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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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290 Anticoagulation Therapy
Recommended for minor ankle and leg swelling, mino
varicosities, pregnancy, and general leg fatigue.
light energizing compression
Recommended for moderate ankle and leg swelling,
moderate varicosities, venous stasis ulcerations,
postschlerotherapy, and preventing DVT.
Recommended for severe ankle and leg swelling,
severe varicosities, post-thrombotic syndrome, venous
stasis ulcerations, lymphadema, and preventing DVT.
Mild support is frequently recommended for minor ankle
and leg swelling, minor varicosities, and leg fatigue.
Great for traveling and those who sit or stand for long
periods of time
https://t.me/med1917
Firm Support- 30–40 mm Hg
Moderate Support- 20–30 mm Hg
Mild Support- 15–20 mm Hg
Light Support- 8–15 mm Hg
Compression Guide
Light Support- 8–15 mm Hg
Mild Support- 15–20 mm Hg
r
A
.
.
Moderate Support- 20–30 mm Hg
Firm Support- 30–40 mm Hg
FIGURE 12-2. Compression Guide
Figure is courtesy of JOBST, Inc. Used with permission.
VENOUS THROMBOEMBOLISM PREVENTION 291
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TABLE 12-8: Inferior Vena Cava Filters
Indications Contraindications Complications
•
•
PE when anticoagulant
therapy is
contraindicated
•
Failure of anticoagulant
therapy in
thromboembolic disease
• Emergency treatment
following massive PE
where anticipated
benefits of conventional
therapy are reduced
Chronic, recurrent PE
•
where anticoagulant
therapy has failed or is
contraindicated
• Massive trauma
(including a GCS
score <8, incomplete
spinal cord injury
with paraplegia or
quadriplegia, complex
pelvic fractures
associated with long
bones, or multiple long
bone fractures)
The PREPIC trial, an 8-year follow-up study, was designed to assess the long-term safety and
efficacy of permanent vena cava filter insertion in patients with a diagnosis of acute proximal DVT
and considered high risk for the development of PE.
to treat of 12 to prevent one PE, but was offset by a number needed to harm of 10 for causing
one DVT (it increased the rate of DVT). No difference in post-thrombotic syndrome or mortality
was observed between patients with or without a permanent filter.
In the PREPIC 2 trial, a 3-month use of a retrievable vena cava filter with anticoagulation in
patients with acute symptomatic PE did not reduce recurrent PE at 3 or 6 months compared to
anticoagulation alone in patients presenting with acute PE (3% filter vs. 1.5% no filter; p=0.50).
No differences were detected in the incidence in symptomatic DVT, major bleeding, or mortality
at 3 or 6 months.
DVT: deep vein thrombosis, GCS: graduated compression stockings, PE: pulmonary embolism
Chronically thrombosed
inferior vena cava
Inaccessible inferior vena
•
cava
•
Patients at risk for septic
embolism
8
Filter insertion resulted in a number needed
• Migration of the filter
(slippage or fracture) to
the heart
Penetration of vena cava
•
wall into vascular or
gastrointestinal systems
•
Caval occlusion
Puncture site bleeding
•
9
292 Anticoagulation Therapy
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FIGURE 12-3. IVC Filter Placement
Source: Image courtesy of Amicus Visual Solutions, Used with permission.
VENOUS THROMBOEMBOLISM PREVENTION 293
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TABLE 12-9: Inferior Vena Cava Filter Comparisons
Types Permanent (P) or
Retrievable (R)
Bird’s Nest Filter
P 40 mm Yes
(Cook Medical)
Maximum IVC
Diameter
MRI
Compatible
a
Alloy
Stainless
steel
VenaTech Low Profile
Filter
(B. Braun Vena Tech)
Nitinol TrapEase Filter
(Cordis Endovascular)
OptEase
(Cordis Endovascular)
Gunther Tulip Filter
(Cook Medical)
Celect
(Cook Medical)
VenaTech LGM Filter
(B. Braun Vena Tech)
Simon Nitinol Filter
(C. R. Bard)
Titanium Greenfield
Filter
(Boston Scientific)
Stainless-Steel
Greenfield Filter
(Boston Scientific)
Denali Vena Cava
Filter (BARD Peripheral
Vascular)
P 35 mm Yes Phynox
P 30 mm Yes Nitinol
R 30 mm Yes Nitinol
R 30mm Yes Conichrome
P 30 mm Yes Conichrome
P 28 mm Yes Phynox
P 28 mm Yes Nitinol
P 28 mm Yes Titanium
P 28 mm Yes
a
Stainless
steel
R 28 mm Yes Nickel-
titanium
Eclipse Vena Cava
Filter (BARD Peripheral
Vascular)
Opton ELITE (Argon
Medical Devices, Inc)
a
No displacement due to the magnetic field has been demonstrated with MRI, but the metallic
component causes an imaging artifact.
R 28 mm Yes Nitinol
R 30 mm Yes Nitinol
294 Anticoagulation Therapy
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• Retrievable filters must be rotated or removed
within 2 weeks or they become permanently
affixed to the IVC wall.
