VTE Prevention In Action Interactive Case Scenarios

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VTE Prevention In ActionInteractive Case
Scenarios
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Dr Raj Patel
Kings Thrombosis Centre
Consultant Haematologist
raj.patel_at_kch.nhs.uk
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Patient 1 Elective THR

• 78-year-old woman, osteoarthritis
• Elective THR
• BMI 31kg/m2, weight 93kg
• DVT post-partum

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Patient 1VTE Risk Assessment
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Patient 1Who performs VTE risk assessment
(elective patient)?
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Patient 1High Risk of VTE

• Major orthopaedic procedure
• Additional risk factors for VTE?
• gt 60 years old
• Anticipated immobility 3 days
• BMI above 30 kg/m2
• Previous VTE

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ACCP, 2008
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ACCP, 2008
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ACCP, 2008
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Patient 1 Treatment

• Is mechanical or pharmacological
• thromboprophylaxis contraindicated?

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Patient 1 Treatment choices-Mechanical
Thromboprophylaxis
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Patient 1 Treatment choices-Pharmacological
Thromboprophylaxis
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Patient 1Other treatment choices?
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ACCP 2008 THR guidance

• LMWH
• (12hrs preop, 12-24hrs postop, 4-6hrs postop 50)
• Fondaparinux (2.5mg, 6-24hrs postop)
• VKA
• Mechanical device alone only if bleeding risk
  high

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Value of Mechanical Thromboprophylaxis?

• No bleeding (useful when bleeding risk high)
• May enhance effectiveness of pharmacological
  thromboprophylaxis
• Big variation in size/pressure/features
• - many brands not assessed in trials
• - fitting/compliance poor on wards
  
• Fewer/smaller studies
• - effect on reducing PE/death unknown
• - less effective in high risk groups
• - no study in medical inpatients

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ACCP 2008Mechanical Thromboprophylaxis

• Recommend primarily where bleeding risk high (1A)
  or as adjunct to pharmacological measure (2B)
• Careful attention to proper use and compliance
  optimal use

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Prevention of DVT after general surgery (ACCP
2001)
Regimen No. trials No. patients No. DVT patients Incidence Risk reduction
Controls 54 4310 1084 25 --
Aspirin 5 372 76 20 20
Stockings 3 196 28 14 44
Low-dose heparin 47 10339 784 8 68
LMWH 21 9364 595 6 76
IPC 2 132 4 3 88
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ACCP 2008 Aspirin
1.4.4 We recommend against the use of aspirin
alone as thromboprophylaxis against VTE for any
patient group (1A).
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Patient 1 Treatment

• LMWH (preop) or oral agent (postop) once daily
• Plus
• Graduated compression stockings and/or SCD

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Patient 1 Pharmacological Thromboprophylaxis
for how long?
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Patient 1 Pharmacological Thromboprophylaxis
for how long?

• ACCP beyond 10 days, up to 35 days (1A)

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Epidurals

• ACCP
• insertion of spinal/epidural needle delayed 8-12
  hrs following prophylactic heparin dose
• removal scheduled just prior to next dose
• following epidural removal, delay next dose by gt
  2 hrs
• Dabigatran not recommended

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Clinical presentation of HIT

• Thrombocytopenia
• Timing of thrombocytopenia
• Thrombosis / other sequelae
• oTher cause unlikely

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Patient 2 Gynaecological surgery

• 63-year-old woman
• Uterine carcinoma
• Weight 135kg, BMI 38 kg/m2
• Abdominal hysterectomy

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Patient 2 VTE risk assessment

• Major gynaecological procedure
• Additional risk factors for VTE?
• gt 60 years old
• Anticipated immobility 3 days
• BMI 38 kg/m2
• Malignancy

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Patient 1 Treatment

• Is mechanical or pharmacological
• thromboprophylaxis contraindicated?

