venous thromboembolism in the surgical patient: prophylaxis and treatment
DESCRIPTION
Venous Thromboembolism in the Surgical Patient: Prophylaxis and Treatment. Pamela Hebbard August 11, 2005. Prophylaxis . Scenario 1. You are going through consent with a 60 y.o. F going for laparotomy for non-resolving SBO. - PowerPoint PPT PresentationTRANSCRIPT
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Venous Thromboembolism in the Surgical Patient:
Prophylaxis and Treatment
Pamela HebbardAugust 11, 2005
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Prophylaxis
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Scenario 1
You are going through consent with a 60 y.o. F going for laparotomy for non-resolving SBO. What is the risk of VTE in the average general surgery patient without prophylaxis?– A. 10% DVT, 0.001% fatal PE– B. 5% DVT, 0.01% fatal PE– C. 25% DVT, 0.05% fatal PE– D. 50% DVT, 1% fatal PE
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Incidence
In general surgery patients without prophylaxis:– 15 - 30% DVT– 0.2% - 0.9% fatal PE
Risk is higher with pelvic surgery, cancer surgeryOf all surgery orthopedic surgery carries the highest risk, at 50-60% DVT
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Scenario 2
52 y.o. F going for R hemicolectomy for cecal cancer. What will you choose for VTE prophylaxis?– A. aspirin to start post-op– B. a low-dose heparin– C. mechanical compression device/stockings– D. warfarin to start post-op– E. some combination of the above
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Methods of Prophylaxis
1. Aspirin• 20% risk reduction compared to placebo (5
trials)
2. Graded compression stockings• 44% risk reduction• Knee-length equally effective and easier to use
than thigh-length• Need to be fitted for them
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Methods of Prophylaxis
3. Heparins• Low-molecular weight and unfractionated• ~70% risk reduction• Equally effective• Risk of bleeding related to dose (LMWH)
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Methods of Prophylaxis
4. Intermittent pneumatic compression• 88% risk reduction• equally effective as heparin• Probably better than stockings• From small, older studies• Also need to be fitted and requires equipment
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Methods of Prophylaxis
5. Warfarin• does have a risk reduction• Older studies, mostly orthopedics• Impractical
6. Heparin + mechanical method• Stockings + LDUH have been shown to
enhance protection from VTE by a further 75% (from 15% to 4%).
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Scenario 3
You have chosen to use a heparin as VTE prophylaxis for your post-op patient with cecal ca. Exactly what order will you write?
• A. heparin 5000 u sc bid• B. heparin 5000 u sc tid• C. heparin 15000 u sc bid• D. heparin ACS/DVT protocol• E. enoxaparin 30mg sc bid• F. enoxaparin 40 mg sc od• G. enoxaparin 80 mg sc bid (1 mg/kg)• H. enoxaparin 120 mg sc od (1.5 mg/kg)
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Heparin Dosing-Prophylaxis
Unfractionated heparin:– 5000 u bid/tid
Lovenox:– 30 mg sc bid– 40 mg sc od**
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Scenario 4
Patient 1: 20 y.o. M - inguinal hernia repairPatient 2: 60 y.o. M - APR
What post-op orders will you write?• A. no heparin for either• B. heparin for both• C.1 - none, 2 - heparin• D.1 - heparin bid, 2 - heparin tid
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Risk Stratification
Low - Risk• “Minor” surgery • <40 y.o• No additional risk factors
Recommendation• Early ambulation only
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Risk Stratification
Moderate Risk– Minor surgery in patients with additional risk factors– Any surgery in pts aged 40-60 w/o additional risk
factors– Major surgery in patients <40 y.o w/o additional
risk factorsRecommendation
• Heparin 5000 bid• LMWH <= 3400 IU/day (Lovenox 30mg od)• May consider stockings if contraindication to heparin
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Risk Stratification
High Risk• Multiple risk factors• age > 60 y.o.• Age 40-60 y.o. with an additional risk
Recommendation• Heparin 5000 tid• LMWH >3400 IU/day (Lovenox 40mg od or
more)
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Risk Stratification
Very High Risk• Major surgery in >40 y.o. with: cancer, previous
VTE, or known hypercoagulable state• Major ortho surgery, elective neurosurgery,
multiple trauma, acute SCI
Recommendation• High risk heparin dosing + stockings/ IPC
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Scenario 5
You are going to give your pt heparin prophylaxis for major abdominal surgery. When do you give the first does?