• The presence of a clot within a temporary filter,
at the time of retrieval, may result in permanent
placement.
• Once the contraindication for anticoagulation has
been resolved, concomitant use of warfarin should
be considered in patients with permanent filters.
• Filter retrieval does not require interruption of
anticoagulation.
MRI procedures should be postponed for 6 weeks
•
following implantation to ensure incorporation
into vessel wall.
• Patients with IVC filters requiring restraints who
are combative should not have restraints over
their abdomen in the region of the filter to prevent
dislodging.
• When retrievable filters are used for temporary
primary or secondary VTE prevention, a system
of care should be in place to assure they are
removed in a timely manner.
VTE Prophylaxis in Medically Ill Patients
See Table 12-10.
TABLE 12-10: VTE Prophylaxis in Medically Ill Patients
UFH Enoxaparin Dalteparin Tinzaparin Fondaparinux Warfarin
5,000 units sub-Q
q 8 hr or
5,000 units sub-Q
q 12 hr
*Not approved by the U.S. FDA.
q: every, sub-Q: subcutaneous, UFH: unfractionated heparin, units: International Units, VTE:
venous thromboembolism
40 mg
sub-Q q
24 hr
5,000 units
sub-Q q
24 hr
Insufficient
evidence
2.5 mg sub-Q
q 24 hr*
Insufficient
evidence
VENOUS THROMBOEMBOLISM PREVENTION 295
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• Numerous clinical trials have not demonstrated
efficacy with the use of UFH 5,000 units every
12 hours and, therefore, UFH 5,000 units every 8
hours would be the preferred UFH regimen.
•
Although not evidence-based, UFH 5,000 units
10
every 12 hours may be considered in individuals
of advanced age and low weight (i.e., TBW <50
kg) or elevated baseline aPTT (>1.3 or 1.4 x
baseline).
Enoxaparin 20 mg once daily has been evaluated
•
and is not more effective compared to placebo.
10
• Enoxaparin 20 mg once daily has demonstrated
equal efficacy compared to UFH 5,000 units every
12 hours.
10
• In head-to-head trials between UFH 5,000 units
every 8 hours and enoxaparin 40 mg daily, the
regimens have demonstrated similar efficacy,
except for higher-risk medically ill patients (heart
failure and ischemic stroke) in which enoxaparin
seems to demonstrate greater protection against
VTE. In these same trials, enoxaparin has
demonstrated significantly less hematoma (>5
cm) compared to UFH. Although some data
suggest a lower bleeding rate with the use of
LMWH in medically ill patients, these findings
are not consistent across trials.
11
• Both apixaban (2.5 mg twice daily) and
rivaroxaban (10 mg once daily) have been
evaluated in medically ill patients.
12,13
Both
trials evaluated 6–14 days of enoxaparin 40
mg once daily to about a month of apixaban
or rivaroxaban. Both trials demonstrated
significant increases in major bleeding with
nominal benefit. Betrixaban 80 mg once daily,
after a 160 mg loading dose, demonstrated
reductions in VTE without a significant increase
in major bleeding.
14
Betrixaban was approved by
the FDA in June 2017. For more information on
betrixaban (Bevyxxa), please see Appendix N.
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VTE Prophylaxis in Nonorthopedic Surgery Patients
See Table 12-11.
TABLE 12-11: VTE Prophylaxis in General Surgery
Surgical
Indication
VTE Prophylaxis in General Surgery
UFH Enoxaparin Dalteparin Tinzaparin Fondaparinux
General surgery 5,000 units
sub-Q q 8 hr or
5,000 unit
sub-Q q 12 hr
Neurosurgery 5,000 units
sub-Q q 8 hr
Vascular surgery 5,000 units
sub-Q q 8 hr or
5,000 units
sub-Q q 12 hr
Gynecologic 5,000 units
sub-Q q 8 hr or
5,000 units
sub-Q q 12 hr
Urologic 5,000 units
sub-Q q 8 hr or
5,000 units
sub-Q q 12 hr
Laparoscopic Patients undergoing laparoscopic procedures without additional VTE risk
factors do not require prophylaxis beyond early ambulation.
Bariatric 5,000 units
sub-Q q 8 hr
Thoracic 5,000 units
sub-Q q 8 hr or
5,000 units
sub-Q q 12 hr
40 mg
sub-Q
q 24 hr
40 mg
sub-Q q
24 hr
40 mg
sub-Q q
24 hr
40 mg
sub-Q
q 24 hr
40 mg
sub-Q
q 24 hr
40 mg
sub-Q
q 12 hr
40 mg
sub-Q
q 24 hr
5,000 units
sub-Q q
24 hr*
Insufficient
evidence
5,000 units
sub-Q q
24 hr*
5,000 units
sub-Q
q 24 hr*
5,000 units
sub-Q
q 24 hr*
7,500 units
sub-Q
q 24 hr
5,000 units
sub-Q
q 24 hr
3,500 units
sub-Q
q 24 hr
Insufficient
evidence
3,500 units
sub-Q q
24 hr
3,500 units
sub-Q
q 24 hr
3,500 units
sub-Q
q 24 hr
Insufficient
evidence
3,500 units
sub-Q
q 24 hr
2.5 mg sub-Q
q 24 hr
Insufficient
evidence
2.5 mg sub-Q
q 24 hr
2.5 mg sub-Q
q 24 hr
2.5 mg sub-Q
q 24 hr
2.5 mg sub-Q
q 24 hr
2.5 mg sub-Q
q 24 hr
Coronary bypass
surgery
*Different strategies on when to initiate dalteparin after surgery have been studied. Please see
the dalteparin package labeling for more details.
