2. Deep vein thrombosis
(DVT) forms in a vein of
the leg.
• Characterized by pain,
swelling or tenderness
of the leg, sometimes
with redness and
warmth
Deep Vein Thrombosis
3. Pulmonary embolism
Pulmonary embolism (PE) occurs when the
blood clot breaks loose and travels to the lungs
• Characterized by shortness of breath, sharp
rib/chest pain and occasionally by
hemoptysis, light-headedness, or collapse
4. Symptoms and Signs of DVT
• Leg pain (90%)
• Tenderness (85%)
• Ankle edema (76%)
• Calf swelling (42%)
• Dilated veins (33%)
• Dusky discoloration
(30%)
• Warmth
• Redness
DVT cannot be reliably
diagnosed on the basis of
history and physical exam, even
in high-risk patients.
Symptomatic DVT
Most hospitalized
patients with DVT
will have NO
SYMPTOMS or SIGNS!
5. Risk of VTE in Hospitalized
Patients
Geerts WT, et al. Chest 2008;358:381S-453S.
Patient Group DVT Prevalence (%)
Medical Patients 10-20
General Surgery 15-40
Major Gynecologic Surgery 15-40
Major Urologic Surgery 15-40
Neurosurgery 15-40
Stroke 20-50
Hip and Knee Arthroplasty,
Hip Fracture Surgery
40-60
Major Trauma 40-80
Spinal Cord Injury 60-80
Critical Care Patients 10-80
6. Pulmonary Embolism
Hospital Risk
•Accounts for 10% of
hospital deaths
•In the UK, PE following
DVT causes between
25,000 and 32,000
deaths each year1
International, cross-
sectional audit of
35,000 inpatients at
risk for VTE found:2
•only 59% of
surgical patients and
40% of medical
patients received
recommended
prophylaxis.
1. UK House of Commons Health Committee. HC 99. Published on 8 March 2005.
2. Cohen AT, et al. Lancet 2008;371:387-394.
7. Characterization of VTE events
In the Worcester County, Mass VTE Study
•60-70% of VTE events were considered to be
provoked by:
• Recent hospitalization (within 3 months)
• Surgery
• Trauma/fracture
• Pregnancy
1. Spencer FA, et al. Arch Intern Med 2007;167:1471-5.
2. Spencer FA, et al. J Thromb Thrombolysis 2009;28:401-9.
Risk for VTE increases with the
number of risk factors and
persists after hospital
discharge.
9. Adapted from: Greer IA. Bailliere’s Clin Obstet Gynaecol 1997;11:403-30.
The risk of DVT and PE is
increased by several factors,
including:
Factors intrinsic to the
patient
Factors related to
underlying disease or
medical condition
Factors introduced by
medical or surgical
treatment
• Age
• Obesity
• Immobility
• History of thrombosis
• Thrombophilia
• Varicose veins
• Venous insufficiency
• Pregnancy
• Trauma
• Heart failure/MI
• Malignancy
• Concomitant
medication
• Chemotherapy
• Orthopaedic surgery
• Major surgery
• Caesarean section
10. 1. VTE is common in hospital patients
2. VTE is fatal (acutely and long-term)
3. VTE is preventable (safely and
inexpensively)
4. Preventing VTE is the standard of
care for almost all hospital patients
in 2011
Slide courtesy of Dr. William Geerts.
Rationale for Thromboprophylaxis
13. Key steps to ensure compliance with ROP:
1.Written policy/guideline
2.Identifies clients at risk & provides VTE prophylaxis
3.Establishes measures of success, uses information to make improvements
4.Provides information to health professionals (on risks & prevention measures)
14. Audrey’s Story
Following a one week wait for surgery and the successful
removal of a benign tumour – Audrey developed a PE.
We are scared and worried about our surgery
or primary reason for being in the hospital as it
is. We rely on you to make us aware of any
possible complications. For me, the blood clot
was far scarier and worse than my brain
tumour and operation.
This experience with the blood clot has
impacted my life. It was the scariest and worst
experience I have ever had and it has left me
fearful and anxious.
