs when the blood clot breaks loose and travels to the lungs

• Characterized by shortness of breath, sharp rib/chest pain and occasionally by hemoptysis, light-headedness, or collapse

Symptoms and Signs of DVT• Leg pain (90%)• Tenderness (85%)• Ankle edema (76%)• Calf swelling (42%)• Dilated veins (33%)• Dusky discoloration

(30%)• Warmth• Redness

DVT cannot be reliably diagnosed on the basis of history and physical exam, even in high-risk patients.

Symptomatic DVT

Most hospitalized patients with DVT

will have NO SYMPTOMS or SIGNS!

Risk of VTE in Hospitalized Patients

Geerts WT, et al. Chest 2008;358:381S-453S.

Patient Group DVT Prevalence (%)

Medical Patients 10-20

General Surgery 15-40

Major Gynecologic Surgery 15-40

Major Urologic Surgery 15-40

Neurosurgery 15-40

Stroke 20-50

Hip and Knee Arthroplasty, Hip Fracture Surgery

40-60

Major Trauma 40-80

Spinal Cord Injury 60-80

Critical Care Patients 10-80

Pulmonary Embolism

Hospital Risk•Accounts for 10% of hospital deaths

•In the UK, PE following DVT causes between 25,000 and 32,000 deaths each year1

International, cross-sectional audit of 35,000 inpatients at risk for VTE found:2

•only 59% of surgical patients and 40% of medical patients received recommended prophylaxis.

1. UK House of Commons Health Committee. HC 99. Published on 8 March 2005.2. Cohen AT, et al. Lancet 2008;371:387-394.

Characterization of VTE events

In the Worcester County, Mass VTE Study•60-70% of VTE events were considered to be provoked by:

• Recent hospitalization (within 3 months)• Surgery• Trauma/fracture• Pregnancy

1. Spencer FA, et al. Arch Intern Med 2007;167:1471-5.2. Spencer FA, et al. J Thromb Thrombolysis 2009;28:401-9.

Risk for VTE increases with the

number of risk factors and

persists after hospital discharge.

Marco’s Story

Adapted from: Greer IA. Bailliere’s Clin Obstet Gynaecol 1997;11:403-30.

The risk of DVT and PE is increased by several factors, including:Factors intrinsic to the

patientFactors related to

underlying disease or medical condition

Factors introduced by medical or surgical

treatment

• Age• Obesity• Immobility• History of thrombosis• Thrombophilia

• Varicose veins• Venous insufficiency• Pregnancy• Trauma• Heart failure/MI• Malignancy

• Concomitant medication• Chemotherapy• Orthopaedic surgery• Major surgery• Caesarean section

1. VTE is common in hospital patients

2. VTE is fatal (acutely and long-term)

3. VTE is preventable (safely and inexpensively)

4. Preventing VTE is the standard of care for almost all hospital patients in 2011

Slide courtesy of Dr. William Geerts.

Rationale for Thromboprophylaxis

Adverse Consequences of VTE

$Slide courtesy of Dr. William Geerts.

Key steps to ensure compliance with ROP:

1.Written policy/guideline

2.Identifies clients at risk & provides VTE prophylaxis

3.Establishes measures of success, uses information to make improvements

4.Provides information to health professionals (on risks & prevention measures)

Audrey’s StoryFollowing a one week wait for surgery and the successful removal of a benign tumour – Audrey developed a PE.

We are scared and worried about our surgery or primary reason for being in the hospital as it is. We rely on you to make us aware of any possible complications. For me, the blood clot was far scarier and worse than my brain tumour and operation.

This experience with the blood clot has impacted my life. It was the scariest and worst experience I have ever had and it has left me fearful and anxious.

“My plea to healthcare professionals: make sure you get people’s attention, and make sure they fully understand their risks and what can be done to prevent a blood clot.”

Guidelines for Prevention of VTE

*Use clinical judgment to weigh the risk of venous thromboembolism versus the risk of bleeding.*Use clinical judgment to weigh the risk of venous thromboembolism versus the risk of bleeding.

Tinzaparin dosing considerations according to weight• 50-100 kg: tinzaparin 4 500 units sc once a day • <50 kg: tinzaparin 3 500 units sc once a day

Clinical order sets for a predominately obese population may warrant two or three weight ranges using prefilled syringe sizes.

• 100-150 kg: tinzaparin 10 000 units sc once a day • 151-200 kg: tinzaparin 14 000 units sc once a day

Prevention of VTE in Hospitalized Patients: Summary of Good Practice

• Due to differences in LMWH molecule size and charge, longer chained and more charged LMWHs like tinzaparin do not appear to require dose adjustments in patients with:• impaired renal function1

• renal failure2,3

• on haemodialysis2,3

• Dose reduction may be necessary with shorter chain LMWHs (i.e. enoxaparin)

Use of LMWHs in Renal Impairment

1. Mahé O, et al.Thromb Haemost 2007;97:581-6.2. PROTECT Investigators. N Engl J Med 2011;364:1305-14. 3. Nutescu EA, et al. Ann Pharmacother 2009;43:1064-83.

Contraindications to Tinzaparin:

Every in-patient w/o contraindication

should be onVTE Prophylaxis