Acute venous or arterial thrombosis Acute venous or arterial thrombosis Is there clinical concern for an anatomic compressive syndrome or occlusive iliofemoral.

Slides:



Advertisements
Similar presentations
Acute venous or arterial thrombosis Acute venous or arterial thrombosis Is there an indication for thrombolysis? Baseline labs: CBC, PT, PTT, fibrinogen.
Advertisements

Vanderbilt Pediatric Hematology Anticoagulation Guidance Protocol Robert F. Sidonio, Jr. MD, MSc. 4/11/12 Enoxaparin Dosing Goal anti-Xa levels are 0.6.
Hyperacute Stroke Treatment: Inclusion and Exclusion Criteria
Chapter Six Venous Disease Coalition Acute Management of VTE VTE Toolkit.
Joint Hospital Surgical Grand Round
Prophylaxis of Venous Thromboembolism
Venous Thromboembolism
HEPARIN INDUCED THROMBOCYTOPENIA GALILA ZAHER MBB ch, dip C Path, MRC Path.
Anticoagulation in Acute Ischemic Stroke. TPA: Tissue Plasminogen Activator 1995: NINDS study of TPA administration Design: randomized, double blind placebo-controlled.
Thrombolytic Therapy for Catheter related venous Thromboses in Infants Dr Osama Bawazir FRCSI, FRCS(Ed), FRCS (glas), FRCSC.
CHEST-2012: High Points and Pearls Alan Brush, MD, FACP Chief, Anticoagulation Management Service Harvard Vanguard Medical Associates.
DVT/VTE Nursing Protocol (Deep Vein Thrombosis) (Venous Thromboembolism) Presented by Maribeth Desiongco MA, RN-BC 2008.
Deep vein thrombosis. Color duplex scan of DVT Venogram shows DVT.
Unprovoked DVT in a young patient
Isolated Thrombolysis for DVT DVT Treatment with the Trellis ® Peripheral Infusion System Manufacturer’s Registry Report Gerard J. O’Sullivan MD Mahmood.
1 TLB PowerPoint presented By Takaya L. Brown, BSN, BSN, CMSRN.
Pulmonary Embolism. Definition: Sudden lodgment of a blood clot in a pulmonary artery with subsequent obstruction of blood supply to the lung parenchyma.
DR FAROOQ AHMAD RANA ASSISTANT PROFESSOR SURGERY
Lymphography and Venography Venous Circulation.
NURS 1950 Pharmacology I 1.  Objective 1: identify general reasons anticoagulants are given 2.
Vanderbilt Pediatric Hematology Anticoagulation Guidance Protocol Robert F. Sidonio, Jr. MD, MSc. 4/12/12 Warfarin Monitoring If inpatient, consider monitoring.
ANTICOAGULANT, THROMBOLYTICS & ANTIPLATELET DRUGS.
Peri-operative management of anticoagulation Marc Carrier MD, MSc FRCPC Assistant Professor, University of Ottawa Associate Scientist, Ottawa Health Research.
Total Joint Replacement
April 23, 2015 Mini-Lecture Nathan King M.D. Anticoagulation Reversal Part 2: UFH & LMWH.
T. P.A. tissue Plasminogen Activator Presented by: Kelly Banasky, RN, BSN GCH Emergency Services Educator.
Renal vein thrombosis Nephrology discussion Dr. Coetser Prof. Van Rensburg and dr. Rossouw.
Venous Thromboembolism
Cancer-Associated Thrombosis
7th ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence-Based Guidelines.
ANTICOAGULATION THERAPY OR CATHETER DIRECTED THROMBOLYSIS Alice Marinho, Carlos Veterano, Maricruz Nunes, Patrícia Baptista, Pedro Aguiar, Pedro Campelo,
To Clot Or Not To Clot… Emergency Care for Coagulation Disorders/Conditions Rebecca Goldsmith Pediatric Thrombosis/Hemophilia Nurse McMaster Children’s.
Stroke and the ED Kurian Thomas, MD Department of Neurology.
Moderate Pulmonary Embolism Treated with Thrombolysis (MOPETT) Trial Mohsen Sharifi, Curt Bay, Laura Skrocki, Farnoosh Rahimi, Mahshid Mehdipour A.T.Still.
