Preventing DVT in Hospitalized Patients Bill Cayley MD
Learning Objectives <ul><li>Participants will be able to: </li></ul><ul><ul><li>Describe risk factors for DVT </li></ul></...
Why do we care about DVTs?
Rationale for DVT Prevention <ul><li>Prevalence </li></ul><ul><ul><li>Hospitalized patients have risk factors for VTE </li...
Risk factors for DVT <ul><li>What are risk factors for DVT in hospitalized patients? </li></ul>
Risk factors for DVT <ul><li>What are risk factors for DVT in hospitalized patients? </li></ul><ul><li>What is Virchow’s T...
Risk factors for DVT <ul><li>Virchow’s Triad </li></ul><ul><ul><li>Stasis </li></ul></ul><ul><ul><li>Vessel Injury </li></...
Risk Factors for DVT <ul><li>Stasis </li></ul><ul><ul><li>Surgery, trauma, immobility, paresis </li></ul></ul><ul><ul><li>...
Absolute Risk of DVT in Hospitalized Patients <ul><li>Patient Group DVT Prevalence, % </li></ul><ul><li>Medical patients 1...
Literature Search <ul><li>Cochrane Collaboration </li></ul><ul><ul><li>www.cochrane.org </li></ul></ul><ul><li>National Gu...
Guidelines <ul><li>Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Th...
What outcomes do we look for?
Outcomes <ul><li>Asymptomatic DVT? </li></ul><ul><li>Symptomatic DVT? </li></ul><ul><li>PE? </li></ul><ul><ul><li>Fatal </...
How can you prevent DVT?
Methods of DVT Prophylaxis <ul><li>Mobilization </li></ul><ul><li>Graduated compression stockings </li></ul><ul><li>Interm...
Mechanical prophylaxis <ul><li>Graduated Compression Stockings (GCS) </li></ul><ul><ul><li>Prophylaxis DVT Rate </li></ul>...
Mechanical prophylaxis <ul><li>Intermittent pneumatic compression (IPC) </li></ul><ul><li>Prophylaxis DVT Rate </li></ul><...
Mechanical prophylaxis <ul><li>Systematic review – surgical patients </li></ul><ul><ul><li>GCS, IPCs as monotherapy </li><...
Mechanical prophylaxis <ul><li>Other issues... </li></ul><ul><ul><li>Not shown to reduce death </li></ul></ul><ul><ul><li>...
Clinical Question <ul><li>A 70 male is going to be hospitalized for an inguinal hernia repair. He takes aspirin for vascul...
Aspirin – a low-risk measure? <ul><li>Small studies inconclusive </li></ul><ul><li>PEP study (Lancet. 2000:1295-302) </li>...
Clinical Question <ul><li>A 60 year old female is hospitalized for a COPD exacerbation. </li></ul><ul><ul><li>Do you need...
General Medicine <ul><li>LMWH and UFH </li></ul><ul><ul><li>Reduce DVT and PE by 56-58% </li></ul></ul><ul><ul><li>No effe...
General Medicine <ul><li>Recommendations </li></ul><ul><ul><li>Ambulation for all patients </li></ul></ul><ul><ul><li>LMWH...
Non-Orthopedic Surgery <ul><li>General </li></ul><ul><li>Gynecologic </li></ul><ul><li>Colorectal </li></ul><ul><li>Urolog...
Clinical Question <ul><li>A 45 year old male was hospitalized for gall bladder disease & his cholecystectomy had to be con...
General Surgery <ul><li>Meta-analysis: Haemostasis. 1997;27:65. </li></ul><ul><ul><li>LMWH & UFH reduce DVT & PE risk </li...
General Surgery <ul><li>ACCP, ICSI, SIGN </li></ul><ul><ul><li>Low-risk pts (young, non-major surgery) </li></ul></ul><ul>...
Clinical Question <ul><li>A 70 year old woman with severe DJD and diabetes is having elective hysterectomy for significant...
