thera VTE

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coal
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259688
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thera VTE
Updated:
2014-02-15 08:34:43
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thera VTE
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thera VTE
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thera VTE
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  1. Virchow's triad
    • stasis - decreased blood flow
    • hypercoagulabitlty
    • endothelial damage
  2. high risk factors for VTE
    • thrombopiliac
    • mechanical mitral valves
    • cancer pts
    • orthopedic surgery
    •   hip & knee replacements
  3. low risk factors for VTE
    • drugs
    • long distance travel
    • pregnancy
    • acute illness
    • increasing age
  4. clinical presentation of DVT
    • pain, warmth, swelling
    • usually unilateral
    • upper or lower extremity
  5. clinical presentation of PE
    • chest pain, tightness, palpitations
    • cough, SOB
    • hemoptysis
    • tachycardia, tachypnea, sweating
  6. diagnosis imaging for DVT
    • d-dimer
    • ultrasound - showing flow
    • venography - gold standard (invasive, dyes)
  7. diagnosis imaging for PE
    • V/Q scan - perfusion O2in vs O2 out
    • CT scan - requires dye
    • pulmonary angiography - gold standard, significant risk of mortality
  8. 3 complications of VTE
    • unstable PE
    • post thrombotic syndrome PTS - scars or post residual clots
    • chronic thromboembolic pulmonary HTN - PTS in lungs
  9. DVT risk score of 0-1 (low) prophylactic Tx
    none, ambulation
  10. DVT risk score of 2 (moderate)prophylactic Tx
    stockings, SCD's, LDUH (BID), LMWH, FXaI
  11. DVT risk score of 3-4 (high)  prophylactic Tx
    SCD's, LDUH (TID), LMWH, FXaI
  12. DVT risk score of >5 (highest) prophylactic Tx
    LDUH, LMWH, FXaI
  13. 3 CI's to pharmacologic prophylaxis of VTE
    • active bleeding
    • platelet count
    • history of HIT
  14. Pros of mechanical prophylaxis
    • inexpensive
    • non-invasive
    • no risk of bleeding
  15. cons of mechanical prophylaxis
    • less effective than pharmacologic prophylaxis
    • poorly tolerated - cumbersome
  16. pros of SQ UFH
    • less expensive than LMWH
    • no renal adjustment needed
    • reversible
  17. cons of SQ UFH
    • BID/TID dosing
    • less effective than LMWH
    • risk of HIT
  18. pros of LMWH
    • effective
    • QD
    • partially reversible
  19. cons of LMWH
    • renal adjustment required
    • expensive
    • small risk of HIT
  20. pros of fondaparinux - arixtra
    • effective
    • QD
    • can be used in pts. w/HIT
  21. cons of fondaparinux - arixtra
    • CI in CrCl < 30ml/min
    • CI in pts < 50 kg
    • expensive
    • irreversible
  22. 5 reasons a VTE could be provoked
    • surgery
    • cancer
    • known thrombophilia
    • noncompliance
    • combo of reversible factors
    •   pregnancy
    •   hormones
    •   smoking
    •   immobility
  23. pros of warfarin
    • well known, inexpensive
    • QD
    • no renal adjustment needed
    • reversible
  24. cons of warfarin
    • drug/food interactions
    • monitoring required
    • slow onset/off of action
  25. pros of rivaroxaban - Xarelto
    • no monitoring required
    • QD - in maintenance phase
    • quick onset/off of action
  26. cons of rivaroxaban/Xarelto
    • avoid in CrCl < 30 ml/min
    • avoid in moderate to severe liver impairment
    • irreversible
  27. duration of therapy for a provoked VTE
    3 months
  28. duration of therapy for an unprovoked VTE
    3 months - reevaluate, may extend if pt is a low/moderate risk. did we find the risk invoved
  29. duration of therapy for 2nd unprovoked VTE
    • extended therapy
    • 3 months if pt is a high bleeding risk
  30. risk factors for bleeding
    • F TRAP DAA CRAP
    • frequent falls
    • thrombocytopenia
    • renal or liver failure
    • age > 65
    • previous bleed
    • diabetes
    • anemia
    • antiplatelet therapy
    • cancer
    • recent surgery
    • alcohol abuse
    • poor anticoagulant control
  31. catergorize risk from known factors
    • low = 0 factors
    • moderate = 1 factor
    • high = 2 or more factors
  32. 4 T's of HIT
    • thrombocytopenia
    • timing of the decrease in platelet count
    • thrombosis of other sequelae
    • oTher causes of thrombcytopenia
  33. probability scores of the 4T's of HIT
    • 0-3 = low
    • 4-5 = intermediate
    • 6-8 = high
  34. Tx of high probability of HIT
    • stop all heparin products immediately
    • send ELISA ass for HIT antibodies
    • give Vitamin K if warfarin has been administered
    • start direct thrombin inhibitor (DTI) or dondaparinux (arixtra) until platelets have recovered to > 150,000 before starting warfarin
    • if warfarin is still indicated, overlap with DTI for at least 5 days

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