VTE Management in Surgical Patients: Optimizing Prophylaxis Strategies

Transcription

1 VTE Management in Surgical Patients: Optimizing Prophylaxis Strategies

2 VTE in Surgical Patients: Recognizing the Patients at Risk

3 Pathogenesis of thrombosis: Virchow s triad and VTE Risk Hypercoagulability increased coagulation reduced fibrinolysis Venous stasis Anethesia Hospitalisation Immobilisation Congestive Ht Failure Myocardial Infarction Cerebrovascular accidents Shock Obesity pregnancy Vascular damage Old Age Surgery Trauma Previous DVT Fracture Diabetes

4 Annual incidence of VTE in Europe Epidemiological data from local populations Western France (EPI-GETBO study)1 VTE: 183 per 100,000 DVT: 124 per 100,000 PE: 60 per 100,000 Sweden (Malmö)2 DVT: 160 per 100,000 Oger E. Thromb Haemost. 2000;83: Nordstrom M, et al. J Intern Med. 1992;232:

5 VTE in the EU: the VITAE study Incidence-based epidemiological model to estimate the total number of VTE events and deaths 641,275 symptomatic DVT 382,550 PE 478,500 VTE-related deaths Emphasizes the need for prophylaxis VITAE: VTE Impact Assessment Group in Europe. 70% Cohen AT, et al. Value in Health. 2005;8:A115.

6 Total VTE events in the USA Incidence-based model to estimate the total annual number of non-fatal and fatal VTE events 613,423 non-fatal VTE 61.4% DVT 38.6% PE 296,370 fatal VTE 0.8% DVT 99.2% PE Heit JA, et al. Blood. 2005;106:Abstract#910.

7 VTE is a leading cause of death in Europe The annual number of deaths related to VTE in the EU exceeds combined deaths due to: AIDS breast cancer prostate cancer transport accidents 5,860 86,831 63,636 53,599 Eurostat statistics on health and safety Available from:

8 VTE: magnitude of the problem Death PH PE PTS Symptomatic DVT Asymptomatic DVT PH = pulmonary hypertension. PTS = post-thrombotic syndrome.

9 Absolute risk of DVT Patient group DVT prevalence, % Medical patients General, major gynaecological, major urological, or neurosurgery THA/TKA or hip fracture surgery Major trauma Based on objective diagnostic testing for DVT in patients not receiving prophylaxis. THA = total hip arthroplasty. TKA = total knee arthroplasty. Geerts WH, et al. Chest. 2004;126 Suppl 3:338S-400S.

10 Incidence of VTE according to surgery Neurosurgery VTE incidence without malignancy (%) VTE incidence with malignancy (%)* Head and neck Vascular Gastrointestinal Urological Surgical procedure Gynaecological Orthopaedic *Symptomatic VTE at 91 days in patients receiving. White RH, et al. Thromb Haemost. 2003;90:

11 Moderate Risk Gynecologic surgeries Hysterectomy, adnexectomy, Laparotomy, ovariotomy, tubectomy, myomectomy General Surgeries GIT surgeries, cholecystectomy, herniotomy, Laparotomy Urological surgeries Nephrectomy, laparotomy Vascular surgeries Central venous access HIGH RISK Age > 40 Varicose veins Inflammatory bowel disease Obesity Oral contraceptive/hrt Nephrotic syndrome Indwelling central venous catheters History of VTE MI Lower extremity paralysis Malignancy Stoke AT III deficiency Protein C & S deficiency Burn

12 78% of Surgical patients have at least One Risk Factor

13 Incidence of PE according to surgery 0.54% Incidence (%) The 0.54% incidence (broken line) represents the mean incidence among the operated-on patients. Huber O, et al. Arch Surg. 1992;127:310-3.

14 Which surgical patients are at risk for VTE and require prophylaxis? Risk stratify patients according to type of surgery additional risk factors, e.g. age, prior VTE, cancer, molecular hypercoagulability VTE is a multihit disorder, the greater the number of risk factors the higher the risk of VTE Determine most suitable VTE prophylaxis contraindications to pharmacological prophylaxis? evidence-based guideline recommendations

15 RATIONALE OF THROMBOPROPHYLAXIS High prevalence of VTE in certain patient groups. Adverse consequences of unprevented VTE. Efficacy, effectiveness and cost-effectiveness of thromboprophylaxis.

16 7th ACCP Conference on Antithrombotic Therapy We recommend that every hospital develop a formal strategy that addresses the prevention of thromboembolic complications. This should generally be in the form of A written thromboprophylaxis policy. Geerts, Chest 2004;126:338S

17 AGENTS FOR PROPHYLAXIS Leg elevation. Early mobilization. Antiembolic stockings ( graduated compression ). Intermittent pneumatic calf compression. Heparins.

