Management of deep vein thrombosis and pulmonary embolism

Management of deep vein thrombosis and pulmonary embolism

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  Management of DeepVein Thrombosis and Pulmonary Embolism Sunil Kumar Daha
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  Treatment ANTICOAGULATION • low-molecular-weight heparin(LMWH), or fondaparinux is used • Warfarin
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  • Low-Molecular-Weight Heparins –Greater bioavailability – More predictable dose response, and a longer half- life than does UFH – No monitoring or dose adjustment required – Adult 7500 -10000 IU followed by 1000 – 1500 IU/ hr in infusion – Child 50-100 U/kg
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  • Fondaparinux – Ananti-Xa pentasaccharide – Administered as a once-daily subcutaneous – No laboratory monitoring is required. – Patients weighing <50 kg receive 5 mg, patients weighing 50–100 kg receive 7.5 mg, and patients weighing >100 kg receive 10 mg
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  Warfarin • Vitamin Kantagonist • Prevents carboxylation activation of coagulation factors II, VII, IX, and X. • Requires at least 5 days to act fully • Usually initiated in a dose of 10 mg in first and second day, on 3rd day 5 mg subsequent doses is titratedd against the INR • Doses of 7.5 or 10 mg can be used in obese patients • When heparin is coumarin with warfarin it is monitored by INR target to 2.5 to 3 for two days, then after stop heparin.
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  Pulmonary embolism dueto DVT
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  Acute management • Oxygen-to hypoxemic patient until SpO2 is more than 90% • IV fluids and plasma - for circulatory shock • Resuscitation by external cardiac massage • Avoids diuretics and vasodilators • Opiates for relieving pain and distress but should be used with caution in hypotensive patient
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  Treatment ANTICOAGULATION • low-molecular-weight heparin(LMWH), or fondaparinux is used • Warfarin • If proven or suspected heparin-induced thrombocytopenia ,a direct thrombin inhibitor—argatroban, lepirudin, or bivalirudin is used
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  Newer anticoagulants • Rivaroxaban,a factor Xa inhibitor, and dabigatran, a direct thrombin inhibitor are used for prevention of VTE • Have rapid onset of action and relatively short half-life so“bridging” with a parenteral anticoagulant is not required • Does not require laboratory monitoring • Have less drug-drug or drug-food interactions
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  Duration of anticoagulanttherapy • If identifiable risk factors are present, anticoagulant can be discontinued after 3 months • If persistant prothrombotic risks or previous history of emboli, should be anticoagulated for life • If cancer associated VTE, heparin should be given for 6 months
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  INFERIOR VENA CAVAL(IVC) FILTERS The indications are: • Active bleeding that precludes anticoagulation • Recurrent venous thrombosis despite intensive anticoagulation • Prevention of recurrent PE in patients with right heart failure who are not candidates for fibrinolysis Disadvantages: • May fail by permitting the passage of small- to medium-size clots • Large thrombi may embolize to the pulmonary arteries via collateral veins that develop • Caval thrombosis with marked bilateral leg swelling
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  Fibrinolysis Indication: Massive pulmonaryembolism • It – Dissolves obstructing pulmonary arterial thrombus – Prevents continued release of serotonin and other neurohumoral factors that exacerbate pulmonary hypertension – Lyses the source of the thrombus in the pelvic or deep leg veins • 100 mg of recombinant tissue plasminogen activator (tPA) administered as a continuous peripheral intravenous infusion over 2 hours. • Contraindications : Intracranial disease,recent surgery, and trauma
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  Surgical intervention 1. Pulmonaryembolectomy 2. Pulmonary thromboendarterectomy • Indication: Patients impaired by dyspnea due to chronic thromboembolic pulmonary hypertension
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  References • Davidson’s Principlesand Practice of Medicine 22nd edition • Harrison’s Principal of internal medicine, 19th edition • Kumar and Clark's, Clinical Medicine, 8th Edition • Essential Medical pharmacology, KD Tripathi, 6th edition
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  Thank You