“My plea to healthcare professionals: make sure you get people’s
attention, and make sure they fully understand their risks and
what can be done to prevent a blood clot.”
15. Guidelines for
Prevention of VTE
*Use clinical judgment to weigh the risk of venous thromboembolism versus the risk of bleeding.
16. Weight Dalteparin
Dose
Enoxaparin
Dose
Tinzaparin
Dose
<40 kg 2 500 U SC
once daily
30 mg SC
once daily
3 500 U SC
once daily
40-100 kg 5 000 U SC
once daily
40 mg SC
once daily
4 500 U SC
once daily
101-150 kg 5 000 U SC BID 40 mg SC BID 10 000 U SC
once daily
151-200 kg 40 U/kg SC
BID
0.4 mg/kg SC
BID
14 000 U SC
once daily
Prevention of VTE in Hospitalized
Patients: Summary of Good Practice
eGFR >30 mL/min
17. In patients with impaired renal function (<30
mL/min):
•Dalteparin: no dose adjustment is required.
•Enoxaparin: a dosage adjustment is recommended
since enoxaparin appears to accumulate in this patient
group and may increase risk of bleeding.
•Tinzaparin: no dose adjustment of tinzaparin at
prophylaxis doses is needed in patients with impaired
renal function1
, renal failure2,3
, or on hemodialysis2,3
.
Use of LMWHs in
Renal Impairment
1. Mahé O, et al.Thromb Haemost 2007;97:581-6.
2. PROTECT Investigators. N Engl J Med 2011;364:1305-14.
3. Nutescu EA, et al. Ann Pharmacother 2009;43:1064-83.
Speaker Notes:
Venous Thromboembolism is the collective term for deep vein thrombosis and pulmonary embolism.
It may help to refer to DVTs as vein blood clots to patients to help them differentiate between blood clots in the legs and blood clots in the brain (stroke).
50% of DVTs produce no symptoms or signs, with the first awareness of a DVT being a pulmonary embolism (PE).
Speaker Notes:
One serious risk of venous thrombosis is part of the clot breaking away and being carried by the blood to the lungs.
This is known as a pulmonary embolism (PE).
The clot interferes with oxygenation of blood in the lungs and can therefore be fatal.
Speaker Notes:
Approximately 50% of patients have some of the expected symptoms and signs of DVT.
However, most hospitalized patients, will have no symptoms or signs.
Clinical diagnosis is unreliable, thus definitive diagnosis requires a Doppler ultrasound.
Speaker Notes:
This table from the ACCP Consensus Guidelines highlights the risk for venous thromboembolic disease in patients that have not been prophylaxed.
Medical patients have a prevalence of DVT in the absence of prophylaxis, of up 10% to 20%, while critical care patients have a 10% to 80% risk. It is important to note that these percentages represent asymptomatic DVTs.
Surgery patients have had most of the attention with regard to VTE prophylaxis.
Unlike surgery patients, the majority of prophylaxis-eligible medical patients are not receiving any prophylaxis or appropriate prophylaxis.
Reference:
Geerts WT, et al. Chest. 2008;358:381S-453S.
Speaker Notes:
In the UK, PE following DVT causes between 25,000 and 32,000 deaths each year, this exceeds the combined total deaths from breast cancer, AIDS and traffic accidents.
References:
UK House of Commons Health Committee. HC 99. Published on 8 March 2005.
Cohen AT, et al. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet 2008;371:387-394.
Speaker Notes:
The 2009 study examined all patients (n=1 567 patients) with a first-time VTE in Worchester County, Massachusetts from 1999 to 2003.
The study also found that:
72% of patients were “community acquired” VTE
20% of all events were unprovoked
30% were thought to be related to malignancy
Using an expected rate of 60% - that means that in Ontario the hospital-acquired VTE rate is about 8 000/year.
References:
Spencer FA, et al. Venous thromboembolism in the outpatient setting. Arch Intern Med. 2007;167:1471-5.
Spencer FA, et al. Incidence rates, clinical profile, and outcomes of patients with venous thromboembolism. The Worcester VTE study. J Thromb Thrombolysis. 2009;28:401-409.
