1. Prophylaxis Diagnosis Treatment Venous Thromboembolism Management

2. Spectrum of Venous Thromboembolism Biologic onset AsymptomaticSymptomaticOutcome Death Recovery Disability Primary prophylaxis ScreeningClinical suspicion Treatment Management

3. “Pulmonary embolism remains the most common preventable cause of death in the hospital.” Hull 1986

4. Venous Thrombosis Prophylaxis Risk Factor Equivalents 1 Factor Age 40-59 Bed confinement >48 hrs Varicose veins Leg edema/ulcer/statis Obesity (>20% ideal wt.) MI (current) CHF (current) Severe COPD Crystalliods (>5L/24 hrs) Confining travel >4hrs Pregnancy/postpartum (1 month) Inflammatory bowel disease Severe infection Estrogen Rx Operation >2 hrs

5. Venous Thrombosis Prophylaxis Risk Factor Equivalents 2 Factors Age > 60 Stroke (current) Trauma Pelvic operation Joint replacement Hip fracture Malignancy Pelvic/long bone fracture Hypercoag. state Hx DVT/PE Spinal Cord Injury 3 Factors

6. Venous Thrombosis Risk Without Prophylaxis  1-5%40-80%>6>6Highest 0.5-1.0%30-40%4-5High 0.1-0.5%10-30%2-3Moderate <0.01%<10%0-1Low PE DVT* Risk Factor EquivalentsRisk OutcomeRisk Profile  Modified from: Geerts W et al CHEST 2001 *Includes calf DVT

7. Bioavailability of LMWH –Reduced HIT Fondaparinux results –50% reduction VTE (ortho patients) –Reduced HIT Intermittent pneumatic compression –Mechanical venous velocity –Alters coagulation –More effective w/ GCS Considerations / Observations VTE Prophylaxis

8. 1.Prophylaxis is effective …Should be considered in all patients 2.Pharmacotherapy: consider renal function –LMWH (enoxaparin) –Fondaparinux 3.Mechanical methods –Stockings (8 -15 mm Hg) plus IPC –Risk of bleeding –Combined w/pharmacoRx in high and highest risk patients Considerations / Observations VTE Prophylaxis

9. 4.Caution with pharmacoRx in patients undergoing neuraxial anesthesia 5.Post-discharge prophylaxis should be considered in patients with continuing high risk 6.Aspirin alone as prophylaxis… …NOT RECOMMENDED! 4.Caution with pharmacoRx in patients undergoing neuraxial anesthesia 5.Post-discharge prophylaxis should be considered in patients with continuing high risk 6.Aspirin alone as prophylaxis… …NOT RECOMMENDED! Considerations / Observations VTE Prophylaxis

10. RecommendationsRecommendations Risk Recommendation Ambulation (all pts) IPC/GCS or, UFH 5000 SQ q 12 hrs or, Enoxaparin 40mg SQ daily IPC/GCS or, UFH 5000 SQ q 12 hrs or, Enoxaparin 40mg SQ daily IPC/GCS plus… UFH 5000U SQ q 8 hrs; or Enoxaparin 40 mg SQ daily or Enoxaparin 30mg SQ q 12 hrs Fondaparinux 2.5 mg SQ daily IPC/GCS plus… UFH 5000U SQ q 8 hrs; or Enoxaparin 40 mg SQ daily or Enoxaparin 30mg SQ q 12 hrs Fondaparinux 2.5 mg SQ daily IPC/GCS plus… UFH 5000 SQ q 8 hrs Enoxaparin 40mg SQ daily Enoxaparin 30mg SQ q 12 hrs IPC/GCS plus… UFH 5000 SQ q 8 hrs Enoxaparin 40mg SQ daily Enoxaparin 30mg SQ q 12 hrs Low (0-1) Moderate (2-3) High (4-5) Highest (>6) Highest (>6)