Professional Documents
Culture Documents
Deep Vein Thrombosis - 2003
Deep Vein Thrombosis - 2003
PRESENTED BY:
SIM SUI THENG
HOSPITAL MIRI
OUTLINE
2
Introduction
Epidemiology
Risk Factors
Clinical Assessment
Prophylaxis
Treatment
Pharmacology
Conclusion
References
INTRODUCTION
3
DVT
Residual thrombus will
Narrowing of lumen +
organize, vein
valvular incompetency
incompletely recanalize
INTRODUCTION
4
Endothelial Venous
Injury Stasis
Virchow’s Triad
Table 2: Clinical Model for Predicting Pretest Probability of Lower Limb DVT16
MANAGEMENT
9
Mechanical Method
Graduated elastic compression stocking & intermittent
pneumatic compression devices
Reduce incidence of DVT
Enhance protection afforded by low dose heparin
Advantages:
Maybe an option for ppl C/I to anticoagulant drugs (risk of
bleeding)
Disadvantages:
Cannot effectively wear these stockings due to unusual limb size &
shape
Not much clinical trials support effectiveness to reduce fatal PE
PROPHYLAXIS
12
Pharmacological approach
Low dose unfractionated heparin
s/c 5000U q12h post-surgery
In ortho surgery, s/c 3500U q8h, starting 2 days pre-surgery &
adjusting the APTT ratio in upper normal range
Low molecular weight heparin (LMWH)
Givens/c as once daily dosing
Generally more effective therapy compared to UFH
Oral anticoagulant
Used when heparin is C/I
Warfarin is used & maintain INR at 2.0-2.5 or 2.0-3.0 (ortho)
The pentasaccharide fondaparinux sodium
Dose: 2.5mg od, target to ortho surgery, starting 6H post-
operation, 2.5mg od for 5-9 days
PROPHYLAXIS
13
Table 3: Risk Stratification & Prevention Strategies in Medical & Surgical Patients17-18
PROPHYLAXIS
14
Objectives:
Relieve symptoms
Reduce the risk of PE to the systemic circulation
Prevent post-thrombotic syndrome
Prevent recurrence
TREATMENT
17
Anticoagulation
1) Low dose unfractionated heparin
Check baseline APTT, PT,
RF, LFT, FBC, thrombophilia Overlapped warfarin with
screen (if necessary) heparin, start 5mg on 1st 2
days, then adjust daily dose
according INR
Check APTT at 6, 12, 24
hours (must achieved target
1.5-2.5 within 24 hours) Discontinue heparin* once
target INR achieved w/i 2
consecutive days
Check platelet count from D3
until end of 2nd week
Anticoagulation (con’t)
2)Low Molecular Weight Heparin (LMWH)
Table 6: LMWHs & Its Recommended Dosage in Treatment of DVT 1,19
LMWH recommended Dose
Enoxaparin (Clexane®) 1.5 mg/kg od OR 1 mg/kg bd
Dalteparin (Fragmin®) 200 IU/kg od OR 120IU/kg bd
Nadroparin (Fraxiparine®) 0.1 ml/kg bd
Nadroparin (Fraxiparine® Forte) 0.1 ml/kg od
Tinzaparin (Innohep®) 175 IU/kg od
Anticoagulation
3) Heparinoids 19
o Used in patients with history of heparin-induced thrombocytopenia
o Danaparoid sodium: IV 2500 units followed by 400 units/hr for 2
hours, then 300 units/hr for 2 hours, then 200 units/hr for 5 days
3) Hirudins 19
o Used in patients with history of heparin-induced thrombocytopenia
o Lepirudin: IV 400mcg/kg followed by 150mcg/kg/hr (adjusted
according to APTT) for 2-10 days
3) Fondaparinux sodium 19
o Targeted to orthopedic surgery patients
o S/C 5 mg od (<50kg), 7.5 mg od (50-100kg), 10 mg od (>100kg) for at
least 5 days
TREATMENT
21
- Following discharge, patients should be followed up within a week with a repeat INR
- If INR remains within therapeutic range, the same dose is maintained & next follow-
