1. LHD Logo Venous Thromboembolism Reducing the Risk DATE

2. Objectives Define venous thromboembolism Heighten awareness – the impact of VTE – the preventable nature of VTE Discuss importance of – VTE risk assessment – appropriate prescribing of prophylaxis – engaging patients Demonstrate how to assess VTE risk

3. Venous Thromboembolism VTE = Deep vein thrombosis (DVT) and/or pulmonary embolism (PE) DVTPE Occurs in deep veins (most commonly in legs and groin) Occurs after DVT dislodges and travels to the lungs Can cause long-term issues – ‘post-thrombotic syndrome’ (PTS) Serious complication which can lead to death PTS affects 23-60% of DVT patients within 2 years Lower-extremity DVT has 3% PE-related mortality rate Patients with PE have 30-60% chance of dying from it

4. What Causes VTE Virchow’s Triad = categories of factors contributing to blood clot formation Stasis Alteration in normal blood flow Endothelial Injury Injury or trauma to the inside of the blood vessel Hypercoagulability Alternation in the constitution of blood causing blood to clot more easily VIRCHOW’S TRIAD

5. The Impact of VTE More than 14,000 Australians develop a VTE per year More than 5,000 of them will die as a direct result VTE causes 7% of all hospital deaths VTE causes more deaths than bowel Ca and breast Ca

6. VTE Risk Factors

7. Intrinsic Risk FactorsExtrinsic Risk Factors Age > 60 yearsSignificantly reduced mobility (relative to normal state) due to injury or illness Obesity (BMI > 30kg/m 2 )Active malignancy or treatment with chemotherapy Prior history of VTEUse of HRT or oral contraception Pregnancy or post-partumSurgical intervention, particularly major orthopaedic surgery or abdominal/pelvic surgery for cancer Known thrombophilia (including inherited disorders) Active infection Varicose veinsInflammatory bowel disease

8. Hospitalisation Hospitalisation = ↑ risk of VTE ~ 50% of VTE cases occur during or soon after hospitalisation – 24% (surgery) – 22% (medical illness) Incidence 100 times greater in hospitalised patients than community residents

9. Preventing VTE

10. Preventability Largely preventable Shift thinking: complication vs adverse event

11. Assessing Risk Who should be assessed?

12. Assess overall VTE risk vs benefit – Assess clotting risk – Assess bleeding risk i.e. contraindications to prophylaxis and/or other bleeding risks Assessing Risk

13. Prescribing Prophylaxis Patient at risk + nil C/I = prescribe Two types of prophylaxis: 1. pharmacological 2. mechanical Ensure C/I to both pharmacological and mechanical prophylaxis have been considered Evidence-based guidelines

14. NHMRC Guidelines

15. Pharmacological Prophylaxis Anticoagulants Alter the process of blood coagulation to prevent VTE formation http://www.healio.com/orthopedics/hip/news/online/%7Ba0ebf835-ae3d-42df- a9e5-ae55b11e0413%7D/new-oral-anticoagulants-for-thromboprophylaxis-after- total-hip-or-knee-arthroplasty The coagulation cascade and activity of anticoagulants

16. Pharmacological Prophylaxis Main anticoagulants include: Drug ClassAgents Unfractionated heparin Preferred in patients with renal impairment LMWHEnoxaparin Dalteparin Most commonly used agents Require dosage adjustment in renal impairment Factor Xa inhibitors Apixaban Rivaroxaban Alternative for prophylaxis in post- hip or knee replacement FondaparinuxAlternative for prophylaxis in post- hip or knee replacement and hip fracture surgery Direct thrombin inhibitors DabigatranAlternative for prophylaxis in prophylaxis post- hip or knee replacement HeparinoidDanaparoidUsed in heparin-sensitivity or HIT

17. Pharmacological Prophylaxis Contraindications may include: Other relative contraindications may exist – weigh risk vs benefit Contraindications Active bleeding Thrombocytopenia (platelets < 50 x 10 9 /L) End stage liver disease (INR > 1.5) Treatment with therapeutic anticoagulant e.g. warfarin with INR > 2 Severe trauma to head or spinal cord, with haemorrhage in last 4 weeks

18. Mechanical Prophylaxis Devices that increase blood flow velocity in leg veins, reducing venous stasis. They include: Device Graduated Compression Stockings (GCS) Provide graduated compression, which is firmest at the ankle. Used mainly for ambulant patients Anti-embolic StockingStandard compression throughout. Used for bedbound or non-ambulant patients Intermittent Pneumatic Compression Device (IPC) Inflatable garment wrapped around legs which is inflated by pneumatic pump. Enhances venous return Foot Impulse Device (FID)Stimulates legs veins to mimic walking and reduce stasis. Used for immobilised patients

19. Mechanical Prophylaxis Contraindications may include: Contraindications Skin ulceration Lower leg trauma Morbid obesity (where correct fitting of stocking cannot be achieved) Massive leg oedema or pulmonary oedema due to CCF Stroke patients (avoid compression stockings)

20. Other Ways to Help Prevent VTE

21. Empowering Patients Engage your patients

22. Questions For further information: stopclots@cec.health.nsw.gov.au www.cec.health.nsw.gov.au