DVT & Pulmonary Thromboembolism

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DVT, Venous & Pulmonary Thromboembolism:

DVT, Venous & P ulmonary T hromboembolism Dr Bikram Gupta MD Anaesthesia,PDCC in Critical Care

Approach to a patient of suspected acute pulmonary thromboembolism:

Approach to a patient of suspected acute pulmonary thromboembolism Step 1 –When to suspect Step 2 –Initiate resuscitation Step 3 - Assess the risk factors Step 4 - Assess clinical probability of PE Step 5 - Initiate treatment Step 6 - Order investigations Step 7 - Identify the risk of adverse outcome for triage Step 8 - Haemodynamically stable patients without myocardial dysfunction or injury Step 9 - Consider thrombolytic Step 10 -Consider invasive treatment Step 11 -Initiate vitamin K antagonist therapy Step 12 -Inferior vena caval filters Step 13 -Long term treatment

Step 1 - When to suspect:

Step 1 - When to suspect Deep venous thrombosis Pulmonary embolism Massive PE Upper extremity DVT : pain and swelling in arms,neck,face or chest, dysfunction of CVC New onset or worsening dyspnea Pleuritic chest pain Tachypnoea Tachycardia Hypoxemia Sustained hypotension without any other obvious cause Syncope/ presyncope hemodynamic instability with SBP <90 or a drop in baseline SBP by >/=40mmHg Signs as before PLUS : Acute right heart failure Elevated J.V.P. Right-sided S3 Parasternal lift Lower extremity DVT : cramping pain,swelling,erythema of leg Groin swelling indicates pelvic vessel involvement Lower abdominal wall swelling, flank collaterals, and bilateral leg swelling indicates IVC involvement

Step 2- Initial resusitation:

Step 2- Initial resusitation Supportive care : oxygen, fluid and vasoactive therapy Mechanical ventilation – noninvasive mask or an endotracheal tube to support pt’s increased mechanical ventilation Adequate preload prior to intubation is paramount Volume resusitation -if patient is hypotensive give 500-1000ml isotonic crystalloid Take detailed history and perform physical examination

Step 3-assessment of risk factors :

Step 3-assessment of risk factors Surgery Major surgery, especially cancer related surgery, hip and knee surgery Trauma Multisystem trauma, especially spinal cord injury and fractures of the spine Malignancy Any malignancy, active or occult chemotherapy and radiotherapy Acute medical illness Stroke, right sided heart failure,sepsis,inflammatory bowel disease, nephrotic syndrome, myeloproliferative disorders Drugs Erythropoisis-stimulaing drugs, estrogen containing compounds Patient specific factors Prior thromboembolism,obesity,increasing age, pregnancy ICU related factors Prolonged mechanical ventilation, neuromuscular paralysis, severe sepsis,vasopressors,platelet transfusions,immobality

Step 4 - Assessment of clinical probability of PE:

Step 4 - Assessment of clinical probability of PE Clinical Signs and Symptoms of DVT? (Calf tenderness, swelling >3cm, erythema , pitting edema affected leg only) +3 Alternative diagnosis less likely than PE +3 Heart Rate > 100 +1.5 Immobilization at least 3 days, or Surgery in the Previous 4 weeks +1.5 Previous, objectively diagnosed PE or DVT? +1.5 Hemoptysis +1 Malignancy +1 Well’s Criteria Low risk <2 Intermediate risk 2-6 High risk >6

Step 4 - Assessment of clinical probability of PE:

Step 4 - Assessment of clinical probability of PE REVISED GENEVA SCORE: CRITERIA POINTS AGE >65YRS 1 PREVIOUS DVT OR PE 3 SURGERY OR FRACTURE WITHIN 1 MONTH 2 ACTIVE MALIGNANT CONDITION 2 UNLATERAL LOWER LIMB PAIN 3 HEMOPTYSIS 2 HEART RATE- 75-94 BEATS /MIN OR -95 BEATS /MIN 3 5 PAIN ON LOWER LIMB DEEP VENOUS PALPATION AND UNILATERAL EDEMA 4 LOW 0-3 INTERMEDIATE 4-10 HIGH ≥11

Step 5-Initial treatment:

Step 5-Initial treatment While diagnostic confirmation is awaited, anticoagulant treatment with S/C LMWH, fondaparinux or I.V. UFH should be initiated as soon as possible (if there is no contraindication).