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Patient 2 Treatment choices-Mechanical
Thromboprophylaxis
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Patient 2 Treatment choices-Pharmacological
Thromboprophylaxis
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Patient 2 135 kg - What dose of LMWH
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Patient 2 Pharmacological Thromboprophylaxis
duration?
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Gynaecologic surgery guidance (ACCP 2008)

• Minor procedures without ARFs early ambulation
  only
• Laparosopic procedures
• - without ARFs early ambulation
• with ARFs LMWH or LDUFH or IPC or GCS (1C)
• Major procedures
• Benign disease LMWH (1A) or LDUFH (1A) or IPC
  (1B)
• Malignancy consider LMWH 28 days
• Bariatric surgery higher doses LMWH or UFH
  suggested (2C)

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Patient 3 Neurosurgery and Spinal Procedures

• 71-year-old woman
• Elective spinal procedure (disc prolapse)
• Smoker
• Varicose veins
• FV Leiden mutation heterozyous

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ACCP, 2008
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Patient 3VTE Risk Assessment
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Patient 3 Risk Assessment for VTE

• Major spinal procedure
• Additional risk factors for VTE?
• gt 60 years old
• Anticipated immobility 3 days
• FV Leiden

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Patient 3 Treatment

• Is mechanical or pharmacological
• thromboprophylaxis contraindicated?

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Patient 3 Treatment choicesMechanical
Thromboprophylaxis
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Patient 3 Treatment choicesPharmacological
Thromboprophylaxis
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Patient 3 Pharmacological Thromboprophylaxis
duration?
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Elective spinal surgery guidance (ACCP 2008)

• No ARFs early ambulation (2C)
• With ARFs either
• Post op LMWH (1B)
• LDUFH (1B)
• Periop IPC (1B) or GCS (2b)
• With multiple ARFs pharmacologic plus mechanical
  (2C)

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Defining the ComplexMedical Patient

• . . . A patient you would give LMWH to, but for
  some reason you feel uncomfortable . . .
• . . . A patient who would benefit from LMWH but
  may have a contraindication . . .

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Patient 4

• 74-year-old woman, 15-year history of type 2
  diabetes
• Peripheral neuropathy (feet), leg ulcers
• BMI 33 kg/m2, 92kg
• Admitted with unilateral lower limb cellulitis,
  immobility, high BMs
• Treated with insulin, hydration and intravenous
  antibiotics

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Patient 4VTE Risk Assessment
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Patient 4 Treatment

• Is mechanical or pharmacological
• thromboprophylaxis contraindicated?

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Patient 4 Treatment choicesMechanical
Thromboprophylaxis
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Patient 4 Treatment choicesPharmacological
Thromboprophylaxis
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Patient 4 Risk Assessment for VTE

• gt 40 years old with acute medical illness and
  reduced mobility?
• Yes
• Additional risk factors
• age gt 70 years
• infection
• BMI 33 kg/m2

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KCH guidelines for medical thromboprophylaxis
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Patient 4 Pharmacological Thromboprophylaxis
for how long?
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Clear Benefits of Thromboprophylaxis over Placebo
RRR 63 45 47
Study RRR Thromboprophylaxis Patients with
VTE ()
MEDENOX1 63 Placebo Enoxaparin 40
mg PREVENT2 49 Placebo Dalteparin ARTEM
IS3 47 Placebo Fondaparinux
14.9
5.5
Plt0.001
5.0
2.8
P0.0015
10.5
5.6
P0.029
VTE at day 14 VTE at day 15.
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Primary Efficacy Endpoints Implications for
Clinical Practice
Number needed to treat justifies
thromboprophylaxis
Trial VTE RRR NNT
MEDENOX1 Distal and proximal 63 venographic
DVT symptomatic VTE fatal
PE PREVENT2 Compression 45 ultrasonographic
DVT symptomatic VTE fatal
PE ARTEMIS3 Distal and proximal
47 venographic DVT symptomatic VTE
fatal PE
10 45 20
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Patient 4

• 74-year-old woman, 15-year history of type 2
  diabetes, diet controlled
• Peripheral neuropathy (feet), leg ulcers
• BMI 33kg/m2
• Admitted with unilateral lower limb cellulitis,
  immobility, and high BMs
• Treated with insulin, hydration and intravenous
  antibiotics

