Venous Thromboembolism Prophylaxis in Adults

Transcription

1 1 P a g e U N C H E A L T H C A R E G U I D A N C E D O C U M E N T Venous Thromboembolism in Adults P U R P O S E This document is intended to provide guidance on the provision of venous thromboembolism (VTE) prophylaxis in adult populations in the inpatient setting. Recomm endations provided in this document are a reflection of current guidelines, clinical evidence, and institutional initiatives. These recommendations are not intended to replace clinical judgment or patient evaluation and are meant as an organizational guideline; they are intended to serve as a tool for decision making. The table below provides recommendations for VTE prophylaxis in a variety of patient populations. The included options do not cover all possible scenarios; clinical judgment must be exercis ed in some situations (i.e. contraindications to anticoagulation, morbid obesity or low body weight, etc.) R E C O M M E N D A T I O N S SCREENING Routine screening for VTE is NOT recommended in asymptomatic individuals, either on a routine basis or on admission / discharge / transfer. Screening should only be performed in patients with symptoms suggestive of VTE. Developed by: [Type Brian text] Murray, PharmD, BCPS

2 2 P a g e R E C O M M E N D A T I O N S V T E P R O P H Y L A X I S Clinical Group 1 st Line Regimen 2 nd Line Regimen SCD Augmentation* M E D I C A L L Y I L L P A T I E N T S (includes critically ill patients) Low Risk for VTE 1 Early Ambulation SCDs Critically Ill or 1 ** OR *SCD Augmentation = Sequential Compression Devices / Intermittent Pneumatic Compression ** SQ q12h may be considered for certain patients based on clinical judgment May be effective in high-risk patients 1 P a d u a P r e d i c t i o n S c o r e f o r m e d i c a l l y i l l, h o s p i t a l i z e d p a t i e n t s R i s k F a c t o r P o i n t s A c t i v e C a n c e r 3 P r e v i o u s V T E ( e x c l u d i n g s u p e r f i c i a l ) 3 R e d u c e d m o b i l i t y ( a n t i c i p a t e d f o r 3 + d a y s ) 3 K n o w n t h r o m b o p h i l i c c o n d i t i o n 3 R e c e n t ( 1 m o n t h ) t r a u m a o r s u r g e r y 2 E l d e r l y ( 7 0 y e a r s ) 1 H e a r t / R e s p i r a t o r y F a i l u r e 1 A c u t e m y o c a r d i a l i n f a r c t i o n o r i s c h e m i c s t r o k e 1 A c u t e i n f e c t i o n o r r h e u m a t o l o g i c d i s o r d e r 1 O b e s i t y ( B M I 3 0 ) 1 O n g o i n g h o r m o n a l t r e a t m e n t 1 * H i g h R i s k o f V T E p r e d i c t e d b y s c o r e 4 p o i n t s ( C a l c u l a t e d V T E R i s k > 1 0 % ) * L o w R i s k o f V T E p r e d i c t e d b y s c o r e < 4 p o i n t s ( C a l c u l a t e d V T E R i s k < 1 % ) * D o e s N O T i n c l u d e c r i t i c a l l y i l l p a t i e n t s Prevention of VTE in nsurgical Patients. CHEST 2012;141(2)(Suppl):e195s-e226s Barbar S, venta F, Rossetto V, et al. J Thromb Heamost 2010;8(11): Phung OJ, Kahn SR, Cook DJ, Murad MH. CHEST 2011;140(2):

