Guidelines to Thromboembolic ProphylaxisClinical Presentation Exploratory laparotomy, diverting...

Guidelines to Thromboembolic Prophylaxis

Maria Georgiades May 3, 2012

www.downstatesurgery.org

Clinical Presentation

40 yo female admitted with weakness

PMH: HTN, MS, GERD, Asthma

PSH: none

NKDA

Meds: methylprednisone, albuterol, atorvastatin, heparin 5000 u SQ q8h

1 week later abdominal pain

19

14

45 320

PMN: 66% Bands:20

138 4.4

99

29 13 0.9

211



Physical Exam: VS: T 100.1F BP 142/87 HR 112 bpm O2sat 98%

BMI : 82 kg/m2

CV: Sinus tachycardia

Pulm: clear to auscultation bilaterally

Abdomen: morbidly obese, tender in the epigastrium



Exploratory laparotomy, diverting transverse end colostomy Findings: perforated sigmoid diverticulitis

Begun on lovenox 80mg q12h for DVT prophylaxis

Clear liquids on POD#3 and advanced as tolerated

Discharged to acute rehab on POD#7.


Outline

Review of Deep Vein Thrombosis

Guidelines for: Nonorthopedic patients Trauma Patients Obese Patients


Presenter

Presentation Notes

I chose to review recent guidelines that were published and focus on 3 patient populations

Epidemiology

VTE – related deaths: 150-200,000 per year after surgery

Immediate threat to life and long term impairment

20 year incidence rates: 26.8%- venous stasis changes

3.7% - venous ulcers


Presenter

Presentation Notes

DVT: 5-9 per 10,000 person-years VTE: 14 per 10,000 person-years Important bc not only can it cause an immediate threat to life but it can cause a long term impairment due to resultant venous insufficiency

RISK FACTORS

Rudolph Virchow- 1862 Stasis of blood flow

Endothelial damage

Hypercoagulability

Racial Predilection Caucasians

African Americans

ACQUIRED INHERITED

Advanced age Factor V Leiden

Hospitalization Prothrombin 20210A

OCP Antithrombin deficiency

Pregnancy Protein S deficiency

Prior VTE Factor XI elevation

Malignancy Dysfibrinogenemia

Major Surgery Mixed Etiology

Obesity homocysteinemia

Nephrotic syndrome F. VII, VIII, IX, XI elevaton

Trauma Hyperfibrinogenemia

Travel >6 hours Activated protein C resistance

Varicose veins Antiphospholipid

Myeloproliferative Polycythemia


Presenter

Presentation Notes

In some patients there may be both a heritable and acquired complonent- mixed etiology -there may be a synergistic effect. If a patient is heterozygous for F 5 leiden (4-8 fold increase); if they take OCP it increases to 35 fold. **also anesthesia >2h and bedrest >4 days.

CLINICAL EVALUATION

Phlegmasia alba dolens- major DVT that obliterates the major deep venous channel of the extremity w/ sparing collateral veins

Pain, pitting edema, blanching

Plegmasia cerulea dolens- extends to collateral veins Massive fluid

sequestration and edema

Extremely painful, edematous and cyanotic

Arterial insufficiency or compartment syndrome

If untreated venous gangrene and amputation


Presenter

Presentation Notes

-Early in the course there may be few or no sx of a DVT. Extremity pain and swelling- nonspecific

RADIOLOGIC EVALUATION

Duplex ultrasound Sensitivity and specificity >95%

Positive findings: Lack of spontaneous flow

Inability to compress vein

Loss of respiratory flow variation


Presenter

Presentation Notes

DUS: combines B mode ultrasound with pulsed Doppler capability -**In the supine patient, normal lower extremity venous flow is phasic (Fig. 24-5), decreasing with inspiration in response to increased intra-abdominal pressure with the descent of the diaphragm and then increasing with expiration. When the patient is upright, the decrease in intra-abdominal pressure with expiration cannot overcome the hydrostatic column of pressure existing between the right atrium and the calf. Muscular contractions of the calf, along with the one-way venous valves, are then required to promote venous return to the heart. Flow also can be increased by leg elevation or compression and decreased by sudden elevation of intra-abdominal pressure (Valsalva's maneuver).

