Perioperative VTE prophylaxis (ACCP 9 th edition Guidelines) Gamal Marey SUNY Downstate Medical Center 10/16/2014

Perioperative VTE prophylaxis (ACCP 9 th edition Guidelines) Gamal Marey SUNY Downstate Medical Center 10/16/2014

Case Presentation 75 y/o AAM Rectal bleeding & obstructive symptoms 11/12 Obstructing mass in the descending colon, s/p left hemicolectomy, Hartmann s procedure 11/2012 Path. complicated diverticulitis Hospital course complicated by urosepsis and B/L PEs Elective Hartmann colostomy reversal on 9/14

Case Presentation PMH- HTN, BPH, COPD, cardiomyopathy, PE 11/12 Coumadin x 18 mons. PSH- umbilical hernia repair, Hartmann s procedure Medications- Enalopril, Doxazosin, Carvedilol, Iron Allergy- NKDA SH- former smoker FH- not relevant

Labs CBC- 4.3/11.9/38/314 BMP- 139/4.6/107/27/21/1.15/100 LFTs- 7.3/4.0/22/13/66/0.4 Coags- 14.3/40.3/1.4

VTE Risk Factors Assessment Age 75 3 Lung dis. 1 Major surgery > 45 min. 2 History of PE. 3 Caprini score : 9 Operation Type 4 ASA 2 Work RUV 2 Wound class 1 HCT<38 1 Rogers score : 10

pre-op. 5000 SC heparin (one dose) Intraop. Intermittent pneumatic compression devices Post-op. 40 mg lovenox Daily

Postop. Course POD#1- clear liquid diet POD#2- Regular diet POD3- Discharged home with VNS

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Outlines Epidemiology Pathophysiology Risk factors Symptoms Diagnosis Prevention guidelines Summary

VTE= DVT+PE

Epidemiology 350.000 to 600.000 Americans suffer each year from DVT and PE 100.000 death 2ry to PE most common preventable cause of hospital death Never events. # 1 priority to improve safety in hospitals

Epidemiology Incidence of symptomatic VTE after abdominal surgeries occurs up to 3.1% with risk of fatal perioperative PE 0.8% Incidence of asymptomatic DVT 25-30% in General surgery patients 20-30% PTS 70 % VTE after hospital discharge (within 90 days). Risk 10-50 times

2003 Nationwide Inpatient Sample Surgical patients with LOS>2 days 7.8 million 44% low risk 14% moderate risk 24% high risk 17% very high risk Many surgical patients at risk for VTE Anderson et al. Am J Hematol. 2007;82:777-782

Pathophysiology Anticoagulants (prostacyclin, thrombomodulin, heparin proteoglycan) Flow Endothelial integrity Procoagulant and proinflammatory conditions involving tissue factor, P-selectin, platelets, monocytes, granulocytes, microparticles

Virchow s Triade

www.downstatesurgery.org

Surgical Risk factors Type and extent of surgery or trauma Type of anesthesia Duration of hospital stay A history of previous VTE or cancer Immobility/ obesity Perioperative Sepsis Malignancy Central venous access Hyper-coagulable state Caucasians and African Americans

Risk of DVT in hospitalized patients No PPx with DVT screening Patient group DVT incidence Medical Patients 10-20% Major GYN/Uro/GS 15-40% Neurosurgery 15-40% Stroke 20-50% Hip/Knee surgery 40-60% Major trauma 40-80% Spinal cord injury 60-80% Critical care patients 15-80%

VTE Consequences Leg swelling and discomfort Dyspnea, chest pain, hypoxemia Extended hospital LOS Fatal PE (34% diagnosed/ 59% undiagnosed) Complications of prolonged anticoagulation Postphlebitic syndrome Chronic pulmonary HTN (PAP>25 mmhg. Persists 6 months after PE

DVT Diagnosis Physical exam Pain, edema, erythema, tenderness, fever, prominent superficial veins, Homan s sign Imaging Duplex ultrasound The ACCP guidelines recommend against routine screening for VTE with Doppler ultrasonography before discharge if the patient is asymptomatic.

