hospitalized medical adults
▪️Introductions
*It is estimated that over half of hospitalized medical patients are at risk for venous thromboembolism.
*PE is the most common preventable cause of hospital death.
🔺clinicians should be aware that VTE prophylaxis does not eliminate the risk of VTE or VTE-related death in hospitalized patients.
🔹Our Approache:
▫️Thrombosis risk assessment+ Bleeding risk assessment+ Selection of method of prophylaxis (Pharmacological or mechanical)
▪️Thrombosis risk assessment:
▫️We consider that medical patients admitted to hospital
with at least one risk factor for VTE are at risk for the development of DVT and/or PE:
*heart failure,
*acute respiratory failure (eg, acute exacerbations of chronic pulmonary disease),
*sepsis
*pregnancy
*inflammatory bowel disease
*known thrombophilia
*prolonged immobility ≥3 days
*age >60 years
*previous VTE
*multiple risk factors
*possibly patients with an elevated D-dimer
*patients who are critically ill
*patients with lower limb paralysis from stroke
*patients with active cancer
*All patients admitted the ICU
*myocardial infarction
*renal failure
*obesity
*inherited or acquired hypercoagulable states
*COVID-19
OR
▫️The Padua Prediction Score(High-risk patients (score ≥4):
*Cancer: Active or treated with chemotherapy and or XRT within the last 6 months (3 points)
*History of venous thrombotic disease (not to include superficial thromboses) (3 points)
*Impaired/reduced mobility of at least 3 days duration (3 points)
*Preexisting hypercoaguable state (3 points)
*Trauma or surgery within 1 month (2 points)
*Age ≥70 years old (1 point)
*Heart or respiratory failure (1 point)
*Stroke or acute MI (1 point)
*Acute infectious disease or rheumatic disease (1 point)
*Obesity with a body mass index ≥30 kg/m2 (1 point)
*Intercurrent hormone replacement treatment (1 point)
▪️Bleeding risk assessment:
▫️Examples of medical patients at high risk of bleeding in whom pharmacologic thromboprophylaxis is typically contraindicated:
*active bleeding or intracranial hemorrhage,
*those in whom a surgical
procedure is planned in the immediate 6 to 12 hours (eg, spinal neuroaxial anesthesia),
*patients who have a moderate or severe coagulopathy,
*patients with a severe bleeding diathesis or
*thrombocytopenia (eg, platelet count <50,000/microL or <100,000/microL plus additional risk factors for bleeding).
🔺The strongest independent risk factors for bleeding at the time of admission were the following:
*Active gastroduodenal ulcer
*Bleeding within the three months prior to admission
*Platelet count <50,000/microL
🔺Epistaxis and menstrual bleeding are not contraindications to pharmacologic thromboprophylaxis.
OR
▫️IMPROVE Bleeding risk model(Score ≥7: High risk of bleeding)
*Age ≥85 years (4.5 points)
*Age 40-84 years (1.5 points)
*Male sex (1 point)
*Current cancer (2 points)
*Rheumatic disease (2 points)
*Central venous catheter (2 points)
*ICU/CCU admission (2.5 points)
*Hepatic failure (INR >1.5) (1.5 points)
*GFR <30 mL/min (2.5 points), 30-59 mL/min (1 point)
*Active gastroduodenal ulcer (4.5 points)
*Bleeding in prior 3 months (4 points)
*Platelet count <50,000/µL (4 points)
✅یکم ساده تر بگیم: یه راهش اینه مثلا طبق این کرایتریاها، اگه یه نفر moderate to highe risk for VTE باشه(یا با معیارهای بالینی که گفته شد یا با padua ≥4). خب باید دارویی ضدانعقاد بگیره.
شرطش چیه که بتونیم داروی ضدانعقاد بدیم؟ کنترااندیکاسیون برای داروهای ضدانعقاد نداشته باشه و یا اینکه low risk for bleeding باشه(یعنی improve score <7باشه) و اگه هم Score ≥ 7 بود، توی این حالت باید از پروفیلاکسی مکانیکی( جوراب فشاری یا IPC) استفاده کنیم و یا تاخیر در شروع دارویی(که as soon as possible اگه شرایط اوکی بشه باید دارویی رو شروع کنیم).