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102 Cards in this Set
- Front
- Back
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2 types of VTE
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DVT
PE |
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CLINICAL PRESENTATION VTE--> DVT
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Often can be silent
Pain in limb Tenderness Swelling Discoloration Palpable cord--> hard papable vein Homan’s sign--> pain on dorsiflexion (extension) of the foot many are none specific unilaterial bilaterial would notindicated a DVT |
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CLINICAL PRESENTATION VTE--> PE
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Sudden onset
Dyspnea Cough Tachypnea Tachycardia Chest pain Anxiety diaphoresis/sweating even more non specific than DVT s/s some overlap with the s/s of MI |
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D-dimer
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blood test that measures the level of d-dimer that is a degragation prodect of clot breakdown
high levels are indicate that there are that clots are being formed and broken down |
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normal d-dimer levels inidcate
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that there is not a possibility of a clot
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Diagnostic testing DVT
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Clinical Probability testing + D-dimer
DVT Doppler Ultrasonography Duplex scanning Venography |
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Clinical Probability testing + D-dimer
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diagnostic test for VTE
score is calculated to estimate risk of VTE |
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doppler ultrasonography
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DVT
sound waves to detect blood flow abnormalities inital and most common method |
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duplex scanning
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combination of sound waves with visiualization of the underlying veins (expensive)
DVT |
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Venography
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gold standard, but invasive
injection of radioactive die into veins and observe the viens through an x-ray |
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Joint Commission VTE Core measures Risk Assessment/Prophylaxis
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VTE Risk Assessment (RA)/Prophylaxis within 24 Hours of Hospital Admission
VTE Risk Assessment (RA)/Prophylaxis within 24 Hours of Transfer to ICU |
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Joint Commission VTE Core measures treatment of VTE
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VTE Patients with Overlap of Anticoagulation Therapy
VTE Patients Receiving Unfractionated Heparin with Platelet Count Monitoring and by Nomogram/Protocol VTE Discharge Instructions |
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Joint Commission VTE Core measures outcomes
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Incidence of Potentially Preventable Hospital-Acquired VTE
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VTE PROPHYLAXIS
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VTE is often clinically silent and potentially fatal
Unable to rely on early diagnosis and treatment of VTE as many patients will die before treatment can be initiated Even disease that is not fatal carries a substantial risk of long-term morbidity Chronic post-thrombotic syndrome (lower pain, swelling, venous insufficiency, can progress to gangren and limb amputation) Strategies that prevent VTE in at risk populations the most important intervention that can be made Surgical patients have long been recognized as an at risk population Medically ill patients often have VTE rates similar to most surgical populations JCAHO regulations starting in 2009 will make VTE prophylaxis one of their quality indicators |
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Absolute Risk of DVT in Hospitalized Patients without prophylaxis treatment
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Medical Patients 10-20%
General Surgery 15-40% Neurosurgery 15-40% Stroke 20-50% Orthopedic Surgery 40-60% Major trauma 40-80% Spinal Cord Injury 60-80% Critical Care Patients 10-80% |
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risk factors for VTE
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Age > 40
Acute Medical Illness •MI •CHF •Inflammatory diseases •Infection Surgery History of VTE Trauma Malignancy Immobility Obesity Smoking Medications •hormones Thrombophilias Pregnancy |
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VTE Risk Assessment Strategies
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Scoring system
Presence of risk factors assigned a number Add up numbers, total indicates level of risk and if should give prophylaxis Scheme by population Yes/No Surgery patients (high risk population) Default prophylaxis Everyone gets it unless physician unchecks option all institutions should have one formal process that is used throughout the hospital |
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Low Risk Patient Populations
•Estimated rate of VTE without prophylaxis: <10% patient group |
•Minor surgical procedures with no additional risk factors
