Tag Archives: dvt

Guidelines for DVT Prophylaxis in Neurocritical Care (from NCS)

DVT Chemoprophylaxis Guideline Recommendations (summary) from the Neurocritical Care Society (published in 2016).

 

ISCHEMIC STROKE

  1. We recommend initiating VTE pharmacoprophylaxis as soon as is feasible in all patients with acute ischemic stroke. (Strong recommendation and high-quality evidence)
  2. In patients with acute ischemic stroke and restricted mobility, we recommend prophylactic-dose LMWH over prophylactic-dose UFH in combination with IPC. (Strong recommendation and high-quality evidence)
  3. Due to insufficient evidence, the panel could not issue a recommendation regarding the use of CS for VTE prophylaxis although their use does not appear to be harmful.
  4. In stroke patients undergoing hemicraniotomy or endovascular procedures, we suggest the use of UFH, LMWH, and/or IPC for VTE prophylaxis in the immediate postsurgical or endovascular epoch except when patients have received rTPA, in which case prophylaxis should be delayed 24 h. (Weak recommendation and low-quality evidence)

INTRACRANIAL HEMORRHAGE

  1. We recommend the use of IPC and/or GCS for VTE prophylaxis over no prophylaxis beginning at the time of hospital admission. (Strong recommendation and high-quality evidence)

  2. We suggest using prophylactic doses of subcutaneous UFH or LMWH to prevent VTE in patients with stable hematomas and no ongoing coagulopathy beginning within 48 h of hospital admission. (Weak recommendation and low-quality evidence)

  3. We suggest continuing mechanical VTE prophylaxis with IPCs in patients started on pharmacologic prophylaxis. (Weak recommendation low-quality evidence)

     

ANEURYSMAL SUBARACHNOID HEMORRHAGE

  1. We recommend VTE prophylaxis with UFH in all patients with aSAH (Strong recommendation and high-quality evidence) except in those with unsecured ruptured aneurysms expected to undergo surgery. (Strong recommendation and low-quality evidence)

  2. We recommend initiating IPCs as VTE prophylaxis as soon as patients with aSAH are admitted to the hospital. (Strong recommendation and moderate-quality evidence)

  3. We recommend VTE prophylaxis with UFH at least 24 h after an aneurysm has been secured by surgical approach or by coiling. (Strong recommendation and moderate-quality evidence)

TRAUMATIC BRAIN INJURY

  1. We recommend initiating IPC for VTE prophylaxis within 24 h of presentation of TBI or within 24 h after completion of craniotomy as supported by evidence in ischemic stroke and postoperative craniotomy. (Weak recommendation and low-quality evidence)
  2. We recommend initiating LMWH or UFH for VTE prophylaxis within 24–48 h of presentation in patients with TBI and ICH, or 24 h after craniotomy. (Weak recommendation and low-quality evidence).
  3. We recommend using mechanical devices such as IPC for VTE prophylaxis in patients with TBI, based on data from other Neurological injuries such as ischemic stroke. (Weak recommendation and low-quality evidence).

BRAIN TUMOR

We recommend VTE prophylaxis with either LMWH or UFH upon hospitalization for patients with brain tumors who are at low risk for major bleeding and who lack signs of hemorrhagic conversion. (Strong recommendation and moderate-quality evidence).

SPINAL CORD INJURY

  1. We recommend initiating VTE prophylaxis as early as possible, within 72 h of injury. (Strong recommendation and high-quality evidence)
  2. We recommend against using mechanical measures alone for VTE prophylaxis. (Weak recommendation and low-quality evidence)
  3. We recommend LMWH or adjusted dose UFH for VTE prophylaxis as soon as bleeding is controlled. (Strong recommendation and moderate-quality evidence)
  4. If VTE prophylaxis with LMWH or UFH is not possible, we suggest mechanical prophylaxis with IPC. (Weak recommendation and low-quality evidence)

