1. Dr. Lesbia Adalgisa Rodriguez PGY3-Cook County Loyola Family Medicine Residency Program Venous Thromboembolism Prophylaxis in the Inpatient Setting

2. Lets start with some critical thinking… 67 yo male with PMH of CHF, COPD, DM, HTN, HLD presenting with several episodes of melena one week ago that have now resolved as well as feelings of lightheadedness and weakness. Guaiac was negative and abdominal exam was completely benign. His CBC in the ER showed a WBC count of 6.5 H/H of 7.2/27.8 with PLTs of 79. RPT CBC several hours later showed a stable hemoglobin. The patient is admitted over night for possible upper GI bleed. Is this patient at risk for DVT/PE? What form of prophylaxis would you initially use on this patient when he hits the floor? If his EGD shows peptic ulcer disease, not actively bleeding, what form of prophylaxis would you then use after his EGD until he is discharged?

3. Objectives Explain why use Venous Thromboembolism (VTE) Prophylaxis List complications of poor VTE Prophylaxis Interpret the risk assessment protocol for VTE prophylaxis in the inpatient setting List the forms of prophylaxis available and when they should be used Practice in your small groups

4. Why is VTE Prophylaxis important? More than 300,000 Americans develop DVT annually and as many as 100,000 deaths occur each year Most hospital inpatients are at risk for thrombosis due to their personal risk factors and Virchow’s Triad Stasis, vessel injury and hypercoagulability The absolute risk of DVT is 10%-20% in general medical patients and more than doubles in other admissions

5. Why is VTE Prophylaxis important? Medical patients account for up to 25% of DVT in the general population and up to 50% of new DVTs occur in the hospital setting The ENDORSE study in 2010 found that up to 50% of hospitalized patients are not receiving appropriate VTE prophylaxis and that general medicine patients that are at risk for VTE are less likely than surgical patients to receive appropriate prophylaxis. Core Measure

7. How are we doing at Stroger? Patients who got VTE prophylaxis on the day of or day after hospital admission or surgery

8. How are we doing at Stroger? Patients who developed a blod clot while in the hospital who did not get treatment that could have prevented it

9. Complications DVT Non-fatal and fatal Pulmonary Embolism Post Thrombotic Syndrome

10. Risks of prophylaxis Bleeding Heparin induced thrombocytopenia

11. Contraindications Recent bleed/current suspected bleed Allergy to the drug If they are already anti-coagulated

12. Current Stroger FMIS Risk Assessment

13. Risk Assessment

14. Risk Assessment Cont.

15. Methods of Prophylaxis Graduated compression stockings Intermittent pneumatic compression Unfractionated heparin Low molecular weight heparins Fondaparinaux

16. Graduated Compression Stockings

17. Sequential Compression Stockings

18. Heparin/Enoxaparin Heparin Acts at multiple sites in the coagulation process SQ, half-life 1.5 hrs Dosed Q 8 hrs when given SQ Enoxaparin LMWH Antithrombin III, inhibits thrombin and factor Xa SQ, halflife 4-7 hrs Dosed Q 12 hrs or Q 24 hrs

19. Fondaparinux Synthetic pentasacharide Acts at thrombin, antithrombin III and Xa Half life 17-21h Dosed Q 24 hrs Used in HIT Preferred in morbidly obese BMI>30

20. Conclusion The reasons for VTE prophylaxis are many It is important to think about every patient separately rather than just choose the same form of prophylaxis for all. Consider using fondaparinaux for patients with BMI >40, not just for patients with HIT We will go back to our 67 yo during our small group discussion.

21. References Caley W.E. Preventing deep vein thrombosis in hospital inpateients. BMJ 2007; 335:147-51 Bergmann J. et al. The ENDORSE Global Survey- Medical subanalysis. Thrombosis and Haemostasis. 103.4/2010 Qaseem A, Chou R, Humphrey LL, et al. Venous thromboembolism prophylaxis in hospitalized patients: a clinical practice gideline from the American College of Physicians. Ann Intern Med. 2011;155:625-632. ACCP Clinical Resource: Antithrombotic Therapy and Prevention of Thrombosis Effect of Fondaparinux Prophylaxis on Anti-factor Xa Concentrations in Patients With Morbid Obesity http://www.medscape.com/viewarticle/749863 University of Michigan – DVT/PE Risk Stratification www.healthcarereportcard.illinois.gov www.guideline.gov