Major Gynecologic Surgery <ul><li>Cochrane: </li></ul><ul><ul><li>UFH prevents DVT in women with malignancy </li></ul></ul...
ACOG Recommendations: <ul><li>Moderate or high risk patients </li></ul><ul><ul><li>Major surgery, CA, other DVT risk facto...
Colorectal surgery <ul><li>Both LMWH and UFH reduce DVT risk </li></ul><ul><li>Adding GCS to either method provides added ...
Other Non-Ortho Surgery <ul><li>Colorectal </li></ul><ul><ul><li>Both LMWH and UFH reduce DVT risk </li></ul></ul><ul><ul>...
Clinical Question <ul><li>You are asked to provide medical consultation on a 75 year old nursing home patient with hyperte...
Orthopedics <ul><ul><li>LMWH better & safer than warfarin or UFH </li></ul></ul><ul><ul><ul><ul><ul><li>Haemostasis. 1997 ...
Orthopedics <ul><li>No difference in DVT rates between: </li></ul><ul><ul><li>Pre-op or post-op initiation of LMWH </li></...
Orthopedic Guidelines <ul><li>ACCP and ICSI </li></ul><ul><ul><li>Elective hip or knee arthroplasty </li></ul></ul><ul><u...
Trauma <ul><li>High risk of DVT or PE </li></ul><ul><ul><li>40–80% DVT </li></ul></ul><ul><li>ACCP & SIGN </li></ul><ul><u...
Key Messages <ul><li>Both GCS & IPCs significantly reduce DVT rates. </li></ul><ul><li>UFH and LMWH equally effective and ...
Information for Patients <ul><li>Deep Vein Thrombosis: What You Should Know. http://familydoctor.org/online/famdocen/home...
THANKS!
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Preventing DVT in Hospitalized Patients

Published on: Mar 4, 2016
Published in: Health & Medicine      
Source: www.slideshare.net


Transcripts - Preventing DVT in Hospitalized Patients

  • 1. Preventing DVT in Hospitalized Patients Bill Cayley MD
  • 2. Learning Objectives <ul><li>Participants will be able to: </li></ul><ul><ul><li>Describe risk factors for DVT </li></ul></ul><ul><ul><li>Discuss methods of DVT prevention </li></ul></ul><ul><ul><li>Discuss the risks and benefits of approaches to DVT prevention </li></ul></ul>
  • 3. Why do we care about DVTs?
  • 4. Rationale for DVT Prevention <ul><li>Prevalence </li></ul><ul><ul><li>Hospitalized patients have risk factors for VTE </li></ul></ul><ul><ul><li>DVT usually clinically silent, difficult to predict complications </li></ul></ul><ul><ul><li>Screening is neither effective nor cost-effective </li></ul></ul><ul><li>Adverse consequences </li></ul><ul><ul><li>Symptomatic DVT and PE or Fatal PE </li></ul></ul><ul><ul><li>Costs of testing and treating </li></ul></ul><ul><ul><li>Increased future risk of recurrent VTE </li></ul></ul><ul><li>Efficacy and effectiveness of prophylaxis </li></ul><ul><ul><li>Prophylaxis prevents DVT and PE </li></ul></ul><ul><ul><li>The prevention of DVT also prevents PE </li></ul></ul><ul><ul><li>Prophylaxis is cost-effective </li></ul></ul><ul><ul><ul><li>Chest. 2004;126:338S-400S. </li></ul></ul></ul>
  • 5. Risk factors for DVT <ul><li>What are risk factors for DVT in hospitalized patients? </li></ul>
  • 6. Risk factors for DVT <ul><li>What are risk factors for DVT in hospitalized patients? </li></ul><ul><li>What is Virchow’s Triad? </li></ul>