The Evolving Management of Pediatric Stroke Christopher A. Miller, MD July 21, 2012.
PULMONARY EMBOLI Kenney Weinmeister M.D.. PULMONARY EMBOLI w Over 500,000 cases per year. w Results in 200,000 deaths. w Mortality without treatment is.
Thrombolysis. What is it? A Procedure that removes or destroys clots A Procedure that removes or destroys clots Preformed in a Angio suit Preformed in.
Presented by: Passant Mounir Nagy Under the supervision of: Prof. Dr/ Seham Hafez.
71-year old male Admitted with worsening shortness of breath PMHx: Severe COPD, A.Fib, CHF/ischemic, PE On long term anticoagulation with Pradaxa 150.
IVC filters what you need to know Sam Chakraverty Consultant Radiologist Ninewells Hospital Dundee, Scotland.
Jomo Osborne Lung-2015 Baltimore, USA July , 2015.
Oral Rivaroxaban for Symptomatic Venous Thromboembolism.
Treatment of Ischaemic Stroke The American Heart Association American Stroke Association Guidelines Stroke. 2007;38:
THROMBOLYTIC DRUGS Pathophysiologic Rationale
Peri-Operative anticoagulation /antiplatelet therapy A Shift in Paradigm BMHGT04/29/09.
Drugs Susan Louw Haematology Registrar. 4 Questions to ask: Can I stop? (What is the risk of thrombosis?) Should I stop? (What is the risk of bleeding?)
Iman Al-Obari, Ms Pharm; Abdulrazaq Al-Jazairi, PharmD; Iman Zaghloul, PhD; Mahasen Saleh, MD Ali Sanei, MD; Aabdulrahman Al Mousa, MD; Zuhair Al-Halees,
FRagmin® and Fast Revascularization during InStablity in Coronary artery disease FRISC II.
DVT cases.  Heparin, low molecular weight heparin, or fondaparinux are usually continued for at least five days, along with another medication called.
Venous thromboembolic diseases: the management of venous thromboembolic diseases and the role of thrombophilia testing June 2012 NICE clinical guideline.
Antithrombotic Therapy for VTE: CHEST Guidelines 2016
Haemostasis. Indications for hemostasis test – Identify patients presenting with bleeding that have a correctable bleeding tendency – Identify patients.
Cerebral Angiography Radiological study of the blood vessels of the brain to enable physicians to localized and diagnose pathology or anomalies of the.
Antithrombotic and Thrombolytic Therapy for Ischemic Stroke Antithrombotic Therapy and Prevention of Thrombosis: ACCP Evidence-Based Clinical Practice.
One of the main causes of DVT is inactivity! When a person is inactive, your blood normally collects in the lower part of your body. (in your legs) This.
STAFFORDSHIRE THROMBOSIS AND ANTICOAGULATION CENTRE (STAC) PATIENT SPECIFIC DIRECTION FOR DALTEPARIN (LMWH) FOR PATIENTS WITH VENOUS THROMBO-EMBOLISM (VTE)/MECHANICAL.
Treatment of deep venous thrombosis and pulmonary embolism Anders Waage.
Antithrombotic and Thrombolytic Therapy for Ischemic Stroke Antithrombotic Therapy and Prevention of Thrombosis: ACCP Evidence-Based Clinical Practice.
Dr. Lesbia Adalgisa Rodriguez PGY3-Cook County Loyola Family Medicine Residency Program Venous Thromboembolism Prophylaxis in the Inpatient Setting.
Outpatient DVT assessment & treatment Daniel Gilada.
Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation NEJM Aug 27, 2015.
CASE PRESENTATION Clifford J Kavinsky, MD, PHD Professor of Medicine and pediatrics Associate Director, Center for Congenital and Structural Heart Disease.
By: Dr. Nalaka Gunawansa
Percutanous thrombolysis of massive pulmonary embolism in an unstable post-op patient with recent epidural catheter and a prolonged cardiac arrest.
Complex Case Presentations. Complications and Management.
Volume 151, Issue 2, Pages e35-e39 (February 2017)
High Risk Diagnosis Extensive or multifocal venous malformations (VM)
Calculate Well’s score for PE (BOX1)
Anticoagulants.