Heit J, et al. Relative impact of risk factors for deep vein thrombosis and pulmonary embolism: a population-based study. Arch Intern Med. 2002;162:1245–1248.
Heit J. The Epidemiology of Venous Thromboembolism in the Community. Arterioscler Thromb Vasc Biol. 2008;28: 370–372.
Speaker Notes:
“Patients without risk factors for VTE are called outpatients.” G. Maynard (2010)
Epidemiological data suggest an incidence in the general population of:1
160 per 100,000 for DVT
120 per 100,000 for PE
In those over age 65 this increases to:2
655 per 100,000 for DVT (4-fold increase)
255 per 100,000 for PE
References:
O’Shaughnessy D.F. Haemostasis and Thrombosis: Current Clinical Practice: Low-Molecular-Weight Heparins in The Prophylaxis and Treatment of Thrombo-Embolic Disease. Hematol. 2000;4:373-380.
Stein PD, et al. Venous thromboembolism according to age: the impact of an aging population. Arch Intern Med. 2004;164:2260-2265.
Speaker Notes:
60-70% of all VTE is hospital-acquired (i.e. this is a public health issue).
Pulmonary embolism is the commonest preventable cause of hospital death.
Speaker Notes:
ROP for VTE.
Speaker Notes:
Key compliance tests and more importantly key steps to ensure hospital-wide compliance.
Speaker Notes:
This is a real story.
Here is more of it:
I was in a hospital bed attached to an IV pole for one week waiting for my surgery. My surgery was successful, although the anesthesia left me feeling unwell. I went home to recuperate but continued to feel unwell, and had limited mobility due to an ongoing problem with my leg. Five days after I was released from hospital I could not stop coughing and I felt quite faint. Upon return to the ER it was discovered I had an enormous blood clot in my lungs- both of them. I ended up in the ICU on an anticoagulant and had to have special medication to dissolve the clot because it was so big and threatened my life. This experience with the blood clot has impacted my life. It was the scariest and worst experience I have ever had and it has left me fearful and anxious. It was a horrifying experience and one I never want to go through again, and I hope no one else has to go through either.
Speakers Notes:
Importantly, the expert committee believes that all medical and surgical patients should receive thromboprophylaxis as they are all at risk.
However, there are precautions and contraindications that may alter time of dosing or type of thromboprophylaxis.
Speaker Notes:
The above dosing recommendations are those of the VTE Prevention Simplified experts.
Different policies/dosing for weight categories exist in hospitals across Canada. Again, the templates supplied can be modified/ adjusted to conform with hospital policy.
sc: subcutaneously
1. Mahé O, et al. Thromb Haemost. 2007;97:581-6; 2. PROTECT Investigators. N Engl J Med. 2011;364:1305-14; 3. Nutescu EA, et al. Ann Pharmacother. 2009;43:1064-83. FRAGMIN Product Monograph. Pfizer Canada Inc. January 6, 2014; LOVENOX Product Monograph. sanofi-aventis Canada Inc. December 20, 2013; INNOHEP Product Monograph. LEO Pharma Inc. February 3, 2011.
Speaker Notes:
Because of differences in the molecules, long chained/charged innohep and UFH can better bind to endothelial cells, be cleared by the reticulo-endothelial pathway, and are less affected/do not appear to accumulate in patients with renal impairment
Tinzaparin can be safely used in patients with CrCl below 30 mL/min.
References:
Mahé O, et al. Tinzaparin and enoxaparin given at prophylactic dose for eight days in medical elderly patients with impaired renal function: a comparative pharmacokinetic study. Thromb Haemost. 2007;97:581-6.
PROTECT Investigators. Dalteparin versus unfractionated heparin in critically ill patients. N Engl J Med. 2011;364:1305-14.
Nutescu EA, et al. Low-molecular-weight heparins in renal impairment and obesity: available evidence and clinical practice recommendations across medical and surgical settings. Ann Pharmacother. 2009;43:1064-83.
Speakers Notes:
These contraindications are specific to innohep®. This is not a complete list.
Reference:
innohep® Product Monograph. Leo Pharma Inc. February 2011.
Speaker Notes:
Remind the groups that patients at risk of VTE can look quite different.
