Transcript DVT PROPHYLAXIS

DVT PROPHYLAXIS
SUNDIP PATEL
7 / 15 / 2009
BACKGROUND
Deep Vein Thrombosis is a common, yet
preventable peri-operative complication
 Highest risk in critical care and spinal cord
injury patients – 60-80%
 Post–General Surgery procedures: 15-40%
 Post-Ortho Procedures: 40-60%
 Variable for Urologic cases
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BACKGROUND
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Pulmonary Embolus
True Prevalance is unknown
 W/O prophylaxis
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Fatal PE in 0.2-.9% of ELECTIVE general
surgery cases
 Fatal PE in 0.1-2.0% of ELECTIVE hip
 Fatal PE in 2.5-7.5% of Fractured Hip
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VIRCHOW TRIAD
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STASIS
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HYPERCOAGULABILITY
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Decreased clearance of the PROcoagulant
INTIMAL INJURY
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From supine positioning and effects of anesthesia
Results from excessive vasodilation caused by
vasoactive amines and anesthesia
Acting in concert, these 3 factors promote
development of DVT in low-flow areas
RISK FACTORS
AGE > 50
 Hx of varicose veins
 Hx of MI
 Hx of Cancer
 Hx of AFib
 Hx of ISCHEMIC Stroke
 Hx of DM
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Urologic Risk
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RISK Level for most UROLOGIC
patients are considered
MODERATE
UROLOGIC RISK
Risk of DVT w/o prophylaxis is 10 – 40%
 RECS:
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Low Molecular Weight Heparin (Lovenox)
Low Dose Unfractionated Heparin
Fondaparinux (ARIXTRA)
Also appropriate to use is
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Graduated Compression Stockings
Intermittent Pneumatic Compression
Venous Foot Pumps
Types of MEDICAL prophylaxis
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LMWH (lovenox)
Greater bioavailability
 Longer duration
 Little monitoring needed
 HIT incidence less
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LDUH
Easy administration
 Cost Effective
 Little monitoring needed
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ARIXTRA
Longer half-life than
LMWH (17H v 4H)
 Not for CKD pts
 No monitoring
 Single daily dosing
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UROLOGIC PROCEDURES
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Transurethral – EARLY AMBULATION
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IF HIGHER RISK, GCS OR IPC
Anti-incontinence and pelvic reconstructive
surgery
Low risk – early ambulation
 Mod risk – IPC or LMWH
 Hi Risk – IPC + LDUH or LMWH
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Urologic laparoscopic and/or robotically
assisted - IPC
 Open Procedures - IPC
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CONTRAINDICATIONS
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ABSOLUTE
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Active bleeding, PLT:20, neurosurgery,
ocular surgery, intracranial bleeding w/in 10
days
RELATIVE
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PLT:20-100, brain metastases, major
abdominal surgery w/in past 2 days, GI
bleeding or GU bleeding w/in past 14 days,
infective endocarditis, malignant
hypertension
PROPHYLAXIS OPTIONS
LMWH – 40mg SQ qd
 LDUH – 5000u SQ B-TID
 ARIXTRA – 2.5 SQ qd
NOT for patients with CrCl <30
For LOW RISK procedures and those with
NO RISK FACTORS, no prophylaxis is
required. ENCOURAGE AMBULATION
EARLY AND FREQUENTLY
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UROLOGIC RECOMENDATIONS
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MAJOR, OPEN PROCEDURES
EITHER LMWH, LDUH, ARIXTRA (GRADE1A)
 IF HIGH RISK OF BLEEDING, USE
MECHANICAL METHODS UNTIL
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LAPAROSCOPIC
IF previous dvt/pe, LMWH or LDUH, may also
add IPC or GCS (Grade 1C)
ALL PATIENTS WITH HISTORY OF CANCER
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SUMMARY
ALL PATIENTS UNDERGOING ANY
SURGERY SHOULD HAVE DVT
PROPHYLAXIS
 GCS AND EARLY AMBULATION SUFFICIENT
IN MOST CASES
 CONTINUE PROPHYLAXIS UNTIL
AMBULATING
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