-Knee arthroscopy •Vascular surgery with no additional risk factors •Minor gynecologic surgery with no risk factors •Minor urologic procedures with no risk factors •Laproscopic procedure with no additional risk factors •Elective spine surgery with no additional risk factors |
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Low Risk Patient Populations
•Estimated rate of VTE without prophylaxis: <10% recomended prophylaxis strategies |
•No specific prophylaxis recommended other than early and aggressive ambulation
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Medium Risk Patient Populations
•Estimated rate of VTE without prophylaxis: 10 - 40% patient group |
•General or Thoracic surgery for benign disease
•Vascular surgery with additional risk factors •Gynecolgic surgery, either laproscopic or open without additional risk factors •Major urologic procedures with additional risk factors •Laproscopic surgery with additional risk factors •CABG •Athroscopic knee surgery with risk factors •Elective spine surgery with additional risk factors •Major neurosurgery •Burns •Medically ill patients (heart failure, respiratory disease, stroke, active cancer, or confined to bed with additional risk factors) •Critical care patients |
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Estimated rate of VTE without prophylaxis: 10 - 40%
recomended prophylaxis strategies |
•LMWH
-Enoxaparin 40 mg SQ daily -Dalteparin 2500 – 5000 units SQ daily > • Unfractionated heparin -5000 units SQ BID or TID (Q8 hour is the best option (tid)) •Fondaparinux 2.5 mg SQ daily |
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High Risk Patient Populations
•Estimated rate of VTE without prophylaxis: 40-80% patient groups |
•General or Thoracic surgery for cancer, or with other major risk factors
•Gynecologic surgery for malignancy •Bariatric Surgery + •Major orthopedic surgery -Elective hip replacement -Hip fracture surgery -Elective knee replacement •Major trauma # •Acute spinal cord injury |
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High Risk Patient Populations
•Estimated rate of VTE without prophylaxis: 40-80% recommended prophylaxis strategies |
•Low molecular weight heparin
-Enoxaparin 30 mg SQ BID -Dalteparin 5000 units daily -Tinzaparin 75 units/kg, or 3500 – 4500 units SQ daily $ •Unfractionated heparin ^ -5000 units SQ TID plus IPC •Fondaparinux 2.5 mg SQ daily •Warfarin (INR 2.0-3.0)* •Consider combining pharmacologic and mechanical methods of prophylaxis in patient considered at very high risk |
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is ASA adequate to prevent VTE
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No, anti-platelet therapies are not indicated need anti-coagulation
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Prevention of Venous Thromboembolism Intermittent Pneumatic Compression Devices
(IPC) |
•Intermittent Pneumatic Compression Devices
-Primary role is use in patients who are at elevated risk of bleeding which precludes the use of pharmacologic prophylaxis -May be used as an adjunct to pharmacologic prophylaxis to enhance efficacy -Careful attention should be used to ensure device is used as intended and to ensure compliance |
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5 steps in response to vasculature injury
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Response to Vascular Injury
1)Vascular Constriction 2)Formation of the Platelet Plug 2a) Activation of the Clotting Cascade 3)Formation of a blood clot 4)Clot dissolution |
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balance of 2 systems _________ and _________ designed to keep the blood flowing and be able to respond to vasculature injury
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anti-coagulation and pro-coagulation.
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Joint Commission National Patient Safety Goals VTE
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• An independent, not-for-profit organization, The Joint Commission is the nation’s predominant standards-setting and accrediting body in health care
• Since 1951, The Joint Commission has maintained state-of-the-art standards that focus on improving the quality and safety of care provided by health care organizations. • Joint Commission standards address the organization’s level of performance in key functional areas, such as patient rights, patient treatment, and infection control. The standards focus not simply on an organization’s ability to provide safe, high quality care, but on its actual performance as well. Standards set forth performance expectations for activities that affect the safety and quality of patient care. |
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National Patient Safety Goals
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The purpose of the Joint Commission’s National Patient Safety Goals (NPSGs) is to promote specific improvements in patient safety
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Requirement 3.5.01
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Reduce the likelihood of patient harm associated with the use of anticoagulation Therapy
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Rationale for Requirement 3.5.01:
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Anticoagulation is a high risk treatment, which commonly leads to adverse drug events due to the complexity of dosing these medications, monitoring their effects, and ensuring patient compliance with outpatient therapy. The use of standardized practices that include patient involvement can reduce the risk of adverse drug events associated with the use of heparin (unfractionated), low molecular weight heparin (LMWH), warfarin, and other anticoagulants.
