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74 Cards in this Set

  • Front
  • Back
Venous Thromboembolism & HIT incidence ___ with each ___ > ___
Incidence doubles w/ each decade over the age of 50
Do patients show symptoms of Venous Thromboembolism & HIT
Lots of patients are asymptomatic

Some patients never express any symptoms
What Ethinicities are at risk of DVT and HIT?
African Americans > Caucasian > Hispanic Americans
Very low incidence in Asian Americans and Pacific Islanders
What the #1 risk factor Venous Thromboembolism & HIT
Prior history of DVT/PE is #1 risk factor
What are Risk factors for VTE?
Age
Hx of VTE--> strongest risk factor for VTE
Venous Stasis--> obsity, CHF, Post-MI
Vascular Injury--> major surgery, Trauma
DRug therapy--> BC, SERM, HIT
How do VTE Present?
Hallmark: lower extremeties. One large will be large red and swollen, other one will be fine
What are symptoms of DVT?
Unilateral swelling ( one leg, not both)
Pain
Redness
Heat
Ulceration
Cord-like obstruction( can feel in calf, feels like rope in there leg)
What are symptoms of PE?
Cough
Chest pain/tightness
Hemoptysis (<30%) (coughing up blood)
Dyspnea
Tachypnea
Tachycardia
Cardiovascular collapse
cyanosis
shock
oliguria

Need immediate help, may need stronger drugs than coagulations
What are LAB tests for VTE?
↑ D-dimer ( bi-product of fibrinolysis) (can measure these levels)
IF patient comes in with a PE or DVT-->D-dimer will be high.
- d-dimer will rule it out
↑ ESR, WBC
Time it takes fr the erythrocytes to pool
WBC maybe elavated, non-specific
What 2 imaging test are used for DVT?
Ultrasound most common, to look at the veins and look for flow through the veins
Venography (gold standard) Not used that much, because it is risky, inject radio pink dye, and take an xray, and see where blood is flowing and where its not
What are 3 imaging tests for PE?
Ventilation-perfusion (V/Q) scan: measures distribtion between air and blood flow in the lungs. Number 1 test for PE
Spiral CT scan-->detecs emboli in the lungs
Pulmonary angiography (gold standard)
What is the Pre-test Probability for DVT?
Risk Factor:
Tenderness=1
Swelling of entire leg=1
> 3cm difference between one leg to the her circumference difference=1
Pitting edema=1
Collateral superficial veins=1
Risk factors= -2
Active cancer
Immobility
Recent surgery or medical illness
Alternative diagnosis likely

≥ 3 = high (>60%)
1-2 = moderate (35%)
≤ 0 = low (<5%)
What is the Pre-test Probability for PE
Risk Factors:
DVT suspected
Clinical features of DVT=3
Recent immobility or surgery=1.5
Active cancer=1
History of DVT/PE=1.5
Hemoptysis=1
HR >100 bpm=1.5
No alternative for SOB or CP=3

≥ 6 = high (>60%)
2-6 = moderate (35%)
≤ 1.5 = low (<5%)
Describe Rating Scale for 1A, 1B, 1C
Strong, high-quality evidence
Apply to most patients in most circumstances; further evidence unlikely to change recommendation


Strong, moderate-quality evidence (limitations)
Apply to most patients in most circumstances; further evidence would help confirm/change recommendation


Strong, low or very low-quality evidence (many limitations in RCTs)
Apply to most patients in most circumstances; higher-quality evidence would support or change recommendation
Describe Rating Scale for 2A, 2B and 2C
Weak, high-quality evidence
best action may differ depending on circumstance, patient, society; further evidence will not change

Weak, moderate-quality evidence
Best action may differ depending on circumstance, patient, society; further evidence will support/change recommendation

