Guideline Development Group


Table 4: Reduced mobility as a risk factor for VTE18, 24



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Table 4: Reduced mobility as a risk factor for VTE18, 24


Degree of immobility

OR

95% CI

P value

Normal

1.0







Limited

1.73

1.08-2.75

0.02

Wheelchair 30 days

2.43

1.37-4.30

0.002

Bed rest 30 days

2.73

1.20-6.20

0.02

Wheelchair 15-30 days

3.33

1.26-8.84

0.02

Bed rest 15-20 days

3.37

1.00-11.29

0.05

Wheelchair 15 days

4.32

1.50-12.45

0.007

Bed rest < 15 days

5.64

2.04-15.56

0.0008

OR = Odds ratio; CI = confidence interval



Table 5: Education Topics for Patients at High Risk for DVT69

  • Risk factors for DVT

  • Possible consequences of DVT

  • Interventions to decrease the risk of DVT

  • Signs/symptoms of DVT and importance of seeking medical help if suspect DVT

  • Importance of follow-up monitoring

  • Importance of compliance

  • Medication issues e.g. regimen, adverse side effects and interactions, dietary restrictions






Table 6: Definition of Immobility in Residents of Long-Term Care Facilities43

Presence of at least 1 of the following:

  • Lower limb cast

  • Bedridden

  • Bedridden except for bathroom privileges

  • Recent decreased ability to walk at least 10 feet for a least 72 hours

  • Inability to walk at least 10 feet



Table 7: Signs and Symptoms of a LE DVT 35, 42, 59, 61

  • Pitting edema

  • Tenderness and pain in leg

  • Erythema

  • Warmth

  • Swelling of the leg

  • Prominent superficial veins



Table 8: Two-Level DVT Wells Score65

Clinical Feature

Points

Active cancer (treatment ongoing, within 6 months, or palliative)

1

Paralysis, paresis or recent plaster immobilisation of the lower extremities

1

Recently bedridden for 3 days or more or major surgery within 12 weeks requiring general or regional anaesthesia

1

Localised tenderness along the distribution of the deep venous system

1

Entire leg swollen

1

Calf swelling at least 3 cm larger than asymptomatic side

1

Pitting edema confined to the symptomatic leg

1

Collateral superficial veins (non-varicose)

1

Previously documented DVT

1

Alternative diagnosis at least as likely as DVT

−2

Clinical probability simplified score

DVT ‘likely’

2 points or more

DVT ‘unlikely’

Less than 2 points


Table 9: Current Anticoagulation Options In Use30, 35, 42, 57, 59, 60, 69, 78-84, 86, 87, 89, 136


Classifications and mechanism of action

Medication Names

Dosage and method of delivery

Peak therapeutic levels achieved **

Unfractionated Heparin

Mechanism of action:



inactivates thrombin and activated factor X (factor Xa) by binding to antithrombin through a high-affinity pentasaccharide.


Heparin

Delivery: IV

Dose: Bolus 80 units/kg followed by infusion of 18 units/kg/hr



24-48 hours

Low Molecular Weight Heparins

Mechanism of action: binds to antithrombin which is mediated by a unique pentasaccharide sequence which causes a change in antithrombin and inactivates factor Xa




Lovenox (enoxaparin)

Fragmin


Enoxaparin (ext release)

Innnohep (tinzaparin sodium)

Others?


Delivery: Subcutaneous injections

Prophylactic dose: 30-40 mg q 12-24 hr

Therapeutic dose:

1-1.5 mg/kg q 12-24 hr



3-5 hours

Fondaparinux (synthetic drug)

Mechanism of action:

provides antithrombotic activity via selectively binding to antithrombin III (ATIII) which in turn results in inhibition of Factor Xa


Arixtra

Delivery: subcutaneous injections

Prophylactic Dose 2.5 mg/day

Therapeutic Dose: 5-10 mg/day (based on weight)


2-3 hours

Vitamin K antagonists

Mechanism of action: inhibiting the synthesis of vitamin K-dependent clotting factors, especially the C1 subunit of vitamin K epoxide reductase (VKORC1) enzyme complex




Coumadin (warfarin)

Delivery: oral

Dosing: individualized based upon individual’s INR response to drug



Used with LMWH or UFH

INR 2-3


Oral direct thrombin inhibitor

Mechanism of action:

Directly inhibits thrombin


Pradaxa (dabigatran)


Delivery: oral

Dosing: 150 mg bid



Peak achieved in 2 hours

Oral direct Xa inhibitors

Mechanism of action: exerts anticoagulant effect via direct inhibition of a single Factor within the coagulation cascade: Factor Xa.