Prevention of VTE in Nonorthopedic Surgical Patients 9th Edition: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

Sources: • Medline • Cochrane Controlled Trials Register • Cochrane Database of Systematic Reviews • 2005-2010


RECOMMENDATIONS FOR PREVENTION OF VTE IN NONORTHOPEDIC SURGICAL PATIENTS

RISK SCORE RECOMMENDATION

Very low risk (<0.5%) Rogers score <7; Caprini 0

EARLY AMBULATION

Low risk for VTE (~1.5%)

Rogers score 7-10; Caprini 1-2

Mechanical prophylaxis

Moderate risk of VTE (~3%)

Rogers score >10 Caprini 3-4

LMWH, LDUH or mechanical prophylaxis

Mod. Risk with high risk of major bleeding Cx

Mechanical prophylaxis


Presenter

Presentation Notes

In general and abdominal-pelvic surgery patients -Very low risk- the harms outweight the benefits- 0-3 fewer nonfatal VTE and 4-10 MORE nonfatal major bleeding complications per 1000 patients treated with LDUH **in moderate risk patients moderate quality evidence indicates that compared with no prophylaxis, pharmoacologic prophylaxis with either LDUH or LMWH will result in twice as many nonfatal vte prevented as nonfatal major bleeding

RECOMMENDATIONS FOR PREVENTION OF VTE IN NONORTHOPEDIC SURGICAL PATIENTS

RISK SCORE RECOMMENDATION

High risk of VTE (~6%) NO bleeding risk

Caprini ≥5 LMWH or LDUH + mechanical prophylaxis

High risk of VTE with cancer and NO bleeding risk

Caprini ≥5 Extended duration LMWH for 4 weeks

High risk of VTE (~6%) *both LMWH or UH are CI or unavailable and NO bleeding risk:

Caprini ≥5 Low dose aspirin, fondaparinux or mechanical prophylaxis

For general and abdomino-pelvic surgery patients: NO IVC filter should be used for primary VTE prevention


Presenter

Presentation Notes

Periodic surveillance with venous compression ultrasound should not be performed – large retrospective study 6 yr period ending in 2000-frequency of surveillance vcu decreased from 32 to 3.4% with no increase in PE. --8 years of follow up a 9% absolute reduction in the risk of PE was offset by the 10% absolute increase in the risk of DVT. High risk- 1-8 fewer deaths from PE -after 2 years there was an 87% increase in the odds of DVT

Trauma Patients

Prospective study -525 patients with TBI 18 patients (3.4%)- hemorrhagic changes on Head CT

Relative Contraindications to pharmacologic prophylaxis: • Severe head injuries • Nonoperatively managed liver or spleen injuries • Renal failure • Spinal column fracture with epidural hematoma • Severe thrombocytopenia and coagulopathy

Chest. 2012; 141;e227S-e277S


Presenter

Presentation Notes

Who were judged to be elgible to receive dvt prophylaxis w/in 48 hrs of admission

RECOMMENDATIONS FOR PREVENTION OF VTE IN MAJOR TRAUMA PATIENTS

Major Trauma Patients LDUH, LMWH or mechanical prophylaxis

Trauma + high risk for VTE (acute SCI, TBI and spinal surgery)

Mechanical prophylaxis + pharmacologic

Trauma with CI to LMWH and LDUH Mechanical prophylaxis • ADD pharmacologic prophylaxis

when risk of bleeding diminishes or CI to heparin resolves

IVC filter should NOT be used for primary VTE prevention


Presenter

Presentation Notes

Periodic surveillance with venous compression ultrasound should not be performed 1-for patients with major trauma who are average risk for VTE and avg risk for bleeding- pharm prophylaxis prevents approximately 4 times as many nonfatal vte events as nonfaal bleeding complications caused and similar results with mechanical prophylaxis 2-lduh or lmwh prevents almost 10 times nonfatal vte events as nonfatal bleeding cx ( prevents 4 deaths /1000 from PE)- addition of mechanical prevent 15 additional nonfatal vte events per 1000 **3 months a reasonable time for dvt prophylaxis in sci patients- >90% of all TE events within one year of injury occurred in the first 91 days.

Extended vs Limited –Duration LMWH

Risk of VTE remains elevated for at least 12 weeks following surgery Risk of VTE remained 10-50 times higher in weeks 7-12 following

inpatient surgery1

Extended –duration prophylaxis reduced risk of symptomatic and asymptomatic DVT by at least 50%2

1 J Trauma. 2003; 54 (6):1116-1124 2 Thromb Haemost. 2008; 100(6):1176-1180


Chest. 2012; 141;e227S-e277S


OBESITY

31% of adults in USA (61 million) are obese- BMI≥ 30 kg/m2

> 64% of Americans are overweight BMI ≥25 kg/m2

Associated Comorbidities: • Diabetes • Heart Disease • CVA • OSA • Depression

Risk Factors associated with Fatal PE: • Severe venous stasis • BMI>60 • Truncal obesity • Obesity hypoventilation syndrome

Singh, Podolsky et al. Obesity Surgery (2012). 22:47-51


Presenter

Presentation Notes

Obesity is a national epidemic Couled with surgery the risk of a PE greatens There have been multiple studies in orthopedic patients and recently bariatric patients using LMWH and its efficacy **** There has been NO DOSE PROTOCOL established****

