Anticoagulation Guidelines Flashcards by Dustin Hill

Loading dose for Initiation of Vitamin K Antagonist Therapy

Sufficiently health patients > treated as outpatients
Initiating VKA thearpy with Warfarin 10 mg daily for the first 2 days
Followed by dosing based on INR measurements

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Initiation Overlap for Heparin and VKA in patients with VTE

VKA therapy started on day 1 or 2 of LMWH or UFH

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Monitoring frequency for VKAs

-patients with VKA therapy and consistently stable INRs

-testing every 12 weeks rather than every 4 weeks

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Monitoring frequency for VKAs

-Single Out-of-Range INR (< 0.5 or supratherapeutic)

continue current dose and recheck within 1-2 weeks

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Monitoring frequency for VKAs

-Bridging for Low INRs > single subtherapeutic INR value

routinely bridge with heparin

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Health care providers who manage oral anticoagulation should do so in a systematic and coordinated fashion and include?

patient education
systematic INR testing
tracking
follow up
good patient communication of results and dosing decisions

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VKA interactions to avoid

Cyclooxygenase-2-selective NSAIDs
Antibiotics (
Antiplatelet agents (except in situations where benefit is known or is highly likely to be greater than harm from bleeding)

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VKA + Antiplatelet agents in which benefit outweighs risk

mechanical valves
ACS
Recent PCI with stents or CABG

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Therapeutic INR range

2-3

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Therapeutic INR range for high-risk groups (antiphospholipid syndrome or previous arterial or venous thromboembolism)

INR 2-3

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Discontinuation of VKA therapy in those who are eligible

recommend abrupt vs. gradual tapering

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VTE dosing for UFH (bolus, basal)

80u/kg - bolus
15u/kg/h - basal
-or fixed dose:
bolus 5,000 u
basal 1,000 u/h

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Cardiac or CVA dosing for UFH (bolus, basal)

70 u/kg - bolus
15 u/kg/h - basal
-or fixed dose:
5,000 u
1,000 u/h

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LMWH renal cutoff for dose reduction

-Cr. clearance < 30 mL/min

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VTE treatment with Fondaparinux (Arixtra) weight cutoff for increased dosage

100 kg

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Fondaparinux (Arixtra) dose for VTE

7.5 mg

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Fondaparinux (Arixtra) dose for VTE with body weight > 100 kg

7.5 mg > 10 mg

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VKA therapy with INR 4.5-10 with no evidence of bleeding

-No indication for Vitamin K

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Indication for Vitamin K therapy in patients on VKA’s

INR > 10

- Oral Vitamin K

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Treatment of VKA associated major bleeding

Rapid reversal with four-factor Prothrombin Complex Concentrate rather than plasma
Vitamin K (5-10 mg administered by slow IV injection)

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VTE prophylaxis contraindications

high risk for major bleeding

- active bleeding

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VTE mechanical thromboprophylaxis options

Graduated compression stockings (GCS)

- Intermittent pneumatic compression

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US screening recommendations for critically ill patients

none, advise against

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VTE prophylaxis recommendations in outpatients with cancer

Study These Flashcards

-recommend against routine prophylaxis with LMWH, LDUH or VKAs

Indication for VTE prophylaxis in cancer outpatients

Prophylactic dose LMWH or LDUH if: - solid tumors - additional risk factors for VTE - low risk of bleeding

Additional risk factors for VTE in cancer outpatients

- previous VTE - immobilization - hormonal therapy - angiogenesis inhibitors - thalidomide - lenalidomide

Recommendations for routine prophylaxis in cancer outpatients with indwelling central venous catheters

-recommend against routine prophylaxis with LMWH, LDUH, or VKA's

Recommendations for VTE prophylaxis in chronically immobilized persons (at home or nursing home)

-recommend against routine prophylaxis with LMWH, LDUH, or VKA's

Risk factors for VTE

- previous VTE - recent surgery or trauma - active malignancy - pregnancy - estrogen use - advanced age - limited mobility - severe obesity - known thrombophilic disorder

Recommendations to prevent VTE in long distance travelers

- frequent ambulation - calf muscle exercises - sitting in an aisle seat if feasible

Recommendations for long distance travelers with increased risk of VTE

-properly fitted, below-knee GCS (providing 15-30 mm Hg of pressure at the ankle)

Recommendations for patients with asymptomatic thrombophilia (without a previous history of VTE)

-recommend against the long-term daily use of mechanical or pharmacologic thromboprophylaxis to prevent DVT