  • 7. Risk factors for DVT <ul><li>Virchow’s Triad </li></ul><ul><ul><li>Stasis </li></ul></ul><ul><ul><li>Vessel Injury </li></ul></ul><ul><ul><li>Hypercoagulability </li></ul></ul>
  • 8. Risk Factors for DVT <ul><li>Stasis </li></ul><ul><ul><li>Surgery, trauma, immobility, paresis </li></ul></ul><ul><ul><li>Increasing age </li></ul></ul><ul><ul><li>Pregnancy and postpartum </li></ul></ul><ul><ul><li>Heart or respiratory failure </li></ul></ul><ul><ul><li>Obesity </li></ul></ul><ul><li>Vessel Injury </li></ul><ul><ul><li>Previous DVT </li></ul></ul><ul><ul><li>Smoking </li></ul></ul><ul><ul><li>Varicose veins </li></ul></ul><ul><ul><li>Central venous catheterization </li></ul></ul><ul><li>Hypercoagulability </li></ul><ul><ul><li>Increasing age </li></ul></ul><ul><ul><li>Malignancy </li></ul></ul><ul><ul><li>Cancer therapy </li></ul></ul><ul><ul><li>Estrogen therapy </li></ul></ul><ul><ul><ul><li>(OCP or HRT) </li></ul></ul></ul><ul><ul><li>Acute medical illness </li></ul></ul><ul><ul><li>Inflammatory bowel disease </li></ul></ul><ul><ul><li>Nephrotic syndrome </li></ul></ul><ul><ul><li>Myeloproliferative disorders </li></ul></ul><ul><ul><li>Paroxysmal nocturnal hemoglobinuria </li></ul></ul><ul><ul><li>Inherited or acquired thrombophilia </li></ul></ul>
  • 9. Absolute Risk of DVT in Hospitalized Patients <ul><li>Patient Group DVT Prevalence, % </li></ul><ul><li>Medical patients 10–20 </li></ul><ul><li>General surgery 15–40 </li></ul><ul><li>Major gynecologic surgery 15–40 </li></ul><ul><li>Major urologic surgery 15–40 </li></ul><ul><li>Neurosurgery 15–40 </li></ul><ul><li>Stroke 20–50 </li></ul><ul><li>Hip or knee arthroplasty, hip fracture surgery 40–60 </li></ul><ul><li>Major trauma 40–80 </li></ul><ul><li>Spinal cord injury 60–80 </li></ul><ul><li>Critical care patients 10–80 </li></ul><ul><ul><ul><li>Chest. 2004;126:338S-400S. PMID: 15383478. </li></ul></ul></ul>
  • 10. Literature Search <ul><li>Cochrane Collaboration </li></ul><ul><ul><li>www.cochrane.org </li></ul></ul><ul><li>National Guideline Clearinghouse </li></ul><ul><ul><li>www.guideline.gov </li></ul></ul><ul><li>Pub Med </li></ul><ul><ul><li>www.ncbi.nlm.nih.gov </li></ul></ul>
  • 11. Guidelines <ul><li>Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. </li></ul><ul><ul><li>http://www.chestjournal.org/cgi/content/full/126/3_suppl/338S </li></ul></ul><ul><li>Scottish Intercollegiate Guidelines Network (SIGN). Prophylaxis of venous thromboembolism. A national clinical guideline. </li></ul><ul><ul><li>http://www.sign.ac.uk/pdf/sign62.pdf </li></ul></ul><ul><li>Institute for Clinical Systems Improvement (ICSI). Venous thromboembolism prophylaxis. </li></ul><ul><ul><li>www.icsi.org </li></ul></ul><ul><li>NICE. Venous thromboembolism: reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing surgery. </li></ul><ul><ul><li>http://guidance.nice.org.uk/CG46 </li></ul></ul>
  • 12. What outcomes do we look for?
  • 13. Outcomes <ul><li>Asymptomatic DVT? </li></ul><ul><li>Symptomatic DVT? </li></ul><ul><li>PE? </li></ul><ul><ul><li>Fatal </li></ul></ul><ul><ul><li>All PE’s? </li></ul></ul><ul><li>Long-term complications? </li></ul>
  • 14. How can you prevent DVT?