Slide 9:

A) Unfractionated heparin(UFH) haemodynamically unstable patient Critically ill patient /renal failure Target PTT – 46-70 seconds or a PTT ratio (test/control) -1.5 to 2.5 Weight based dosing regimen ( <130 kg) but if body weight >130 kg ,then dosing based on adjusted weight(kg) Adjusted weight(kg) = IBW + 0.4 X (actual wt –IBW)

Weight based heparin dosing regimen:

Weight based heparin dosing regimen Give initial bolus dose of 80 U/kg and follow with continuous infusion of 18 U/kg/hr.( use actual body weight) 2. Check aPTT 6 hrs after start of infusion and adjust heparin dose as indicated below:- aPTT (sec) PTT ratio Dose change <35 1.2x control 80 U/kg bolus ,increase drip by 4U/kg/hr 35-45 1.3-1.5xcontrol 40U/kg bolus ,increase drip by 2U/kg/hr 46-70 1.5-2.3x control No change 71-90 2.3 – 3.0 x control Reduce drip by 2 U/kg/hr >90 >3x control Hold heparin for 1 hr , reduce drip by 3U/kg/hr 3. Check aPTT 6 hrs after each dose adjustment. When in the desired range 46-70 seconds, monitor daily.

Low molecular weight heparin:

Low molecular weight heparin B) Enoxaparin -1mg/kg S/C BD , reduce dose by 50% in pt with a creatinine clearance <30 ml/min, e.g. 1 mg/kg once daily) No need for routine monitoring but in pt with renal failure or morbid obesity , the lab test of choice is the anti– Xa level in plasma, which should be measured fours hours after LMWH administration. Desired anti– Xa level is 0.6-1.0 units/ml for bd dosing and >1 unit/ml for OD dosing. C)Dalteparin-5000 U s/c BD D) Fondaparinux - Wt. <50 kg-5 mg s/c OD Wt. 50-100 kg -7.5 mg s/c OD Wt. >100 kg-10 mg s/c OD

Step 6 – order investigation:

Step 6 – order investigation NON SPECIFIC TESTS: ECG – sinus tachycardia, Acute RV strain , S 1 Q 3 T 3 Chest X-ray – Hampton’s hump sign (peripheral wedge shaped opacity resulting from infarction) Westermark’s sign (focal oligemia ) Palla’s sign (An enlarged right descending pulmonary artery) ABG Baseline PT/INR, PTT, Platelet count Renal function test

Hampton’s hump:

Hampton’s hump

Westermark’s sign:

Westermark’s sign Westermark's Sign: an abrupt tapering of a vessel caused by pulmonary thromboembolic obstruction. This CXR shows enlargement of the left hilum accompanied by left lung hyperlucency , indicating oligemia ( Westermark's sign).

Slide 16:

ABG : Hypoxemia Hypocapnia (low CO2) Respiratory Alkalosis Massive PE: hypercapnia , mix resp and metabolic acidosis (inc lactic acid) Patients with pulse ox readings <95% are at increased risk of in-hospital complications, resp failure, cardiogenic shock, death

Step 6 – order investigation:

Step 6 – order investigation Choice of further investigation depends upon: a)Index of suspicion of PTE b)Haemodynamic stability of patient c)Availability of tests at the center d)Sensitivity, specificity and positive predictive value of each test

Slide 18:

Suspected PE Clinical probability assessment by clinically or by score-WELL`S or REVISED GENEVA SCORE Haemodynamically stable Haemodynamically unstable Low /intermediate clinical probability High clinical probability Critically ill bt can be moved to CT room Critically ill bt can`nt be moved to CT room High density D- dimer testing normal elevated MDCT for CTA PE ruled out negative PE confirmed MDCT available MDCT not available TE/TTE & compression USG both lower limbs RV dysfunction or &/ or DVT No RV dysfunction & DVT Treat Search for alternative diagnosis

Lab Findings in P.E. (D-dimer):

Lab Findings in P.E. (D-dimer) D-dimer : Degredation product of fibrin >500 is abnormal Sensitivity: High, 95% of PE pts will be positive Specificity: Low Negative Predictive Value: Excellent

Ventilation : perfusion scans:

Ventilation : perfusion scans Almost entirely been supplanted by CTA in modern era Why ?????? Interpreted as either intermediate probability ( i.e. with a 40 % likelihood of PE) or indeterminate ( unknown risk for subsequent PE) Performing the ventilation component of a V/Q scan is technically challenging for mechanically ventilated patient.