up will be 2 weeks later
- If INR still within therapeutic range, then monthly follow-up with INR is advised
- Frequent visits are required if therapeutic INR is not achieved
TREATMENT
22
Supportive treatment
Adequate analgesia (Non-aspirin analgesics)
Legs are elevated above heart
Graduated elastic compression stockings applied as soon as
patient can tolerate
Encourage mobilisation
PHARMACOLOGY
23
Unfractionated Heparin
MOA: Potentiates the action of antithrombin III and thereby
inactivates thrombin (as well as activated coagulation factors IX,
X, XI, XII and plasmin) and prevents the conversion of fibrinogen
to fibrin 13
Onset: Immediate (IV); ~20-30mins (S/C); not IM (hematoma)
Does not cross placenta & not excreted in breast milk
Renal & hepatic clearance, affected by obesity, renal function,
hepatic function, malignancy, presence of PE & infections
Anticoagulant response is nonlinear
Main side effects: Bleeding, thrombocytopenia, osteoporosis
(long term therapy), hyperkalemia
PHARMACOLOGY
24
Warfarin
MOA: Inhibits Vitamin K epoxide reductase in the liver, an enzyme required
for the activation of factors II, VII, IX, X
Onset: 36-72 hours, full therapeutic effect: 5-7 days
Oral absorption is rapid & complete (F~100%)
Hepatic metabolism via CYP2C9, minor include CYP2C19, 1A2, 3A4
Crosses placenta & cause embryopathy (nasal hypoplasia, stippled epiphyses)
in 1st trimester, CNS abnormalities & fetal hemorrhage C/I in pregnancy!
Can be used in breastfeeding (does not enter breast milk)
Side effects: bleeding, angina, purple toes syndrome, skin necrosis
PHARMACOLOGY
29
Warfarin (Con’t)
Factors influencing INR:
Dietary Vitamin K intake
Alcohol consumption
Underlying diseases: diarrhea, prolonged fever, CHF, liver disease,
hepatic congestion, hyper- and hypothyroidism
Concurrent drug administered
Monitoring parameters:
PT
INR
Signs& symptoms of bleeding (gum bleeding, dark stool,
hematuria, skin petechiae etc)
PHARMACOLOGY
30
Warfarin (Con’t)
Table 9: Clinically Significant Warfarin Drug Interactions
Antibiotics
Oral contraceptives
Omeprazole/Ranitidine
Antiepileptics
Antifungals
Statins
Antiplatelets/anticoagulants
Thyroid drugs
NSAIDS
CONCLUSION
31
13) Hirsh DR, Ingenito EP, Goldhaber SZ: Prevalence of deep venous thrombosis
among patients in medical intensive care. JAMA 1995; 274: 335–337
14) Cade JF. High risk of the critically ill for VTE. Crit Care med 1982; 10:448-450
15) Fraisse F, Holzapfel L, Couland J-M. Nadroparin in the prevention of deep vein
thrombosis in acute decompensated COPD. Am J Respir Crit Care Med 2000;
161:1109-1114
16) Wells, Hirsch J, Anderson DR, et al. Accuracy of clinical assessments of deep-vein
thrombosis. Lancet 1995;354:1275-1297
17) Gallus AS, Salzman EW, Hirsh J. Prevention of VTE: In: Colman RW, Hirsh J,
Marder VJ, eal, eds. Haemostasis and thrombosis: basic principles and clinical
practice. 3rd ed. Philadelphia, PA: JB Lippincott, 1994: 1331-1345.
18) Nicholaides AN, Bergqvist D, Hull R, et al. Prevention of VTE: international
consensus statement ( guidelines according to scientific evidence). Int Angiol
1997; 16: 3-38.
19) British National Formulary 55, March 2008. British Medical Association.
20) UpToDate
21) Lexi-Comp’s Drug Information Handbook, 13th Edition.
THANK YOU!