to minimize negative outcomes and maximize positive outsomes |
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Implementation Expectations for 3.5.01
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The organization implements a defined anticoagulant management program to individualize the care provided to each patient receiving anticoagulant therapy.
To reduce compounding and labeling errors, the organization uses ONLY oral unit dose products and pre-mixed infusions, when these products are available. When pharmacy services are provided by the organization, warfarin is dispensed for each patient in accordance with established monitoring procedures. The organization uses approved protocols for the initiation and maintenance of anticoagulation therapy appropriate to the medication used, to the condition being treated, and to the potential for drug interactions. For patients being started on warfarin, a baseline International Normalized Ratio (INR) is available, and for all patients receiving warfarin therapy, a current INR is available and is used to monitor and adjust therapy. When dietary services are provided by the organization, the service is notified of all patients receiving warfarin and responds according to its established food/drug interaction program. When heparin is administered intravenously and continuously, the organization uses programmable infusion pumps The organization has a policy that addresses baseline and ongoing laboratories tests that are required for heparin and low molecular weight heparin therapies. The organization provides education regarding anticoagulation therapy to prescribers, staff, patients, and families Patient/family education includes the importance of follow-up monitoring, compliance issues, dietary restrictions, and potential for adverse drug The organization evaluates anticoagulation safety practices safety goals that organiztions must be compliant with as of 2009 |
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Unfractionated Heparin (UFH)
Pharmacology and mechanism of action |
UFH binds to both anti-thrombin and increases the ability to inactivate clotting factos II and Xa
in order to inactivate thrombin (II) UFH has to bind both AT and thrombin it alsoe inhibits Xa but does not have to bind it directly only binds with AT |
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ROA UFH
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IV or SQ
never IM because a hemotosis will form not orally avaiable |
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onset of UFH
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imediate if given IV
1-2 hours for SQ |
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T 1/2 life UFH
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dose dependent but usually 1 hour
higher doses will have longer T 1/2 lives |
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indications of UFH
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prophylaxis or treatment of VTE
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adverse effects UFH
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bleeding
thrombocytopenia |
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dosing UFH
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Weight based nomograms have emerged lately and have shown to be superior to empiric dosing in terms of achieving adequate anticoagulation.
Rapid therapeutic anticoagulation in the 1st 24 hours effective in decreasing recurrence Dose varies by indication |
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UFH DVT prophylaxis dose
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5000 units SQ q12h h vs q8h
to have appropriate efficacy use Q8 hours to prevent DVT |
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Venous Thromboembolism (DVT/PE): UFH
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Intravenous therapy – monitored
Bolus: 80 units/kg Continuous Infusion: 18 units/kg/hour SQ therapy – unmonitored Initial dose:333 units/kg Subsequent: 250 units/SQ BID |
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dose for Acute Coronary Syndromes and arterial thromboembolism (atrial fibrillation, mechanical valve):
UFH |
Bolus: 60-70 units/kg
Continuous infusion: 12-15 units/kg/hour |
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Dose UFH With thrombolysis for acute MI:
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Bolus:60 units/kg (max 4000 units for initial dose)
Continuous Infusion: 12 units/kg/hour (max 1000 units/hour) |
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dose adjustments for UFH should be ________
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weight based
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if aPTT is 85-94 seconds
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Decrease infusion by 1 unit/kg/hr
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Activated partial thromboplastin time (aPTT)
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The therapeutic aPTT range needed for adequate anticoagulation will vary from institution to institution due to
a.different thromboplastin reagents b.different labs and personnel CAUTION: The therapeutic range is often defined as 1.5-2.5 x control value but this does not always correlate to therapeutic heparin concentrations. Each laboratory should establish an aPTT range (in seconds) that corresponds to an UFH plasma concentration of 0.2-0.4 IU/ml as measured by the protamine sulfate titration assay or 0.3-0.7 IU/mL as measured by anti-factor Xa assay. Each institution will have their own defined therapeutic range for aPTT |
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you _____ _______need to monitor aPTT when giving heparin for VTE prophylaxis
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do not
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Reversal of heparin effect
