Mutidisciplinary cooperation on VTE prevention and managment TAO YANG Dpartment of vascular surgery Shanxi DAYI Hospita Tai yuan Shanxi China
Disclosure Speaker name: Tao Yang... I have the following potential conflicts of interest to report: Consulting Employment in industry Stockholder of a healthcare company Owner of a healthcare company Other(s) I do not have any potential conflict of interest
VTE is a major public health problem Acute symptoms, fatal PE, Posthrombotic Syndrome are major causes of disability and societal burden
The risk of developing VTE depends on the condition and/or procedure for which the patient is admitted and on any predisposing risk factors elderly smoke obesity clinical/ family history of VTE recent surgery, trauma critical patients acute myocardium infarction patients with heart-lung failure ischemia stroke Severe pulmonary disease cancer oral contraceptive pregnant/postpartum tumor chemotherapy diabetes rheunatic diseases inflammatory bowel disease nephrotic syndrome hormon replacement therapy metabolic syndrome Acute infectious diseases long-haul travel permanent pacemaker long-term CVC
Why VTE prvention is so important? 1. VTE is an important cause of death in hospitalised patients. 2. Treatment of non-fatal symptomatic VTE is associated with a considerable cost to the health service.
VTE prevention Gudelines from different countries or orgnizations ACCP CMA NCCN NICE
VTE Prevention got increasing attention in CHINA 1 2 1. http://www.moh.gov.cn/publicfiles/business/htmlfiles/mohyzs/pggtg/200805/35449.htm 2. http://www.moh.gov.cn/publicfiles/business/htmlfiles/mohyzs/s3586/200909/42741.htm
M internal medicine surgical department VTE management team obstetrics-gynecology oncology department imaging department D T laboratory medicine ultrasonic department invasive department vascular surgery
Recommended procedures for prevention of venous thromboembolism in hospitalized patients
Risk assessment -VTE Padua score for inpatient in intrenal medicine Risk Factors score Active cancer 3 Previous venous thromboembolism (VTE) 3 Reduced mobility 3 Known thrombophilic condition 3 Recent trauma or/and surgery 2 Age 70 years 1 Heart and/or respiratory failure 1 Acute myocardial infarction or stroke 1 Acute infection and/or rheumatologic disorder 1 Obesity (BMI 30Kg/m 2 ) 1 Hormonal treatment 1 Clinical probability simplified score Low risk High risk <4 4 Barbar S, Noventa F, Rossetto V,et al. A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score[J].J Thromb Haemost, 2010, 8(11): 2450-2457
Risk assessment -VTE Caprini score for surgical inpatient 0 very low risk 1~2 low risk 3~4 medium risk 5 High risk Caprini JA. Why thrombosis prophylaxis fails]]. Vase Ds Manag. 2009, 6(2),47-51
Risk assessment -VTE Khorana score for inpatient with malignancy Type of cancer Fisk Factors Points Stomach of pancreatic 2 Lung,lymphoma,gynecologic,bladder,or testicular 1 Platelet count 350,000/mm 3 1 Hemoglobin<10 g/dl 1 White-cell count >11,000/mm 3 1 BMI 35Kg/m 2 1 Clinical probability simplified score Low risk 0 Medium risk 1~2 High risk Prevention of thrombosis in children with cancer and tunnelled CVCs,JCO June 10, 2013 vol. 31 no. 17 2189-2204 3
Risk assessment -Bleeding Regard hospitalised patients as being at risk of bleeding if they have any of the following risk factors: Active bleeding Acquired bleeding disorders (such as acute liver failure) Concurrent use of anticoagulants known to increase the risk of bleeding (such as warfarin with INR higher than 2) Lumbar puncture/epidural/spinal anaesthesia expected within the next 12 hours Lumbar puncture/epidural/spinal analgesia within the previous 4 hours Acute stroke Thrombocytopenia (platelets less than 50 10 9 /l) Uncontrolled systolic hypertension (180 mmhg or higher) Untreated inherited bleeding disorders (such as haemophilia and von Willebrand s disease). Reducing the Risk of Venous Thromboembolism (Deep Vein Thrombosis and Pulmonary Embolism) in Patients Admitted to Hospital,Venous Thromboembolism.NICE Clinical Guidelines, No. 92 2010
VTE prophylaxis recommendations VTE Risk category VTE prophylaxis recommendations High risk Pharmacological VTE prophylaxis Continue pharmacological VTE prophylaxis until the patient no longer has significantly reduced mobility Medium risk High/medium VTE risk with high bleeding risk low risk Pharmacological VTE prophylaxis Mecahnic prophylaxis until the patient can have pharmacological VTE prophylaxis Basic prophylaxis
VTE prevention informed consent to hospitalised patient both benefit and risk of pharmacological and mechanical prophylaxis DVT-PE self risks Risk of complications Postthrombotic syndrome CTEPH Retiring VTE and disabling Preventive measures risk Hemorrhage and bruising HIT Cerebral /gastrointestinal hemorrhage death The occurrence of venous thromboembolism Sign informed consent
Basic prophylaxis 1. VTE knowledge education 2. Improve lifestyles education:quit smoking, abstain from alcohol, control blood sugar and lipids 3. Soft and delicate operation, avoid intimal injury 4. Avoiding dehydration
mechanical prophylaxis Ankle pump movement Foot impulse Anti embolisim stocking Intermittent pneumatic compression device
pharmacological prophylaxis
Vena caval filters Temporary or retrievable IVCF to patients who are at very high risk of VTE and for whom mechanical and pharmacological VTE prophylaxis are contraindicated.
