Venous Thromboembolism (VTE) Prevention

Transcription

1 Venous Thromboembolism (VTE) Prevention 7 VTE Risk Assessment: General Patient Population Assess VTE risk at admission, post-op, and transfer See page 2 for VTE risk assessment among Obstetrical (OB) patients See page 3 for Orthopedic Surgery patients undergoing Total Hip Arthroplasty (THA) or Total Knee Arthroplasty (TKA) See Appendix A, B and C for more details on risk factors, contraindications, and special populations Must meet all three: Ambulatory patient NO additional VTE risk factors (see page 5) Expected LOS < 48 hours LOW RISK Also consider: Minor surgery in patient (same day surgery or OR time < 30 minutes) NO additional VTE risk factors On FULL anticoagulation No pharmacologic prophylaxis None - Ambulation HIGH RISK All other patients who are NOT in the LOW, or VERY HIGH groups or are NOT receiving FULL anticoagulation Most medical and surgical inpatients Ambulation if drug therapy contraindication is documented VERY HIGH RISK CrCl < 30 CrCl > 30 CrCl < 30 CrCl > 30 Bariatric Surgery Abdominal or pelvic surgery for cancer, robotic and non-robotic surgery Multiple myeloma patients receiving an IMID with doxorubicin, mulitagent chemotherapy and/or dexamethasone 480mg/month or myeloma patients with 2 or more VTE risk factors and receiving IMIDs Neurosurgery Stroke (within the last month) Q24H Ambulation when patient is able Hip, pelvic, or severe lower extremity fractures Acute spinal cord injury (SCI) Multiple major trauma (e.g., multiple fractures due to a fall or motor vehicle accident) 30 mg SQ Ambulation when patient is able

2 2 VTE Risk Assessment: Obstetrical Patients Assess risk at admission, post-op, and transfer LOW RISK Must meet ALL: o Uncomplicated pregnancy* and vaginal delivery o NO additional VTE risk factors (see page 5) o Expected LOS < 48 hours No pharmacologic prophylaxis o BMI < 30 None - Ambulation o Parity < 3 o No current nicotine use HIGH RISK Ambulation All other patients who are NOT in the LOW, or VERY HIGH groups or are NOT receiving FULL anticoagulation Most medical and surgical inpatients instead of heparin ONLY if drug therapy contraindication is documented VERY HIGH RISK CrCl <30 CrCl > 30 CrCl < 30 CrCl >30 Cesarean hysterectomy Previous DVT Known thrombophilia Q24H Ambulation when patient is able *Complications include: Chorioamnionitis / endomyometritis Severe pre-eclampsia Immobility for > 4 days before operation

3 3 VTE Risk Assessment: Orthopedic Patients Assess risk at admission, post-op, and transfer See Appendix B and C for more details and information regarding Special Populations Follow recommendations of specialists for the following special populations: Vascular Medicine Referral Hematology Referral Cardiology Referral Chronic venous insufficiency Lymphedema Prior VTE (DVT or PE) Hypercoagulable state Sickle cell Hemophilia Atrial fibrillation Mechanical valve replacement LOW RISK Primary THA or TKA plus ALL of the following: o Age 65 years o BMI 35 kg/m 2 o No history of cancer or congestive heart failure Aspirin 325 mg by mouth twice a day for 6 weeks None - Ambulation VERY HIGH RISK * CrCl < 30 CrCl > 30 CrCl < 30 CrCl > 30 Revision or radical debridement of THA or TKA or one of the following: o BMI > 35 kg/m 2 o Age > 65 years o History of cancer or congestive heart failure 30 mg SQ *Note: Administer dose of pharmacologic prophylaxis within 8 to 10 hours of surgical end time.