q: every, sub-Q: subcutaneous, units: International Units
5,000 units
sub-Q q 8 hr or
5,000 units
sub-Q q 12 hr
40 mg
sub-Q
q 24 hr
5,000 units
sub-Q
q 24 hr
3,500 units
sub-Q
q 24 hr
Not discussed
in current
guidelines
VENOUS THROMBOEMBOLISM PREVENTION 297
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• General surgery
Meta-analysis comparisons between UFH
and LMWHs demonstrate comparative
efficacy in preventing DVT, but a greater
reduction in the incidence of PE when a
LMWH is used.
Mechanical prophylaxis is sometimes
inappropriately selected over pharmacologic
prophylaxis due to concerns of bleeding in
surgical patients. A meta-analysis of almost
34,000 surgical patients demonstrated that
the most common bleeding complications
are injection site bruising (6.9%) and
wound hematomas (5.7%). Major bleeding
complications in <1% of patients.
Gastrointestinal bleeding: 0.2%
Retroperitoneal bleeding: 0.08%
Surgery needed for bleeding: 0.7%
15
16
Neurosurgery
•
Pharmacologic prophylaxis is typically
given with mechanical prophylaxis, and the
combination has been demonstrated to be
equally safe and more effective compared to
mechanical prophylaxis alone.
Pharmacologic prophylaxis is typically
started 18-24 hours after neurosurgery.
• Vascular surgery
Routine prophylaxis is recommended for
patients with additional risk factors such as
advanced age, limb ischemia, long duration
of surgery, and intra-operative local trauma.
Due to the limited number of trials in
patients with vascular surgery, dosing
recommendations are based on evidence of
pharmacologic agents in general surgery.
298 Anticoagulation Therapy
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• Gynecologic surgery
Gynecologic cancer surgery
•
• Urologic surgery
Low-risk gynecologic surgery procedures
(laparoscopic procedures or procedures
lasting <30 minutes) do not require
prophylaxis beyond early ambulation.
Major surgery without malignancy should
receive UFH or a LMWH.
UFH three x daily is more effective than twice
daily. UFH three x daily and a LMWH seem
to have similar efficacy and safety.
In a subgroup analysis of a general surgery
trial, fondaparinux was more effective than
dalteparin in patients undergoing surgery for
17
cancer.
Patients undergoing transurethral or
laparoscopic urologic procedure do
not require prophylaxis beyond early
ambulation.
Due to the limited number of trials in
patients undergoing urologic surgery, dosing
recommendations are based on evidence of
pharmacologic agents in general surgery.
• Bariatric surgery
Higher than recommended doses of LMWH
and UFH are needed. UFH three x daily and
enoxaparin 40 mg twice daily have been
evaluated.
18
been evaluated in a retrospective study using
anti-Xa levels.
• Thoracic surgery
Due to the limited number of trials in
patients undergoing thoracic surgery, dosing
recommendations are based on evidence of
pharmacologic agents in general surgery.
Dalteparin 7,500 units daily has
VENOUS THROMBOEMBOLISM PREVENTION 299
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• Coronary bypass surgery
Due to the limited number of trials in
patients undergoing coronary artery bypass
surgery, dosing recommendations are based
on evidence of pharmacologic agents in
general surgery.
Due to concerns about higher incidence of
HIT in cardiac surgery patients, a LMWH
may be preferred over UFH for prophylaxis.
VTE Prophylaxis in Orthopedic Surgery
See Table 12-12.
• UFH has consistently demonstrated insufficient
protection against VTE in patients undergoing
orthopedic surgery and, therefore, should not
be considered an acceptable alternative to the
options listed below.
•
Although aspirin has a recommendation from
the ACCP and the American Association of
Orthopedic Surgeons (AAOS) guidelines, the
recommendation is based on a single study with
multiple limitations.
4,19,20
• Patients placed on mechanical prophylaxis after
surgery due to high risk of bleeding should have
their risk of bleeding consistently reassessed, with
pharmacologic prophylaxis started as soon as the
bleeding risk is decreased.
• Patients undergoing knee arthroscopy typically
do not need VTE prophylaxis beyond early
mobilization, unless they have additional VTE
risk factors or have a complicated procedure.
In those cases, patients should receive VTE
prophylaxis with a LMWH.
• Dalteparin has not been evaluated in a published
prospective trial for VTE prophylaxis in knee
replacement surgery.
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