Local hospital guidelines / LHH.
Local hospital guidelines / LHH.
DVT Chemoprophylaxis Guideline Recommendations (summary) from the Neurocritical Care Society (published in 2016).
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)
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)
We suggest continuing mechanical VTE prophylaxis with IPCs in patients started on pharmacologic prophylaxis. (Weak recommendation low-quality evidence)
ANEURYSMAL SUBARACHNOID HEMORRHAGE
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)
We recommend initiating IPCs as VTE prophylaxis as soon as patients with aSAH are admitted to the hospital. (Strong recommendation and moderate-quality evidence)
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
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
COMPLICATED SPINAL SURGERY
ELECTIVE INTRACRANIAL / INTRA-ARTERIAL PROCEDURES
INTRACRANIAL ENDOVASCULAR PROCEDURES
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.
“Deep Veins Of The Upper Extremity.” Uptodate.com. Web. 27 July 2017.
“Primary (Spontaneous) Upper Extremity Deep Vein Thrombosis.” Uptodate.com. 27 July 2017.
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.
*Standard dosing (enoxaparin 30 q12h) may be inadequate in high risk trauma; lead to inc rates of DVT
Monitor antifactor Xa level
–Send trough before 4th dose
–With this approach, majority of patients require enoxaparin in 40 q12h dose
Patients with morbid obesity or renal failure may require monitoring of Anti-Xa levels.
Early RCTs on LMWS excluded the following patients:
1. BMI>50 kg//m2
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.
Target range for prophylactic doses of LMWH not well defined.
Table. Target anti-factor Xa ranges for prophylactic doses of LMWH.
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.
BOTTOM LINE: Reasonable anti-factor Xa target range is 0.2-0.5 IU/mL. Prospective studies are required to validate this recommendation.
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).
Caprini Risk Score