Clinical variable Active cancer (treatment ongoing or within previous 6 months or palliative) 1 Paralysis, paresis, or recent plaster immobilization of the lower extremities 1 Recently bedridden for 3 days or more, or major surgery within the previous 12 weeks requiring general or regional anesthesia Localized tenderness along the distribution of the deep venous system 1 Entire leg swelling 1 Calf swelling at least 3 cm larger than that on the asymptomatic leg (measured 10 cm below the tibial tuberosity) Pitting edema confined to the symptomatic leg 1 Collateral superficial veins (non-varicose) 1 Previously documented DVT 1 Score Alternative diagnosis at least as likely as DVT ) -2 Clinical probability simplified score DVT likely DVT unlikely Diagnosis of DVT Wells Score 1 1 2 1 Wells PS, Anderson DR, Rodger M, Forgie MA, Kearon C, Dreyer JF, Kovacs G, Mitchell M, Lewandowski B, Kovacs MJ. Evaluation of D-Dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med 2003; 349: 1227 35.
Strategy for diagnosis of DVT Diagnostic algorithm using clinical probability, D- dimer and ultrasound in patients with suspected DVT. Diagnostic algorithm using clinical probability of DVT likely, D-dimer and ultrasound in patients with suspected DVT.
Diagnosis of PE Wells score Clinical variable Clinical signs and symptoms of DVT (minimum of leg swelling and pain with palpation of the deep veins) Score 3 An alternative diagnosis is less likely than PE 3 Heart rate greater than 100 beats per minute 1.5 Immobilisation (for more than 3 days) or surgery in the previous four weeks 1.5 Previous DVT/PE 1.5 Haemoptysis 1 Malignancy (on treatment, treated in the last 6 months, or palliative) 1 Clinical probability simplified score PE likely PE unlikely 4 3 Wells PS, Anderson DR, Rodger M, Forgie MA, Kearon C, Dreyer JF, Kovacs G, Mitchell M, Lewandowski B, Kovacs MJ. Evaluation of D-Dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med 2003; 349: 1227 35.
Strategy for diagnosis of PE Strategy for diagnosis of PE using CTPA in patients who are PE likely. Strategy for diagnosis of PE using CTPA in patients who are PE unlikely.
Treatment and Management on DVT Etiological removal anticoagulant Inferior vena caval filters Prevent thrombus propagation Prevent PTE, reduce morbidity protect CDT Prevent DVT RECURRENCE thrombectomy PMT SUR Relieve patients' symptoms Prevent Post thrombotic syndrome Iliocaval stents Placement compression therapy
Treatment and Management on PE Konstantinides SV, Torbicki A, Perrier A, et al. 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J, 2014.
The proportion of patients who had VTE prophylaxis was increasing year by year 120,00% 100,00% 80,00% 60,00% 40,00% 20,00% 96,89% 89,08% 94,54% 85,43% 86,24% 84,32% 78,56% 92,40% 79,65% 73,54% 69,32% 70,89% 79,50% 67,83% 74,30% 63,34% 59,31% 73,40% 61,76% 64,45% 58,65% 59,71% 55,23% 47,87% 50,10% 47,83% 45,89% 42,76% 40,42% 38,76% 0,00% In 2015 In 2016 In 2017
Incidence of VTE in high risk group was disreasing year by year 35,00% 30,00% 28,87% 25,00% 20,00% 15,00% 10,00% 5,00% 19,59% 19,43% 19,34% 17,72% 16,67% 14,54% 14,09% 13,87% 13,38% 13,03% 11,53% 13,65% 12,54% 13,75% 10,06% 11,56% 10,93% 9,23% 10,84% 9,46% 9,08% 8,87% 8,08% 9,68% 7,32% 8,87% 7,24% 7,69% 6,23% 0,00% In 2015 In 2016 In 2017
SUMMARY 1. Comprenhnsive assessment 2. Nomative VTE prevention 3. Meticilous surgery 4. Careful nursing 5. Timely diagnosis 6. Professional treatment Prevention Diagnosis Treatment Mutidisciplinary cooperation
Mutidisciplinary cooperation on VTE prevention and managment TAO YANG Dpartment of vascular surgery Shanxi DAYI Hospita Tai yuan Shanxi China