Step 7- identify the risk of adverse outcome for triage:

Step 7- identify the risk of adverse outcome for triage Based on clinical features and markers of myocardial dysfunction or injury Myocardial dysfunction (right ventricular dilatation, hypokinesia and ventricular septal bowing) based on Echo McConnell sign- RV free wall hypokinesis or akinesis coupled with normal or hyperkinetic RV apex performance “D Sign” Myocardial injury markers (elevated troponin and BNP level)

Lab Findings in P.E. (BNP):

Lab Findings in P.E. (BNP) BNP (beta natruretic peptide) Insensitive test Patient’s with PE have higher levels than pts without, but not ALL patients with PE have high BNP Good prognostic value measure : if BNP >90 associated with adverse clinical outcomes (death, CPR, mechanical vent, pressure support, thrombolysis, embolectomy)

Lab Findings in P.E. (Troponin):

Lab Findings in P.E. (Troponin) Troponin High in 30-50% of pts with mod to large PE Prognostic value if combined pro-NT BNP Trop I >0.07 + NT- proBNP >600 = high 40 day mortality

Risk stratification for triage:

Risk stratification for triage Admit in ward Admit in HDU Admit to ICU Absence of RV dysfunction and normal troponin level Haemodynamically stable with RV dysfunction or injury Haemodynamically unstable and RV Dysfunction or injury Anticoagulant therapy Watch for vitals and respiratory distress Consider early mobilisation Start anticoagulation preferably UFH (APTT – 1.5 -2.5 to normal) Supportive measures and Start anticoagulation preferably UFH (APTT – 1.5 -2.5 to normal) Step 8 - CONSIDER THROMBOLYSIS IF NO CONTRAINDICATION Discontinue heparin during thrombolysis

Pulmonary embolism severity index :

Pulmonary embolism severity index Predictors Points assigned Age,per year Age ,in years Male sex +10 H/O cancer +30 H/O heart failure +10 H/O chronic lung disease +10 Pulse ≥ 110/min +20 SBP < 100 mm Hg +30 Respiratory rate ≥ 30 /min +20 Temperature <36 0 c +20 Altered mental status +60 Arterial oxygen saturation<90 % +20

Pulmonary embolism severity index :

Pulmonary embolism severity index class Point Risk I ≤ 65 Low II 66-85 Low III 86-105 High IV 106-125 High V >125 High

Thrombolytic therapy regimens for acute PE:

Thrombolytic therapy regimens for acute PE Complications – 1. major hemorrhage : 9-12 % 2. ICH : 1-2 %

Contraindication for thrombolysis :

Contraindication for thrombolysis Absolute contraindications: 1)prior ICH 2)Known structural cerebral vascular lesion 3) Ischaemic stroke within 3 months 4) suspected aortic dissection 5)Active bleeding or bleeding diathesis 6) Significant head truma or facial truma within 3 months

Contraindication for thrombolysis :

Contraindication for thrombolysis Relative contraindication: 1)history of chr ., severe or poorly controlled HTN 2)severe uncontrolled HTN on presentation (SBP>180 or DBP>110 mm of Hg) 3) trumatic or prolonged CPR(>10 min) 4)major surgery <3 weeks 5)recent internal bleed 6) noncomprssible vascular punctures 7)for streptokinase -prior exposure>5 days ago or prior allergic reaction 8)pregnancy 9) chr . Use of anticoagulants(with INR>1.7 or PT >15s)

Step 8- consider invasive treatment:

Step 8- consider invasive treatment Pt in whom thrombolytic therapy is contraindicated and whose hemodynamic status does not improve with medical treatment, the following should be considered :- Percutaneous mechanical thrombolectomy Surgical embolectomy

Step 9 – initiate Vit.k antagonist therapy:

Step 9 – initiate Vit.k antagonist therapy WARFARIN: Should be initiated as soon as possible, preferably on the first treatment day and heparin should be continued. Heparin discontinued when INR ≥2 for at least 24 hrs Given for 3-6 months LMWH preferred over warfarin in pregnancy

Step 10- Inferior vena cava filter:

Step 10- Inferior vena cava filter Indication: Contraindication to anticoagulant therapy Recurrent thromboembolism despite anticoagulant therapy Bleeding while on anticoagulants

Step 11- duration of therapy for venous thromboembolism:

Step 11- duration of therapy for venous thromboembolism Venous thromboembolism Duration of therapy Triggered DVT (e.g. associated with Sx,trauma ) 3 month Triggerd PE (e.g. associated with Sx,trauma ) 3 month Idiopathic DVT Atleast 3 month,consider indefinite Idiopathic PE Atleast 3 month,consider indefinite Cancer –associated VTE Indefinite or as long as cancer active or under therapy Recurrent VTE Indefinite therapy VTE associated with moderate risk or low risk thrombophilia Dictated by presence or absence of situational triggers Distal DVT 3 month

Thromboprophylaxis:

Thromboprophylaxis

VTE prophylaxis options:

VTE prophylaxis options Pharmacologic prophylaxis Mechanical prophylaxis UFH Graduated compression thromboembolus deterrent (TED) stockings LMWH Dalteparin ( half life 4 h) Enoxaparin ( half life 3.5 h) Tinzaparin ( half life 4.5 h) Intermittent pneumatic compression devices Fondaparinux ( half life 17-21 h) Rivaroxaban ( half life 5-9 h)

Pharmacologic VTE prophylaxis regimens:

Pharmacologic VTE prophylaxis regimens Patient population Regimen Medical inpatient and general surgery UFH heparin 5,000 units q8-12 h Dalteparin 5,000 units q24 h Enoxaparin 40 mg q24h Fondaparinux 2.5 mg q24 h Orthopedic surgery ( total knee or hip arthoplasty ) Dalteparin 5,000 units q24 h Enoxaparin 40 mg q24h Fondaparinux 2.5 mg q24 h Rivaroxaban 10 mg q24 h Warfarin 5 mg q24 h (INR 2-3) Major trauma Enoxaparin 30 mg q12h Craniotomy IPC Any of the above + active bleeding or high risk of bleeding IPC Note :- addition of mechanical px to pharmacologic px has been shown to further reduce VTE in some patients.

Dose modification in some patients group:

Dose modification in some patients group Obesity UFH 5,000 units every 8 hrs.( BMI < 50) 7,000 units every 8 hrs .( BMI 50) Enoxaparin 0.5 mg/kg 0nce daily (BMI> 40) Renal failure Enoxaparin 30 mg OD ( for Crcl < 30 ml/min) Dalteparin No recommended dose adjustment

Contraindication to VTE prophylaxis:

Contraindication to VTE prophylaxis Pharmacologic prophylaxis Mechanical prophylaxis Active or high risk of bleeding Arterial insufficiency Indwelling neuroaxial catheter Open wounds Coagulopathy Acute DVT Platelet count <50,000/µl

Diagnosis of DVT:

Diagnosis of DVT Wells criteria can be used to assess the likelihood of DVT and PE prior to obtaining diagnostic imaging. Wells clinical DVT model Clinical characteristic Score Active cancer 1 Paralysis,paresis or recent plaster cast immobilisation of the lower extremities 1 Recently bedridden for 3 d or more, or major surgery within the previous 12 wk requiring GA/RA 1 Localised tenderness along the distribution of the deep venous system 1 Entire leg swollen 1

Wells clinical DVT model continue…. :

Wells clinical DVT model continue…. Clinical characteristic Score Calf swelling atleast 3 cm larger than the asymptomatic side( measured 10 cm below the tibial tuberosity ) 1 Pitting edema confined to the symptomatic leg 1 Collateral superficial vein ( nonvaricose ) 1 Previously documented deep vein thrombosis 1 Alternative diagnosis at least as likely deep vein thrombois -2 Low risk = <1,intermediate score =1 or 2, high risk = 3 or more

Investigation :

Investigation Upper extremity DVT Lower extremity DVT Duplex USG Duplex USG CT venography CT venography

Thank you:

Thank you

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