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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3865_Библиотеки_им_академика_М_И_Перельмана
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PART II.
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CONDITIONS REQUIRING
ANTICOAGULATION
THERAPY
12. Venous Thromboembolism Prevention
13. Venous Thromboembolism Treatment
14. Atrial Fibrillation
15. Acute Coronary Syndromes
16. Prosthetic Heart Valves
17. Mechanical Circulatory
Support Devices
281
18. Heparin-Induced
Thrombocytopenia
19. Pregnancy
Pediatrics
20.
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12
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Chapter
VENOUS THROMBOEMBOLISM
PREVENTION
Paul P. Dobesh and Kelsey Aker
INTRODUCTION
Venous thromboembolism (VTE), which encompasses both deep vein thrombosis
(DVT) and pulmonary embolism (PE), is a significant healthcare problem producing considerable morbidity, mortality, and resource utilization. In the United
States alone, over a million DVT events and more than 100,000 deaths per year
are attributed to PE. These events occur in a wide range of both surgical and
medical patients. With appropriate prophylaxis, many of these VTE events can be
prevented. Despite more than 30 years of demonstrated efficacy and safety of VTE
prophylaxis, it is substantially underutilized. This underutilization has led to the
recent involvement of government and other regulatory agencies in an attempt to
improve VTE prophylaxis for both surgical and medical patients in U.S. hospitals.
Numerous pharmacologic agents, clinical trials, and nationally recognized clinical
guidelines (Table 12-1) as well as limited data in special populations can provide
challenges to understanding what constitutes appropriate VTE prophylaxis.
1
283
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TABLE 12-1: Venous Thromboembolism Prevention Guidelines
and Resources
Guideline/Resource Web Link
American College of
Chest Physicians (CHEST
Guidelines)
Surgical Care Improvement
Project (SCIP)
Agency for Healthcare
Research and Quality (AHRQ)
The Joint Commission http://www.jointcommission.org/venous_thromboembolism/
Deep Vein Thrombosis
Coalition
American Academy of
Orthopedic Surgeons (AAOS)
American Society of Clinical
Oncology (ASCO)
National Comprehensive
Cancer Network (NCCN)
2-4
5
http://journal.publications.chestnet.org/article.
aspx?articleid=1085923
http://www.jointcommission.org/specifications_manual_for_
national_hospital_inpatient_quality_measures.aspx
http://www.ahrq.gov/qual/vtguide/
http://www.preventdvt.org/home.aspx
http://www.aaos.org/research/guidelines/VTE/VTE_full_
guideline.pdf
http://jco.ascopubs.org/content/early/2015/01/20/
JCO.2014.59.7351.full
http://www.jnccn.org/content/9/7/714.short
http://www.nccn.org/professionals/physician_gls/pdf/vte.pdf
VENOUS THROMBOEMBOLISM PREVENTION 285
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Rates and Risk Factors for Venous Thromboembolism
See Tables 12-2–12-6.
TABLE 12-2: Approximate Risk of VTE
Patient Populations
Patient Group DVT Prevalence without Prophylaxis
Medically ill patients
•
Heart failure
•
Chronic obstructive pulmonary disease
Infection
•
General surgery 15–40%
Major gynecologic surgery 15–40%
Major urologic surgery 15–40%
Neurosurgery 15–20%
Stroke 20–50%
Major orthopedic surgery
Total hip replacement surgery
•
•
Hip fracture surgery
Total knee replacement surgery
•
Major trauma 40–80%
Spinal cord injury patients 60–80%
Critical care patients 10–80%
a
Rates of deep vein thrombosis (DVT) are determined by venography.
6
a
in Different Hospitalized
10–20%
40–60%
57%
60%
84%
TABLE 12-3: Levels of Thromboembolic Risk as Classified by
6
ACCP
Level of Risk Approximate DVT Risk
Low risk
Minor surgery in mobile patients
Medical patients that are fully mobile
Moderate risk
Most general, open gynecologic or urologic surgery patients
Medical patients, bed rest or sick
High risk
Hip or knee replacement surgery, hip fracture surgery
Major trauma, spinal cord injury
*Many incidence rates with surgical procedures are classical data. With advances in technology
and a lack of randomized controlled trials, current rates are unknown but would likely decrease as
surgical techniques improve.
