Venous Thrombo-embolism Prevention Flashcards Preview

Year 3 - CR > Venous Thrombo-embolism Prevention > Flashcards

Flashcards in Venous Thrombo-embolism Prevention Deck (52)
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1

What is a venous thromboembolism

- Blood clot that starts in the calf- they may remain localise or they may go across the vein to occlude it and grow proximally
- can embolism and move around and spread to other areas of the body

2

What are the consequences of venous thromboembolism

- DVT
- PE
- Post thrombotic syndrome
- leg ulcers

3

What is the 3rd most common cause of cardiovascular death

PE

4

what is the second most common cause of death in cancer and commonest cause of preventable hospital related death and most common cause of maternal mortality

PE

5

Why is VTE important

Common - 1 in 1000 per year
- treatments effective but significant risks - major and fatal bleeding

6

If you get a VTE what are you at risk of in the future

- Post thrombotic syndrome
- Chronic thromboembolic pulmonary hypertension (CTEPH)

7

What are most death from PE due to

- diagnostic failure rather than treatment failure - most patients die as the diagnosis is not suspected

8

What is your chances of dying from a DVT and PE

VTE – natural history
30-day case fatality PE vs DVT
– 7%v2%(OR3.8, 95% CI 1.6-9.2)
– ≈ 50% of above deaths from PE (approx. 4% v 1%)

9

What is pulmonary embolism the most common cause of

- Most common cause of missed or delayed diagnosis

10

After you stop anticoagulants after 3 months what is the risk of developing another VTE

- Overall 5% per year initially
• 20% at 5 years
• 30% at 10 years
– Higher (≈10% in first year) if unprovoked than if provoked by temporary risk factor

11

What is post thrombotic sydnrome

- complicates 40% of DVT cases
- develops within 2 years of DVT diagnosis
- variable severity
- reduced quality of life
- cost to individual and society

12

What are the symptoms of post-thrombotic syndrome

- pain
- swelling
- skin induration/discolouration
- ulceration

13

what 3 risk factors lead to VTE/PE development
- virchows triad

- blood flow
- blood coagulability
- vessel wall damage

14

What are the major risk factors for VTE

• Fracture of hip/pelvis
• Hip or knee replacement surgery
• Major general surgery especially for malignancy
• Major trauma
• Spinal cord injury
• Hospitalisation with acute medical illness

15

What are the moderate risk factors for VTE

• Previous VTE
• Malignancy/chemotherapy
• Pregnancy and post-partum period
• Combined oc pill or hormone therapy
• Central venous line
• Thrombophilia
Risk factors
• Other medical conditions e.g. nephrotic syndome, inflammatory bowel disease, Behçets syndrome

16

What are weak but common risk factors for VTE

• Age
• Travel-related thrombosis
• Obesity
• Varicose veins
• Diet
• Smoking
• Air pollution

17

describe how hospital admission leads to VTE risk

VTE following hospital discharge
Worcester DVT study (2007)
• 74% presented as outpatients
– 37% recent hospitalisation +/- surgery
– 23% recent major surgery +/- hospitalisation – 29% recent cancer diagnosis
– 20% previous VTE diagnosis
– 70% ≥1 VTE risk factors

18

why do cancer patients have an increased risk of VTE

– Cancer is prothrombotic
– Immobility
– Chemotherapy
– Central venous lines

19

of patients presenting with unprovoked VTE...

5% have a new cancer diagnosed within 3 years

20

What is the 2nd leading cause of death in cancer patients

VTE

21

When you are pregnant what increases your risk of developing a VTE

• Obesity
• Maternal age > 35 years
• Caesarean section (especially emergency)

22

What is trousseau syndrome

- the connection between VTE and cancer

23

Describe how the risk of VTE change in pregnancy

- mostly level during pregnancy but increases before delivery
- after delivery it massively increases in the first 6 weeks after delivery

24

What are the NICE guidelines for VTE

- All patients on admission receive an assessment of VTE and bleeding risk using the clinical risk assessment criteria
- patients are offered verbal and written information on VTE prevention as part of the admission process
- patients provided with anti-embolism stockings have them fitted and monitored
- patients are re-assessed within 24 hours of admission for risk of VTE and bleeding
- patients assessed to be at risk of VTE are offered VTE prophylaxis in accordance with NCIE guidelines
- patients are offered verbal and written information on VTE prevention as part of the discharge process
- patients are offered extended VTE prophylaxis

25

Name thrombosis risk

- Active cancer or cancer treatment
- age over 60
- dehydration
- known thrombophiliais
- obesity
- one or more significant medical co-morbidities - e.g. heart disease, metabolic, endocrine or respiratory pathologies, acute infectious diseases
- personal history or first degree relative with a history of VTE
- use of hormone replacement therapy
- use of oestrogen containing contraceptive therapy
- varicose veins with phlebitis
- pregnancy or less than 6 weeks post partum

admission related
- significantly reduced mobility for 3 days or more
- hip or knee replacemetn
- hip fracture
- total anaesthetic and surgical times greater than 90 minutes
- surgery involving pelvis or lower limb with a total anaesthetic and surgical time greater than 60 minutes
- acute surgical admission with inflammatory or intra-abdominal condition
- critical care admission
- surgery with significant reduction in mobility

26

Name the bleeding risks

Patient related
- active bleeding
- acquired bleeding disorders
- concurrent use of anticoagulatns known to increase the risk of bleeding
- acute stroke
- thrombocytopaenia
- uncontrolled systolic hypertension - 230/120 or higher
- untreated inherited bleeding disorder

Admission related
- neurosurgery, spinal surgery or eye surgery
- other procedure with high bleeding risk
- lumbar puncture/epidural/spinal anaesthesia expected within the next 12 hours
- lumbar puncture/epidural/spinal anaesthesia within the previous 4 hours

27

Name the mechanical methods of thromboprophylaxis

- Anti embolism stockings
- intermittent pneumatic compression

28

Name the pharmacological methods of thromboprophyalxis

– Unfractionated heparin
– Low molecular weight heparin
– Fondaparinux
– New direct oral anticoagulants (DOACs)

29

describe parenteral thromboprophylaxis

– Unfractionated heparin 5000 u sc bd or tds

– Low molecular weight heparin
• Enoxaparin 40 mg sc od
• Dalteparin 5000 u sc od
• Tinzaparin 4500 u sc od

– Fondaparinux - synthetic pentasaccharide - 2.5 mg sc od

30

describe oral thromboprophylaxis

– Direct thrombin inhibitor
• Dabigatran

– Factor Xa inhibitor
• Rivaroxaban
• Apixaban
• Edoxaban (not yet licensed for VTE prevention)