Spotlight Case January 2006 An Ounce of Prevention

2 Source and Credits This presentation is based on the Jan AHRQ WebM&M Spotlight Case See the full article at CME credit is available through the Web site –Commentary by: Nils Kucher, MD; University Hospital Zurich, Switzerland –Editor, AHRQ WebM&M: Robert Wachter, MD –Spotlight Editor: Tracy Minichiello, MD –Managing Editor: Erin Hartman, MS

3 Learning Objectives Assess risk for venous thromboembolism (VTE) in hospitalized patients List recommended strategies for VTE prevention for various risk groups Identify patients who qualify for extended- duration prophylaxis Appreciate interventions that may increase system-wide use of VTE prophylaxis

4 Case: An Ounce of Prevention A 47-year-old woman was admitted to the plastic surgery service after a motor vehicle collision with major trauma to her right hand, which required repair with use of an abdominal flap. On postoperative day 2, she suffered a sudden cardiopulmonary arrest. After successful resuscitation, a chest CT revealed a massive pulmonary embolism (PE).

5 The Burden: Venous Thromboembolism 1.5/1,000 per year in US adults 1% of hospitalized patients Nearly 20% of surgical patients who do not receive prophylaxis > 50% of patients undergoing total hip and total knee replacement patients who fail to receive prophylaxis Tsai AW, et al. Arch Intern Med. 2002;162: Clagett GP, Reisch JS. Ann Surg. 1988;208: Clagett GP, et al. Chest. 1998;114(suppl 5):531S-560S.

6 Risk of Pulmonary Embolism Following Deep Vein Thrombosis (DVT) Diagnosis Risk of symptomatic PE in patients with lower extremity DVT ranges between 15% and 30% Occurs less often (3%) in patients with upper extremity DVT Joffe HV, et al. Circulation. 2004;110: Kucher N, et al. Thromb Haemost. 2005;93:

7 Mortality and Pulmonary Embolism More than 100,000 people die from PE per year in U.S. 30-day mortality of PE is 10% 50% of deaths following hip fracture surgery due to PE PE identified at autopsy in 60% of patients with lower extremity fractures See notes for complete references

8 Pulmonary Embolism and Trauma Coon WW. Surg Gynecol Obstet. 1976;143: Patient survival time following trauma Incidence of PE on autopsy

9 Case (cont.): An Ounce of Prevention Review of the patient's chart revealed no pre- or postoperative DVT prophylaxis.

10 Prophylaxis Candidacy for VTE prophylaxis based on risk profile of both the individual and the clinical scenario DVT prophylaxis continues to be underutilized despite detailed guidelines –Only 42% of 5,451 inpatients with hospital- acquired DVT had received prophylaxis Goldhaber SZ, et al. Lancet. 1999;353:

11 Patient Risk Factors Cancer Congestive heart failure Chronic lung disease Age > 70 years Obesity Prior VTE Thrombophilic disorders Acute respiratory failure Kakkar VV, et al. Am J Surg. 1970;120:

12 Clinical Risk Factors Surgery –Highest in orthopedic, spinal, pelvic, and neurosurgery Trauma –Lower extremities and pelvis –Increased with surgery and general anesthesia Bed rest –In and out of hospital Clagett GP, et al. Chest. 1998;114(suppl 5):531S-560S.

13 Recommended VTE Prophylaxis Strategies in Surgical Settings IndicationPrevention Strategy General SurgeryUFH 5,000 units q 8h, 1 st dose 2h preoperatively, continued for 7 days or LMWH once daily Cancer SurgeryEnoxaparin 40 mg daily, 1 st dose 10-14h preoperatively if possible, for 28 days UFH = unfractionated heparin LMWH = low molecular weight heparin

14 Recommended VTE Prophylaxis Strategies in Surgical Settings (cont.) IndicationPrevention Strategy Total Hip Replacement Enoxaparin 40 mg daily, beginning preoperative evening, continuing out-of- hospital for days Enoxaparin 30 mg BID, 1 st dose 12-24h postoperatively, until hospital discharge Dalteparin 2,500 units ≥ 4h post-op, then 5,000 units daily until hospital discharge or for 35 days

15 Recommended VTE Prophylaxis Strategies in Surgical Settings (cont.) IndicationPrevention Strategy Total Hip Replacement (cont.) Fondaparinux 2.5 mg 4-8h post-op, then ≥ 12h after 1st dose, then daily for 5-9 days Warfarin daily, 1 st dose 7.5 mg 24-48h preoperatively, adjusted to target INR of Warfarin daily, 1 st dose 5 mg preoperative evening, adjusted to target INR of and continued 4-6 weeks