Weak, low or very low-quality evidence
Other alternatives equally reasonable; higher-quality evidence would support/change recommendation
What do you do first when patient comes into the hospital?
Screening at admission to assess:
Risk factors
Pre-test probability of DVT/PE
What is nonpharmacological Prophylaxis of VTE?
1: Walk around, if patient is mobile and complying on compression to move the blood that is good
2: graduated compression stockings--> reduce VTE rate by 60%
3: Intermittent Pneumatic Compression (IPC)--> reduced vte by 60%--> must be used with pharm TX
4. Inferior Vena Cava (IVC) filter
what is Pharmacologic Prophylaxis for VTE
The use of UFH, LMWHs, fondaparinux should be used first-line for hospitalized patients (1A) according to manufacturer’s dosing recommendations (1A)
What Pharmacologic Prophylaxis should not be used as a primary agent?
Aspirin should not be used as primary agent (1A)
Also, other antiplatelet drugs
What are Low level Risk patient risk factors?
% for DVT, PE and Fatal PE?
Prevention stratgey for Low risk?
Low
Minor surgery, age <40 yrs, no RF

DVT-2
PE-0.2
Fatal PE- 0.002

Ambulation
What risk factors make a patient Moderate level of risk
Moderate
Major/minor surgery, age 40-60, no RF
Major surgery, age <40 yrs, no RF
Minor surgery, clinical RF present
Acutely ill (MI, ischemic stroke, CHF exacerbation), no RF present
For moderate risk patients, what % chance do they have of getting DVT, PE and Fatal PE?
10-20
1-2
0.1-0.4
What are prevention strategies for Moderate risk patients
UFH 5,000 units SC q12h
Dalteparin 2,500 units SC q24h
Enoxaparin 40mg SC q24h
Tinzaparin 3,500 units SC q24h
IPC
Compression stockings
What risk factors make a patient high level of risk?
High
Major surgery, age >60 yrs, no RF
Major surgery, age 40-60, clinical RF present
Acutely ill (MI, ischemic stroke, CHF exacerbation), clinical RF present
For high risk patients, what % chance do they have of getting DVT, PE and Fatal PE?
20-40

2-4

0.4-1.0
What are prevention strategies for high risk patients
UFH 5,000 units SC q8h
Dalteparin 5,000 units SC q24h
Enoxaparin 40mg SC q24h
Fondaparinux 2.5mg SC q24h
Tinzaparin 75 units/kg SC q24h
IPC
What risk factors make a patient highest level of risk?
Highest
Major lower-extremity orthopedic surgery
Hip fracture
Multiple trauma
Major surgery, age >40 yrs, prior Hx of VTE
Major surgery, age >40 yrs, malignancy
Major surgery, age >40 yrs, hypercoagulable state
Spinal cord injury or stroke with limb paralysis
For highest risk patients, what % chance do they have of getting DVT, PE and Fatal PE?
40-80

4-10

0.2-5
What are prevention strategies for highest risk patients
Adjusted dose UFH SC q8h (aPTT >36s)
Dalteparin 5,000 units SC q24h
Desirudin 15mg SC q12h
Enoxaparin 30mg SC q12h
Fondaparinux 2.5mg SC q24h
Tinzaparin 75 units/kg SC q24h
Warfarin (INR 2-3)
IPC with UFH 5,000 units SC q8h
For Orthopedic Surgery, which therapires should be used?
(LMWH, fondaparinux, or warfarin) for 10 days (1A)
For total hip replacement therapy how long should it be extended?
therapy should be extended to 10-35 days (1A)
Total knee replacement therapy should be for how long?
therapy should be 10 days (1A); extended therapy here is 2B
Hip fracture surgery - therapy should be extended to ?
10-35 days (1A)
What is Dabigatran (Pradaxa®)
used for? What is the dosing for them?
Approved for use in Canada for postoperative ppx
220mg PO daily for 10 days (TKR) or 28-35 days (THR)
Rivaroxaban (Xarelto®) is used for what? What is the dosing for?
Approved for use for postoperative ppx
10 mg PO daily for 12-14 days (TKR) or 35 days (THR)
What studies was Rivaroxaban studied in? What did they show?
RECORD1, RECORD2, RECORD3
All showed non-inferiority of rivaroxaban against enoxaparin
Increased rates of bleeding in rivaroxaban groups
Case Study 1 DF is a 63 year old, morbidly obese woman who presents for elective abdominal surgery for diverticulitis. She has a significant medical history for hypertension, type 2 diabetes mellitus, peripheral vascular disease, and chronic kidney disease. Her current home medications include enalapril 10mg BID, metformin 500mg BID, and glipizide 10mg daily. Her blood pressure reading in the pre-op area was 135/85 mmHg. She reports that her blood sugar at home is normally in the low 100’s. Her A1c is 6.4. Labs reveal CKD with a calculated CrCL of 46 mL/min.