  • 15. Methods of DVT Prophylaxis <ul><li>Mobilization </li></ul><ul><li>Graduated compression stockings </li></ul><ul><li>Intermittent pneumatic compression </li></ul><ul><li>Aspirin </li></ul><ul><li>Unfractionated heparin </li></ul><ul><li>Low-molecular weight heparins </li></ul><ul><ul><li>Enoxaparin, dalteparin </li></ul></ul><ul><li>Vitamin K antagonists </li></ul><ul><ul><li>Warfarin, acenocoumarol, phenindione, & dicoumarol </li></ul></ul><ul><li>Fondaparinux (Factor Xa inhibitor) </li></ul>
  • 16. Mechanical prophylaxis <ul><li>Graduated Compression Stockings (GCS) </li></ul><ul><ul><li>Prophylaxis DVT Rate </li></ul></ul><ul><ul><li>None 27% </li></ul></ul><ul><ul><li>GCS 13% </li></ul></ul><ul><ul><li>“ Background” Prophylaxis 15% </li></ul></ul><ul><ul><li>GCS + “Background” 2% </li></ul></ul><ul><ul><ul><ul><ul><li>Elastic compression stockings for prevention of deep vein thrombosis. Cochrane Database Syst Rev. 2000;(3):CD001484. PMID: 10908501 </li></ul></ul></ul></ul></ul>
  • 17. Mechanical prophylaxis <ul><li>Intermittent pneumatic compression (IPC) </li></ul><ul><li>Prophylaxis DVT Rate </li></ul><ul><ul><li>None 29% </li></ul></ul><ul><ul><li>GCS 15% </li></ul></ul><ul><ul><li>IPC 8-11% </li></ul></ul><ul><ul><ul><ul><ul><li>Am Surg. 1998 Nov;64:1050-8. PMID: 9798767. </li></ul></ul></ul></ul></ul>
  • 18. Mechanical prophylaxis <ul><li>Systematic review – surgical patients </li></ul><ul><ul><li>GCS, IPCs as monotherapy </li></ul></ul><ul><ul><ul><li>2/3 reduction in DVT </li></ul></ul></ul><ul><ul><li>GCS, IPCs added to pharmacotherapy </li></ul></ul><ul><ul><ul><li>Additional 50% reduction in DVT </li></ul></ul></ul><ul><ul><li>GCS, IPCs may reduce PE by 40% </li></ul></ul><ul><ul><ul><ul><ul><li>Health Technol Assess. 2005 Dec;9(49):1-78. </li></ul></ul></ul></ul></ul>
  • 19. Mechanical prophylaxis <ul><li>Other issues... </li></ul><ul><ul><li>Not shown to reduce death </li></ul></ul><ul><ul><li>Use with caution in vascular insufficiency </li></ul></ul>
  • 20. Clinical Question <ul><li>A 70 male is going to be hospitalized for an inguinal hernia repair. He takes aspirin for vascular prophylaxis. </li></ul><ul><ul><li>Should he stop ASA for surgery? </li></ul></ul>
  • 21. Aspirin – a low-risk measure? <ul><li>Small studies inconclusive </li></ul><ul><li>PEP study (Lancet. 2000:1295-302) </li></ul><ul><ul><li>1700 hip surgery patients, f/u to 35 days </li></ul></ul><ul><ul><ul><ul><li>ASA vs Placebo </li></ul></ul></ul></ul><ul><ul><li>Fatal PE .3% vs .6% </li></ul></ul><ul><ul><li>Symptomatic DVT .9% vs 1.3% </li></ul></ul><ul><ul><li>Small risk increase in hematemesis and wound bleeding </li></ul></ul><ul><li>ACCP & ICSI </li></ul><ul><ul><li>Recommend against relying on aspirin for DVT prevention </li></ul></ul><ul><li>SIGN </li></ul><ul><ul><li>Advocates ASA for DVT prevention in surgical patients. </li></ul></ul>
  • 22. Clinical Question <ul><li>A 60 year old female is hospitalized for a COPD exacerbation. </li></ul><ul><ul><li>Do you need to provide DVT prophylaxis? </li></ul></ul><ul><ul><li>What do you order? </li></ul></ul>
