VTE ✔️

Question 1

VTE

Answer 1

blood clot that forms in vein which partially or completely obstructs blood flow
~ Hospital-acquired VTE = occurs within 90 days of hospital admission

Question 2

Risk factors for VTE

Answer 2

~ 60+
~ surgery
~ trauma
~ significant immobility
~ malignancy
~ BMI >30
~ acquired or inherited hypercoagulable states
~ pregnancy & postpartum period
~ hormonal therapy (COC or HRT)

Question 3

DVT

Answer 3

in deep veins of legs or pelvis but may affect other sites
~ Symptoms = unilateral localised pain, swelling, tenderness, skin changes, &/or vein distension.

Question 4

PE

Answer 4

thrombus travels in blood (embolus) & obstructs blood flow to lungs causing respiratory dysfunction
~ Symptoms = chest pain, shortness of breath, and/or haemoptysis.

Question 5

Mechanical prophylaxis of VTE

Answer 5

~ anti-embolism stockings
~ Intermittent pneumatic compression (IPC)
~ Anti-embolism stockings worn day & night until sufficiently mobile; not offered to patients admitted with acute stroke or i.e. peripheral arterial disease, peripheral neuropathy, severe leg oedema, or local conditions (e.g. gangrene, dermatitis)

Question 6

rapid reversal of effects of heparin with

Answer 6

Protamine sulfate (only partially reverses effects of LMWH)

Question 7

VTE in pregnancy

Answer 7

~ LMWH
~ routine measurements of peak anti-Xa if body <50kg or >90kg or renal impairment
~ compression stockings
~ stop @labour

Question 8

risk of bleeding

Answer 8

~ Thrombocytopenia
~ Acute stroke
~ Bleeding disorders
– acquired = liver failure
– inherited = haemophilia, Von Willebrand
~ Anticoagulants
~ Systolic hypertension

Question 9

duration of VTE prophylaxis

Answer 9

general surgery = 5-7 days / until mobile
Major cancer surgery in abdo/pevlis = 28 days
Knee/hip = extended duration

Question 10

Unfractionated heparin

Answer 10

~ activates thrombin
~ SHORTER action
~ preferred if
== high risk of bleeding
== renal impairment
~ measure APTT (activated partial thromboplastin time)

Question 11

LMWH

Answer 11

~ inactivates factor Xa
~ LONGER action
~ preferred choice as lower risk of osteoporosis, HIT
~ used in pregnancy

Question 12

Heparins SE (unfractionated & LMWH)

Answer 12

1. Haemorrhage
2. hyPER-kalaemia
3. Osteoporosis
4. HIT

Question 13

warfarin tablet colours

Answer 13

WHITE = 0.5mg
BROWN = 1mg
BLUE = 3mg
PINK = 5mg

Question 14

Warfarin duration of tx

Answer 14

DVT = 6 weeks
provoked VTE (COC, pregnancy, leg plaster cast) = 3 months
unprovoked (AF) = at least 3 months/long-term

Question 15

Warfarin interactions

Answer 15

~ Miconazole gel = contra-indicated as increases warfarin Cp

Question 16

warfarin SEs

Answer 16

~ bleeding (antidote = vit K, phytomenadione)
~ Calciphylaxis

Question 17

NOACs in VTE

Answer 17

~ prophylaxis after knee/hip surgery
~ Edoxaban = tx / prevention of recurrent VTE

Question 18

Duration of VTE prophylaxis

Answer 18

General surgery = 5-7 days / until mobile
major surgery in abdo/pelvis = 28 days
knee/hip = extended duration

Question 19

VTE tx

Answer 19

~ LMWH or UFH (renal failure)
~ at least 5 days & until INR 2+ for at least 24h
~ Monitor APTT (if UFH)
~ Start DOAC at same time

Question 20

Heparins SEs

Answer 20

~ Haemorrhage (Withdraw use reversal agent !)
~ hyPER-kalaemia (more risk in DM, CKD)
~ Osteoporosis
~ HIT

Question 21

HIT in heparin use

Answer 21

occurs 5-10 days after
~ 30% reduction in platelets, skin allergy, thrombosis
~ monitor before tx & >4 days after

Question 22

essential monitoring with Heparins (unfractionated)

Answer 22

APTT (activated partial thromboplastin time)

Question 23

Major bleed in warfarin

Answer 23

Stop warfarin
IV Phytomenadione
Dried prothrombin complex or Fresh frozen plasma

Question 24

INR 5-8 + no bleeding

Answer 24

~ withhold 1-2 doses
~ reduce maintenance dose
~ measure INR 2-3 days after

Question 25

INR 5-8 + minor bleed

Answer 25

~ STOP warfarin ~ IV phytomenadione ~ repeat if INR high after 24h ~ INR<5 = re-start warfarin

Question 26

INR >8 + minor bleed

Answer 26

~ STOP warfarin ~ IV phytomenadione ~ repeat if INR high after 24h ~ INR<5 = re-start warfarin

Question 27

INR >8 + no bleed

Answer 27

~ STOP warfarin ~ ORAL phytomenadione ~ repeat if INR high after 24h ~ INR<5 = re-start warfarin

Question 28

elective surgery + warfarin

Answer 28

~ STOP warfarin 5 days before ~ ORAL phytomenadione 1 day if INR >1.5 ~ re-start warfarin on EVE / next day

Question 29

emergency surgery + warfarin

Answer 29

~ delay 6-12h ~ No delay; IV phytomenadione + dried prothrombin complex

Question 30

intracerebral haemorrhage

Answer 30

AVOID - aspirin, statin, anticoagulants (increases risk of bleeding: only if essential) TX Hypertension & avoid hypoperfusion

Question 31

low dose aspirin use

Answer 31

75mg daily secondary prevention of CVD/event

Question 32

Clopidogrel use

Answer 32

following ACS or PCI

Question 33

Dipyridamole use, counselling and expiry

Answer 33

secondary prevention of stroke Take 30-60 mins before food Persantin Retard capsule container = 6 weeks

Question 34

Glycoprotein IIa/IIb inhibitors

Answer 34

Abciximab Eptifibatide Tirofiban

Question 35

Ischaemic stroke

Answer 35

blood clot obstructs blood supply TIA (mini stroke) and ischaemic strokes

Question 36

Haemorrhagic stroke

Answer 36

weak blood vessels burst in brain (intracerebral haemorrhage)

Question 37

TIA long term management

Answer 37

Aspirin + MR dipyridamole

Question 38

Ischaemic stroke long term management

Answer 38

Clopidogrel - AF related = anticoagulated

Question 39

Both TIA/Ischaemic strokes

Answer 39

Statins (regardless cholesterol levels) TX hypertension: not with BB

Question 40

Warfarin + surgery if high risk of VTE

Answer 40

VTE in last 3 months, AF with previous stroke/TIA, mechanical valve = bridge with LMWH (treatment dose) + stop 24h before surgery

Question 41

Warfarin + surgery if high risk of bleeding

Answer 41

start LMWH 48 hours after surgery

Question 42

Dabigatran expiry

Answer 42

4 month expiry !!1

Question 43

warfarin INR targets (within 0.5 units)

Answer 43

2.5 = VTE, AF, MI, Cardioversion, Bioprosthetic mitral valve 3.5 = Recurrent VTE in patients on anticoagulant + INR >2

Question 44

warfarin INR monitoring

Answer 44

every 3 moths once stable !!! (!2 weeks)