General and abdominal-pelvic surgery in patients at very low risk for VTE (< 0.5%; Rogers score < 7, Caprini score 0)

- Early ambulation | - No specific pharmacologic or mechanical prophylaxis

- General and abdominal-pelvic surgery | - low risk VTE (1.5%; Rogers score 7-10; Caprini score)

-mechanical prophylaxis with intermittent pneumatic compression devices

General and abdominal-pelvic surgery | -Moderate risk for VTE (3.0%; Rogers score > 10; Caprini score 3-4)

- LMWH or LDUH (if not at high risk for major bleeding complications) - IPCs (if major bleeding complications)

General and abdominal-pelvic surgery - High risk for VTE (6.0%; Rogers Caprini score > 5) - Not at high risk for major bleeding complications

-Pharmacologic prophylaxis > LMWH or LDUH and -Mechanical prophylaxis > elastic stockings or IPC's

General and abdominal-pelvic surgery patients | -IVC filter indications

not used for primary VTE prevention

General and abdominal-pelvic surgery patients | -periodic surveillance with venous compression US

-should not be performed

Cardiac surgery patients with an uncomplicated postoperative course

-mechanical prophylaxis (preferably IPC > no prophylaxis or pharmacologic prophylaxis)

Cardiac surgery patients | -hospital course prolonged by one or more nonhemorrhagic surgical complications

``` mechanical prophylaxis + pharmacologic prophylaxis (LDUH or LMWH) ```

Thoracic surgery patients - moderate risk for VTE - not at high risk for perioperative bleeding

-LDUH or -LMWH or -mechanical prophylaxis (IPC) all > no prophylaxis

Thoracic surgery patients - high risk for VTE - not high risk for perioperative bleeding

``` Pharmacologic prophylaxis (LDUH or LMWH) + Mechanical prophylaxis (IPC or elastic stockings) ```

Thoracic surgery patients | -high risk for major bleeding

-mechanical prophylaxis

Craniotomy

mechanical prophylaxis > none

Craniotomy | -high risk for VTE (craniotomy for malignant disease)

``` mechanical prophylaxis + pharmacologic prophylaxis (once adequate hemostasis is established and risk of bleeding decreases) ```

Spinal surgery

mechanical prophylaxis

Spinal surgery | -high risk for VTE (malignant disease or those undergoing surgery with a combined anterior-posterior approach)

``` mechanical prophylaxis + pharmacologic prophylaxis (once adequate hemostasis is established and risk of bleeding decreases) ```

Major Orthopedic surgery (total hip arthroplasty (THA), total knee arthroplasty (TKA), hip fracture surgery (HFS))

Minimum 10-14 days -LMWH, fondaparinux, apixaban, dabigatran, rivaroxaban, LDUH, adjusted dose VKA, ASA or intermittent pneumatic compression device (IPCD) (*one panel member believed ASA should not be included)

IPCD requirements

- capable of recording and reporting proper wear time on a daily basis for inpatients and outpatients - efforts should be made to achieve 18 h of daily compliance

Major orthopedic surgery (THA, TKA, HFS) + receiving LMWH as thromboprophylaxis timetable to start pre- and post-procedure prophylaxis

-LMWH > 12 hours pre- or post-operatively

Major orthopedic surgery duration of thromboprophylaxis in the outpatient setting

35 days

Major orthopedic surgery thromboprophylaxis recommendations during hospital stay

Dual prophylaxis - antithrombotic agent - IPCD

Major orthopedic surgery + Increased risk of bleeding thromboprophylaxis recommendations

-IPCD or no prophylaxis rather than pharmacologic treatment

Major orthopedic surgery + decline/uncooperative with injections or IPCD thromboprophylaxis recomendations

Apixaban or Dabigatran | alternatively rivaroxaban or adjusted-dose VKA if apixaban or dabigatran are unavailable

Major orthopedic rusgery + Increased bleeding risk or contraindications to both pharmacologic and mechanical thromboprophylaxis IVC placement recommendations

No use of IVC filter < No prophylaxis

Following major orthopedic surgery + Screening for DVT with Doppler before hospital discharge

Not recommended

Isolated lower-leg injuries distal to the knee | requiring leg immobilization

-No pharmacologic prophylaxis

Knee arthroscopy without history of prior VTE

No prophylaxis

Interruption of VKA before surgery timetable

discontinue 5 days prior to sugery

Anticoagulation Guidelines Flashcards

(59 cards)