16 Recommended VTE Prophylaxis Strategies in Surgical Settings (cont.) IndicationPrevention Strategy Total Knee Replacement Enoxaparin 30 mg BID, beginning 12-24h postoperatively, continued for an average of 9 days Fondaparinux 2.5 mg, 1 st dose 4-8h postoperatively, 2 nd dose ≥ 12h after 1 st dose, then daily for 5-9 days Hip Fracture Surgery Fondaparinux 2.5 mg, 1 st dose 4-8h postoperatively, 2 nd dose ≥ 12h after 1 st dose, then daily for 5-9 days. If surgery is delayed > 24-48h after admission, give 1 st dose 10-14h preoperatively

17 Recommended VTE Prophylaxis Strategies in Surgical Settings (cont.) IndicationPrevention Strategy NeurosurgeryEnoxaparin 40 mg daily, 1 st dose ≤ 24h postoperatively, continued until hospital discharge, plus GCS Craniotomy for Brain Tumor Enoxaparin 40 mg daily or UFH 5,000 units BID, 1 st dose on 1 st postoperative morning, continued until hospital discharge, plus GCS/IPC, plus predischarge venous ultrasonography GCS = graduated compression stockings IPC = intermittent pneumatic compression devices

18 Duration of Prophylaxis Recommendations for extending the duration of prophylaxis in high-risk scenarios: Geerts WH, et al. Chest. 2004;126(suppl 3):338S-400S. Cancer surgery28 days postoperatively Total hip replacement and hip fracture repair days postoperatively TraumaThroughout inpatient rehabilitation and after discharge in patients with significantly impaired mobility

19 Application of ACCP Guidelines to this Patient Administer DVT prophylaxis to all trauma patients with at least one additional risk factor –Is this patient obese, on OCP or HRT; does she have a previous history of thrombosis, concomitant respiratory or cardiac disease? Use LMWH in high-risk prophylactic doses –Such as enoxaparin 30 mg q 12 hours Geerts WH, et al. Chest. 2004;126(suppl 3):338S-400S.

20 Application of ACCP Guidelines to this Patient If pharmacologic prophylaxis contraindicated due to concerns for bleeding related to surgery or trauma, use mechanical prophylaxis –Intermittent pneumatic compression devices and/or graduated compression stockings Perform screening ultrasound if no pharmacologic prophylaxis used Geerts WH, et al. Chest. 2004;126(suppl 3):338S-400S.

21 Application of ACCP Guidelines to this Patient Do not place inferior vena cava (IVC) filter for prophylaxis –Permanent IVC filters are associated with a 50% increase in risk of DVT at 1 year, typically due to filter thrombosis –Removable filters increasingly used, no specific recommendations yet Geerts WH, et al. Chest. 2004;126(suppl 3):338S-400S. Decousus H, et al. N Engl J Med. 1998;338:

22 CT Scan in a Patient with IVC Filter Thrombosis, Causing 50% Obstruction of the IVC

23 Case (cont.): An Ounce of Prevention The patient was aggressively resuscitated and started on systemic anticoagulation with heparin, and then warfarin. After a 3-day stay in the intensive care unit, the patient was transferred to the floor. Ultimately, she was discharged to home without any evidence of anoxic brain injury or permanent pulmonary sequelae from her PE.

24 VTE Prevention: Increasing Awareness American Public Health Association (APHA) –Created a national coalition to advocate for greater awareness of DVT and PE among health care providers and the general public The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) –Encouraged by APHA to make adherence to DVT prevention guidelines part of accreditation process Public Health Leadership Conference on Deep-Vein Thrombosis; 2003.

25 VTE Prevention: Increasing Awareness Electronic alerts CME Anderson FA Jr, et al. Arch Intern Med. 1994;154: Dexter PR, et al. N Engl J Med. 2001;345: Durieux P, et al. JAMA. 2000;283:

26 VTE Prevention: Computerized Alerts Randomized control trial of computer alerts that suggest DVT prophylaxis for eligible patients according to risk profile Kucher N, et al. N Engl J Med. 2005;352: Risk factorPoints Cancer, prior VTE, hypercoagulability 3 each Major surgery2 Advanced age, bed rest, obesity, OCP/HRT 1 each

27 VTE Prevention: Electronic Alerts If risk score 4 or higher, computer randomly sent single alert regarding recommended DVT strategy to responsible physician of 1255 eligible patients Physician required to acknowledge alert and could decline recommended prophylaxis Kucher N, et al. N Engl J Med. 2005;352:

28 Example of Electronic VTE Alert

29 A single computer alert to the responsible physician doubled the prophylaxis rate and reduced the VTE rate at 90 days by 41% Hospitals with adequate information systems resources should consider implementation of electronic alerts Kucher N, et al. N Engl J Med. 2005;352: VTE Prevention: Electronic Alerts

30 Take-Home Points Know the common VTE risk factors Assess VTE risk for each hospitalized patient individually Become familiar with the various VTE prophylaxis regimens for different at-risk patient groups Apply the current ACCP guidelines to prevent VTE in hospitalized patients Use hospital information systems to increase awareness of VTE and implement adequate prophylaxis in patients at risk