VTE Prevention In Action Interactive Case Scenarios

VTE Prevention In Action

Interactive Case Scenarios

Dr Raj Patel

King’s Thrombosis Centre

Consultant Haematologist

raj.patel@kch.nhs.uk

Patient 1: Elective THR

• 78-year-old woman, osteoarthritis

• Elective THR

• BMI 31kg/m2, weight 93kg• DVT post-partum

Patient 1:VTE Risk Assessment

0

4

71

1. Low risk of VTE

2. 2: Moderate risk of VTE

3. 3: High risk of VTE

Patient 1:Who performs VTE risk assessment (elective patient)?

32

0

1

1

2

0

0

1. At surgical pre-assessment clinic by nurse

2. At surgical pre-assessment clinic by anaesthetist

3. At surgical pre-assessment clinic by surgeon

4. On day of admission by nurse

5. On day of admission by junior doctor

6. On day of admission by anaesthetist

7. Other (eg ward pharmacist)

Patient 1:High Risk of VTE

• Major orthopaedic procedure

• Additional risk factors for VTE?– > 60 years old – Anticipated immobility 3 days– BMI above 30 kg/m2

– Previous VTE

ACCP, 2008

ACCP, 2008

ACCP, 2008

Patient 1: Treatment

Is mechanical or pharmacological

thromboprophylaxis contraindicated?

Patient 1: Treatment choices-Mechanical Thromboprophylaxis

0

10

1

3

59

1. None

2. Full-length Anti-Embolism Stockings only

3. Knee-length Class II Graduated Compression Stockings only

4. Sequential Compression Device only

5. Anti-Embolism Stocking plus Sequential Compression Device

Patient 1: Treatment choices-Pharmacological Thromboprophylaxis

0

41

7

8

23

1. None (mechanical device only)

2. LMWH commencing before or after surgery

3. Fondaparinux

4. Dabigatran

5. Rivaroxaban

Patient 1:Other treatment choices?

1

2

5

59

1. Tranexamic acid

2. Aspirin

3. Warfarin

4. None of the above

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

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

ACCP 2008:Mechanical Thromboprophylaxis

• Recommend primarily where bleeding risk high (1A) or as adjunct to pharmacological measure (2B)

• Careful attention to proper use and compliance ‘optimal use’

RegimenRegimen No. trialsNo. trials No. No. patientspatients

No. DVT No. DVT patientspatients

Incidence Incidence %%

Risk Risk reduction reduction

%%

ControlsControls 5454 43104310 10841084 2525 ----

AspirinAspirin 55 372372 7676 2020 2020

StockingsStockings 33 196196 2828 1414 4444

Low-dose Low-dose heparinheparin

4747 1033910339 784784 88 6868

LMWHLMWH 2121 93649364 595595 66 7676

IPCIPC 22 132132 44 33 8888

Prevention of DVT after general surgery Prevention of DVT after general surgery (ACCP 2001)(ACCP 2001)

ACCP 2008: Aspirin

1.4.4 We recommend against the use of aspirin alone as thromboprophylaxis against VTE for any patient group (1A).

Patient 1: Treatment

• LMWH (preop) or oral agent (postop) once daily

Plus

• Graduated compression stockings and/or SCD

Patient 1: Pharmacological Thromboprophylaxis –for how long?

1

1

23

57

1. None given

2. Until hospital discharge

3. 10 post-op days

4. 28-35 post-op days

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

Patient 1:Pharmacological Thromboprophylaxis –for how long?

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 > 2 hrs

• Dabigatran: not recommended

Clinical presentation of Clinical presentation of HITHIT

• ThrombocytopeniaThrombocytopenia• Timing of thrombocytopeniaTiming of thrombocytopenia• Thrombosis / other sequelaeThrombosis / other sequelae• oTher cause unlikelyoTher cause unlikely

Patient 2: Gynaecological surgery

• 63-year-old woman

• Uterine carcinoma

• Weight 135kg, BMI 38 kg/m2

• Abdominal hysterectomy

Patient 2: VTE risk assessment

• Major gynaecological procedure

• Additional risk factors for VTE?– > 60 years old – Anticipated immobility 3 days– BMI 38 kg/m2

– Malignancy

Patient 1: Treatment

Is mechanical or pharmacological

thromboprophylaxis contraindicated?