  • 23. General Medicine <ul><li>LMWH and UFH </li></ul><ul><ul><li>Reduce DVT and PE by 56-58% </li></ul></ul><ul><ul><li>No effect demonstrated on death </li></ul></ul><ul><li>LMWH vs UFH </li></ul><ul><ul><li>No difference in DVT or PE </li></ul></ul><ul><ul><li>Lower risk of major bleeding (by 52%) </li></ul></ul><ul><ul><ul><li>Thromb Haemost. 2000 Jan;83(1):14-9. PMID: 10669147 </li></ul></ul></ul>
  • 24. General Medicine <ul><li>Recommendations </li></ul><ul><ul><li>Ambulation for all patients </li></ul></ul><ul><ul><li>LMWH or UFH </li></ul></ul><ul><ul><ul><li>For patients with HF, Respiratory disease, immobility PLUS other risk factors </li></ul></ul></ul><ul><ul><li>Mechanical prophylaxis </li></ul></ul><ul><ul><ul><li>If anti-coagulants contraindicated. </li></ul></ul></ul><ul><ul><ul><li>Consider for all bed-bound patients </li></ul></ul></ul><ul><ul><ul><ul><li>Chest 2004 Sep;126(3 Suppl):338S-400S. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Institute for Clinical Systems Improvement (ICSI). </li></ul></ul></ul></ul>
  • 25. Non-Orthopedic Surgery <ul><li>General </li></ul><ul><li>Gynecologic </li></ul><ul><li>Colorectal </li></ul><ul><li>Urologic </li></ul><ul><li>Vascular </li></ul>
  • 26. Clinical Question <ul><li>A 45 year old male was hospitalized for gall bladder disease & his cholecystectomy had to be converted from laparoscopic to open. </li></ul><ul><ul><li>Does he need DVT prophylaxis? </li></ul></ul><ul><ul><li>What would you use? </li></ul></ul>
  • 27. General Surgery <ul><li>Meta-analysis: Haemostasis. 1997;27:65. </li></ul><ul><ul><li>LMWH & UFH reduce DVT & PE risk </li></ul></ul><ul><ul><li>LMWH reduced minor bleeds 25% </li></ul></ul><ul><li>Meta-analysis: Br J Surg. 2001 Jul;88(7):91. </li></ul><ul><ul><li>LMWH & UFH reduced all DVT, reduced PE </li></ul></ul><ul><ul><li>Same bleeding risk </li></ul></ul><ul><li>Meta-analysis: Thromb Res. 2001;102:295. </li></ul><ul><ul><li>Confirmed LWMH and UFH equally effective & safe for DVT prevention </li></ul></ul>
  • 28. General Surgery <ul><li>ACCP, ICSI, SIGN </li></ul><ul><ul><li>Low-risk pts (young, non-major surgery) </li></ul></ul><ul><ul><ul><li>Early and persistent mobilization </li></ul></ul></ul><ul><ul><li>Moderate-risk pts (major surgery OR > 40 yrs) </li></ul></ul><ul><ul><ul><li>Use LMWH or UFH </li></ul></ul></ul><ul><ul><li>High-risk pts (major surgery, > 40 yrs) </li></ul></ul><ul><ul><ul><li>GCS, plus LMWH or UFH </li></ul></ul></ul><ul><ul><li>Use GCS if risk of bleeding precludes anti-coagulants. </li></ul></ul><ul><li>NICE </li></ul><ul><ul><li>Inpatients having surgery should be offered GCS from the time of admission to hospital unless contraindicated </li></ul></ul>
  • 29. Clinical Question <ul><li>A 70 year old woman with severe DJD and diabetes is having elective hysterectomy for significant uterine prolapse. </li></ul><ul><ul><li>Do you recommend DVT prophylaxis? </li></ul></ul><ul><ul><li>What prophylaxis? </li></ul></ul>
