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Venous ThromboembolismReducing the Risk
<Name of session> DATE
Objectives• Define venous thromboembolism• Heighten awareness– the impact of VTE– the preventable nature of VTE
• Discuss importance of – VTE risk assessment– appropriate prescribing of prophylaxis– engaging patients
• Demonstrate how to assess VTE risk
Venous Thromboembolism
• VTE = Deep vein thrombosis (DVT) and/or pulmonary embolism (PE)
DVT PEOccurs in deep veins (most commonly in legs and groin)
Occurs after DVT dislodges and travels to the lungs
Can cause long-term issues – ‘post-thrombotic syndrome’ (PTS)
Serious complication which can lead to death
PTS affects 23-60% of DVT patients within 2 years
Lower-extremity DVT has 3% PE-related mortality rate
Patients with PE have 30-60% chance of dying from it
What Causes VTE• Virchow’s Triad = categories of factors
contributing to blood clot formationStasis
Alteration in normal blood flow
Endothelial InjuryInjury or trauma to the
inside of the blood vessel
HypercoagulabilityAlternation in the constitution of blood causing blood to clot
more easily
VIRCHOW’S TRIAD
The Impact of VTE• More than 14,000
Australians develop a VTE per year
• More than 5,000 of them will die as a direct result
• VTE causes 7% of all hospital deaths
VTE causes more deaths than bowel Ca and breast Ca
VTE Risk Factors
VTE Risk FactorsIntrinsic Risk Factors Extrinsic Risk Factors
Age > 60 years Significantly reduced mobility (relative to normal state) due to injury or illness
Obesity (BMI > 30kg/m2) Active malignancy or treatment with chemotherapy
Prior history of VTE Use of HRT or oral contraception
Pregnancy or post-partum Surgical intervention, particularly major orthopaedic surgery or abdominal/pelvic surgery for cancer
Known thrombophilia (including inherited disorders)
Active infection
Varicose veins Inflammatory bowel disease
Hospitalisation• Hospitalisation = ↑ risk of VTE
• ~ 50% of VTE cases occur during or soon after hospitalisation– 24% (surgery)– 22% (medical illness)
• Incidence 100 times greater in hospitalised patients than community residents
Preventing VTE
Preventability• Largely preventable• Shift thinking: complication vs adverse event
VTE Prevention
Risk Assessment
Prescribing Appropriate Prophylaxis
Patient Groups
ALL adult patients
admitted into hospital
Patients discharged from ED with significantly
reduced mobility relative to normal state eg in a cast/boot
following lower leg injury
Pregnant and post-partum
women
Others: Pre-admission for
elective surgery
Assessing Risk• Who should be assessed?
• Assess overall VTE risk vs benefit– Assess clotting risk– Assess bleeding risk
i.e. contraindications to prophylaxis and/or other bleeding risks
• <indicate what tool is available at your facility (State Tool* or Local Tool)>
Assessing Risk
Prescribing Prophylaxis
• Patient at risk + nil C/I = prescribe• Two types of prophylaxis:
1. pharmacological 2. mechanical
• Ensure C/I to both pharmacological and mechanical prophylaxis have been considered
• Evidence-based guidelines
NHMRC Guidelines
Pharmacological Prophylaxis• Anticoagulants• Alter the process of blood
coagulation to prevent VTE formation
http://www.healio.com/orthopedics/hip/news/online/%7Ba0ebf835-ae3d-42df-a9e5-ae55b11e0413%7D/new-oral-anticoagulants-for-thromboprophylaxis-after-total-hip-or-knee-arthroplasty
The coagulation cascade and activity of anticoagulants
Pharmacological Prophylaxis• Main anticoagulants include:
Drug Class Agents
Unfractionated heparin
Unfractionated heparin
Preferred in patients with renal impairment
LMWH EnoxaparinDalteparin
Most commonly used agentsRequire dosage adjustment in renal impairment
Factor Xa inhibitors
ApixabanRivaroxaban
Alternative for prophylaxis in post- hip or knee replacement
Fondaparinux Alternative for prophylaxis in post- hip or knee replacement and hip fracture surgery
Direct thrombin inhibitors
Dabigatran Alternative for prophylaxis in prophylaxis post- hip or knee replacement
Heparinoid Danaparoid Used in heparin-sensitivity or HIT
Pharmacological Prophylaxis• Contraindications may include:
• Other relative contraindications may exist – weigh risk vs benefit
Contraindications
Active bleeding
Thrombocytopenia (platelets < 50 x 109/L)
End stage liver disease (INR > 1.5)
Treatment with therapeutic anticoagulant e.g. warfarin with INR > 2Severe trauma to head or spinal cord, with haemorrhage in last 4 weeks
Mechanical Prophylaxis• Devices that increase blood flow velocity in
leg veins, reducing venous stasis.• They include:
Device
Graduated Compression Stockings (GCS)
Provide graduated compression, which is firmest at the ankle. Used mainly for ambulant patients
Anti-embolic Stocking Standard compression throughout.Used for bedbound or non-ambulant patients
Intermittent Pneumatic Compression Device (IPC)
Inflatable garment wrapped around legs which is inflated by pneumatic pump. Enhances venous return
Foot Impulse Device (FID) Stimulates legs veins to mimic walking and reduce stasis. Used for immobilised patients
Mechanical Prophylaxis• Contraindications may include:
Contraindications
Skin ulceration
Lower leg trauma
Morbid obesity (where correct fitting of stocking cannot be achieved)Massive leg oedema or pulmonary oedema due to CCF
Stroke patients (avoid compression stockings)
Other Ways to Help Prevent VTE
Empowering Patients• Engage your patients
Empower with
Information
VTE risk factors
What you as their Dr are doing to prevent their
development of a VTE
Signs and symptoms
of VTE
What they can do to help prevent a VTE