Patient 2: Treatment choices-Mechanical Thromboprophylaxis

2

9

3

3

49

15

1. None

2. Anti-Embolism Stockings only

3. Class II Graduated Compression Stockings only

4. Sequential Compression Device only

5. Anti-embolism stocking plus Sequential Compression

6. Class II Graduated Compression Stockings plus Sequential Compression

Patient 2: Treatment choices-Pharmacological Thromboprophylaxis

1

69

1

7

2

1. None (mechanical device only)

2. Prophylactic LMWH

3. Dabigatran

4. Rivaroxaban

5. Warfarin (INR 2-3) post-op

Patient 2: 135 kg - What dose of LMWH

23

16

33

3

1. : Standard once daily dose (e.g. enoxaparin 40mg daily)

2. : Increased dose once daily (e.g. enoxaparin 60-80mg daily)

3. : Standard dose, increased frequency (eg enoxaparin 40mg twice daily)

4. : Increased frequency and dose (eg enoxaparin 60mg twice daily)

Patient 2: Pharmacological Thromboprophylaxis – duration?

0

9

18

43

8

1. None given

2. Until discharge

3. 10 post-op days

4. 28-35 days

5. Until in remission

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)

Patient 3: Neurosurgery and Spinal Procedures

• 71-year-old woman

• Elective spinal procedure (disc prolapse)

• Smoker

• Varicose veins

• FV Leiden mutation heterozyous

ACCP, 2008

Patient 3:VTE Risk Assessment

0

18

51

1. Low risk of VTE

2. Moderate of VTE

3. High risk of VTE

Patient 3: Risk Assessment for VTE

• Major spinal procedure

• Additional risk factors for VTE?– > 60 years old – Anticipated immobility 3 days– FV Leiden

Patient 3: Treatment

Is mechanical or pharmacological

thromboprophylaxis contraindicated?

Patient 3: Treatment choicesMechanical Thromboprophylaxis

0

2

2

3

68

1. None

2. Anti-Embolism Stockings only

3. Class II Graduated Compression Stockings only

4. Sequential Compression Device only

5. Anti-embolism stocking plus Sequential Compression

Patient 3: Treatment choicesPharmacological Thromboprophylaxis

27

41

0

1

1

1. None: mechanical device only

2. LMWH

3. Dabigatran

4. Rivaroxaban

5. Warfarin post-op

Patient 3: Pharmacological Thromboprophylaxis – duration?

9

20

20

25

1. None given

2. Until discharge

3. 10 post-op days

4. 28-35 days

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)

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 . . .

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

Patient 4:VTE Risk Assessment

0

69

1. Low risk of VTE

2. High risk of VTE

Patient 4: Treatment

Is mechanical or pharmacological

thromboprophylaxis contraindicated?

Patient 4: Treatment choicesMechanical Thromboprophylaxis

55

5

1

6

1

0

1. None

2. Anti-Embolism Stockings only

3. Class II Graduated Compression Stockings only

4. Sequential Compression Device only

5. Anti-embolism stocking plus Sequential Compression

6. Class II Graduated Compression Stockings plus Sequential Compression

Patient 4: Treatment choicesPharmacological Thromboprophylaxis

62

12

1

1

2

1. Prophylactic dose LMWH

2. Low dose unfractionated heparin

3. Dabigatran

4. Rivaroxaban

5. Warfarin

Patient 4: Risk Assessment for VTE

• > 40 years old with acute medical illness and reduced mobility?– Yes

• Additional risk factors– age > 70 years– infection– BMI 33 kg/m2

KCH guidelines for medical thromboprophylaxis

Patient 4: Pharmacological Thromboprophylaxis –for how long?

0

32

13

12

16

1. None given

2. Until discharged

3. 10 days

4. 28-35 days

5. Until fully mobile

Clear Benefits of Thromboprophylaxis over

Placebo

MEDENOX1 63% Placebo

Enoxaparin 40 mg

PREVENT2 49% Placebo

Dalteparin

ARTEMIS3 47% Placebo

Fondaparinux

14.9*

5.5

Study RRR Thromboprophylaxis Patients with VTE (%)

5.0*

2.8

10.5†

5.6

*VTE at day 14; †VTE at day 15.

P<0.001

P=0.0015

P=0.029

RRR

63%

45%

47%

Primary Efficacy Endpoints: Implications for Clinical Practice

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

Trial VTE RRR NNTNumber needed to treat – justifies

thromboprophylaxis

10

45

20

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

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

10

39

12

5

1. Withhold LMWH

2. Prophylactic dose LMWH (eg enoxaparin 40mg)

3. reduced dose LMWH (eg enoxaparin 20mg)

4. UFH

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

• Mild asymptomatic thrombocytopenia

• Seek haematology advice?

