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Prevention of Venous

Thromboembolism

2012 CHEST GUIDELINES REVIEW


PRESENTED BY:
.............................................
VENOUS THROMBOEMBOLISM
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 Result of clot formation in


venous circulation
 Manifests as deep vein
thrombosis (DVT) or
pulmonary embolism (PE)
 Develops as a result of three
primary components known
as Virchow’s triad
 Venous Stasis
 Vascular Injury
 Hypercoagulability
DVT PROPHYLAXIS
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 Incidence of DVT in the hospital is 10-40% per month


for medical or general surgical patients and 40-60%
following major orthopedic surgeries

 Consequences of unprevented VTE:


 Symptomatic DVT or PE
 Fatal PE
 Increased spending for investigation symptomatic patients
 Increased risk of recurrence
 Chronic post-thrombotic syndrome

 DVT prophylaxis, has a desirable benefit-to-risk ratio


RISK FACTORS

Strong Risk Factors Moderate Risk Factors Weak Risk Factors


Odds Ratio > 10 Odds Ratio 2-9 Odds Ration <2

• Hip or Leg Fracture • Athroscopic Knee Surgery • Bed rest>3 days


• Hip or Knee Replacement • Central Venous Lines • Immobility due to sitting
• Major General Surgery • Chemotherapy • Increasing Age
• Major Trauma • CHF or Respiratory Failure • Laparoscopic Surgery
• Spinal Cord Injury • Hormone Replacement • Obesity
Therapy • Pregnancy/ Antepartum
• Malignancy • Varicose Veins
• Oral Contraceptive Therapy
• Paralytic Stroke
• Pregnancy/ Postpartum
• Previous VTE
• Thrombophilia

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GENERAL THROMBOPROPHYLAXIS
RECOMMENDATIONS
Level of Risk Estimated DVT Risk Suggested Thromboprophylaxis
Low
 Minor surgery in mobile
patients <10% Early and aggressive ambulation
 Medical patients who are fully
mobile
Moderate
 Medical pts, bed rest or sick LMWH, LDUH BID/TID or
 Most general, open gynecologic Fondaparinux
or urologic surgery patients
10%-40%
 Moderate VTE + High bleeding Mechanical
risk Thromboprophylaxis

High Risk
 Hip or knee arthroplasty,
Major Trauma, SCI LMWH
40% - 80%
 High VTE + High Bleeding risk Mechanical Thromboprophylaxis

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PREVENTION OF VTE IN
NONSURGICAL PATIENTS
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ANTITHROMBOTIC THERAPY AND


P R E V E N T I O N O F T H R O M B O S I S , 9 TH E D ; A C C P
GUIDELINES
CONSIDERATIONS
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 50 – 70% of symptomatic thromboembolic events and


70 – 80% of fatal PEs occur in non-surgical patients

 Additional risk factors for VTE in medical patients

Stroke with
Advanced age Previous VTE Cancer lower extremity
weakness

Congestive COPD
Sepsis Bed Rest
Heart Failure Exacerbation
Acutely Ill Hospitalized Medical Patients
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Recommended Recommended Against

 Low-Molecular Weight  The use of thromboprophylaxis


Heparins, Low Dose beyond period of
Unfractionated Heparin or immobilization or acute
Fondaparinux for patients hospital stay
with high risk for thrombosis

 Optimal use of mechanical


thromboprophylaxis with GCS  The use of pharmacologic
or IPC for patients with prophylaxis or mechanical
contraindications to prophylaxis in patients at low
anticoagulant
thromboprophylaxis risk of thrombosis
Other Nonsurgical Patient Recommendations
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Critically-Ill Outpatients with Cancer

 Recommend against routine


 Low-Molecular Weight
prophylaxis with LMWH or
Heparins or Low dose
LDUH if no additional risk
Unfractionated Heparin factors
is suggested  Recommended for patients with solid
tumors who have additional risk
factors
 Mechanical prophylaxis
with GCS or IPC for
those who are at high  Recommend against use of
risk for major bleeding vitamin K antagonists
until bleeding risk (Warfarin) for prophylaxis
decreases
PHARMACOLOGICAL THERAPY
FOR VTE PROPHYLAXIS
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• Aspirin
• Unfractionated
heparin
• Low-molecular weight
heparins
• Vitamin K antagonists
Warfarin,
• Fondaparinux (Factor
Xa inhibitor)
QUESTIONS?
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