What else do you want to find out about?
History of VTE

History of hypercoaguable state
Case Study 1

What are DF's risk factors for VTE?
Obesity,
major surgery,
venous stasis- PVD,
Age greater then 60
Case Study 1
What nonpharmacologic interventions do you want to make (if any)?
intermittent pneumatic compression devices while int he hospital
Case Study 1

What pharmacologic interventions do you want to make (if any)?
UFH 5,000 units sc q8h is the best choice

LMWH- caution with renal impairment

Fondaparinux also an option renail impairment and long t1/2

BE careful because patients has chronic kidney disease
CRCL: 46-> cut off is 30
For acute treatment of DVT/PE what would you use?
Use LMWH, fondaparinux, UFH, or SC adjusted dose UFH (1A)

The dose of UFH should maintain an aPTT that corresponds to anti-Xa level of 0.3-0.6 IU/mL (1C)

LMWH is preferred in patients with cancer (1A)
Duration of acute treatment for DVT/PE?
UFH, LMWH, or fondaparinux should be overlapped for ≥ 5 days until INR is >2.0 (1A)

Patients with cancer should be treated for 6 months (1A)

A longer period of 10 days of heparin therapy should be used for patients with massive PE or severe iliofemoral thrombosis (1C)
Long-term anticoagulation for treatment of DVT/PE
Oral anticoagulation (INR 2.0-3.0) should be continued for at least 3 months (1A)

Patients with idiopathic VTE, hypercoagulable state, or antiphospholipid antibodies should be treated indefinitely (1A)

Patients with continuing risk factors should be treated for at least 12 months (1C)
Treatment of DVT/PE with UFH is given how? What is the dosing?
Given as bolus and continuous infusion

Dosing:
80 units/kg bolus
18 units/kg/hr infusion thereafter titrated to aPTT corresponding to 0.3-0.7 IU/mL anti-Xa activity
Treatment of DVT/PE with UFH monitoring parameters?

Level of evidence?
aPTT
CBC
Bleeding

1A
What is the advantage of LMWH compared to UGH when treating DVT/PE?
no need for frequent monitoring
Treatment of DVT/PE with LMWH, what are the agents and dosing?
Enoxaparin 1 mg/kg SC q12h OR 1.5 mg/kg SC q24h
Dalteparin 100 units/kg SC q12h OR 200 units/kg SC q24h
Tinzaparin 175 units/kg SC q24h
What is monitored when treating DVT/PE with LMWH

level of evidence?
Monitoring:
Bleeding
SCR

1A
Treatment of DVT/PE with Fondaparinux has what kind of dosing and administration?
Fixed dose of 7.5 mg SC daily
10 mg SC daily if ≥100kg
5 mg SC daily if <50kg
Treatment of DVT/PE with Fondaparinux monitoring parameters?

What is the level of evidence?
Monitoring:
Bleeding
SCR

Level of evidence: 1A
IS warfarin used for acute TX of DVT/PE?
NO
How is warfarin dosed for chronic DVT/PE?

How long to treat general patients for?

Level of evidence?
Dosing:
It’s an art!
Most patients start at 5mg daily
IF they are over 65 start at 2.5 mg
Titrate to goal INR: 2.0-3.0

3-6 months

1A
What kind of patients should thrombolysis be used?