3 3 P a g e Clinical Group 1 st Line Regimen 2 nd Line Regimen SCD Augmentation O N C O L O G Y P A T I E N T S Medical Patients (Inpatient) Medical Patients (Outpatient) Routine prophylaxis NOT recommended Major Cancer Surgery* 7-10 days (High risk 4 weeks) * P r o p h y l a x i s s h o u l d b e g i n b e f o r e s u r g e r y N O T E : S p e c i a l c o n s i d e r a t i o n o f p a t i e n t - s p e c i f i c r i s k f a c t o r s f o r t h r o m b o s i s ( s e e b e l o w ) a n d b l e e d i n g ( i. e. b r a i n t u m o r s, t h r o m b o c y t o p e n i a ) i s r e q u i r e d i n t h i s p a t i e n t p o p u l a t i o n. A p p r o p r i a t e u s e o f c l i n i c a l j u d g m e n t i s r e q u i r e d. R i s k F a c t o r s f o r C a n c e r - A s s o c i a t e d T h r o m b o s i s C a n c e r - R e l a t e d T r e a t m e n t - R e l a t e d P a t i e n t - R e l a t e d B i o m a r k e r s P r i m a r y S i t e C h e m o t h e r a p y O l d e r A g e P l a t e l e t s ( 3 5 0, ) S t a g e A n t i a n g i o g e n i c a g e n t s R a c e L e u k o c y t e s ( > 1 1, ) C a n c e r H i s t o l o g y H o r m o n a l T h e r a p y M e d i c a l C o m o r b i d i t i e s H e m o g l o b i n ( < 1 0 ) T i m e f r o m d i a g n o s i s E S A a g e n t s T r a n s f u s i o n s I n d w e l l i n g a c c e s s d e v i c e s R a d i a t i o n t h e r a p y S u r g e r y > 6 0 m i n O b e s i t y H i s t o r y o f V T E L o w p e r f o r m a n c e s t a t u s P r o t h r o m b o t i c m u t a t i o n s VTE and Treatment in Patients with Cancer: ASCO Clinical Practice Guideline Update. J Clin Oncol 2013;31(17):

4 4 P a g e Clinical Group 1 st Line Regimen 2 nd Line Regimen SCD Augmentation G E N E R A L S U R G E R Y / V A S C U L A R S U R G E R Y / L A P A R O S C O P Y Very Low Risk for VTE 2 Early Ambulation SCDs Low Risk for VTE 2 Moderate Risk for VTE / Vascular 2 2 SCDs T H O R A C I C S U R G E R Y ( i n c l u d i n g L u n g T r a n s p l a n t ) At Risk for VTE C A R D I A C S U R G E R Y ( i n c l u d i n g H e a r t T r a n s p l a n t ) Low Risk for VTE At Risk for VTE (complicated co urse) M A J O R T R A U M A All Patients SCDs alone Enoxaparin 30mg SQ q12h OR Alternative to pharmacologic prophylaxis Alternative to pharmacologic prophylaxis (when not contrain dicated) Alternative to pharmacologic prophylaxis Alternative to pharmacologic prophylaxis (when not contrain dicated) Prevention of VTE in northopedic Surgical Patients. CHEST 2012;141(2)(Suppl):e227s-e277s. Bush S, LeClaire A, Hampp C, Lottenberg L. J Intensive Care Med 2011;26(2): weeks if undergoing abdominal / pelvic surgery for can cer