4 Key Clinical Points Risk assessment to be completed via IHIS admission, pre-op, or post-op order sets upon admission. Patients should be reassessed daily to evaluate appropriateness of thromboprophylaxis (See Appendix A) In the absence of a major contraindication, use pharmacological thromboprophylaxis starting as soon as it is considered safe. If pharmacological thromboprophylaxis is contraindicated due to active bleeding or high risk for clinically important bleeding, use mechanical thromboprophylaxis. o Note: The Physician (APN, PA, or Pharmacist) is required to document that the patient is at a high risk for bleeding or has another contraindication to pharmacologic prophylaxis (See Appendix A). SCDs should be used in all patients for whom pharmacologic prophylaxis is contraindicated and in all very high risk patients unless patient is intolerant or has contraindications to SCDs. SCD contraindications may include: o Severe lower extremity peripheral vascular disease o Recent lower extremity revascularization Continue thromboprophylaxis until hospital discharge. For very high risk populations, consider continuing thromboprophylaxis for up to 4-6 weeks. For surgical patients, DVT / PE prophylaxis must be administered within 24 hours of surgical end-time, unless documented contraindication. Be aware of black box warning for LMWH related to epidural / spinal anesthesia, or lumbar puncture. Prior to an invasive/surgical procedure consult the surgeon/ proceduralist about the need to order or hold antithrombotic medications. For special populations see recommendations (Appendix B and C). References Guyatt GH, et al. (2012). Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th Edition: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest, 141(2): (Suppl) 7S -47S. Johanson NA, et al. (2009). Prevention of symptomatic pulmonary embolism in patients undergoing total hip or knee arthroplasty. Journal of the American Academy of Orthopaedic Surgeons,17(3): National Comprehensive Cancer Network (NCCN). Clinical Practice Guidelines in Oncology: Cancer-Associated Venous Thromboembolic Disease. V NCCN.org. Nyquist P - Neurocrit Care (2016) Prophylaxis of Venous Thrombosis in Neurocritical Care Patients An Evidence-Based Guideline A Statement for Healthcare Professionals from the Neuroc.pdf Surg Obes Relat Dis Jul-Aug;9(4): doi: /j.soard Epub 2013 Apr 15. Spinal Cord Injury Thromboprophylaxis Investigators. (2003). Prevention of Venous Thromboembolism in the acute treatment phase after spinal cord injury: a randomized, multicenter trial comparing low-dose heparin plus intermittent 7 pneumatic compression with enoxaparin. Journal of Trauma Injury Infection and Critical Care, 54(6): Hebbeler SL, et al. (2004). Daily vs twice daily enoxaparin in the prevention of venous thromboembolic disorders during rehabilitation following acute spinal cord injury. Journal of Spinal Cord Medicine, 27(3): Lyman GH, et al. (2015). Venous Thromboembolism Prophylaxis and Treatment in Patients with Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update Journal of Clinical Oncology, 33(6): Lyman GH, et al. (2013). Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update. Journal of Clinical Oncology, 31: Wang TF, at al. (2014). Efficacy and safety of high-dose thromboprophylaxis in morbidly obese inpatients. Journal of Thrombosis and Haemostasis, 111(1): Order Sets VTE prophylaxis orders are included in admission, pre-op, post op, and specialty group order sets as SmartGroups Quality Measures VTE incidence Appropriate VTE prophylaxis received Hospital Acquired Potentially Preventable VTE Guideline Authors Iahn Gonsenhauser, MD, MBA Thomas Scharschmidt, MD Daniel Eiferman, MD Dustin Chase, MD Julianna Roddy, PharmD, BCOP Tzu-Fei Wang, MD Joe Melucci, RPh, MBA Guideline Approved January 31, 2018 Fourth Edition. Disclaimer: Clinical practice guidelines and algorithms at The Ohio State University Wexner Medical Center (OSUWMC) are standards that are intended to provide general guidance to clinicians. Patient choice and clinician judgment must remain central to the selection of diagnostic tests and therapy. OSUWMC s guidelines and algorithms are reviewed periodically for consistency with new evidence; however, new developments may not be represented. Copyright The Ohio State University Wexner Medical Center. All rights reserved. No part of this document may be reproduced, displayed, modified, or distributed in any form without the express written permission of The Ohio State University Wexner Medical Center.

5 5 Appendix A: Risk Factors / Contraindications / Other Considerations Additional VTE Risk Factors VTE Prophylaxis Contraindications (Pharmacological) Absolute Relative Other Conditions Age > 70 years Obesity (BMI > 30 kg/m 2 ) Impaired mobility (bedrest with bathroom privileges) Prior history of VTE Active malignancy Known thrombophilic state Hormone replacement Estrogen-based contraceptives Acute or chronic lung disease Active hemorrhage Risk of bleeding outweighs benefit of pharmacologic prophylaxis. Examples include recent: o Severe trauma to head or spinal cord with hemorrhage o Intraocular surgery o Gastrointestinal, genitourinary hemorrhage o Thrombocytopenia (< 50 K) or abnormal INR o End-stage liver disease -induced thrombocytopenia o See OSUWMC HIT guideline for Non-heparin anticoagulant selection, dosing, and monitoring. Epidural analgesia with spinal catheter (current or planned). Acute myocardial infarction o Active intracranial lesions / Congestive heart failure neoplasms Nephrotic syndrome o Hypertensive urgency / emergency