Xarelto (rivaroxaban)

Eliquis (Apixaban



Delivery: oral

Xarelto Dosing: 15 mg bid for first 21 days, 20 mg qd after day 21

Eliquis dosing:

5 mg bid


2-3 hours



Table 10: Indicators of Heparin Induced Thrombocytopenia (HIT)

  • Skin lesion reaction at injection site

  • Systemic reaction to a bolus administration of heparin

  • 50% decrease in platelet count from baseline labs while on heparin

Delayed onset HIT:



Table 11: Risk of Bleeding19


  • Active bleeding

  • Acute stroke

  • Acquired bleeding disorders (such as acute liver failure)

  • Concurrent use of anticoagulants known to increase the risk of bleeding (such as Coumadin with an INR >2)

  • Lumber puncture/epidural/spinal anesthesia expected to be given within next 12 hours

  • Thrombocytopenia (platelets less than 7,500)

  • Uncontrolled systolic hypertension (defined as BP of 230/120 mm Hg or higher)

  • Untreated inherited bleeding disorders such as hemophilia or von Willebrand’s disease

Table 12: Indications and Contraindications to Inferior Vena Cava Filter Placement137

Absolute Indications

Relative Indications

Contraindication to anticoagulation

Large free-floating proximal DVT

Therapeutic anticoagulation is unable to be achieved or maintained

Therapeutic anticoagulation not achieved




VTE with decreased cardiopulmonary reserve




Poor compliance with anticoagulation medication




High risk of complication from anticoagulation

Absolute Contraindications

Relative Contraindications

Complete, chronic thrombosis of the IVCF

Severe, uncorrectable coagulopathy

Inability to gain central venous access

Bacteremia or sepsis



Table 13: Complications Related to Inferior Vena Cave Filters137, 138

Insertion Complications

Thrombotic Complications

Hematoma at insertion site

Insertion site thrombosis

Misplacement

IVCF thrombosis

Pneumothorax

New or progression of DVT

IVC damage/wall penetration

New or progression of PE

Filter migration

Post-thrombotic syndrome

Air embolism




Carotid artery puncture




Arteriovenous fistula




Infection





List of Figures


Figure 1. Search strategy by keywords, MeSH terms, and databases

Figure 2: Screening for Risk of Venous Thromboembolism Algorithm

Figure 3: Determining Likelihood of a Lower Extremity Deep Vein Thrombus Algorithm

Figure 4: Mobilizing Patients with Known Lower Extremity Deep Vein Thrombus Alogrithm


Figure 1. Search strategy by keywords, MeSH terms, and databases



Keywords:


DVT

“Venous Thrombosis”

“Deep Vein Thrombosis”

VTE


“Venous Thromboembolism"

“Pulmonary Embolism”

Walking

Walk


Ambulation

Ambulate


Ambulated

Movement


Mobility

Immobilization

Immobilisation

"Mobility Limitation"

“Motor Activity”

“Early Ambulation"

"Early Activization"

"Early Activisation"

"Early Mobilization"

"Early Mobilisation"

Anticoagulants

Anticoagulant

Anticoagulation

Dabigatran

Desirudin

Ximelagatran

Edoxaban

Rivaroxaban

Apixaban

Betrixaban

"YM150"

Razaxaban

“Factor Xa Inhibitor”

“Factor Xa Inhibitor”

“Direct Thrombin Inhibitors” “Direct Thrombin Inhibitor” Coumadin

Warfarin


Fondaparinux

Idraparinux

“International Normalized Ratio"

“INR”


“Prothrombin Time”

“Vena Cava Filter*”

"Intermittent Pneumatic Compression Devices”

"Compression Stockings"

"Compression Socks"

"Compression Hose"

"Compression Hosiery"

MeSH Terms:


“Venous Thrombosis"

"Pulmonary Embolism"

“Walking”

“Movement”

"Immobilization"

"Mobility Limitation"

"Motor Activity"

"Early Ambulation"

"Activities of Daily Living"

"Anticoagulants"

"Coumarins

"Fibrin Modulating Agents"

"Factor Xa/antagonists and inhibitors"

"Thrombosis/prevention and control"

"Antithrombins"

"Citric Acid"

"Heparinoids"

"Vitamin K/antagonists and inhibitors"

"Antithrombin Proteins"

"Fibrinolytic Agents"

"International Normalized Ratio"

"Prothrombin Time"

"Vena Cava Filters"

"Intermittent Pneumatic Compression Devices"

"Stockings, Compression"

Databases:


PubMed

CINAHL


Web of Science

Cochrane Database of Systematic Reviews

Database of Abstracts of Reviews of Effects (DARE)

Physiotherapy Evidence Database (PEDro)












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