18 LEG ELEVATION

19 EARLY MOBILIZATION.

20 Antiembolic stockings Reduce DVT incidence by 50%.

21 Intermittent pneumatic calf compression.

22 THROMBOEMBOLIC PROPHYLAXIS PROTOCOL

23 Thromboprophylaxis Protocol STEPS 1. Determine level of risk. 2. Decide the way. 3. Check for contraindications. 4. Sign in.

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25 RECOMMENDATIONS SHORTCUTS

26 Surgery related risk Level of Risk Successful Prevention Strategies Minor surgery in patients < 40 yr with no additional risk Factors Low No specific prophylaxis; early and aggressive mobilization Minor surgery in patients with additional risk factors Surgery in patients yr with no additional risk factors Moderate LWMH (Clexane 20mg) Surgery in patients >60 yr, Surgery in patients yr with additional risk factors (prior VTE, cancer, molecular hypercoagulability) High Surgery in patients with multiple risk factors (age > 40 yr, cancer, prior VTE) Highest General surgery patients with a high risk of bleeding GCS ± IPC, at least initially until the bleeding risk decreases ± GCS or IPC LWMH (Clexane 40mg ) + GCS ± IPC LMWH (Clexane 40mg ) +GCS + IPC + Post discharge LWMH General

27 Surgery related risk Successful Prevention Strategies Brief procedures of < 30 min for benign disease No specific prophylaxis; early and aggressive mobilization laparoscopic gynecologic procedures, in whom additional VTE risk factors are present LWMH (Clexan 20mg) major gynecologic surgery for benign disease, without additional risk factors LWMH (Clexan 40mg ) ± GCS or IPC + GCS ± IPC extensive surgery for malignancy, and for patients LMWH (Clexan 40mg). with additional VTE risk factors or LMWH + GCS ± IPC continued until hospital discharge patients who are at particularly high risk, including continuing prophylaxis for 2 to 4 weeks those who have undergone cancer surgery and after hospital discharge are > 60 years of age or have previously experienced VTE Gynecologic

28 Surgery related risk Successful Prevention Strategies transurethral or other low-risk urologic procedures No specific prophylaxis; early and aggressive mobilization major, open urologic procedures LWMH (Clexan 40 mg) + GCS ± IPC patients who are actively GCS ± IPC at least until the bleeding risk bleeding, or are at very high risk for bleeding decreases multiple risk factors LMWH (Clexan 40mg). + GCS ± IPC continued until hospital discharge Urologic

29 Surgery related risk Successful Prevention Strategies No risk factors No specific prophylaxis; early and aggressive mobilization additional thromboembolic risk factors LWMH (Clexan 40 mg) + GCS ± IPC Laparoscopic

30 risk Successful Prevention Strategies all trauma patients with at least one risk factor for VTE LMWH + GCS ±IPC until hospital discharge, including the period of inpatient rehabilitation active bleeding or a high risk for hemorrhage GCS ±IPC high risk for VTE (eg, in the presence of DUS screening a SCI, lower extremity or pelvic fracture, major head injury, or an indwelling femoral venous line) and who have received suboptimal prophylaxis or no prophylaxis Trauma

31 risk Successful Prevention Strategies moderate risk for VTE LMWH ( Clexan 20 mg ) + GCS ±IPC (eg, medically ill or postoperative patients high risk for bleeding GCS ± IPC at least until the bleeding risk decreases higher risk, such as that following major trauma or orthopedic surgery LMWH ( Clexan 40 mg )+ GCS ±IPC Critical Care

32 risk Successful Prevention Strategies CHF,Severe respiratory disease, stroke, LMWH ( Clexan 40 mg ) + GCS ±IPC or confined to bed with additional risk factors high risk for bleeding GCS ± IPC at least until the bleeding risk decreases Medical

33 THE STANDARD ANTITHROMBOTIC

34 Duration of VTE risk (2) ENOXACAN II: prospective study of duration of prophylaxis with LMWH in patients undergoing abdominal surgery for cancer Enoxaparin 40 mg o.d. for 6 to 10 days Placebo or enoxaparin 40 mg o.d. for an extra 21 days p = 0.02 p = % o.d. = once daily. Bergqvist D, et al. N Engl J Med. 2002;346:

35 Conclusions High incidence of VTE Leading cause of death Burden of disease is high Appropriate thromboprophylaxis, taking in to account the strength and number of risk factors present, can reduce the burden of disease VTE is a preventable public health crisis

36 Be Aware. Assess Risk. Prophylax. VTE awareness + Systematic risk assessment + Effective prophylaxis = Improved patient safety in our hospital VTE Safety ZONE - A simple strategy for significant improvement in patient safety

37 Thank YOU