Prevention of Venous

Thromboembolism

2012 CHEST GUIDELINES

REVIEW
Presented by:
.............................................
VENOUS THROMBOEMBOLISM

Result of clot formation in

venous circulation
Manifests as deep vein
thrombosis (DVT) or pulmonary
embolism (PE)
Develops as a result of three
primary components known as
Virchow’s triad
Venous Stasis
Vascular Injury
Hypercoagulability
 DVT PROPHYLAXIS
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Incidence of DVT in the hospital is 10-40% per month

for medical or general surgical patients and 40-60%
following major orthopedic surgeries
Consequences of unprevented VTE:
Symptomatic DVT or PE
Fatal PE
Increased spending for investigation symptomatic patients
Increased risk of recurrence
Chronic post-thrombotic syndrome

DVT prophylaxis, has a desirable benefit-to-risk ratio

 RISK FACTORS
S
M
W
te
o
r
ad
o
e
k Strong Risk Factors Moderate Risk Factors Weak Risk Factors
Odds Ratio > 10 Odds Ratio 2-9 Odds Ration <2
rn
R
ag
i
tR
s Hip or Leg Fracture Athroscopic Knee Bed rest>3 days
i
e Hip or Knee Surgery Immobility due to
k Replacement Central Venous Lines sitting
s
R
F Major General Surgery Chemotherapy Increasing Age
ik Major Trauma CHF or Respiratory Laparoscopic Surgery
a
sF Spinal Cord Injury Failure Obesity
cka Hormone Pregnancy/
tFc Replacement Therapy Antepartum
o Malignancy Varicose Veins
at Oral Contraceptive
rco Therapy
str Paralytic Stroke
Pregnancy/
o
s Postpartum
r Previous VTE
s Thrombophilia
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 GENERAL THROMBOPROPHYLAXIS
RECOMMENDATIONS
Level of Risk Estimated DVT Risk Suggested Thromboprophylaxis
Low <10% Early and aggressive ambulation
Minor surgery in mobile patients
Medical patients who are fully
mobile

Moderate 10%-40% LMWH, LDUH BID/TID or

Medical pts, bed rest or sick Fondaparinux
Most general, open gynecologic
or urologic surgery patients
Mechanical
Moderate VTE + High bleeding Thromboprophylaxis
risk

High Risk 40% - 80% LMWH

Hip or knee arthroplasty, Major
Trauma, SCI Mechanical Thromboprophylaxis

High VTE + High Bleeding risk

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 PREVENTION OF VTE IN
NONSURGICAL PATIENTS
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Antithrombotic Therapy and Prevention of Thrombosis, 9th

Ed; ACCP Guidelines
 CONSIDERATIONS
7

50 – 70% of symptomatic thromboembolic events and 70

– 80% of fatal PEs occur in non-surgical patients

Additional risk factors for VTE in medical patients

SSepsis
C Advanced
Previous
Cancer
Bed Rest VTE
age
t
o
O Stroke with
r Advanced age
n
P Previous VTE Cancer lower extremity
o
g
D weakness
k
e
E
se
x
atwCongestive Heart COPD
Sepsis Bed Rest
ci Failure Exacerbation
vt
e
h
re
l
H
b
 Acutely Ill Hospitalized Medical Patients
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Recommended Recommended Against

Low-Molecular Weight
The use of thromboprophylaxis
Heparins, Low Dose beyond period of immobilization
Unfractionated Heparin or acute hospital stay
or Fondaparinux for
patients with high risk The use of pharmacologic
prophylaxis or mechanical
for thrombosis prophylaxis in patients at low risk
of thrombosis
Optimal use of
mechanical
thromboprophylaxis
Other Nonsurgical Patient Recommendations
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Critically-Ill Outpatients with Cancer

Low-Molecular Weight
Heparins or Low dose Recommend against routine
prophylaxis with LMWH or LDUH
Unfractionated Heparin if no additional risk factors
is suggested Recommended for patients with solid
tumors who have additional risk factors

Mechanical prophylaxis Recommend against use of

vitamin K antagonists (Warfarin)
with GCS or IPC for for prophylaxis
those who are at high
risk for major bleeding
until bleeding risk
PHARMACOLOGICAL THERAPY
FOR VTE PROPHYLAXIS
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•Aspirin
•Unfractionated heparin
•Low-molecular weight
heparins
•Vitamin K antagonists
Warfarin,
•Fondaparinux (Factor Xa
inhibitor)
QUESTIONS?
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