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-Protamine: Cationic protein that binds to heparin (anionic)
-Ratio is 100 units UFH to 1 mg protamine -For patients on IV infusion, give 1mg of protamine for every 100 units of UFH that has been given in the last 3 hours unlike other injectable heparin given more than 3 hours ago is likely to have been cleared from the body because the T 1/2 is 1 hour |
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Monitoring UFH
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aPTT
Determination of therapeutic range Each institution has own range corresponding to heparin levels or activity No monitoring with prophylaxis |
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LMWH MOA
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Has a pentasaccharide sequence that binds to Anti-thrombin
does not bind to both thrombin and ATIII so doesn 't inactivate thrombin only targets and inactivates factor Xa |
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do you need to monitor LMWH
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no because a more consistent response is produced
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because of the shorter chain legth of LMWH
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the bioavailibilty is better and the T 1/2 is longer
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ROA of LMWH
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SQ (occasionally IV)
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Enoxaparin indications
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•VTE Prophylaxis: multiple populations
•VTE Treatment •Outpatient treatment of DVT •Acute coronary syndromes |
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Dalteparin indications
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•VTE Prophylaxis: some populations
•Treatment VTE •Acute coronary syndromes |
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Tinzaparin indications
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•Treatment of DVT with or without PE
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LMWH names
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Enoxaparin (Lovenox)
Dalteparin (Fragmin) Tinzaparin (Innohep) |
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onset of action of LMWH
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3-5 hours
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T 1/2 of LMWH
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3-6 hours so can give qd-bid
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adverse effects of LMWH
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bleeding, throbocytopenia (incidence is lower than UFH, but there is cross-sensitivity
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dose of LMWH depends on
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indication
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enoxaparin dose for prophylaxis treatment
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30 mg SQ BID
or 40 mg SQ once daily |
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is the use of LMWH prophylaxisly weight based
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no
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dalteparin dose for prophylaxis treatment
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2500 units
or 5000 units SQ once daily |
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tinzaparin dose for prophylaxis treatment
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3500-4500 units SQ once daily
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treatment dose of enoxaparin
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Treatment: 1 mg/kg BID or 1.5 mg/kg QD
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PCI dose of enoxaparin
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on current therapy
0.3 mg/kg IV bolus if last dose > 8 hours ago 0.75 mg/kg IV bolus if no previous therapy |
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treatment dose of dalteparin
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100 units/kg SQ twice daily or 200 units/kg SQ once daily
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treatment dose of tinzaparin
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Treatment: 175 units/kg SQ once daily
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Prophy dose adjustment for body size – prophylaxis of LMWH
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> 150 kg or BMI > 40
Enoxaparin 40 mg SQ BID |
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dose adjustment for renal dysfunction for LMWH
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Enoxaparin
Prophylaxis: 30 mg QD Treatment: 1 mg/kg QD Tinzaparin and dalteparin No indication there is accumulation By package insert, caution when using in patients with Clcr < 30 ml/min |
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monitoring of LMWH
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Generally not needed
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monitoring in special populations of LMWH
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Body weight extremes
Renal dysfunction with prolonged administration Changes in Vd (such as pregnancy) monitoring anti X1 levels aPTT not useful Anti-Xa levels can be used Goal peak level 0.5-1.0 units/ml (BID treatment dosing) Goal peak > 1.0-1.2 units/ml for once daily dosing Check level at peak activity, 4-5 hours after dose given peak level is 4-5 hours after dose |
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reversal of LMWH
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protamine only partially reverses
1 mg protamine for every 1 mg of enoxaparin or 100 units of dalteparin or tinzaparin |
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a synthetic pentasaccharide