5 5 P a g e 2 C a p r i n i S c o r e f o r h o s p i t a l i z e d s u r g i c a l p a t i e n t s 1 P o i n t 2 P o i n t s 3 P o i n t s 5 P o i n t s A g e A g e A g e 7 5 S t r o k e ( < 1 m o ) M i n o r S u r g e r y A r t h r o s c o p i c S u r g e r y H i s t o r y o f V T E E l e c t i v e A r t h r o p l a s t y B M I > 2 5 M a j o r O p e n S u r g e r y ( > 4 5 m i n ) F a m i l y H i s t o r y o f V T E H i p, p e l v i s, l e g f r a c t u r e S w o l l e n l e g s L a p a r o s c o p i c s u r g e r y F a c t o r V L e i d e n A c u t e s p i n a l c o r d i n j u r y P r e g n a n c y / p o s t p a r t u m C o n f i n e d t o b e d ( > 7 2 h ) L u p u s a n t i c o a g u l a n t H i s t o r y o f u n e x p l a i n e d / r e c u r r e n t s p o n t a n e o u s a b o r t i o n O r a l c o n t r a c e p t i v e s, h o r m o n e r e p l a c e m e n t S e p s i s ( < 1 m o ) S e r i o u s l u n g d i s e a s e ( i n c l u d i n g p n e u m o n i a ) A b n o r m a l p u l m o n a r y f u n c t i o n A c u t e m y o c a r d i a l i n f a r c t i o n C o n g e s t i v e h e a r t f a i l u r e ( < 1 m o ) H i s t o r y o f i n f l a m m a t o r y b o w e l d i s e a s e M e d i c a l p a t i e n t, b e d r e s t I m m o b i l i z e d p l a s t e r c a s t C e n t r a l v e n o u s a c c e s s A n t i c a r d i o l i p i n a n t i b o d i e s E l e v a t e d s e r u m h o m o c y s t e i n e H I T * V a l i d a t e d i n g e n e r a l, v a s c u l a r, a n d u r o l o g i c a l s u r g e r y p a t i e n t s * V e r y L o w R i s k = 0 * L o w R i s k = 1-2 * M o d e r a t e R i s k = 3-4 * H i g h R i s k 5 O t h e r c o n g e n i t a l / a c q u i r e d t h r o m b o p h i l i a Caprini JA, Arcelus JI, Hasty JH, Tamhane AC, Fabrega F. Semin Thromb Hemost 1991;17(suppl 3):

6 6 P a g e 2 R o g e r s S c o r e fo r h o s p i t a l i z e d s u r g i c a l p a t i e n t s R i s k F a c t o r O p e r a t i o n t y p e o t h e r t h a n e n d o c r i n e R e s p i r a t o r y a n d h e m i c 9 T A A, e m b o l e c t o m y / t h r o m b e c t o m y, v e n o u s r e c o n s t r u c t i o n, e n d o v a s c u l a r r e p a i r 7 A n e u r y s m 4 M o u t h, p a l a t e 4 S t o m a c h, i n t e s t i n e s 4 I n t e g u m e n t 3 H e r n i a 2 A S A P h y s i c a l S t a t u s C l a s s i f i c a t i o n 3, 4, o r F e m a l e G e n d e r 1 W o r k R V U > T w o p o i n t s f o r a n y o f t h e b e l o w 2 D i s s e m i n a t e d c a n c e r C h e m o t h e r a p y f o r m a l i g n a n c y w i t h i n 3 0 d a y s P r e o p e r a t i v e s e r u m s o d i u m > m m o l / L T r a n s f u s i o n > 4 u n i t s P R B C i n 7 2 h o u r s b e f o r e o p e r a t i o n V e n t i l a t o r d e p e n d e n t O n e p o i n t f o r a n y o f t h e b e l o w 1 W o u n d c l a s s ( c l e a n / c o n t a m i n a t e d ) P r e o p e r a t i v e h e m a t o c r i t l e v e l < 3 8 % P r e o p e r a t i v e b i l i r u b i n l e v e l > 1. 0 m g / d L D y s p n e a A l b u m i n l e v e l 3. 5 m g / d L E m e r g e n c y * M o d e l d e v e l o p e d i n g e n e r a l, v a s c u l a r, a n d t h o r a c i c s u r g e r y p a t i e n t s * V e r y L o w R i s k < 7 * L o w R i s k = 7-10 * M o d e r a t e R i s k > 1 0 P o i n t s Rogers SO Jr, Kilaru RK, Hosokawa P, Henderson WG, Zinner MJ, Khuri SF. J Am Coll Surg 2007;204(6):

7 7 P a g e Clinical Group 1 st Line Regimen 2 nd Line Regimen SCD Augmentation N E U R O L O G Y Ischemic Stroke Hemorrhagic Stroke (stable) n-stroke, At Risk for VTE n-stroke, (neuromuscular illness) N E U R O S U R G E R Y Low Risk for VTE At Risk for VTE Trauma / Acute Spinal Cord Injury S P I N A L S U R G E R Y Low Risk for VTE (OR 30mg SQ q12h if spinal cord involved ) SCDs SCDs alone x h, then Heparin 5000 units SCDs alone x h, then Enoxaparin 30mg SQ q12h SCDs SCDs alone x h, then Heparin 5000 units SCDs alone x h, then Enoxapari n 40mg SCDs alone x h, then Heparin 5000 units OR Heparin 5000 un its May be effective in high-risk patients SCDs alone until anticoagulatio n acceptable May be effective in high-risk patients (when not contraindicated) t Recommended t Recommended Prevention of VTE in northopedic Surgical Patients. CHEST 2012;141(2)(Suppl):e227s-e277s. Sherman DG, Albers GW, Bladin C, PREVAIL Investigators. Lancet 2007;369(9570):