• No adjustment in prophylaxis

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

57

1

9

7

1. withhold LMWH

2. prophylactic dose LMWH (eg enoxaparin 40mg)

3. reduced dose LMWH (eg enoxaparin 20mg)

4. UFH

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

• Significant unexplained thrombocytopenia

• Seek haematology advice

• Withhold LMWH

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

Patient 4:Creatinine 156 micromol/L (60–120)CC 40mls/min

11

32

14

11

3

1. omit LMWH

2. standard dose LMWH (eg enoxaparin 40mg)

3. reduced dose LMWH (eg enoxaparin 20mg)

4. UFH 5000u twice daily

5. UFH 5000u three times daily

Patient 4:Drug monitoring required?

30

7

3

16

4

0

1. no

2. APTR

3. anti-Xa level 1hr post dose

4. anti-Xa level 3-4hrs post dose

5. anti-Xa level pre-dose (trough level)

6. INR

Patient 4:

Mild renal impairment

ACCP:

- consider renal function with LMWH

- elderly, diabetics, high bleeding risk

Patient 4:Mild renal impairment

ACCP options:

-avoid drugs which bioaccumulate

-lower dose

-monitor drug level or anticoagulant effect

1. UFH

2. LMWH reduced dose

3. LMWH standard dose with anti-Xa monitoring if prolonged use

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

Patient 4:Creatinine 256 micromol/L (60–120)CC <20mls/min

12

1

26

27

4

1. omit LMWH

2. standard dose LMWH (eg enoxaparin 40mg)

3. reduced dose LMWH (eg enoxaparin 20mg)

4. UFH 5000u twice daily

5. UFH 5000u three times daily

Patient 4 :Drug monitoring required?

2

3

0

1

1. No

2. APTR

3. INR

4. anti-Xa level 3-4hrs post dose

Patient 4: Severe renal impairment options:

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

UFH

Patient 4: BMI=16 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

Patient 4: BMI=16 kg/m2

• Very low body weight patient

• Would you change LMWH prophylaxis?

Patient 4: BMI=16 kg/m2

16

11

43

0

0

1. Give LMWH standard prophylactic dose

2. Give LMWH standard prophylactic dose and monitor anti-Xa

3. Reduce LMWH dose

4. UFH 5000u twice daily

5. No heparin

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

Patient 4 : very elderly

• Would you change LMWH prophylaxis?

Patient 4 : very elderly

41

0

24

0

5

3

1. Continue LMWH

2. Increase LMWH dose

3. Reduce LMWH dose

4. UFH 5000u three times daily

5. UFH 5000u twice daily

6. Stop heparin

Patient 5

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

KCH guidelines for medical thromboprophylaxis

Patient 5: Risk Assessment for VTE

• > 40 years old with acute medical illness and reduced mobility?– yes

• Additional risk factors– respiratory disease/acute infectious

disease

• Is pharmacological thromboprophylaxis contraindicated?– no

Patient 5: Treatment

• LMWH: enoxaparin 40 mg s.c. daily

• AES

Patient 5: Very urgent arterial blood gas

– would you change LMWH prophylaxis?

Patient 5 :Very Urgent Arterial Blood Gas

4

25

2

4

3

1. Reduce LMWH dose

2. Continue LMWH and press long/hard

3. UFH

4. Stop heparin altogether

5. Delay procedure for 12-24hrs following last LMWH dose

Patient 5:Needs non-urgent Central Venous Line

– would you change LMWH treatment?

Patient 5: Non-Urgent Central Venous Line

3

1

9

2

44

1. Reduce LMWH dose

2. UFH 5000u three times daily

3. Continue LMWH and press long/hard

4. Stop heparin altogether

5. Delay procedure for 12-24hrs following last LMWH dose

Patient 5:Ultrasound guided liver biopsy

– would you change LMWH prophylaxis?

Patient 5:Ultrasound guided liver biopsy

4

1

2

18

47

1. Reduce LMWH dose

2. UFH 5000u three times daily

3. Continue LMWH

4. Stop heparin altogether

5. Delay procedure for 24hrs following last LMWH dose

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’

Patient 5: Falling platelets, HIT?

1

0

71

1

1. UFH infusion

2. Increase LMWH dose to prevent thrombosis

3. Stop all heparins and seek urgent haematology opinion

4. Transfuse platelets to prevent bleeding