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VTE clot in the body within the venous system
DVT clot in the extremities
PE clot in the lungs
Virchow's Triad Alteration in blood, alteration in vessel, alteration in blood flow
hypercoagulable state malignancy, gene mutations, hereditary deficiencies, pregnancy
vascular injury major orthopedic surgery, trauma, fracture, indwelling venous catheters
venous stasis major medical illness, major surgery, paralysis, plycythemia vera (thick blood), obesity, varicose veins
strongest risk factor for VTE prior history of DVT and PE
VTE risk factors age > 40, obesity, history of VTE, cancer, bed rest > 5 days, major surgery, HF, varicose veins, fracture, estrogen tx, stork, multiple trauma, childbirth, MI
pathophysiology of VTE: vessel vascular injury, exposed subendothelium tissue factor, collagen
pathophysiology of VTE: blood/circulating elements Hypercoagulable state: platelets, platelet activating factor, clotting factors, prothrombin, fibrinogen, vWF
pathophysiology of VTE: blood flow venous stasis: slow rate of flow, turbulent flow
Hypercoaguable state must have 1-2 of the following: thrombosis with first incident at age < 40, recurrent thrmobosis, family history of thrombosis, thormbosis in an unusual site
clnical presentation of VTE most patients never develop symptoms, may suffer long-term consequences: PTS, recurrent VTE
DVT signs and sx dilated superficial veings, palpable cord in affected leg, homan's sign, unilateral leg edema, erythema, tenderness, leg swelling, pain, warmth, skin discoloration
DVT dx lab tests D-dimer (elevated), ESR (elevated) WBC (elevated)
DVT dx diagnostic tests duplex ultrasonography (most common), venography (gold standard)
DVT complications loss of a limb, post-thrombotic syndrome, may progress to a PE, death
PE signs and sx tachypnea, tachycardia, diaphoresis, distended neck veins, diminished breath sounds, circulatory shock (worst); cough +/- blood, chest pain, chest tightness, SOB, palpitations, dizziness
PE dx if D-dimer is postive, then CT scan (most common), ventilation/perfusion scan, pulmonary angiography (gold standard)
VTE px goals identify all patients at risk, determine each patient's level of risk, implement regiments that provide sufficient protection for the level of risk
VTE risk classifaction rogers score, caprini score
VTE px, non-pharmacologic ambulation, graduated compression stockings, intermittent pneumatic compression, inferior vena cava (IVC) filters
ambulation increases venous flow, promotes the flow of natural antithrombotic factors in the lower extermities
graduated compression stockings constricts the diameter of veints, increases the rate of blood flow; actually has an additive effect with pharmacologic interventions
Intermittent pneumatic compressions constricts the diameter of the veins, increases the rate of blood flow
inferior vena cava filter prevents the embolization of a thrombus formed in the lower extremities in the pulmonary circulation. does not prevent formatino of thrmbous; only use if high risk for PE and risk of bleeding is too high for pharmacologic therapy
VTE px- pharmacologic UFH or LMWH, fondaparinux, warfarin, DOACs
Heparin dose for VTE px 5000 units sq q 8 or 12 h, no monitoring
Enoxaparin dose for VTE px 30 mg sq q 12 h or 40 mg sq d; CrCl <30 ml/min: decrease dose to 30 mg qd
Fondaparinux dose of VTE px 2.5 mg sq daily; C/I if CrCl< 30 ML/min
INR target for warfarin and VTE px 2 to 3
rivaroxaban dose for VTE px 10 mg po qd; CrCl < 30: avoid use, avoid use in hepatic impairment
apixaban dose for VTE px 2.5 mg po BID: CrCl < 30: not recommended for prophylaxis
VTE risk level for minor surgery, fully ambulatory low
Recommended VTE px options for low risk early ambulation +/- intermittent pneumatic compression devices
VTE risk level for most surgical patients moderate
VTE risk level for medically ill with limited mobility or bed rest moderate
VTE risk level for major trauma patients moderate
Recommended VTE px options for moderate risk LMWH, low dose UFH, fondaparinux (medically ill only) OR IPC alone
VTE risk level for surgical patients (non-ortho) or medically ill with additional risk factors high
VTE risk level for spinal cord injury patients high
Recommended VTE px options for high risk LMWH, low dose UFH, PLUS IPC
VTE risk level for ortho surgery patients very high
Recommended VTE px options for very high risk patients depending on surgery type: LMWH, fondaparinux, apixaban, dabigatran, rivaroxabna, low dose UFH, warfarin or aspirin
VTE px duration for medical/surgical patients until discharge or fully ambulatory
VTE px duration for ortho patients at least 10-14 days (suggested up to 35 days)