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fondaparinux
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fondaparinux MOA
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pentasaccharide sequence that binds ATIII inactivating Xa
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ROA fondaparinux
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SQ only
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onset of fondaparinux
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2-3 hours (peak level of activity)
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T 1/2 of fondaparinux
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17-21 HOURS
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how is fondaparinux cleared from the body
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renally so it is problamatic in patients with renal dysfuntion
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Dose adjustment for renal dysfunction of fondaparinux
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Not available, contraindicated in patients with Clcr < 30 ml/min, anuria, dialysis
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indications of fondaparinux
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prophyalaxsis and treatment of VTE
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adverse effects of fondaparinux
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bleeding
does not cause heparin induced thrombocytopenia |
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dose of fondaparinux is based on
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indication
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prophylaxsis dose of fondaparinux
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Prophylaxis: 2.5 mg QD
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treatment dose of fondaparinux for ACS
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Treatment ACS : 2.5 mg QD
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treatment dose of fondaparinux for VTE
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Treatment VTE: 5 mg (< 50 kg), 7.5 mg (50-100 kg), 10 mg (> 100 kg)
all QD |
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monitoring of fondaparinix
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Generally not needed
Minimal info on whether anti-Xa can be used monitoring anti-Xa levels in special populations |
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Reversal of fondaparinux effect
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none
problamatic becasue it has a long T1/2 and is renally cleared |
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names of direct thrombin inhibitors
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hirudin
lepirudin argatroban bivalrudin |
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lepirudin
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Type of Product=Recombinant
Mean Molecular Weight=large Plasma T ½ 1.3 hours Route of Administration IV Antibody formation Yes Clearance Renal Monitoring of anticoagulant effect monitor aPTT Indication HIT |
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argotroban
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Type of Product= synthetic
Mean Molecular Weight= small Plasma T ½ 39-51 minutes Route of Administration = IV Antibody formation= NO Clearance= Hepatic Monitoring of anticoagulant effect aPTT Indication= HIT |
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bivalirudin
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Type of Product= sythetic
Mean Molecular Weight= small Plasma T ½ = 25 minutes Route of Administration= IV Antibody formation= NO Clearance= prteolytic cleavage in plasma (good for multi organ dysfunction) Monitoring of anticoagulant effect= aPTT Indication ACS/PCI (can be used for HIt but not FDA approved) |
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direct thrombin inhibitors MOA
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Binds directly to thrombin
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Presence of hepatic or renal dysfunction direct thrombin inhibitor
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Renal – avoid lepirudin
Hepatic – avoid argatroban Both – bivalirudin best choice |
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Dosing for special populations direct thrombin inhibitors
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Argatroban
Typical dose 2 ug/kg/min Critically ill – 1.0 ug/kg/min Lepirudin Omit bolus in ciritically ill, renal insufficiency (reduce dose) |
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dosing per indication of direct thrombin inhibitors
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Bivalirudin
ACS – 0.1 mg/kg bolus, 0.25 mg/kg/hr infusion HIT – 0.15 mg/kg/hour PCI – 0.75 mg/kg bolus, 1.75 mg/kg/hr infusion |
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reversal of DTI
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none but they are all short acting agents
once the infusion is stopped the drug will be cleared shortly |
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Monitoring
DTI |
Lepirudin
1.5-2.5 times the patient’s control value Example baseline aPTT 36, goal range 54-90 Argatroban/bivalirudin 1.5-3.0 times the patent’s control value |
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HF is mainly a disease of the
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elderly
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are most HF patients cared for by a cardiologist
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no
there are not enough cardiologist acces to care |
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what are the main comorbitities associated with HF
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heart arrhythmias
COPD renal failure DM |