8 8 P a g e Clinical Group 1 st Line Regimen 2 nd Line Regimen SCD Augmentation O R T H O P E D I C S U R G E R Y Lower Leg Injuries, At Risk for VTE Lower Leg Injuries, Hip / Knee Arthroscopy Hip / Knee Arthroscopy, Total Knee Replacement Knee Replacement, Total Hip Replacement Hip Replacement, Hip Fracture Surgery Early Mobilization SCDs Early Mobilizati on SCDs ASA 325mg PO BID ASA 325mg PO BID SCDs 6 weeks ASA 325mg PO BID Warfarin Goal INR: weeks 6 weeks 6 weeks 2-6 weeks Prevention of VTE in Orthopedic Surgery Patients. CHEST 2012;141(2)(Suppl):e278s-e325s. AAOS Guidelines (

9 9 P a g e Clinical Group 1 st Line Regimen 2 nd Line Regimen SCD Augmentation B A R I A T R I C S U R G E R Y All Patients B U R N S All Patients T R A N S P L A N T Kidney Transplant SQ q12h (starting POD # 1) Heparin 7500 units SCDs alone (if heparin contrain dicated) Alternative to pharmacologic prophylaxis Liver Transplant SCDs SCDs Donors SDCs alone (if heparin contrain dicated) O B S T E T R I C S S e e A p p e n d i x A f o r S e r v i c e G u i d e l i n e Prevention of VTE in northopedic Surgical Patients. CHEST 2012;141(2)(Suppl):e227s-e277s.

10 10 P a g e A P P E N D I X A - VTE Guidelines for Inpatient Obstetrics Antepartum Hospitalized Patient All patients should receive SCDs (sequential compression devices) Continue chemotherapy (Heparin or LMWH) if previously receiving prophylactic or full anticoagulation Add prophylactic anticoagulation (Heparin or LMWH) if: o BMI >40 o Personal Hx VTE not already on prophylaxis o 3 Group 1 Risk Factors (see below) Postpartum Hospitalized Patients Cesarean o All patient receive SCDs placed prior to delivery and continue until fully ambulatory o Continue any antepartum prophylactic or full anticoagulation o Add prophylactic chemotherapy (Heparin or LMWH) if: BMI >40 Personal Hx VTE not already on prophylaxis Family Hx VTE plus any thrombophilia 2 Group 1 or Group 2 Risk Factors (see below) Vaginal o Continue any antepartum prophylactic or full anticoagulation o Add chemoprophylaxis (Heparin or LMWH) if: BMI >40 Personal Hx VTE not already on prophylaxis Family Hx VTE plus any thrombophilia 2 of Group 1 or Group 2 Risk Factors (see below) Discharge Chemoprophylaxis: See VTE Algorithm on mombaby.org Risk Factors Group 1 Group 2 Thrombophilia not already on prophylaxis Cesarean delivery Age >40 Peripartum hemorrhage BMI >30 Hysterectomy Medical complications (IBD, Sickle cell, SLE, etc.) General anesthesia Pregnancy complications (Multiples, HTN, IUGR) Postpartum infection Strict bed rest Prophylactic Anticoagulation Regimens Enoxaparin Unfractionated Heparin <50 kg 20mg daily 1 st trimester 5,000-7,500 units q12h kg 40mg daily 2 nd trimester 7,500-10,000 units q12h kg 30mg BID 3 rd trimester 10,000 units q12h kg 40mg BID >170 kg 0.6 mg/kg/day in 2 divided doses