10PrevofVTEinNonsurgicalPts.ppt

7/24/2019 10PrevofVTEinNonsurgicalPts.ppt

1/23

Prevention of Venous

Thromboembolism in NonsurgicalPatients

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Copyright: American College of Chest Physicians 2012

Antithrombotic Therapy and Prevention of

Thrombosis, 9th ed: American College of Chest

Physicians Evidence-Based Clinical Practice

Guidelines


2/23

Guideline Team Expertise in: thrombosis, bleeding disorders, critical care,

preventive medicine, methodology, cost effectiveness andtwo frontline physicians

Susan R. Kahn MD, MSc

Wendy Lim MD, MSc

Andrew Dunn, MD

Mary Cushman, MD

Francesco Dentali, MD

Elie A. Akl, MD, MPH, PhD

Deborah J. Cook MD, MSc

Alex A. Balekian, MD, MSHS

Russell C. Klein, MD

Hoang Le, MD, FCCP

Sam Schulman, MD

Mohammad Hassan Murad, MD, MPH


3/23

Hospitalized Acutely Ill Medical Patients

For acutely ill hospitalized medical patients at increased risk

of thrombosis, we recommend anticoagulant

thromboprophylaxis with low-molecular-weight heparin

[LMW!, low-dose unfractionated heparin "L#$% bid,

L#$ tid, or fondaparinux (Grade 1B) &

Remarks: In choosing the specific anticoagulant drug to be used

for pharmacoprophylaxis, choices should be based on patient

preference, compliance, and ease of administration (eg, daily vsbid vs tid dosing), as well as on local factors affecting acquisition

costs (eg, prices of various pharmacologic agents in individual

hospital formularies)


4/23


For acutely ill hospitalized medical patients at low risk of

thrombosis, we recommend against the use of pharmacologic

prophylaxis or mechanical prophylaxis (Grade 1B).


5/23


For acutely ill hospitalized medical patients who are bleeding

or at high risk for bleeding, we recommend against

anticoagulant thromboprophylaxis (Grade 1B).


6/23


7/23


8/23


For acutely ill hospitalized medical patients at increased risk ofthrombosis who are bleeding or at high risk for ma'or bleeding,

we suggest the optimal use of mechanical thromboprophylaxis

with graduated compression stockings "()*% (Grade !") or

intermittent pneumatic compression "+)% "(rade )% , ratherthan no mechanical thromboprophylaxis& When bleeding risk

decreases, and if ./0 risk persists, we suggest that

pharmacologic thromboprophylaxis be substituted for

mechanical thromboprophylaxis (Grade !B)&

Remarks# $atients who are particularly averse to the potential for

s%in complications, cost, and need for clinical monitoring of G"&

and I$" use are li%ely to decline mechanical prophylaxis


9/23


In acutely ill hospitalized medical patients who receive an

initial course of thromboprophylaxis, we suggest against

extending the duration of thromboprophylaxis beyond the

period of patient immobilization or acute hospital stay

(Grade 2B).


10/23

Critically Ill Patients

In critically ill patients, we suggest against routine ultrasound

screening for DVT (Grade 2C).


11/23


For critically ill patients, we suggest using LMWH or LDUH

thromboprophylaxis over no prophylaxis (Grade 2C).


12/23


For critically ill patients who are bleeding, or are at high risk

for major bleeding, we suggest mechanical

thromboprophylaxis with GCS (Grade 2C) or IPC (Grade 2C)

until the bleeding risk decreases, rather than no mechanical

thromboprophylaxis. When bleeding risk decreases, we suggest

that pharmacologic thromboprophylaxis be substituted for

mechanical

thromboprophylaxis (Grade 2C).


13/23

Patients With Cancer

In outpatients with cancer who have no additional risk factors

for VTE, we suggest against routine prophylaxis with LMWH

or LDUH (Grade 2B) and recommend against the prophylactic

use of vitamin K antagonists (Grade 1B).

Remarks: Additional risk factors for venous thrombosis

in cancer outpatients include previous venous thrombosis,

immobilization, hormonal therapy, angiogenesis inhibitors,thalidomide, and lenalidomide.


14/23


+n outpatients with solid tumors who ha1e additional risk factors

for ./0 and who are at low risk of bleeding, we suggest

prophylactic dose LMW or L#$ o1er no prophylaxis (Grade

!B)&

Remarks:'dditional ris% factors for venous thrombosis in cancer

outpatients include previous venous thrombosis, immobiliation,

hormonal therapy, angiogenesis inhibitors, thalidomide, andlenalidomide


15/23


+n outpatients with cancer and indwelling central 1enous

catheters, we suggest against routine prophylaxis with LMW

or L#$ (Grade !B) and suggest against the prophylactic

use of 1itamin 2 antagonists (Grade !")&


16/23

Chronically Immobilized Outpatients

+n chronically immobilized persons residing at home or at a

nursing home, we suggest against the routine use of

thromboprophylaxis (Grade !")&


17/23

Long-distance Travel

For long-distance travelers at increased risk of VTE (including

previous VTE, recent surgery or trauma, active malignancy,

pregnancy, estrogen use, advanced age, limited mobility, severe

obesity, or known thrombophilic disorder), we suggest frequent

ambulation, calf muscle exercise, or sitting in an aisle

seat if feasible (Grade 2C).


18/23

Long-distance Travel

For long-distance tra1elers at increased risk of ./0 "including

pre1ious ./0, recent surgery or trauma, acti1e malignancy,

pregnancy, estrogen use, ad1anced age, limited mobility, se1ere

obesity, or known thrombophilic disorder%, we suggest use of

properly fitted, below-knee ()* pro1iding 34 to 56 mm

g of pressure at the ankle during tra1el (Grade !")& For all

other long-distance tra1elers, we suggest against the use of ()*

(Grade !")&


19/23

Long-Distance Travel

For long-distance travelers, we suggest against the use of aspirin

or anticoagulants to prevent VTE (Grade 2C).


20/23

Persons With Asymptomatic Thrombophilia

In persons with asymptomatic thrombophilia (ie, without a

previous history of VTE), we recommend against the long-term

daily use of mechanical or pharmacologic thromboprophylaxis

to prevent VTE (Grade 1C).


21/23

Thromboprophylaxis in these settings is

described in the surgical chapter:

Trauma

Spinal cord injuries

Burn victims

Thromboprophylaxis using aspirin: no

statement was made due to sparse data inmedical patients

Other Nonsurgical Settings


22/23

Acknowledgement of Support

The ACCP appreciates the support of the following organizations

for some part of the guideline development process:

Bayer Schering Pharma AG

National Heart, Lung, and Blood Institute (Grant No.R13 HL104758)With educational grants from

Bristol-Myers Squibb and Pfizer, Inc.Canyon Pharmaceuticals, and

sanofi-aventis U.S.

Although these organizations supported some portion of the developmentof the guidelines, they did not participate in any manner with the scope,

panel selection, evidence review, development, manuscript writing,

recommendation drafting or grading, voting, or review. Supporters did not

see the guidelines until they were published.


23/23

Endorsing Organizations

This guideline has received the endorsement of thefollowing organizations:

American Association for Clinical Chemistry

American College of Clinical Pharmacy American Society of Health-System Pharmacists

American Society of Hematology

International Society of Thrombosis and Hemostasis

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10PrevofVTEinNonsurgicalPts.ppt