1. DVT PROPHYLAXIS SUNDIP PATEL 7 / 15 / 2009

2. BACKGROUND Deep Vein Thrombosis is a common, yet preventable peri-operative complication Highest risk in critical care and spinal cord injury patients – 60-80% Post–General Surgery procedures: 15-40% Post-Ortho Procedures: 40-60% Variable for Urologic cases

3. BACKGROUND Pulmonary Embolus True Prevalance is unknown W/O prophylaxis Fatal PE in 0.2-.9% of ELECTIVE general surgery cases Fatal PE in 0.1-2.0% of ELECTIVE hip Fatal PE in 2.5-7.5% of Fractured Hip

4. VIRCHOW TRIAD STASIS From supine positioning and effects of anesthesia HYPERCOAGULABILITY Decreased clearance of the PROcoagulant INTIMAL INJURY Results from excessive vasodilation caused by vasoactive amines and anesthesia Acting in concert, these 3 factors promote development of DVT in low-flow areas

5. RISK FACTORS AGE > 50 Hx of varicose veins Hx of MI Hx of Cancer Hx of AFib Hx of ISCHEMIC Stroke Hx of DM

6. Urologic Risk RISK Level for most UROLOGIC patients are considered MODERATE

7. UROLOGIC RISK Risk of DVT w/o prophylaxis is 10 – 40% RECS: Low Molecular Weight Heparin (Lovenox) - Low Dose Unfractionated Heparin - Fondaparinux (ARIXTRA) - Also appropriate to use is - Graduated Compression Stockings - Intermittent Pneumatic Compression - Venous Foot Pumps

8. Types of MEDICAL prophylaxis LMWH (lovenox) Greater bioavailability Longer duration Little monitoring needed HIT incidence less LDUH Easy administration Cost Effective Little monitoring needed ARIXTRA Longer half-life than LMWH (17H v 4H) Not for CKD pts No monitoring Single daily dosing

9. UROLOGIC PROCEDURES Transurethral – EARLY AMBULATION IF HIGHER RISK, GCS OR IPC Anti-incontinence and pelvic reconstructive surgery Low risk – early ambulation Mod risk – IPC or LMWH Hi Risk – IPC + LDUH or LMWH Urologic laparoscopic and/or robotically assisted - IPC Open Procedures - IPC

10. CONTRAINDICATIONS ABSOLUTE Active bleeding, PLT:20, neurosurgery, ocular surgery, intracranial bleeding w/in 10 days RELATIVE PLT:20-100, brain metastases, major abdominal surgery w/in past 2 days, GI bleeding or GU bleeding w/in past 14 days, infective endocarditis, malignant hypertension

11. PROPHYLAXIS OPTIONS LMWH – 40mg SQ qd LDUH – 5000u SQ B-TID ARIXTRA – 2.5 SQ qd NOT for patients with CrCl <30 For LOW RISK procedures and those with NO RISK FACTORS, no prophylaxis is required. ENCOURAGE AMBULATION EARLY AND FREQUENTLY

12. UROLOGIC RECOMENDATIONS MAJOR, OPEN PROCEDURES EITHER LMWH, LDUH, ARIXTRA (GRADE1A) IF HIGH RISK OF BLEEDING, USE MECHANICAL METHODS UNTIL LAPAROSCOPIC IF previous dvt/pe, LMWH or LDUH, may also add IPC or GCS (Grade 1C) ALL PATIENTS WITH HISTORY OF CANCER

13. SUMMARY ALL PATIENTS UNDERGOING ANY SURGERY SHOULD HAVE DVT PROPHYLAXIS GCS AND EARLY AMBULATION SUFFICIENT IN MOST CASES CONTINUE PROPHYLAXIS UNTIL AMBULATING