THROMBOEMBOLISM

Question 1

Types of thromboembolism

Answer 1

DVT
PE

Question 2

VTE

Answer 2

Blood clot in vein
obstructs blood flow

Question 3

DVT

Answer 3

Blood clot occurs in a deep vein
leg or pelvis
Unilateral localised pain or swelling
Typically in the calf of one leg.

Question 4

Pulmonary Embolism (PE)

Answer 4

Blood clot detaches and travels to the lungs and blocks the pulmonary artery.
Chest pain
Shortness of breath

Question 5

Risk factors of VTE

Answer 5

Surgery
Trauma
Significant immobility
Malignancy
Obesity
Pregnancy
Hormonal Therapy (COC or HRT)

Question 6

How to diagnose VTE

Answer 6

D-dimer test for diagnosis

Question 7

Methods of thromboprophylaxis (2)

Answer 7

Mechanical - graduated compression stockings
Pharmacological - anticoagulants

Question 8

Mechanical thromboprophylaxis

Answer 8

Graduated Compression Stockings
* Wear until the patient is sufficiently mobile

Question 9

Pharmacological thromboprophylaxis

Answer 9

Anticoagulants
Start within 14 hours of admission
Patients with risk factors for bleeding should only receive pharmacological prophylaxis when their risk of VTE outweighs their risk of bleeding

Question 10

VTE Prophylaxis - surgery

Answer 10

Mechanical - graduated compression stockings
Pharmacological - anticoagulants

Question 11

Mechanical prophylaxis - surgery

Answer 11

Prophylaxis should continue until the patient is sufficiently mobile or discharged from hospital

Question 12

Pharmacological prophylaxis - surgery

Answer 12

Considered when the risk of VTE outweighs the risk of bleeding

Question 13

Surgery - type of anticoagulant

Answer 13

LMWH - suitable in all types of general and orthopaedic surgery
Unfractionated heparin - preferred in renal impairment
Fondaparinux sodium - lower limb immobilisation or pelvis fragility fractures

Question 14

Unfractionated heparin vs LMWH

Answer 14

if we need to stop fluidity of their blood quickly

Question 15

Surgery - how long do we continue VTE prophylaxis for?

Answer 15

Continue for at least 7 days post-surgery, or until sufficient mobility has been re-established
28 days after major cancer surgery in the abdomen
30 days in spinal surgery

Question 16

Elective hip replacement either:

Answer 16

LMWH for 10 days and then 75mg aspirin for 28 days
LMWH for 28 days in + stockings until discharge
Rivaroxaban

Question 17

Elective knee replacement either:

Answer 17

75mg aspirin for 14 days
LMWH for 14 days in + stockings until discharge
Rivaroxaban

Question 18

General medical patients with high risk of VTE

Answer 18

should be given pharmacological prophylaxis for at least 7 days or mechanical prophylaxis until mobile

Question 19

VTE prophylaxis - Pregnancy high risk of VTE

Answer 19

If risk of VTE that outweighs the risk of bleeding
* LMWH during hospital admission
* Pregnant women: prophylaxis until no risk of VTE or till patient discharged

Question 20

Women who have given birth, had a miscarriage or termination of pregnancy during the past 6 weeks →

Answer 20

start LMWH 4-8 hours after the event → continue for a minimum of 7 days

Question 21

Pregnancy - Additional mechanical prophylaxis if immobilised →

Answer 21

until sufficiently mobile or discharged from hospital

Question 22

Treatment of VTE: pregnancy

Answer 22

LMWH; unfractionated if patient is at high risk of haemorrhage (unfractionated = short half life)

Question 23

VTE Treatment

Answer 23

Confirmed proximal DVT or PE: Apixaban or Rivaroxaban

Question 24

VTE Treatment - if rivaroxaban or apixaban unsuitable

Answer 24

If unsuitable offer:
(LMWH) for at least 5 days followed by Dabigatran or Edoxaban
LMWH + warfarin for at least 5 days or until the INR is at least 2.0 for 2 consecutive readings, followed warfarin alone

Question 25

Duration of treatment - VTE treatment

Answer 25

Distal DVT (calf): 6 Weeks Proximal DVT / PE: At least 3 months (3 to 6 months for those with active cancer) Provoked DVT / PE: Stop at 3 months if the provoking factor resolved Unprovoked DVT / PE: 3 Months + Recurrent DVT / PE: Longterm

Question 26

Warfarin - maintain INR of 2.5

Answer 26

VTEs, AF, Cardioversion, MI, Cardiomyopathy

Question 27

Warfarin -Maintain INR of 3.5

Answer 27

Recurrent VTEs or mechanical heart valves

Question 28

Warfarin - major bleed

Answer 28

Stop warfarin - IV phytomenadione and dried prothrombin

Question 29

INR >8, minor bleeding:

Answer 29

Stop warfarin - IV phytomenadione

Question 30

INR >8, no bleeding:

Answer 30

Stop warfarin - oral phytomenadione

Question 31

INR 5-8, minor bleeding

Answer 31

Stop warfarin - IV phytomenadione

Question 32

INR 5-8, no bleeding:

Answer 32

Withhold 1-2 doses of warfarin

Question 33

When should you restart warfarin?

Answer 33

Restart warfarin when INR <5

Question 34

How often should INR be monitored?

Answer 34

INR should be monitored every 1-2 days in early treatment, and then every 12 weeks

Question 35

Warfarin - side effects

Answer 35

MHRA Warning: SKIN NECROSIS AND CALCIPHYLAXIS - Painful skin rash Haemorrhage: Prolonged Bleeding - Vitamin K1 (phytomenadione) antidote

Question 36

Warfarin - CI

Answer 36

Pregnancy: Avoid in the first and third trimester Use contraception

Question 37

Warfarin - interactions

Answer 37

Vitamin K Rich Foods Pomegranate and Cranberry Juice Miconazole (OTC Daktarin oral gel) CYP450 Enzyme Inhibitors and Inducers

Question 38

warfarin interactions - Vitamin k rich foods

Answer 38

Avoid major changed in diet with leafy greens Reduces efficacy of warfarin

Question 39

warfarin interactions - Pomegranate and Cranberry Juice

Answer 39

Increases patient INR

Question 40

Miconazole (OTC Daktarin oral gel)

Answer 40

Increases patient INR

Question 41

CYP450 Enzyme Inhibitors and Inducers

Answer 41

Increases or decreases warfarin concentration respectively

Question 42

Warfarin - Minor procedures with low risk of bleeding

Answer 42

Performed with an (INR) of less than 2.5 Restart warfarin within 24 hours of procedure

Question 43

Warfarin - procedures where there is a risk of severe bleeding:

Answer 43

Stop warfarin 3-5 days before Give Vitamin K if INR is 21.5 the day before surgery Patients high risk of thromboembolism: bridge with LMWH → stop LMWH 24 hours before surgery → restart LMWH 48 hours after

Question 44

Warfarin - emergency Surgery

Answer 44

If can be delayed by 6-12 hours: IV Vitamin K If can't be delayed by 6-12 hours: IV Vitamin K + dried prothrombin complex