DVT PROPHYLAXIS

EZYAN ZAMZUARY SUPERVISOR MR ROHAMAN TASASRIB

WHAT IS DVT???

Presence of coagulated blood ( thrombus) in one of the deep venous conduit that return blood to the heart Most commonly involves the deep veins of the leg. Often resulting in potentially life threatening emboli to the lungs

Insidence
Annual incidence of 80cases per 100,000 Each year in US, more then 200,000 people develop venous thrombosis, of those 50,000 cases are complicated by PE Lower extremity DVT is the most common venous thrombosis It is the underlying source of 90% of acute PEs which causes 25,000 death per year in US

Clinical presentation
pain and swelling of unilateral lower limb with fever Presence of one or more risk factors

Risk factors

Physical examination:
-Calf pain on dorsiflexion of the foot discolouration of the lower limb -blenched appearance because of edema

DVT risk stratificati on

Making a diagnosis

complication
Pulmonary embolism Renal vein thrombosis Acute myocard infarction Ischemic stroke Postthrombotic syndrome

DVT prophylaxis

When to start prophylaxis?

Low risk patient: Younger then 40, minor surgical procedure with no additional risk factor Risk: 2-5% no specific prophylaxis, only requires early and aggressive ambulation

Moderate risk patient Aged 40-60 undergoing non major surgery with no additional risk factor

Surgery requiring tourniquet, lower extremity fractures, cast immobilization, spinal surgery

<40yo, major surgery

need for chemoprophylaxis with or without mechanical methode

High risk patient >60yo 40-60yo with additional risk factor (previous VTE, malignancy, hypercoagulability) Highest risk factor >40yo, with additional risk factors undergoing hip or knee replacement surgery or having hip fracture, open lower limb fracture, multiple trauma or spinal cord injury

need for combination between chemoprophylaxis and mechanical

Methode of prophylaxis
Mechanical Limb physiotherapy Early ambulation - post surgery Intermittent pneumatic compression devices Graded compression elastic stockings

Pharmacological Standard unfractionated heparin Low molecular weight heparin Warfarin Fondaparinux Rivaroxaban(xarelto)

Mechanical prophylaxis
How it works: decrease venous stasis Improve blood flow velocity Increase level of circulating fibrinolysin

Advantages: Reduces 60% incidense of DVT in low risk patient Requires no monitoring No increase risk of bleeding

Issues Efficacies: time of use and need for patient compliance

Graded compression elastic stockings

Intermittent pneumatic compression device

Pharmacological prophylaxis

warfarin
Oral anticoagulant drug Dose: Initial: 2-5mg orally/iv OD, adjusted based on INR Maintainance: 2-10mg od orally Mechanism of action: Antagonist to vitamin K intefere with the interaction btw vit K and factor II, VII, IX, X Pharmacokinetics Absorbed rapidly from gastrointestinal tract and bound to plasma protein

Contraindication Pt with high risk of bleeding Pregnant; known or suspected Hypersensitivity to warfarin Spinal puncture, CNS surgery, any procedure with potentilal for uncontrollable bleeding

Recent or potential

Poor coorperation/ compliance

Monitoring INR 2.5(2-3)

toxicology Overdose: prolonged PT/INR and risk of bleeding

FFP if active bleeding Serial PT/INR every 6hours Iv vitamin K if only INR>5 and not receive any chronic treatment

Pentasacharide fondaparinux sodium

New class of synthetic antithrombotic agents\acts: selective inhibitiojn of factor Xa Dose 2.5mg OD 6hours postoperatively
Risk reduction >50% without increasing the risk of bleeding Not requiring monitoring

Duration:
Usually 5-9days Hip surgery : up to 24days

Before starting
No severe renal impairment -creatnine clearence less then 30ml/mincontraindicated

No thrombocytopenia -plt <100,000

PTTK
Insensitive and not necessary except in infants, children, obese or underweight patients, or those with renal disease, longterm treatment, pregnancy, or unexpected bleeding or thrombosis

Contraindication
Severe renal impairment (creatinine clearance [CrCl] <30 mL/min Active major bleeding. Bacterial endocarditis. Thrombocytopenia associated with a positive in vitro test for anti-platelet antibody in the presence of fondaparinux sodium. Body weight <50 kg

Rivaroxaban(xarelto)

Selectively inhibits factor Xa without the need of cofactor (antithrombin III)

Dose: Knee arthroplasty

10mg od started 6-10hrs after surgery and continued untill 12days

Hip fracture repair

10mg od started 6-12hrs aft surgery continued untill 35days

Contraindiction: active bleeding Hypersensitivity

Precaution: Severe renal impairment Hepatic impairment Traumatic/repeated epidural or spinal punctures- delay administration for 24 hrs

Unfractionated heparin(UFH)
Mechanism of action Acts in conjunction with a circulating plasma cofactor, antithrombin (AT)III catalyzes the inactivation of factors IIa, Xa, Ixa and XIIa Inactivate thrombint prevent fibrin formation

Pharmacokinetics Effective with iv and sc Inactivated in GI tract Rapid onset of action Brief half live

Disadvantages Requirementfor aPTT monitoring for adjusted dose regimements Short half live Low bioavailability Unable to be delivered orally Risk (2-4%) of heparin induced thrombocytopenia Which can result in disseminated intravascular coagulation

LMWH
Eg: enoxaparin Subcutaneous OD injection Prophylaxis of VTE More effective in orthopedic surgery and slightly more effectivr in general surgery without increasing risk of bleeding Advantage:
Less likely to produce heparin induced thrombocytopenia and osteoporosis Easy to administer OD injection No need monitoring

Disadvantages: non HALAL

THANK YOU