• A. 2 hrs pre-op• B. in recovery room• C. once up to the floor• D. after the epidural comes out
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Timing
Optimal timing is 2 hrs pre-opDVT’s begin intra-operativelyTiming may need to be adjusted if neuraxial anesthesia is being used (no strict guidelines?)
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Scenario 6
Consider again your patient with colon cancer. How long should you continue her VTE prophylaxis?
• A. until ambulating• B. 7 days• C. until discharge• D. 4 weeks• E. 6 months
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Timing
For most patients, heparin until ambulating well is satisfactory.For high risk patients, heparin should continue for 7-10 days minimumAbdominal or pelvic surgery for cancer: 4 weeks of LMWH reduces the incidence of DVT compared to 1 week.
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Treating DVT/PE
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Scenario 7
Your post-op patient is noted to have a swollen firm left calf. U/S documents proximal DVT. What is your initial treatment?
• A. heparin 5000 u sc tid• B. heparin ACS/DVT protocol• C. enoxaparin 30mg sc bid• D. enoxaparin 80 mg sc bid (1 mg/kg)• E. enoxaparin 120 mg sc od (1.5 mg/kg)
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Initial Treatment
Choice of heparin infusion or LMWH scBoth shown to be equally effective and safeSame treatment for DVT and PELMWH easier to administer, cheaper--assuming no contraindications
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Initial Treatment
Start warfarin at same time as heparinContinue heparin for at least 5 days and INR 2-3Out-patient therapy is equally as safe as in-hospital treatment
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Scenario 8
70 y.o. M post-op from Hartmann’s for diverticulitis. DVT post-op. PHx DM, HTN, CAD, and stroke. How long does he continue on warfarin?– A. 3 mo at INR 2-3– B. 6 mo at INR 2-3– C. 12 mo at INR 2-3– D. 6 mo at INR 2-3, then indefinitely at INR 1.5-2– E. Indefinitely at INR 2-3
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Warfarin Therapy
First episode of DVT -- usually 6 monthsDVT due to transient risk factor (Surgery): 3 months of tx may be consideredPREVENT and ELATE have shown that indefinite treatment does decrease the risk of recurrence. They disagree on the necessary target INR.Long-term therapy needs to be balanced against the risk of bleeding.
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Scenario 9
62 yo w/ recently diagnosed mucinous adenocarcinoma in the liver with no known primary. Presents with syncope, now normotensive, and found to have PE on CT. Treatment?
• A. Start LMWH and warfarin, continue warfarin indefinitely or until cure
• B. Start heparin drip and warfarin, continue warfarin indefinitely.
• C. LMWH indefinitely• D. LMWH for 6 months
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VTE in Cancer Patients
LMWH is better than unfractionated heparin for cancer patients.Antithrombotic and antineoplastic effectsLMWH is better than warfarin for long-term tx in cancer patients (less fatal bleeding)
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Scenario 10
You are called to see a post-op pt with a swollen leg. It is indeed swollen, tense and a deep red-purple colour. You note some skin necrosis. An U/S documents DVT. Treatment?– A. IV heparin– B. full-dose Lovenox– C. debride skin– D. thrombectomy
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Surgery for DVT
Phlegmasia ceruluea dolens/ venous gangrene is an absolute indication for surgery.Femoral venotomyInterventional radiologyHigh incidence of post-phlebitic syndrome
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Other Treatments
Thrombolytics• Controversial• Best evidence in unstable patient with PE• Indicated in massive ileofemoral thrombolysis
and low-risk to bleed
New medications• Fondaparinux• ximelagatran
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IVC Filters
Protect against fatal PEIn general, for use in patients with contraindication to anticoagulationMay consider filter + anticoag is patient with severe cardiopulmonary dz where recurrent PE may be fatal.Information based on poor, older studiesRetrievable filters (new)
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Further Info
ACCP Guidelines Chest, Sept 2004, Vol126, supp 3.
AJS 2005, 189:14-25.