VENOUS THROMBOEMBOLISM Flashcards
(38 cards)
What are the two types of Venous Thromboembolism?
Pulmonary Embolism - blockage of artery in the lungs
Deep Vein Thrombosis - blood clot in the body, usually legs
What is the treatment for Venous Thromboembolism?
- Antiplatelets - aspirin, clopidogrel etc
- Anticoagulants - warfarin, apixaban etc
- Thrombolytics - alteplase
Who must be assessed for risk of VTE?
ALL patients admitted to hospital have to be assessed for their risk of VTE and bleeding on admission
Which patients are in high risk of VTE?
- Substantial reduction in mobility
- Obesity / overweight
- Malignant disease (cancer)
- History of VTE
- Thrombolytic disorder
- Patients over 60 years of age
- Pregnancy
- Dehydration
*HRT and combined hormone contraception (oestrogen) - Family history
When should mechanical and pharmacological prophylaxis be given?
Mechanical prophylaxis - to patients due for surgery and continue wearing day and night until patient is mobile. E.g. anti-embolism stockings
Pharmacological prophylaxis - to patients undergoing orthopaedic surgery whose risk of VTE outweighs risk of bleeding
Who should not be offered stockings for thromboembolism prophylaxis?
Patients with:
- Acute stroke
- Peripheral arterial disease
- Peripheral neuropathy
- Severe leg oedema
- Local conditions e.g dermatitis, gangrene
When should pharmacological prophylaxis be given?
Asap or within 14 hours of admission
How long should pharmacological prophylaxis be given for?
Until the patient is mobile
What kind of heparin is preferred in patients with renal failure?
Unfractionated heparin
What kind of heparin can be used used in all types of general and orthopaedic surgery?
Low weight molecular heparins (LWMH)
Which patients should receive unfractionated heparin?
Pt with renal impairment or increased risk of bleeding
What is the preferred heparin for prophylaxis in surgical patients?
LMWH Heparins as first line
Then unfractionated heparin.
But if patient has renal impairment or high risk of bleeding then unfractionated heparin first
What creatinine clearance level classifies as renal impairment?
crcl: 15-50ml/min
Which drugs are given for VTE Prophylaxis?
- Offer fondaparinux sodium to patients undergoing hip or knee surgery, G.I bariatric surgery, or day surgery procedures
Continue for 7 days after surgery or until patient is fully mobile.
- DOACs - for elective hip/knee replacement surgery after LMWH or low dose aspirin
What’s the treatment for PE/DVT?
For confirmed DVT or PE: Rivaroxaban, Apixaban
Alternative - LMWH for at least 5 days followed by Dabigatran or Edoxaban
OR LMWH given concurrently with a vitamin K antagonist for at least 5 days or until INR is at least 2.0
For patients with renal impairment:
- Apixaban
- Rivaroxaban
- LMWH for at least 5 days followed dabigatran (if crcl is more than 30ml/min) or Edoxaban
Can heparins be taken when pregnant?
Heparins are safe in pregnancy as they do not cross the placenta.
However LWMH is preferred as it carries a lower risk of osteoporosis and heparin-induced thrombocytopenia (low blood platelets).
But they are eliminated more rapidly in pregnancy so a dose alteration is required
Examples of LMWH heparin?
Dalteparin, Enoxaparin, Tinzaparin
How long do patients have to keep taking anticoagulant treatment?
Confirmed proximal DVT or PE - at least 3 months
(3-6 months for active cancer)
Provoked DVT or PE (has a cause e.g. contraceptive, pregnancy etc) - 3 months
(3-6 months for active cancer)
Unprovoked DVT or PE - more than 3 months
(more than 6 months for active cancer)
What should be done in VTE if a haemorrhage (a side effect of heparin) occurs?
Withdraw the heparin.
What can be used to reverse the effects of heparin?
Protamine sulphate.
But it only partially reverses the effects of LWMH.
What’s the mechanism of action for Tranexamic acid?
Inhibits fibrinolysis
What are the indications for Tranexamic acid??
- Local fibrinolysis
- Management of menorrhagia
- Hereditary angioedema, epistaxis (nose bleed)
Helps blood to clot - used for nose bleed and heavy periods
What are the doses for tranexamic acid?
Menorrhagia - 1g THREE times a day for up to 4 days. Must be started when menstruation starts.
MAX 4g per day
Fibrinolysis - 1-1.5g 2-3 times a day
Epistaxis - 1g 3 times a day for 7 days
Can be taken with or without food
What are the side effects, monitoring, patient advice and contraindications for tranexamic acid?
Side effect - Diarrhoea (if so, reduce the dose), nausea and vomiting
Monitoring: Regular liver function tests in long term treatment of hereditary angioedema
Advice: increase risk of DVT if taken with contraceptive pill
Contraindications: Epilepsy, DVT, PE, Irregular periods, renal problems, pregnancy