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Patient 4Platelet count 110x109/L (Not
bleeding)
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Patient 4Platelet count 110x109/L (Not
bleeding)

• Mild asymptomatic thrombocytopenia
• Seek haematology advice?
• No adjustment in prophylaxis

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Patient 4Platelet count 20x109/L (Not bleeding)
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Patient 4Platelet count 20x109/L (not bleeding)

• Significant unexplained thrombocytopenia
• Seek haematology advice
• Withhold LMWH

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Patient 4

• 74-year-old woman, 15-year history of type 2
  diabetes, diet controlled
• Peripheral neuropathy (feet), leg ulcers
• BMI 33kg/m2
• Admitted with unilateral lower limb cellulitis,
  immobility, and high BMs
• Treated with insulin, hydration and intravenous
  antibiotics

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Patient 4Creatinine 156 micromol/L (60120)CC
40mls/min
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Patient 4Drug monitoring required?
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Patient 4 Mild renal impairment

• ACCP
• - consider renal function with LMWH
• - elderly, diabetics, high bleeding risk

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Patient 4Mild renal impairment

• ACCP options
• -avoid drugs which bioaccumulate
• -lower dose
• -monitor drug level or anticoagulant effect
• UFH
• LMWH reduced dose
• LMWH standard dose with anti-Xa monitoring if
  prolonged use

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Patient 4

• 74-year-old woman, 15-year history of type 2
  diabetes
• Peripheral neuropathy (feet), leg ulcers
• BMI 33kg/m2
• Admitted with unilateral lower limb cellulitis,
  immobility, and high BMs
• Treated with insulin, hydration and intravenous
  antibiotics

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Patient 4Creatinine 256 micromol/L (60120)CC
lt20mls/min
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Patient 4 Drug monitoring required?
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Patient 4 Severe renal impairment

• options
• -avoid drugs which bioaccumulate
• -lower dose
• -monitor drug level or anticoagulant effect
• UFH

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Patient 4 BMI16 kg/m2

• 74-year-old woman, 15-year history of type 2
  diabetes, diet controlled
• Peripheral neuropathy (feet), leg ulcers
• BMI 16 kg/m2
• Admitted with unilateral lower limb cellulitis,
  immobility, and high BMs
• Treated with insulin, hydration and intravenous
  antibiotics

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Patient 4 BMI16 kg/m2

• Very low body weight patient
• Would you change LMWH prophylaxis?

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Patient 4 BMI16 kg/m2
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Patient 4 very elderly

• 98-year-old woman, 15-year history of type 2
  diabetes, diet controlled
• Peripheral neuropathy (feet), leg ulcers
• BMI 33kg/m2
• Admitted with unilateral lower limb cellulitis,
  immobility, and high BMs
• Treated with insulin, hydration and intravenous
  antibiotics

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Patient 4 very elderly

• Would you change LMWH prophylaxis?

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Patient 4 very elderly
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Patient 5

• 66-year-old man admitted with acute exacerbation
  of COPD

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KCH guidelines for medical thromboprophylaxis
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Patient 5 Risk Assessment for VTE

• gt 40 years old with acute medical illness and
  reduced mobility?
• yes
• Additional risk factors
• respiratory disease/acute infectious disease
• Is pharmacological thromboprophylaxis
  contraindicated?
• no

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Patient 5 Treatment

• LMWH enoxaparin 40 mg s.c. daily
• AES

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Patient 5 Very urgent arterial blood gas

• would you change LMWH prophylaxis?

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Patient 5 Very Urgent Arterial Blood Gas
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Patient 5Needs non-urgent Central Venous Line

• would you change LMWH treatment?

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Patient 5 Non-Urgent Central Venous Line
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Patient 5Ultrasound guided liver biopsy

• would you change LMWH prophylaxis?

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Patient 5Ultrasound guided liver biopsy
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Patient 5 HIT?

• 6 days after admission his platelet count falls
  to 70x109/L and the next day is 30x109/L
• You are asked if this is heparin-induced
  thrombocytopenia

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Patient 5 Falling platelets, HIT?