VTE prophylaxis

Question 1

first line for VTE prophylaxis

Answer 1

Low molecular weight heparin (LMWH) (eg enoxaparin, dalteparin) is preferred to unfractionated heparin (UFH) for venous thromboembolism (VTE) (ie deep vein thrombosis [DVT] or pulmonary embolism [PE]) prophylaxis. LMWH is safer, more effective and associated with a lower incidence of heparin-induced thrombocytopenia, and a slightly lower incidence of mortality .

Question 2

VTE prophylaxis in patients with obesity

Answer 2

The optimal VTE prophylaxis in patients with obesity has not been fully determined, but there is no clear evidence that higher doses of LMWH are required in patients with obesity

Question 3

unfractionated heparin for VTE prophylaxis

Answer 3

Unfractionated heparin (UFH) is preferred to LMWH for VTE prophylaxis in some circumstances, such as for patients with severe kidney impairment or when rapid reversal of anticoagulation may be necessary.
For VTE prophylaxis, 8-hourly dosing of UFH is more effective but has a higher bleeding risk than 12-hourly dosing

Question 4

Fondaparinux

Answer 4

Fondaparinux is an alternative to LMWH for VTE prophylaxis in patients undergoing major orthopaedic surgery of the lower limbs, or abdominal surgery. It can be used for patients with a history of heparin-induced thrombocytopenia (HIT). The first dose of fondaparinux is administered at least 6 hours after surgery, and only after haemostasis has been established.

Question 5

DOACS for VTE prophylaxis

Answer 5

Direct-acting oral anticoagulants (DOACs) (eg apixaban, dabigatran, rivaroxaban) are effective for venous thromboembolism (VTE) (ie deep vein thrombosis [DVT] or pulmonary embolism [PE]) prophylaxis following total hip or knee replacement surgery.
For nonsurgical patients, low molecular weight heparin (LMWH) is recommended over DOACs, because DOACs have an increased risk of major bleeding in this setting .

Question 6

Methods of mechanical prophylaxis for VTE

Answer 6

professionally fitted graduated compression stockings providing 16 to 20 mmHg pressure at the ankle (also known as antiembolism stockings)
intermittent pneumatic compression devices
pneumatic foot compression or pump.

Question 7

when should anticoagulant VTE prophylaxis start after surgery

Answer 7

Do not start anticoagulant prophylaxis in the first 6 hours after surgery because the bleeding risk is increased; it should be started between 6 and 12 hours postoperatively, provided the surgeon judges that the bleeding risk is low. However, dabigatran can be started with a low first dose 1 to 4 hours after a total hip or knee replacement.

Question 8

VTE prophylaxis while inserting or withdrawing an epidural catheter

Answer 8

Wait at least 12 hours after giving a prophylactic dose of low molecular weight heparin (LMWH) (eg enoxaparin 40 mg), or 24 hours after a therapeutic dose of LMWH (eg enoxaparin 1 mg/kg or 1.5 mg/kg) to insert or withdraw an epidural catheter. Once the catheter is inserted or withdrawn, wait at least 4 hours before giving a subsequent dose of LMWH.
For patients who are receiving other anticoagulants, or patients with kidney impairment, seek expert advice about inserting or withdrawing an epidural catheter.

Question 9

VTE prophylaxis for TURP or radical prostatectomy

Answer 9

IPC or graduated compression stockings

For patients at high risk of VTE, the surgeon may consider LMWH or UFH in addition to or instead of IPC or graduated compression stockings. Caution is required because TURP and radical prostatectomy convey a significant bleeding risk

Question 10

VTE prophylaxis for neurosurgery

Answer 10

IPC or graduated compression stockings

For patients at high risk of VTE, the surgeon may consider LMWH or UFH in addition to or instead of IPC or graduated compression stockings. Caution is required because neurosurgery conveys a significant bleeding risk

Question 11

examples of surgical patients with especially high risks of bleeding

Answer 11

TURP, radical prostatectomy, neurosurgery, trauma

Question 12

VTE prophylaxis for long distance travel

Answer 12

Do not use pharmacological prophylaxis in long-distance travellers without other risk factors for VTE. Consider pharmacological prophylaxis or graduated compression stockings in patients who are at substantially increased VTE risk .
Use single dose rapid onset anticoagulant such as Xa inhibitor or enoxaparin on the day of departure

Question 13

what are appropriate anticoagulant choices while breast feeding

Answer 13

Appropriate anticoagulant options for use while breastfeeding include LMWH and warfarin, but not direct-acting oral anticoagulants (DOACs).

Question 14

appropriate anticoagulants while pregnant

Answer 14

If VTE prophylaxis is given to pregnant patients, low molecular weight heparin (LMWH) or unfractionated heparin (UFH) must be used.

Question 15

Virchow tried

Answer 15

vascular endothelial damage
venous stasis
hypercoagulability