long distance travel tips to prevent VTE for flights > 8 hours avoid constrictive clothing around waist or lower extremities, maintain adequate hydration, frequent calf muscle contraction, isle seat preferred (add graded compression stockings for those with mild risk factors for VTE)
long distance travel tips to prevent VTE for flights > 8 hours for patients WITH risk factors for VTE same as everyone else + graded compression stockings
VTE tx goals- short term aim is to prevent: propagation or local extension of clot, embolization, death
VTE tx goals- longer term (> 6 months) prevent complications, such as: post-thrombotic syndrome (PTS), pulmonary hypertension, recurrent VTE
VTE tx: acute phase (5-14 days) IV or SC UFH, SC LMWH, SC Fondaparinux, DOACs
VTE tx: subacute phase (3 to 6 months) PO warfarin, INR 2-3, SC LMWH in cancer patients or patients with CI's to warfarin, DOACs
VTE tx: chronic phase (> 6 months) PO warfarin, INR 2-3, DOACs
VTE acute tx want to use fast-acting agents; treatment DOES NOT actively dissolve clots; prevents them from getting bigger
DVT tx outpatient treatment is preferred
PE tx low-risk PE outpatient tx or early discharge within 5 days is preferred
Acute tx- UFH aim for aPTT 60-100 seconds, IV dose 80 units/kg bolus followed by 18 units/kg/hr drip
Acute tx- LMWH, enoxaparin dose 1 mg/kg sq BID or 1.5 mg/kg sq qd; adjustment needed if CrCl < 30
Acute tx- Fondaparinux dose adjusted based off of weight; <50 kg = 5 mg sq qd; 50-100 kg = 7.5 mg sq qd; >100kg = 10mg sq qd; CrCl 30-50, use cation; CrCl < 30: C/I
Acute tx- Rivaroxaban 15 mg po BID for 3 weeks, then 20 mg po qd; Avoid if CrCl < 30
Acute tx- Apixaban 10 mg po BID for 7 days, then 5 mg po BID; no renal adjustments for DVT/PE
Acute tx- other options- DTIs must have parenteral anticoagulant for 5-10 days; ONLY for patinets with HIT or a history of HIT with VTE
acute tx- other options- antiplatelets not effective for VTE
acute tx- fibrinolytics Alteplase (FDA indicated); Still anitcoagulate with UFH, but at reduced doses
Catheter-Directed CDT- DVT recommended over systemic administration
Catheter-Directed CDT- PE systemic administration is preferred over CDT
Acute treatment- thrombectomy recommended for PE if: hypotension, failed thrombolysis, shock that is likely to cause death before thrombolysis can take effect
acute tx- length of therapy acute tx: given for at least 5 days; overlapped with a long-term treatment for those 5 days; acute treatment can be d/c once stable on long-term tx
long term treatment options warfarin, LMWH, DOAC, IVC filter
warfarin bridge therapy must be overlapped by acute treatment for at least 5 days regardless of INR, must have at least 2 consecutive therapeutic INR values; MOST MEET BOTH OF THESE REQUIREMENTS
INR monitroing once INR is stable, you can monitor once every 12 weeks, for stable patients with a single out-of-range INR of < 0.5 above or below therapetuic, we suggest continuing current dose and testing INR within 1-2 weeks
Warfarin reversal Vitamin K should only be administered when bleeding is present or when INR > 10
Warfarin counseling indication for warfarin and goal INR, importance of lab monitoring, stress compliance, drug ineractions, dietary interaction, alcohol, signs/sx of clotting and/or bleeding
long term treatment- LMWH enoxaparin 1 mg/kg sq q 12 h for at least 3 months
long-term treatment- dabigatran 150 mg PO BID
long-term treatment- rivaroxaban 15 mg PO BID for 3 weeks, then 20 mg PO d
long-term teratment- apixaban 10 mg po BID for 7 days, then 5 mg po bid
provoked VTE trauma, surgery, cancer, exogenous androgen, estrogens, etc
unprovoked VTE no identifiable cause
long term tx-duration provoked 3 months of tx is recomended
long term tx- duration unprovoked 3 months of tx then evaluate bleed risk
long term tx- pregnancy D/C LMWH or UFH 24 hours before schedules delivery; anticoagulation continued until 6 weeks after delivery and at least 3 months of therapy
long term tx- cancer patients LMWH x 3 months, then evaluate risk; Xa inhibitors have limited studies and is not currently recommended
long term tx- LMWH in obesity recommendations enoxaparin 1mg/kg BID preferred
long term tx- renal impairment UFH is not clinically affected, doses of LMWH should be adjusted for renal impairment; fondaparinux C/I; Oral anti-xa inhibitors C/I with CrCl < 30 ml/min; Apixaban is not adjusted in VTE tx of px; dabigatran adjusted at CrCl 15-30 min
monitoring for VTE- aPTT for UFh at treatment doses
monitoring for VTE- INR for warfarin only
monitroing for VTE- Anti-Xa can be used for LWMH, heparin and fondaparinux
Created by: Bmiller01



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