  • 30. Major Gynecologic Surgery <ul><li>Cochrane: </li></ul><ul><ul><li>UFH prevents DVT in women with malignancy </li></ul></ul><ul><ul><li>Warfarin prevents DVT in women w/o malignancy </li></ul></ul><ul><ul><li>LMWH – just as effective as UFH </li></ul></ul><ul><ul><li>No studies of ASA </li></ul></ul><ul><ul><ul><ul><li>Anticoagulant and aspirin prophylaxis for preventing thromboembolism after major gynaecological surgery. Cochrane Database Syst Rev. 2003;(4):CD003679. </li></ul></ul></ul></ul>
  • 31. ACOG Recommendations: <ul><li>Moderate or high risk patients </li></ul><ul><ul><li>Major surgery, CA, other DVT risk factors </li></ul></ul><ul><ul><li>GCS or IPC </li></ul></ul><ul><ul><ul><li>Apply intraoperatively, cont. till ambulatory </li></ul></ul></ul><ul><ul><li>UFH </li></ul></ul><ul><ul><ul><li>Start 2-8 hrs pre-op, continue till D/C </li></ul></ul></ul><ul><ul><li>LMWH </li></ul></ul><ul><ul><ul><li>Start 12 hrs pre-op, continue till D/C </li></ul></ul></ul><ul><ul><ul><ul><li>American College of Obstetricians and Gynecologists (ACOG). Prevention of DVT and pulmonary embolism. </li></ul></ul></ul></ul>
  • 32. Colorectal surgery <ul><li>Both LMWH and UFH reduce DVT risk </li></ul><ul><li>Adding GCS to either method provides added protection </li></ul><ul><ul><li>Heparins and mechanical methods for thromboprophylaxis in colorectal surgery. Cochrane Database Syst Rev. 2003;(4):CD001217 </li></ul></ul>
  • 33. Other Non-Ortho Surgery <ul><li>Colorectal </li></ul><ul><ul><li>Both LMWH and UFH reduce DVT risk </li></ul></ul><ul><ul><li>GCS provide added protection </li></ul></ul><ul><li>Urologic </li></ul><ul><ul><li>Minimal evidence </li></ul></ul><ul><ul><li>UFH, LMWH, GCS, or IPC for pts w/ high DVT </li></ul></ul><ul><li>Vascular </li></ul><ul><ul><li>Most are on anti-platelet agents anyway </li></ul></ul><ul><ul><li>Base prophylaxis on other risk factors </li></ul></ul>
  • 34. Clinical Question <ul><li>You are asked to provide medical consultation on a 75 year old nursing home patient with hypertension and heart disease who needs ORIF of a left hip fracture. </li></ul><ul><ul><li>What DVT prophylaxis do you recommend? </li></ul></ul>
  • 35. Orthopedics <ul><ul><li>LMWH better & safer than warfarin or UFH </li></ul></ul><ul><ul><ul><ul><ul><li>Haemostasis. 1997 Mar-Apr;27(2):75-84. </li></ul></ul></ul></ul></ul><ul><ul><li>LMWH better & safer than warfarin or UFH for TKR </li></ul></ul><ul><ul><ul><ul><ul><li>Thromb Haemost. 1998 May;79(5):902-6. </li></ul></ul></ul></ul></ul><ul><ul><li>LMWH or IPC better than ASA or warfarin for TKR </li></ul></ul><ul><ul><ul><ul><ul><li>J Bone Joint Surg Br. 2000 Aug;82(6):795-800 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>J Arthroplasty. 2001 Apr;16(3):293-300 </li></ul></ul></ul></ul></ul><ul><ul><li>LMWH & UFH similarly effective after hip fx surgery </li></ul></ul><ul><ul><ul><ul><ul><li>Cochrane Database Syst Rev. 2002;(4):CD000305. </li></ul></ul></ul></ul></ul><ul><ul><li>LMWH better than Vit K antagonists in ortho surgery </li></ul></ul><ul><ul><ul><ul><ul><li>J Thromb Haemost. 2004 Jul;2(7):1058-70. </li></ul></ul></ul></ul></ul>