When does throbomlysis used the best?
Reserved for use in patients with PE and evidence of shock
Systolic bp is going down, HR is going up

Early

1B
What are approved thrombolysis agents for PE patients?
Streptokinase 250,000 units IV over 30 minutes, then 100,000 units/hr x 24h
Not a thrombin specific plasminagen activator
Risk of bleeding is higher
Urokinase 4,400 units/kg IV over 10 minutes, then 4,400 units/kg/hr x 12-24h
Alteplase 100 mg IV over 2 hours
For Pregnant patients DVT/PE treatment consists of what?
UFH or LMWH can be used

LMWH may be preferred - UFH linked to osteoporosis and multiple injections
What can be used in Pediatrics with VTE?
UFH or LMWH can be used
What is dosing for Pediatrics with VTE?
UFH or LMWH can be used
UFH 75-100 units/kg bolus, then 28 units/kg/hr (age 2-12 months) or 20 units/kg/hr (age >1 year)
LMWH dosed to anti-Xa activity (less evidence)
Overlap with warfarin
Starting dose 0.2mg/kg titrated to INR 2.0-3.0
What DVT/PE treatment would you use in cancer patients? Dosing/duration?

What is not used?
LMWH is preferred agent
Enoxaparin 1 mg/kg SC q12h
Dalteparin 200 units/kg SC q24
Duration of 3-6 months

WARFARIN IS CONTRAINDICATED
For HAT, type 1 HIT, what does the platelet count drop to? which days is it seen between?
Platelet nadir = 100K between days 2-4
For HIT; Type 2 HIT

What does the platelet cont drop to? Between which days?
Platelet nadir = 20k-150k between days 7-14
How does HIT typically present?
Venous thrombosis
Proximal DVT
PE (25% of patients)

sometimes you can get an arterial thrombosis (MI,Stroke)

Heparin-induced skin necrosis

Platelet fall >50%
How do you diagnosis HIT?
4-T test

thrombocytopenia
Timing of platelet nadir
Thrombosis or other sququelae
Other causes for TCP
What are the scoring parameters for thrombocytopenia?
2 points= Platelet fall >50% and nadir ≥20k
1 point =Platelet fall 30-50% or nadir 10-19k

o point = Platelet fall <30% or nadir <10k
What are the scoring parameters for timing of platelet nadir
2 points =Clear onset 5-10 days or platelet fall ≤1 day (prior exposure w/in 30 days)
1 point= Consistent with days 5-10 but not clear; onset after day 10; or fall ≤1 day (prior exposure 30-100 day)
0 points= none
What are the scoring parameters for Thrombosis or other sequelae
2 points= New confirmed thrombosis; skin necrosis; acute reaction pos IV bolus
1 point = Progressive or recurrent thrombosis; non-necrotizing skin lesions; suspected unproven thrombosis
0 points =none
What are the scoring parameters for other causes for TCP
2 points= none apparent
1 point = possible
0 points= definite
What are the risk categories for HIT?
6-8 points = high-risk (HIT probable)
4-5 points = intermediate risk (HIT possible)
0-3 points = low risk (HIT unlikely)
Can 4T's test confirom or completely rule out HIT alone?
NO

Does have 99.5% negative predictive value
What is used along with 4T's test?
Functional Assays
Serotonin-release assay (SRA)
Washed platelet assay
95% sensitivity
much more labor intensive
what are 5 steps of managment of HIT?
Stop all heparin products immediately!
Treatment doses
Prophylactic doses
Heparin coated IVs/Catheters
Heparin flushes
Begin alternative anticoagulant
Obtain confirmatory lab assessment (if not done already)
± surgical extraction of thrombus
Start long-term anticoagulation when ready
What are alternative anti-coagulation drugs for HIT? What is FDA approved for it? What is not FDA approved but is still used? What dont you use?
FDA approved for HIT:
Lepirudin 0.4 mg/kg bolus, then 0.15 mg/kg/hr infusion titrated to aPTT 1.5-2.5x control
Argatroban 2 mcg/kg/min infusion titrated to aPTT 1.5-3x control
Not FDA approved, but used
Bivalirudin 0.15-0.2 mg/kg/hr infusion titrated to aPTT 1.5-2.5x control

DONT USE LMWH
What do you monitor with DTIs for HIT
CBC
aPTT
SCr
LFTs-argatroban
When do you begin warfarin in long term management?
Begin warfarin therapy when platelets >150k
How do you dose warfarin in long term HIT?
Overlap with DTI for at least 5 days
2 consecutive days of INR in TR (2.0-3.0)