6 Appendix B: VTE Prophylaxis for Special Populations- Recommendations 6 BMI < 40 Thromboprophylaxis Agents by Clinical Category (CrCl < 30 ml/min) UFH UFH LMWH 30 mg SQ (CrCl 30 ml/min) LMWH 40 mg SQ Q 24H LMWH 40 mg SQ Aspirin 325 mg PO BID SCD Abdominal and/or pelvic surgery for cancer X X X X X Acute spinal cord injury X X X X Bariatric surgery X X X X X Cancer Multiple Myeloma Very High Risk X X X X X Elective hip or knee arthroplasty - Low Risk 325 mg PO BID Elective hip or knee arthroplasty - High Risk X X X X X Hip/pelvic/severe lower extremity fractures X X X X X Major trauma X X X X X Neurosurgery X X X X X OB - High Risk X X OB - Very High Risk X X X X Stroke (within the last month) X X X X X All other patients who are NOT in the Low, Very High, or full anticoagulation categories X X Preferred Agent unless contraindicated Alternative Agent in the presence of contraindications

7 Appendix C: VTE Prophylaxis for Special Populations For very high risk populations, consider continuing thromboprophylaxis for up to 4-6 weeks. 7 VTE Population Acute Spinal Cord Injury (SCI) Additional Considerations For SCI associated with evidence of a spinal hematoma on CT or MRI, use mechanical thromboprophylaxis instead of pharmacological thromboprophylaxis at least for the first few days after injury. Following acute SCI, do not use UFH alone. Do not use an IVC filter as thromboprophylaxis. Post-Discharge Prophylaxis Continue pharmacological thromboprophylaxis for 8 to 12 weeks. Cancer Routine pharmacological thromboprophylaxis for primary prevention of VTE is not recommended in outpatient cancer patients with no additional risk factors for VTE. Routine thromboprophylaxis with LMWH or LDUH should be considered for outpatients with solid tumors who have additional risk factors for VTE and low risk of bleeding. Patients undergoing major cancer surgery should receive prophylaxis starting before surgery and continuing for at least 7-10 days. o Extending post-operative prophylaxis up to 4 weeks should be considered in those undergoing major abdominal or pelvic surgery with high risk features. Routine pharmacological thromboprophylaxis with either LMWH (for very high-risk) or aspirin mg (for low-risk) is recommended in those receiving IMIDs (thalidomide, lenalidomide, or pomalidomide). o If low-risk patients are admitted to the hospital, the risk elevates to high risk. o Very High risk patients are those receiving an IMID with doxorubicin, multi-agent chemotherapy and/or dexamethasone 480mg per month or multiple myeloma patients with 2 or more VTE risk factors and receiving IMIDs. Routine pharmacological prophylaxis is not recommended to prevent catheter-related thrombosis in those patients with indwelling central venous catheters. Intracranial Hemorrhage/ Subarachnoid Hemorrhage Obese Patients Orthopedic Patients Trauma Thromboprophylaxis should be initiated within the first 48 hours of hematoma stability or securing of the aneurysm. The surgeon should determine when the patient has achieved hemostasis. See OSUWMC Intracerebral Hemorrhage (ICH)/ Intraparenchymal Hemorrhage (IPH) Management guideline or Aneurysmal Subarachnoid Hemorrhage (SAH) guideline for more information. Although there is no consensus on what constitutes a high-risk patient, there is general agreement in the published literature that patients with higher BMIs (> 55 kg/m2), immobility, venous stasis, pulmonary hypertension, obesity hypoventilation syndrome, hypercoagulable state, and a history of VTE place patients in a higher risk category for VTE and an IVC filter may be considered in addition to chemoprophylaxis. LMWH is the preferred agent for prevention of VTE in patients undergoing Bariatric Surgery or those with higher BMI s as listed in the statement above. DO NOT obtain Doppler Ultrasonography to screen for DVT in asymptomatic patients DO NOT obtain Doppler Ultrasonography to screen for DVT in asymptomatic patients Placement of an IVC filter does NOT prevent DVT formation. For patients discharged to home or inpatient rehabilitation, no thromboprophylaxis is indicated. For patients discharged to Skilled Nursing or Long Term Care Facilities, pharmacological thromboprophylaxis is recommended. Pharmacological thromboprophylaxis is evaluated on a case by case basis for this patient population. For major orthopedic surgery, pharmacological thromboprophylaxis is recommended in the outpatient period for at least 35 days post operatively. Pharmacological thromboprophylaxis is evaluated on a case by case basis for this patient population.