Evaluating the Safety and Efficacy of BMI-Based Preoperative Administration of Low-Molecular-Weight Heparin in Morbidly Obese Patients Undergoing Roux-en-Y Gastric Bypass Surgery

Retrospective review; 170 patients

SCDs + single dose enoxaparin w/in 1 hr prior to incision followed by BID administration postoperatively


BMI: <40mg/kg2- 30mg 41-49mg/kg2-40mg

<50-59mg/kg2-50mg >59 mg/kg2-60mg


Presenter

Presentation Notes

Patients underwent gastric bypass surgery by a single surgeon at a tertiary care center 3/2004 and 12/2007 2- along with early ambulation on POD 1 ** the patients that fell into the 50 mg of lovenox group were excluded early on due to the fact that lovenox comes in 30, 40, 60 mg prefilled syringe

Evaluating the Safety and Efficacy of BMI-Based Preoperative Administration of Low-Molecular-Weight Heparin in Morbidly Obese Patients Undergoing Roux-en-Y Gastric Bypass Surgery

+ No VTE events in postoperative period or 2 year follow up


Presenter

Presentation Notes

Compared to incidence of postop thromboembolic events and postoperative bleeding complications -post op bleeding in 5 patients (2.9%) -lovenox was discontinued and patients transferred to icu 4 managed nonop; 1 required an ex lap (port hematoma, hematochezia, tachycardia and h/h drops. And lastly perforation of gastric remanant.

Unfractioned heparin vs. LMWH

Equivalent efficacy for prophylaxis of thromboembolism

LMWH: Better bioavailability

More predictable anticoagulant effect

Non-randomized prospective- laparoscopic gastric bypass 238 –LDUH 5,000 units TID; 238 enoxaparin 40mg BID

1 PE in LDUH

Postop transfusion: enoxaparin vs LDUH: 6% vs 1%



Conclusion

Nonorthopedic surgical patients should be risk categorized and ordered appropriate VTE prophylaxis

If no contraindications trauma patients can safely be given pharmacologic prophylaxis

IVC filters are not recommended as primary VTE prophylaxis

Obesity/BMI should be considered when dosing for VTE prophylaxis


Presenter

Presentation Notes

In summary the learning points from this presentation

References

Prevention of VTE in Nonorthopedic Surgical Patients 9th Edition: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141;e227S-e277S

Evaluating the Safety and Efficacy of BMI-Based Preoperative Administration of Low-Molecular-Weight Heparin in Morbidly Obese Patients Undergoing Roux-en-Y Gastric Bypass Surgery. Singh, Podolsky et al. Obesity Surgery (2012). 22:47-51

Bergqvist D et al.Duration of prophylaxis against venous thromboembolism with enoxaparin after surgery for cancer. N. Engl J Med. 2002; 346 (13): 975-980

Pannucci CJ,et al. Postoperative enoxaparin prevents symptomatic venous thromboembolism in high risk plastic surgery patients. Plast Reconstr Surg. 2011 Nov;128(5):1093-103.

Pannucci CJ, Jaber RM, Zumsteg JM, Golgotiu V, Spratke LM, Wilkins EG. Changing practice: implementation of a venous thromboembolism prophylaxis protocol at an academic medical center.Plast Reconstr Surg. 2011 Nov;128(5):1085-92.

Fecher K, Ewald W, Fürst A, Hohmann V, Bramlage P. [Prophylaxis of thromboembolic events in surgery : DVT prophylaxis: A comparison of out-patient and hospitalized patients. Unfallchirurg. 2011 Sep 11.


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RECOMMENDATIONS FOR PREVENTION OF VTE IN CARDIOTHORACIC SURGICAL PATIENTS

CARDIAC SURGICAL PATIENTS

Uncomplicated course

Mechanical Prophylaxis

If hospital course prolonged by ≥ 1 surgical complication (non-hemorrhagic)

LMWH/ LDUH + mechanical prophylaxis

THORACIC SURGICAL PATIENTS

Moderate risk of VTE

LMWH, LDUH or mechanical prophylaxis

High risk for VTE with NO risk of bleeding

LDUH or LMWH+ mechanical prophylaxis

High risk for VTE + risk for major bleeding

Mechanical prophylaxis until can restart pharmacologic prophylaxis


RECOMMENDATIONS FOR PREVENTION OF VTE IN SPINAL SURGICAL PATIENTS

SPINAL SURGERY Mechanical prophylaxis

SPINAL SURGERY + high risk VTE Mechanical prophylaxis + pharmacologic prophylaxis once adequate hemostasis established


Presenter

Presentation Notes

1-mechanical prophylaxis preferred over no prophylaxis, LMWH or UH

Guidelines to Thromboembolic ProphylaxisClinical Presentation Exploratory laparotomy, diverting...

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