Current status of thrombolytic therapy
Presentation transcript:

Acute venous or arterial thrombosis Acute venous or arterial thrombosis Is there clinical concern for an anatomic compressive syndrome or occlusive iliofemoral or IVC DVT?________________________________ ____ Consider anatomic thrombotic obstruction: May-Thurner Syndrome -Acute occlusive iliofemoral vein/lower IVC thrombosis in left lower extremity Paget-Schroetter Syndrome -Subclavian thrombosis with recent vigorous exercise of upper extremity (pitcher, drummer, etc.) Is there clinical concern for an anatomic compressive syndrome or occlusive iliofemoral or IVC DVT?________________________________ ____ Consider anatomic thrombotic obstruction: May-Thurner Syndrome -Acute occlusive iliofemoral vein/lower IVC thrombosis in left lower extremity Paget-Schroetter Syndrome -Subclavian thrombosis with recent vigorous exercise of upper extremity (pitcher, drummer, etc.) Is there an indication for thrombolysis? Baseline labs: CBC, PT, PTT, fibrinogen activity, FVIII activity, D-dimer (quantitative) and CRP -Defer hypercoaguability workup until outpatient -Start UFH or Enoxaparin ____________________________________________ _ Start Enoxaparin: <3 month old 1.7mg/kg/dose BID 3-12 months old 1.5mg/kg/dose BID 1-5 years old 1.2mg/kg/dose BID 6-18 years of age 1mg/kg/dose BID -Notify Kathy Jernigan for teaching (pager ) Goal anti-Fxa 0.5-1, 4-5 hours after second dose ____________________________________________ UFH (clinically unstable, expected surgery or post- cardiac surgery) : Load: 75 units/kg over 10 minutes (max 5000 units) Maintenance: < 1 year of age: 28 units/kg/hr ≥ 1 year of age: 20 units/kg/dose Goal PTT seconds (Consider only hrs) and anti-FXa inhibition Baseline labs: CBC, PT, PTT, fibrinogen activity, FVIII activity, D-dimer (quantitative) and CRP -Defer hypercoaguability workup until outpatient -Start UFH or Enoxaparin ____________________________________________ _ Start Enoxaparin: <3 month old 1.7mg/kg/dose BID 3-12 months old 1.5mg/kg/dose BID 1-5 years old 1.2mg/kg/dose BID 6-18 years of age 1mg/kg/dose BID -Notify Kathy Jernigan for teaching (pager ) Goal anti-Fxa 0.5-1, 4-5 hours after second dose ____________________________________________ UFH (clinically unstable, expected surgery or post- cardiac surgery) : Load: 75 units/kg over 10 minutes (max 5000 units) Maintenance: < 1 year of age: 28 units/kg/hr ≥ 1 year of age: 20 units/kg/dose Goal PTT seconds (Consider only hrs) and anti-FXa inhibition Does patient meet inclusion and exclusion criteria for tPA? Check baseline tPA labs: CBC PT/PTT Fibrinogen activity Plasminogen activity D-dimer (quantitative) FVIII activity CMP CRP Check baseline tPA labs: CBC PT/PTT Fibrinogen activity Plasminogen activity D-dimer (quantitative) FVIII activity CMP CRP Vanderbilt Pediatric Hematology Thrombolysis (tPA) Protocol Inclusion Criteria for tPA -Symptoms present < 14 days -Thrombus site and extent confirmed by objective imaging -No more than 48 hours of UFH or LMWH for thrombus (systemic tPA only) -Platelet count > 100,000/  l -Fibrinogen > 100 mg/dl -No thrombus in previous site Exclusion criteria for tPA -Active bleeding -Active seizures < 48 hours -Invasive procedure < 3 days (chest tube, lumbar puncture, liver biopsy etc) -Major surgery < 10 days -CNS bleeding or surgery < 14 days -History of HIT -Allergic reaction to UFH, LMWH or alteplase -Renal or liver failure -Uncontrolled Hypertension Yes No Key UFH: Unfractionated Heparin LMWH: Low molecular weight Heparin CNS: Central Nervous