Prevention of Venous Thromboembolism 8 th ACCP Guidelines Chest 2008

Do you have a Thromboprophylaxis Policy ?

Hospital Thromboprophylaxis Policy For every general hospital, we recommend that a formal, active strategy that addresses the prevention of VTE be developed (Grade 1A) We recommend that the local thromboprophylaxis strategy be in the form of a written, institution-wide thromboprophylaxis policy (Grade 1C) We recommend the use of strategies shown to increase thromboprophylaxis adherence, – including the use of computer decision support systems (Grade 1A), – preprinted orders (Grade 1B), – and periodic audit and feedback (Grade 1C). Passive methods such as distribution of educational materials or educational meetings are not recommended as sole strategies to increase adherence to thromboprophylaxis (Grade 1B).

Do you risk assess your patients in your ICU for VTE & Bleeding ?

Critical Care 8.1. For patients admitted to a critical care unit, we recommend routine assessment for VTE risk and routine thromboprophylaxis in most (Grade 1A).

Risk Assessment ICUHigh Risk HeparinsMDNoneReason A1310none3ICH, GpIIbIIa, B73GCS-14ICH, CKD, Postop-2 C121IPC-47ICH/SDH-4, GI bleed 3 D185GCS-3(+3)10Postop-3, Sepsis-4, CCF-1, Trauma-1, MI-1

8.2. For critical care patients who are at moderate risk for VTE (eg, medically ill or postoperative general surgery patients), we recommend using LMWH or LDUH thromboprophylaxis (Grade 1A).

General Surgery For moderate-risk general surgery patients who are undergoing a major procedure for benign disease, we recommend thromboprophylaxis with LMWH, LDUH, or fondaparinux (Grade 1A) For higher-risk general surgery patients who are undergoing a major procedure for cancer, we recommend thromboprophylaxis with LMWH, LDUH three times daily, or fondaparinux (each Grade 1A).

Critical Care 8.3. For critical care patients who are at higher risk (eg, following major trauma or orthopedic surgery), we recommend LMWH thromboprophylaxis (Grade 1A) For critical care patients who are at high risk for bleeding, we recommend the optimal use of mechanical thromboprophylaxis with GCS and/or IPC at least until the bleeding risk decreases (Grade 1A). When the high bleeding risk decreases, we recommend that pharmacologic thromboprophylaxis be substituted for or added to the mechanical thromboprophylaxis (Grade 1C).

Medical Conditions For acutely ill medical patients admitted to hospital with congestive heart failure or severe respiratory disease, or who are confined to bed and have one or more additional risk factors, including active cancer, previous VTE, sepsis, acute neurologic disease, or inflammatory bowel disease, we recommend thromboprophylaxis with LMWH (Grade 1A), LDUH (Grade 1A), or fondaparinux (Grade 1A) For medical patients with risk factors for VTE, and for whom there is a contraindication to anticoagulant thromboprophylaxis, we recommend the optimal use of mechanical thromboprophylaxis with GCS or IPC (Grade 1A).

Trauma For major trauma patients, if LMWH thromboprophylaxis is contraindicated due to active bleeding or high risk for clinically important bleeding, we recommend that mechanical thromboprophylaxis with IPC or possibly with GCS alone be used (Grade 1B). When the high bleeding risk decreases, we recommend that pharmacologic thromboprophylaxis be substituted for or added to the mechanical thromboprophylaxis (Grade 1C).

Neurosurgery For patients undergoing major neurosurgery, we recommend that thromboprophylaxis be used routinely (Grade 1A), with optimal use of IPC (Grade 1A). Acceptable alternatives to IPC are post operative LMWH (Grade 2A) or LDUH (Grade 2B) For patients undergoing major neurosurgery who have a particularly high thrombosis risk, we suggest that a mechanical method (ie, GCS and/or IPC) be combined with a pharmacologic method (ie, postoperative LMWH or LDUH) (Grade 2B).

Acute Spinal Cord Injury For patients with acute SCI, we recommend thromboprophylaxis with LMWH, commenced once primary hemostasis is evident (Grade 1B). Alternatives include the combined use of IPC and either LDUH (Grade 1B) or LWMH (Grade 1C).

Mechanical Methods of Thromboprophylaxis We recommend that mechanical methods of thromboprophylaxis be used primarily in patients at high risk of bleeding (Grade 1A), or possibly as an adjunct to anticoagulant-based thromboprophylaxis (Grade 2A) For patients receiving mechanical methods of thromboprophylaxis, we recommend that careful attention be directed toward ensuring the proper use of, and optimal adherence with, these methods (Grade 1A).

Problems with Mechanical Devices Less effective than pharmacological measures Pressure Sores & Non Optimal Use GCS reduced risk from 27% to 13% GCS + UFH from 15%-2% GCS contraindicated in arterial insufficiency GCS not effective in Strokes (Lancet 2010) IPC reduced DVT risk from 7%-2% IPC contraindicated in DVT for risk of PE Should not restrict ambulation

Renal Impairment and Anticoagulant Dosing We recommend that renal function be considered when making decisions about the use and/or the dose of LMWH, fondaparinux, and other antithrombotic drugs that are cleared by the kidneys, particularly in elderly patients, patients with diabetes mellitus, and those at high risk for bleeding(Grade 1A) Depending on the circumstances, we recommend one of the following options in this situation: avoiding the use of an anticoagulant that bioaccumulates in the presence of renal impairment, using a lower dose of the agent, or monitoring the drug level or its anticoagulant effect (Grade 1B).

Barriers Overestimation of Risk of Bleeding than Clotting Poor Awareness

Future The newer oral anticoagulants – rivaroxaban (Johnson & Johnson/Bayer) – dabigatran (Boehringer Ingelheim)

Summary All ICUs should develop a VTE prophylaxis policy All patients should be assessed for risk of VTE daily Raise awareness of VTE Surgeons have to be convinced about VTE prevention