Evidence-‐Based Management of An/coagulant Therapy - ICU

Evidence-­‐Based Management of An4coagulant Therapy Preven4on of VTE in nonsurgical pa4ents Preven4on of VTE in nonorthopedic surgical pa4ents An4thrombo4c Therapy and Preven4on of Thrombosis, 9th ed: American college of chest physicians Evidence-­‐based clinical prac4ce guidelines Chest, february 2012 T Vandendriessche

Background and Methods • High-­‐quality an4coagula4on management needed • narrow therapeu4c index: effec4ve safe • Randomized controlled trials(RCT) • Many lower-­‐quality evidence (>50 pt per group)

Opdeling • An4coagulant Therapy • DVT profylaxy in trauma pa4ents • DVT profylaxy in cri4cally ill pa4ents (medical)

An4co: Specific for ICU • acute VTE: VKA therapy started on day 1 or 2 of LMWH or UFH therapy rather than wai4ng for several days to start – Meta-­‐analysis 4 RCT DVT, PE, LV mural thrombosis – No differences in recurrent VTE, bleeding, death – early ini4a4on 4 days fewer in hospital • Stable therapeu4c INRs with a single subtherapeu4c INR value: against rou4nely administering bridging with heparin

An4co: Specific for ICU • decisions during maintenance VKA therapy: validated decision support tools • When taking VKA’s, avoid NSAID’s and AB (cotrimoxazole, quinolones, cefalo, metronidazole, amoxicillin, amoxiclav, fluconazole) • When discon4nuing VKA: abrupt not gradual tapering

An4co: Specific for ICU • If star4ng IV UFH, ini4al bolus (70-­‐80U/kg) and Con4nu Infusion (15-­‐18U/kg), weight adjusted or fixed dose 5000U, 1000U/h – 3 RCT weight based or fixed dose nomogram – Similar therapeu4c aPTTs – No evidence that monitoring improves outcome • Therapeu4c LMWH renal insufficiency (CrCL

VKA’s and high INR • INR 4,5-­‐10 and no bleeding: no Vitamine K – 4 RCT’s compared vitamine K with placebo – Bleeding: Rates were similar, 2% vit K tg 0,8% placebo – TE 5/423 vit K, 4/441 placebo (not significant) – No evidence of benefit for outcome • INR > 10 and no bleeding: oral Vitamine K – No randomised trials – Retrospec4ve study 89 pt – vitamine K 2mg PO compared withdrawal VKA, INR>5 day 3: 11%-­‐46%

VKA’s and high INR • VKA-­‐associated bleeding: – Rapid reversal desirable – PPSB: first choice – NO FFP: prepara4on, volume, allergic – Vitamine K, 5-­‐10 mg IV or oral

Major trauma pa4ents • Inflamma4on, fractures, immobilisa4on, surgical interven4on -­‐> high risk of VTE • Consequences of bleeding complica4ons • Risk factors VTE: – Spinal trauma, acute spinal cord injury – Trauma4c brain injury – Older age, male, black, – Complete paraplegie – >3 days of mechanical ven4la4on

Major trauma pa4ents • Risk factors of bleeding (base line risks) – trauma4c brain injury – Non opera4vely liver or spleen injury – Renal failure – Spinal column fracture with epidural hematoma – Severe thrombocytopenie and coagulopathy

Major trauma pa4ents • average risk of VTE (~3%) and average risk major bleeding: – LMWH/LDUH prevent 4 4mes as many non fatal VTE events as nonfatal bleeding complica4ons – mechanical prophylaxis prevent 4 4mes as many nonfatal VTE events (skin complica4ons) • High risk of VTE (~6%) and average risk bleeding – LMWH/LDUH prevent 10 4mes non fatal VTE as nonfatal bleeding complica4ons, and prevent 4/1000 death of PE – mechanical prophylaxis prevent 15 nonfatal VTE/1000 pa4ents

Major trauma pa4ents • High risk of bleeding – Low quality evidence – LMWH/LDUH: number nonfatal VTE events prevented = number nonfatal bleeding complica4ons – Mechanical prophylaxis prevents nonfatal VTE events

Conclusion Major trauma pa5ent • LDUH/LMWH or mechanical prophylaxis beler than no prophylaxis • High risk for VTE: adding mechanical to pharmacologic prophylaxis • If CI for LMWH/LDUH, mechanical beler than no prophylaxis, adding LMWH when risk diminshes • IVC filter should not be used for primary preven4on • Periodic surveillance with VCU should not be performed

Medical pa4ents • Risk of VTE depends on (no validated) – Acute illness, chronic illnesses, prehospital diagnosis, ICU specific exposures (MV,CVC,…) • Risk of bleeding: – 80% 1 or more episodes of bleeding (minor)

Medical pa4ents: results • No ultrasound screening for DVT • LMWH or LDUH thromboprophylaxis or mechanical prophylaxis beler than no prophylaxis • Pt bleeding or at high risk for major bleeding, mechanical prophylaxis with GCS (graduated compression stockings) or IPC (intermilent pneuma4c compression) un4l the risk decreases