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R9 > Chapter 146 - Thromboembolic disease - prophylaxis > Flashcards

Chapter 146 - Thromboembolic disease - prophylaxis Flashcards

1
Q

Definition of ambulation based on the MEDENOX study

A

1) unassisted 2) distance > 10m

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2
Q

Rogers score for DVT missed these key factors

A

1) obesity 2) IBD 3) obstetric accident 4) family history 5) past history 6) CHF 7) MI 8) stroke 9) central line

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3
Q

Caprini risk score factors and point system

A

FIGURE 146.2

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4
Q

Boston University algorithm for prophylaxis based on Caprini score

A

FIGURE 146.1

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5
Q

What is early angulation

A

Promoting early sitting in chairs which is worse for getting DVT

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6
Q

Categories of mechanical DVT prophylaxis

A

Passive = elastic compression stocking Active = intermitten pneumatic compression

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7
Q

Graduated elastic compression stocking for DVT prophylaxis pressure profile

A

18-23mmHg at ankle 8 mmHg at knee/thigh

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8
Q

Graduated elastic compression risk reduction for DVT

A

29% to 15% Risk reduction 68%

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9
Q

Short comings of graduated elastic compression

A

1) lack of standardized pressures 2) cannot be used if ABI < 0.8 or without palpable foot pulse 3) cannot be use in patients with severe leg edema due to CHF 4) skin complications = ulcer, blister, necrosis

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10
Q

Indication for graduated elastic compression

A

1) use in low to moderate risk patients 2) use in combination with anticoagulation

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11
Q

Benefit of intermittent pneumatic compression devices

A

1) increase tPA, prostacyclin and TF pathway inhibitor 2) use in higher risk patients

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12
Q

Risk reduction of DVT with the use of intermittent pneumatic compression

A

50-60%

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13
Q

ENDORSE study key points

A

9% of surgical patients have both high VTE risk and bleeding risk need mechanical prophylaxis

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14
Q

CLOTS 3 trial key points

A

Evaluated efficacy of IPC for VTE after stroke 1) adherence 59% 2) DVT reduction 8.7 to 5.8% 3) symptomatic DVT 6.3 to 4.6% 4) skin breakdown higher in IPC 3.1% than 1.4%

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15
Q

Relatively contraindication to IPC use and downsides

A

1) skin infections 2) severe edema due to CHF 3) acute DVT (controversial) 4) ? cause peroneal nerve palsy 5) poor compliance in general

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16
Q

Foot compression devices key points

A

1) inelastic slippers or boots with air bladder 2) chamber inflates to 200 mmHg over 3 seconds q20sec 3) may be useful in trauma where legs not compressible 4) otherwise limited utility with poor evidence

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17
Q

Action of aspirin

A

1) irreversibly acetylates cyclooxygenase 1 (COX1) 2) inhibits platelet generation f thromboxane A1

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18
Q

ASA in DVT prophylaxis

A

limited evidence to be used as single agent in high risk patient

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19
Q

Downside of using warfarin as DVT prophylaxis

A

1) takes 3-5 days to titrate 2) therapeutic window can drop thus increase risk of DVT

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20
Q

What is heparin and what is the molecular weight

A

1) sulfated polysaccharide 2) molecular weight 15,000 Da

21
Q

Anticoagulation actions of heparin

A

1) inactivation of thrombin 2) inactivation of factor Xa 3) reduce thrombin-induced platelet activation

22
Q

Reduction in risk of DVT with heparin

A

68%

23
Q

How is LMWH derived and what is molecular weight

A

1) enzymatic or chemical depolymerization of UFH 2) molecular weight 5000 Da

24
Q

Mechanism of action of LMWH

A

1) inhibition of factor Xa 2) lesser extent inhibit thrombin

25
Q

Why does LMWH not need as much routine testing?

A

Reduced protein binding capacity of LMWH provides more predictable pharmacodynamics

26
Q

How is LMWH cleared

A

Kidneys

27
Q

Comparing LMWH with heparin in DVT and PE

A

1) DVT RR 0.7 for LMWH 2) PE RR 0.4 for LMWH no difference in bleeding

28
Q

What is fondaparinux

A

Synthetic pentasaccharide

29
Q

How is fondaparinux administered

A

subcutaneous

30
Q

What is half life of fondaparinux

A

17-21 hours

31
Q

Mechanism of fondaparinux

A

inhibit factor Xa

32
Q

PENTHIFRA study

A

1) 656 patients undergoing hip fracture 2) fondaparinux vs placebo 3) reduced VTE 1.4% vs 35%

33
Q

fondaparinux vs LMWH in orthopedic procedure

A

1) RR of VTE lower 0.55 2) major bleeding risk higher 2.7 vs 1.7%

34
Q

Fondaparinux for DVT prophylaxis dose

A

2.5 mg sc daily

35
Q

Current DOAC classes and specific ones

A

Direct thrombin inhibitor: 1) dabigatran Factor X inhibitor 1) Edoxaban 2) apixaban 3) rivaroxaban

36
Q

Dose of dabigatran after orthopedic procedure for prophylaxis

A

220 mg daily similar effect as LMWH

37
Q

Rivaroxaban dose and compared to LMWH

A

10 mg daily more effective than LMWH similar bleeding risk apixaban similar

38
Q

Edoxaban dose and effect

A

30 mg daily more effective than LMWH higher bleeding

39
Q

APOLLO study key points

A

1) double blindd placebo-control 2) major abdominal surgery 3) IPC +/- fondaparinux 4) VTE 5.3 vs 1.7% (combined therapy)

40
Q

Duration of post-cancer DVT prophylaxis

A

4 weeks of prophylaxis has lower rate of DVT at 3 months than 1 week 0.9% vs 9.7%

41
Q

Incidence of 30d VTE in open vs endo AAA

A

1% open 0.5% pevar

42
Q

Special risk of VTE in cardiac surgery patients

A

HIT risk is higher

43
Q

Adjustment of DVT prophylaxis in bariatric surgery

A

Enoxaparin 40 mg BID LMWH 0.5 mg/kg/day decrease VTE, no increase in bleed oral drug absorption may be affected from the surgery itself

44
Q

RIETE (Compterized registry of patients with VTE) key points

A

1) 40663 patients with VTE 2) 0.96% had VTE within 60 days of neurosurgery 3) 2.6% of those died from fatal PE 4) 77% of VTE occur after discharge 5) 55% VTE occur after prophylaxis stopped

45
Q

Million woman study key points

A

1) 947454 middle aged women 2) follow up 6 years 3) 270 VTE deaths 4) 70x more likely to be readmitted with VTE within 6 weeks 5) risk of VTE is high for 12 weeks after surgery

46
Q

Caprini score > 8 risk of VTE treatment duration prophylaxis

A

6-18% 30 days prophylaxis

47
Q

Caprini score 1-2 treatment

A

early ambulation

48
Q

Caprini score 3-4 treatment

A

pneumatic compression added +/- anticoag

49
Q

Caprini score 5+ treatment

A

anticoagulation and IPC and ambulation for 7-10 days

R9 (200 decks)

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