NEUROMUSCULAR DISEASE

  1. We recommend using prophylactic doses of UFH (bid or tid) LMWH, or fondaparinux as the preferred method of VTE prophylaxis. (Strong recommendation and moderate-quality evidence)
  2. We recommend using IPC for VTE prophylaxis for patients in whom the bleeding risk is deemed too high for pharmacologic prophylaxis. (Strong recommendation and moderate-quality evidence)
  3. We suggest combining pharmacologic and mechanical VTE prophylaxis (with IPC) in patients with neuromuscular disease. (Weak recommendation and low-quality evidence)
  4. We suggest using GCS only for VTE prophylaxis in patients in whom neither pharmacologic prophylaxis nor IPC use is possible. (Weak recommendation and low-quality evidence)
  5. We suggest continuing VTE prophylaxis for an extended period of time, at a minimum for the duration of the acute hospitalization, or until the ability to ambulate returns. (Weak recommendation and very low-quality evidence)

SPINE SURGERY

  1. Ambulatory back surgery with unique positioning strategies such as prone or kneeling has been associated with zero rates of VTE, and we suggest considering the use of IPC only for VTE prophylaxis in this surgical population. (Weak recommendation and low-quality evidence)
  2. In standard elective spine surgery, we recommend using ambulation with mechanical VTE prophylaxis (GCS or IPC) alone, or combined with LMWH. In patients with increased risk for VTE, we recommend combined therapy with ambulation, GCS or IPC, and LMWH. (Strong recommendation and moderate-quality evidence).
  3. Because of the increased risk of bleeding, we recommend using UFH only as an alternative to other methods of VTE prophylaxis. (Strong recommendation and moderate-quality evidence)

COMPLICATED SPINAL SURGERY

  1. We recommend using IPC with LMWH or UFH. (Strong recommendation and moderate-quality evidence)
  2. We recommend against the routine use of IVC filters in the setting of severe spinal cord injury or complicated spine surgery. (Weak recommendation and low-quality evidence)
  3. We suggest considering a removable prophylactic IVC filter as a temporary measure only in patients with PE and DVT or those with DVT at risk for PE who cannot be anticoagulated. (Weak recommendation and low-quality evidence)

ELECTIVE CRANIOTOMY

  1. We recommend using IPC with either LMWH or UFH within 24 h after craniotomy. (Strong recommendation and moderate-quality evidence)
  2. We recommend the use of IPC with LMWH or UFH within 24 h after standard craniotomy in the setting of glioma resection. (Strong recommendation and moderate-quality evidence)

ELECTIVE INTRACRANIAL / INTRA-ARTERIAL PROCEDURES

  1. We suggest the use of CS and IPC until the patient is ambulatory. (Weak recommendation and low-quality evidence)
  2. We suggest immediate prophylactic anticoagulation with LWMH or UFH. (Weak recommendation and low-quality evidence)

INTRACRANIAL ENDOVASCULAR PROCEDURES

  1. We recommend initiating pharmacoprophylaxis with UFH and/or mechanical VTE prophylaxis with IPC or CS in patients with hemiparesis from stroke or other neurological injury within 24 h if activated prothrombin time is measured. (Weak recommendation and low-quality evidence) If during the procedure rTPA or other thrombolytics are used, then extra caution is advised, and delay of initiation of chemoprophylaxis only for at least 24 h after the procedure should be considered. (Weak recommendation and low-quality evidence)
  2. Patients undergoing elective procedures may not require LMWH or UFH, but may benefit from early ambulation, and/or mechanical prophylaxis with IPC or CS. (Weak recommendation- very low-quality evidence)

 

Reference:

Nyquist, P., Bautista, C., Jichici, D., Burns, J., Chhangani, S., DeFilippis, M., Goldenberg, F., Kim, K., Liu-DeRyke, X., Mack, W. and Meyer, K. (2015). Prophylaxis of Venous Thrombosis in Neurocritical Care Patients: An Evidence-Based Guideline: A Statement for Healthcare Professionals from the Neurocritical Care Society. Neurocritical Care, 24(1), pp.47-60.

 

Upper Extremity Veins

Deep Veins:

Upper-extremity-deep-veins.jpg

1. paired ulnar, radial and interosseous veins in forearm
2. paired brachial veins of upper arm
3. axillary vein (continues as subclavian vein)

 

Superficial Veins:

Upper_extremity_veins_edt

 

  1. cephalic vein
  2. basilic vein

 

References

“Deep Veins Of The Upper Extremity.” Uptodate.com. Web. 27 July 2017.