System tPA: Tissue Plasminogen Activator (usually alteplase) Gtt: drip HIT: Heparin induced thrombocytopenia No Yes Systemic tPA 1) Begin systemic tPA: mg/kg/hr if <2 months of age mg/kg/hr if >2 months of age 2) Perform cranial U/S if <1 month old within 7days 3) Concurrent UFH gtt at 10 Units/kg/hr -Do not adjust PTT to therapeutic goal 4) tPA labs q8hrs 5) Maintain fibrinogen and plt count >100 6) tPA x 24 hours and re-image with U/S Systemic tPA 1) Begin systemic tPA: mg/kg/hr if <2 months of age mg/kg/hr if >2 months of age 2) Perform cranial U/S if <1 month old within 7days 3) Concurrent UFH gtt at 10 Units/kg/hr -Do not adjust PTT to therapeutic goal 4) tPA labs q8hrs 5) Maintain fibrinogen and plt count >100 6) tPA x 24 hours and re-image with U/S Catheter-directed tPA 1) Contact Interventional Radiology for catheter-directed tPA 2) Start therapeutic UFH gtt 3) Make NPO for procedure 4) Start mIVF 5) Lab goals: Platelet >100k Fibrinogen >100mg/dL 6) CTA/V of affected area prior to catheter-directed tPA 7) Once catheter tPA done: a) Goal PTT seconds x 48hrs b) Check tPA labs q8h x 48 hrs c) Convert to Enoxaparin after 48hrs Catheter-directed tPA 1) Contact Interventional Radiology for catheter-directed tPA 2) Start therapeutic UFH gtt 3) Make NPO for procedure 4) Start mIVF 5) Lab goals: Platelet >100k Fibrinogen >100mg/dL 6) CTA/V of affected area prior to catheter-directed tPA 7) Once catheter tPA done: a) Goal PTT seconds x 48hrs b) Check tPA labs q8h x 48 hrs c) Convert to Enoxaparin after 48hrs Yes No Robert F. Sidonio, Jr. MD, MSc. tPA labs CBC PT/PTT Fibrinogen activity D-dimer (quantitative) BMP -CMP if LFTS abnormal at baseline No clot lysis Double tPA dose Repeat U/S in 24hrs No clot lysis Double tPA dose Repeat U/S in 24hrs >0-50% clot lysis Increase tPA by 50% Repeat U/S in 24hrs >0-50% clot lysis Increase tPA by 50% Repeat U/S in 24hrs >50-95% clot lysis Cont. same dose tPA Repeat U/S in 24hrs >50-95% clot lysis Cont. same dose tPA Repeat U/S in 24hrs >95% clot lysis Stop tPA -Therapeutic UFH x 48 hrs - tPA labs x 48hrs -Switch to Enoxaparin >95% clot lysis Stop tPA -Therapeutic UFH x 48 hrs - tPA labs x 48hrs -Switch to Enoxaparin 0-50% clot lysis Either the following: -Continue same tPA dose and repeat U/S in 24hrs -Stop tPA __________________________________________ Once tPA done: Therapeutic UFH x 48 hrs, tPA labs x 48hrs Switch to Enoxaparin 0-50% clot lysis Either the following: -Continue same tPA dose and repeat U/S in 24hrs -Stop tPA __________________________________________ Once tPA done: Therapeutic UFH x 48 hrs, tPA labs x 48hrs Switch to Enoxaparin >50-100% clot lysis Either the following: -Continue same tPA dose and repeat U/S in 24hrs -Stop tPA ________________________________________ Once tPA done: Therapeutic UFH x 48 hrs, tPA labs x 48hrs Switch to Enoxaparin >50-100% clot lysis Either the following: -Continue same tPA dose and repeat U/S in 24hrs -Stop tPA ________________________________________ Once tPA done: Therapeutic UFH x 48 hrs, tPA labs x 48hrs Switch to Enoxaparin Indications for thrombolysis Strong Indications -Life, limb or organ-threatening thrombosis -Arterial or venous thrombosis causing ischemia -Superior Vena Cava Syndrome -Massive PE with cardio instability -Bilateral renal vein thrombosis -Cerebral Sinovenous thrombosis with neurologic decline -Large atrial thrombi (congenital heart disease) Intermediate Indications -Acute iliofemoral or IVC thrombosis -May-Thurner Syndrome -Paget-Schroetter Syndrome Obtain pediatric hematology consult 4/1/12