Perioperative VTE Prevention Patient specific factors/ Risk Stratification. using evidence based scoring systems Procedure Specific factors prophylaxis Based on RA, risk/benefit, efficacy/safety and evidence based guidelines

Rogers VTE Risk Assessment Grading System

Rogers VTE Risk Assessment Grading System

Caprini VTE Risk Assessment Grading System

Bahl et al. Ann Surg. 2010;251:344-350

Prevention of VTE Mechanical prophylaxis Intermittent pneumatic compression therapy Continous external compression therapy Pharmaco-prophylaxis Low dose Unfractionated heparin (UFH) Low molecular weight heparin (LMWH) Fondparinux New oral anticoagulants Warfarin Aspirin Vena Caval interruption (EAST)

Evidence: anticoagulant thromboprophylaxis in general surgery Unfractionated heparin (UFH) reduces risk of fatal PE by 66% Low-molecular weight heparin (LMWH) reduces risk of symptomatic VTE by 80% in patients undergoing abdominal surgery Prophylactic anticoagulants reduce the risk of silent DVT by 30-70%

UFH vs. LMWH Non-randomized prospective- laparoscopic gastric bypass 238 UFH 5,000 units TID; 238 enoxaparin 40mg BID 1 PE in UFH Postop transfusion: enoxaparin vs UFH: 6% vs 1% Conclusion Equivalent efficacy for VTE prophylaxis LMWH- better Biovability and more predictable effect Singh, Podolsky et al. Obesity Surgery (2012). 22:4

UFH vs. LMWH LMWH More expensive less frequent dosing Longer half life UFH Less expensive More dosing Shorter half life Contraindicated in renal failure Greater safety in pts with epidural catheters Lower risk of HIT Higher risk of HIT

ACCP 9th Edition Guidelines General and abdominal-pelvic surgery Caprini = 0 / Rogers Score: < 7 ( very low VTE risk <0.5%) Ambulation www.downstatesurgery.org No pharmacological (1B) or mechanical ppx (2C) is needed Harms > benefits (4-10 bleeds/1000 pts vs. 0-3 nonfatal VTE)

ACCP 9th Edition Guidelines General and abdominal-pelvic surgery Caprini=1-2/ Rogers Score: 7-10 ( Low VTE risk ~ 1.5%) Use mechanical ppx (IPC) over nothing (2C) Harms = benefits with pharmacologic ppx (19/1000 vs. 13/1000)

ACCP 9th Edition Guidelines General and abdominal-pelvic surgery Caprini=3-4/ Rogers Score: >10 (moderate VTE risk ~ 3%) Not at high bleeding risk, use LMWH (2B), UFH (2B), or mechanical ppx (IPC)(2C) over none 2 fold more VTE prevented than bleeding events High bleeding risk, use mechanical ppx (2C)

ACCP 9th Edition Guidelines General and abdominal-pelvic surgery Caprini >5 (high VTE risk ~ 6%) Not at high bleeding risk, use LMWH (1B), UFH (1B), and add mechanical ppx (2C) High bleeding risk, use mechanical ppx (2C) until bleeding risk less; then start pharmacoppx.

ACCP 9th Edition Guidelines General and abdominal-pelvic surgery Abdominal or pelvic surgery for cancer History of VTE Spinal cord injury Extended Duration thrombo-ppx Recommend LMWH x 4 weeks (1B)

Cardiac: similar, but IPC for non complicated po course; add pharmacologic for complicated po course (2C) Thoracic: pharmacologic (2B) and IPC (2C) Trauma: IPC + pharmacologic prophylaxis (2B) IVC filter should NOT be used for primary prevention (2C)

ACCP 9 th Edition Guidelines (Critically ill medical patients) At High risk of thrombosis, use LMWH, LDUH, or fondaparinux (1B) At High risk for bleeding, Mechanical ppx (IPC) (2C)