“Primary (Spontaneous) Upper Extremity Deep Vein Thrombosis.” Uptodate.com. 27 July 2017.

Anticoagulation in Patients with Brain Metastases

Treatment:

  • Anticoagulate in patients with brain tumors and VTE except if risk of ICH is high: i.e.
    • melanoma mets
    • renal cell carcinoma mets
    • choriocarcinoma mets
    • thyroid carcinoma mets
  • treat x 3-6 months; long term if malignant gliomas
  • LMWH recommended versus warfarin
  • If risk of ICH high:
    • IVC filter if significant residual brain mets
    • if mets already removed / treated effectively and medical condition too unstable – anticoagulate

DVT Prophylaxis:

  • do not anticoagulate except in post-operative period
  • use SCDs with post-op LMWH or UFH 12-24 hours after surgery
  • cotninue prophylaxis until ambulation resumed

 

REFERENCE:

Uptodate. “Anticoagulant and antiplatelet therapy in patients with brain tumors.” Accessed 08/12/2016.

Lyman GH, Khorana AA, Falanga A, et al. American Society of Clinical Oncology guideline: recommendations for venous thromboembolism prophylaxis and treatment in patients with cancer. J Clin Oncol 2007; 25:5490.

 

Anti-factor Xa Levels (Enoxaparin and Heparin)

*Standard dosing (enoxaparin 30 q12h) may be inadequate in high risk trauma; lead to inc rates of DVT

Monitor antifactor Xa level

  • Normal value = <0.1
  • >0.5 considered therapeutically anticoagulated
  • 0.2 to 0.5 considered target level for prophylaxis

–Send trough before 4th dose

  • If normal –>increase to 40mg q12h; then 50 sq q12h or even 60 q12h

–With this approach, majority of patients require enoxaparin in 40 q12h dose

(Marino)

 

Patients with morbid obesity or renal failure may require monitoring of Anti-Xa levels.

  • anti-Xa levels in plasma should be measured 4 hours after LMWH administration
  • desired anti-Xa level = 0.6-1.0 units/mL for BID dosing and >1 unit/mL for OD dosing

 

Early RCTs on LMWS excluded the following patients:

1. BMI>50 kg//m2

2. Pregnant

3. Renally impaired (Cr clearance <30 ml/min)

 

UFH affects Factor II and Factor Xa, LMWH affects predominantly Factor Xa.

Peak anti-factor Xa level is reached 3-5 hours after administration.

 

Suggested peak anti-factor Xa levels for enoxaparin (therapeutic):

1. BID dosing – 0.6 to 1.0 IU/mL

2. OD dosing – 1.0-2.0 IU/mL

 

Table. Target anti-factor Xa ranges for therapeutic anticoagulation with LMWH.

Capture

Target range for prophylactic doses of LMWH not well defined.

Table. Target anti-factor Xa ranges for prophylactic doses of LMWH.

Captureb

Limited evidence available, but guidelines by ACCP suggests use of increased doses of LMWH perioperative for bariatric patients. Anti-factor Xa monitoring is recommended in patients with high-risk trauma and burns. Critically ill patients on inotropes may also be subtherapeutic on LMWH due to impaired peripheral circulation.

 

Table.  Target anti-factor Xa ranges for thromboprophylaxis in bariatric patients.

Capturec.JPG

BOTTOM LINE:  Reasonable anti-factor Xa target range is 0.2-0.5 IU/mL. Prospective studies are required to validate this recommendation.

ab

Therapeutic_Unfractionated_Heparin_Infusion_Guideline.pdf

References

Marino, P. and Sutin, K. (2007). The ICU book. Philadelphia: Lippincott Williams & Wilkins.

Wei, M. and Ward, S. (2015). The anti-factor Xa range for low molecular weight heparin thromboprophylaxis. Hematology Reports, 7(4).

https://www.uwhealth.org/files/uwhealth/docs/anticoagulation/Therapeutic_Unfractionated_Heparin_Infusion_Guideline.pdf

 

 

Caprini Risk Assessment Model for DVT

Caprini Risk Score

  • a tool to assess risk of VTE among surgical patients
  • includes 20 variables
  • derived from a prospective study of 538 general surgery patients

38tt2_Table_2_Caprini_Risk_Assessment_Model

a17tab02M