ACCP: American College of Chest Physicians
without Prophylaxis*
<10%
10–40%
40–80%
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TABLE 12-4: Venous Thromboembolism Risk Factors
• Age >40 years
•
Surgery
•
Major trauma or lower-extremity injury
•
Immobility, lower extremity paresis
Cancer (active or occult)
•
•
Cancer therapy
Hormonal therapy
Chemotherapy
Angiogenesis inhibitors
Radiation therapy
Pregnancy and the postpartum period
•
•
Paroxysmal nocturnal hemoglobinuria
Myeloproliferative disorders
•
•
Inflammatory bowel disease
Nephrotic syndrome
•
•
Acute medical illness
Heart failure
Respiratory disease
Infection
Stroke
Central venous catheterization
•
•
Smoking
Varicose veins
•
•
Medications
Estrogen-containing oral contraceptives
Hormone replacement therapy
Selective estrogen receptor modulators
Erythropoiesis-stimulating agents
Recent concentrated clotting factors
• Inherited or acquired thrombophilia; see Chapter 22
• Obesity
• Previous/history of venous thromboembolism
• Venous compression (tumor, hematoma, arterial abnormality)
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TABLE 12-5: Validated Risk Score for Prediction of Cancer-
Associated Thromboembolism
Predictive Variables Risk Score
Site of Cancer Very high risk (stomach, pancreas) 2
Pre-chemotherapy platelet count
≥350,000/mm
Hemoglobin <10 g/dL or use of
red cell growth factors
Pre-chemotherapy leukocyte count
>11,000/mm
Body mass index ≥35 kg/m
Risk Score Risk Level Estimated Rate of VTE
0 Lower risk 0.5%
1–2 Intermediate risk 2%
>3 High risk 7%
VTE: venous thromboembolism
3
3
2
7
High risk (lung, lymphoma, gynecologic) 1
1
1
1
1
at 2.5 Months
• The incidence of VTE increases as the cancer
stage advances (local, regional, and remote).
• The incidence of VTE is higher within 3–6
months of the diagnosis of cancer.
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TABLE 12-6: Venous Thromboembolism Systematic Prophylaxis
Strategies
Tool Description
Risk-scoring forms Match risk level with appropriate prophylactic strategy.
Electronic alerts Electronic medical record requires response to prophylactic
Default prophylaxis strategy All patients receive prophylaxis with efforts placed on
Opt-out approach May be considered in the following clinical scenarios:
HIT: heparin-induced thrombocytopenia, INR: international normalized ratio, LMWH: low
molecular weight heparin, UFH: unfractionated heparin
screening before proceeding; daily reports for high-risk
patients not on prophylaxis.
identifying contraindications rather than indications.
•
Healthy, fully ambulatory, <40 yr
Immobility/length of stay estimated <2 days
•
•
Warfarin with INR >1.4 or on therapeutic anticoagulation
Imminent invasive procedure
•
•
Recent intraocular or intracranial surgery
•
Spinal tap or epidural anesthesia within 12 hr
Thrombocytopenia
•
•
History of HIT/hypersensitivity to UFH or LMWH
Active bleeding
•
•
Active or chronic severe liver disease
Comfort care/hospice
•
Nonpharmacological Prophylaxis Options
See Tables 12-7–12-9 and Figures 12-1–12-3.
TABLE 12-7: Nonpharmacological Prophylaxis Options
Option Description
TED hose Stocking without a compression gradient.
Graduated compression
stocking
Intermittent pneumatic
compression device
IVC filter Medical device implanted into the inferior vena cava to catch
IVC: inferior vena cava, TED: thromboembolic disease
Stockings with a gradual decline in pressure from the distal to the
proximal end.
A microprocessor directs pressurized air into segmental
diaphragms secured around the leg for a fixed period of time.
The compression is delivered in a sequential manner up the leg,
producing a wavelike milking effect to evacuate leg veins.
emboli.
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SIZE ANKLE
7˝– 8 ˝ (18–21 cm)
S
3
8 ˝– 9 ˝ (21–25 cm)/
M
10˝– 11 ˝ (25–29 cm)/
L
1
11 ˝– 13˝ (29–33 cm)/
XL
1
/
4
7
/
8
8
3
8
2
CALF THIGH HIP
3
11˝– 15˝ (28–38 cm)
7
1
11 ˝– 16 ˝ (30–42 cm)/
/
8
2
1
1
/
12 ˝– 18 ˝ (32–46 cm)/
2
8
3
5
13 ˝– 19 ˝ (34–50 cm)/
/
8
8
15 ˝– 24 ˝ (40–62 cm)/
18 ˝– 27 ˝ (46–70 cm)/
21 ˝– 30 ˝ (54–78 cm)/
23 ˝– 32˝ (60–81 cm)/
3
/
4
8
1
1
/
8
2
1
3
/
4
4
5
8
28˝– 46˝ (71–117 cm)
30˝– 50˝ (76–127 cm)
32˝– 54˝ (81–137 cm)
40˝– 65˝ (102–166 cm)
FIGURE 12-1. Custom Fit Graduated Stocking Measurements
Source: Figure is courtesy of JOBST, Inc. Used with permission.
• It may be easier to wear the stockings if the
patient lies down and elevates each leg above the
heart for several minutes to reduce swelling.
• Graduated stockings should be placed first thing
in the morning.
• Rubber gloves may be used to help get a better
grip on the stocking fabric.
• Cornstarch or grease-free talcum can be used in
patients with moist skin to pull stocking up.
Never fold or roll the graduated stocking down—
•
the garment becomes a tourniquet.
• Stocking may not fit after (1) weight loss or
gain or (2) changes in leg swelling. A stocking
that falls or wrinkles on its own is too large and
should be refitted.
• Stockings should be replaced every 3–6 months as
the stocking may lose its elasticity over time.
• Follow-up is very important in patients
prescribed graduated stockings. Monitoring the
proper use of the stocking should occur daily for
the inpatient setting and at each office visit for
the outpatient setting.
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