Pharmacologic Thrombo-prophylaxis Considerations UFH Initiate 1-2 hours prior to induction of general anesthesia TID dosing superior to BID dosing If pharmacologic thrombo-prophylaxis is indicated, continue until hospital discharge or at least 7 days postoperatively

Relative Contraindications to pharmacologic prophylaxis Severe head injuries Nonoperatively managed liver or spleen injuries Renal failure Spinal column fracture with epidural hematoma Severe thrombocytopenia and coagulopathy Chest. 2012; 141;e227S-e277S

Treatment of Acute VTE Delay in initiation of therapeutic anticoagulation >24 hrs is associated with increased rate of VTE Use LMWH or fondaparinux over IV UFH (2C) Use anticoagulant therapy over systemic thrombolysis or venous thrombectomy (2C) Contraindication to anti-coagulation, an IVC filter is recommended (1B)

Treatment of Acute VTE 1 st VTE 2ry to reversible factor (provoked) 1 st VTE unprovoked -At the end of 3 mon. -If no CI -During long term Rx Duration 3 mon. 1A At least 3 mon. Assess for long term Rx Long term Rx Assess Risk/benefit Recurrent VTE Long term Rx. 1A VTE 2ry to cancer Long term Rx. LMWH during 1st 3-6 mon., then anticoagulate as long as the cancer is active Grade 1A 1C 1A 1C 1A 1C Kearon C, et al. Chest 2008; 133 (6 suppl):454s-545s.

Strategies to improve VTE ppx Hospital policy of risk assessment Electronic alerts to prevent VTE computer decision-support systems preprinted orders Reliable data collection and performance tracking periodic audit and feedback

NEW ENGLAND SURGICAL SOCIETY ARTICLES Reducing Postoperative Venous Thromboembolism Complications with a Standardized Risk-Stratified Prophylaxis Protocol and Mobilization Program Michael R Cassidy, MD, Pamela Rosenkranz, RN, BSN, MEd, David McAneny, MD, FACS Standardized electronic physician orders Caprini risk stratification. The derived scores dictate the nature and the duration of VTE ppx comparing 2 years before and after implementing trial with NSQIP VTE outcomes DVT decreased by 84% from 1.9% to 0.3% PE fell by 55% from 1.1% to 0.5%

Conclusion VTE remains a substantial health problem in the US prophylaxis remains underutilized VTE risk factor stratification on admission Identify contraindications to prophylaxis Order risk appropriate VTE prophylaxis Reassess VTE risk factors and contraindications during hospital stay IVC filters are not recommended as primary VTE prophylaxis

References - White RH, Zhou H, Romano PS. Incidence of symptomatic venous thromboembolism after different elective or urgent surgical procedures. Thromb Haemost 2003; 90:446. - Sandler DA, Martin JF. Autopsy proven pulmonary embolism in hospital patients: are we detecting enough deep vein thrombosis? J R Soc Med 1989; 82:203. - Martino MA, Borges E, Williamson E, et al. Pulmonary embolism after major abdominal surgery in gynecologic oncology. Obstet Gynecol 2006; 107:666. - Dismuke SE, Wagner EH. Pulmonary embolism as a cause of death. The changing mortality in hospitalized patients. JAMA 1986; 255:2039 - Bergqvist D et al.duration of prophylaxis against venous thromboembolism with enoxaparin after surgery for cancer. N. Engl J Med. 2002; 346 (13): 975-980 - Pannucci CJ,et al. Postoperative enoxaparin prevents symptomatic venous thromboembolism in high risk plastic surgery patients. Plast Reconstr Surg. 2011 Nov;128(5):1093-103.

Q- what is the most common inherited thrombophilia? A- Antiphospholipid antibodies B- Antithrombin III deficiency C- Protein C/S deficiency D- Factor V Leiden E- Prothrombin gene 20210A mutation F- Hyperhomocystinemia

Q- what is the most common inherited thrombophilia? A- Antiphospholipid antibodies B- Antithrombin III deficiency C- Protein C/S deficiency D- Factor V Leiden E- Prothrombin gene 20210A mutation F- Hyperhomocystinemia

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