  • 36. Orthopedics <ul><li>No difference in DVT rates between: </li></ul><ul><ul><li>Pre-op or post-op initiation of LMWH </li></ul></ul><ul><ul><li>Different currently-accepted LMWH doses </li></ul></ul><ul><ul><ul><ul><ul><li>Arch Intern Med. 1999 Jan 25;159(2):137-41. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Thromb Haemost. 2003 Oct;90(4):654-61. </li></ul></ul></ul></ul></ul>
  • 37. Orthopedic Guidelines <ul><li>ACCP and ICSI </li></ul><ul><ul><li>Elective hip or knee arthroplasty </li></ul></ul><ul><ul><ul><li>LMWH, vitamin K antagonists, fondaparinux </li></ul></ul></ul><ul><ul><li>Hip fracture surgery </li></ul></ul><ul><ul><ul><li>LMWH, vitamin K antagonists, fondaparinux, or UFH </li></ul></ul></ul><ul><ul><ul><li>Start LMWH or UFH at hospital admission if fracture repair will be delayed. </li></ul></ul></ul><ul><li>NICE </li></ul><ul><ul><li>Hip fracture or elective orthopedic surgery </li></ul></ul><ul><ul><ul><li>LMWH/Fondaparinux + mechanical </li></ul></ul></ul>
  • 38. Trauma <ul><li>High risk of DVT or PE </li></ul><ul><ul><li>40–80% DVT </li></ul></ul><ul><li>ACCP & SIGN </li></ul><ul><ul><li>LMWH for prophylaxis </li></ul></ul><ul><ul><li>Mechanical prophylaxis if risk of bleeding precludes anticoagulants. </li></ul></ul><ul><ul><ul><ul><ul><li>Prophylaxis of venous thromboembolism. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2002 Oct. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Chest. 2004;126:338S-400S. PMID: 15383478. </li></ul></ul></ul></ul></ul>
  • 39. Key Messages <ul><li>Both GCS & IPCs significantly reduce DVT rates. </li></ul><ul><li>UFH and LMWH equally effective and general surgery patients. </li></ul><ul><ul><li>GCS can provide additional protection for high-risk patients. </li></ul></ul><ul><li>Use either GCS placed intraoperatively, or UFH or LMWH started preoperatively, gynecologic surgery at risk of DVT </li></ul><ul><ul><li>Major surgery, malignancy, or other DVT risk factors. </li></ul></ul><ul><li>Use LMWH, vitamin K antagonists, or fondaparinux after elective major hip or knee surgery. </li></ul><ul><li>For hip fracture </li></ul><ul><ul><li>Start LMWH or UFH pre-op if delay until surgery </li></ul></ul><ul><ul><li>Post-operative DVT prophylaxis: LMWH, UFH, vitamin K antagonists, or fondaparinux. </li></ul></ul>
  • 40. Information for Patients <ul><li>Deep Vein Thrombosis: What You Should Know. http://familydoctor.org/online/famdocen/home/seniors/common-older/800.html (accessed 6 June 2007) </li></ul><ul><li>Deep Vein Thrombosis (DVT). http://www.patient.co.uk/showdoc/23068982/ (accessed 6 June 2007) </li></ul><ul><li>CG46 Venous thromboembolism: Understanding NICE guidance. http://guidance.nice.org.uk/CG46/publicinfo/pdf/English . (accessed 6 June 2007) </li></ul>
  • 41. THANKS!

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