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Venous Thromboembolism (VTE) - Coggle Diagram
Venous Thromboembolism (VTE)
RISK FACTORS FOR VTE (FARIQ)
Vessel Wall Injury
Atherosclerosis
Thrombophlebitis
Physical Trauma/ Strain/ Injury
Venepuncture
Stasis of Blood
Immobility
Venous Obstruction (Obesity, Tumour, Pregnancy)
Varicose Veins
Bradycardia & Low Blood Pressure
Hypercoagulability of Blood
Major Surgery/ Trauma
Inherited Thrombophilia
Malignancy
Infection/ Sepsis
Inflammation
Dehydration
Treatment of VTE (Quraisyah)
Anticoagulants
does NOT dissolve formed blood clots
prevents elongation of current blood clot
prevents formation of new blood clots
reduce risk of embolism
prevents death
At least 3 months, depending on patient's risk factors
Pharmalogical classes
Direct factor Xa inhibitor
Rivaroxaban
Dose
Treatment: 15mg BD x 3 weeks then 20mg OD (15mg for patients with high bleeding risks)
Prophylaxis: 10mg OD for 31-39 days
Side effects
Abdominal pain
Constipation
Diarrhoea
Dizziness
Dyspepsia
Haemorrhage
Headache
Hypotension
Nausea
Pain in extremities
Pruritus
Rash
Renal impairment
Vomiting
Apixaban
Dose
Treatment: 10mg BD x 1 week then 5mg BD
Prophylaxis (total hip/knee arthroplasty): 2.5mg BD beginning 12-24 hours postpoeratively
Side effects
Anemia
Bruising
Haemorrhage
Nausea
Contraindications
Active bleeding
Malignant neoplasms
Oesophageal varices
Recent brain/opthalmic/spine surgery
Recent GI ulcer
Recent intracranial haemorrhage
Significant risk of major bleeding
(NO REVERSAL AGENT AVAILABLE)
Vascular aneurysm
Acute coronary syndrome-previous stroke/transient ischemic attack (Rivaroxaban)
Monitoring requirements
Signs of bleeding
No routine anticoagulant monitoring required
Counselling points
To take with or without food. Take after food if it causes an upset stomach
Please watch out for signs of bleeding (blood in stools, black tarry stools, blood in urine, etc.) or anemia
Tablets may be crushed and mixed with water or apple puree just before administration
Vitamin K epoxide reductase antagonist
Warfarin
Dose
Individualized dosage, according to patient's INR (typical target INR: 2-3)
Initiated at 5mg OD or less for asians
once daily/OD
Individualized response & sensitivity (increased with age)
Side effects
Alopecia
Diarrhoea
Haemorrhage
Hepatic dysfunction
Jaundice
Nausea
Pancreatitis
Purpura
Pyrexia
Rash
Skin necrosis (increased in patients with protein C or protein S deficiency)
Vomiting
Purple toes
Contraindications
Avoid use within 48 hours postpartum
Haemorrhagic stroke
Significant bleeding
First trimester of pregnancy
Monitoring requirements
Signs of bleeding
INR (at baseline, until INR is within therapeutic range & at 8-12 weeks intervals once INR is stable)
Full blood count
Counselling points
Brands are not interchangeable
Comes in 1mg, 3mg or 5mg strength
Important to take everyday
Ensure diet is consistent in weekly vegetables and fruits intake
Inform healthcare profession that you are taking warfarin
Please watch out for signs of bleeding (blood in stools, black tarry stools, blood in urine, etc.) or anemia. Do not rub bruises and observe for enlargement or spreading of bruise
Reversal agent: Vitamin K1 (Phytonadione)
Interactions
Drugs that increase INR by inhibiting CYP 450
Ciprofloxacin
Metronidazole
Trimethoprim-sulfamethoxazole
Clarithromycin
Amiodarone
Fluconazole
Drugs that decrease INR by inducing CYP 450
Carbamazepine
Phenobarbital
Rifampicin
Alterations in vitamin K status
Vitamin K rich diet will reduce effect of warfarin hence INR will decrease therefore patient needs to consume more warfarin for the therapeutic effect
Vit K rich food: Leafy vegetables, green tea, livers etc.
Drugs that alter GI flora (eg. Broad spectrum antibiotics like Augmentin and Piptazo) as GI flora produces Vitamin K
Disease state interactions
Conditions that increase INR
Hyperthyroidism
Poor nutritional state
Fever
Diarrhoea
Hepatic disorders
Fluid overload
Conditions that decrease INR
Hypothyroidism
Direct factor lla inhibitor
Dabigatran
Dose
Treatment: 150mg BD after 5 days of parenteral anticoagulant
Will be reduced to 110mg BD if:
patient is also on concomitant verapamil
patient's CrCl is 30-50ml/min
patient has high bleeding risk
Avoid giving to patients who weigh less than 50kg
Side effects
Abdominal pain
Anemia
Diarrhoea
Dyspepsia
Haemorrhage
Nausea
Contraindications
same as Direct factor Xa inhibitors +
patients with mechanical prosthetic heart valve(s)
Monitoring requirements
same as direct factor Xa inhibitors
Counselling points
To take with or without food. Take after food if it causes an upset stomach
Please watch out for signs of bleeding (blood in stools, black tarry stools, blood in urine, etc.) or anemia
Dispense in an individual unit dose blister package --> sensitive to moisture
Swallow whole, do not chew or crush
Reversal agent: Idarucizumab
Unfractioned Heparin (UFH)
Dose
Not required to know
Side effects
Alopecia
Hyperkalaemia
Haemorrhage
Contraindications
recent cerebral haemorrhage
Acute bacterial Endocarditis
Monitoring requirements
Signs of bleeding
Platelet counts measured before and during course of Heparin if longer than 4 days
Counselling points
Medication will be administered while patient is admitted
Low Molecular Weight Heparins (LMWH)
Enoxaparin
Dose:
SC 1mg/kg BD or 1.5mg/kg OD
Side effects:
Alopecia
Hyperkalemia
Injection-site reactions
Hemorrhage
Heparin-induced thrombocytopenia
Contraindications:
Acute bacterial endocarditis
Epidural anesthesia with treatment doses
Peptic ulcer
Recent cerebral hemorrhage
Caution:
Elderly
Monitoring Requirements:
Monitor for signs of bleeding
Platelet counts should be measured before heparin and during the course if its longer than 4 days
Serum potassium level if patient is at risk of hyperkalemia (DM, CKD, acidosis)
Counselling points:
patients should be sitting down
select an area on the abdomen at least 5cm away from the belly button
do not expel the air bubble inside the injection
insert the needle at a 90-degree angle into the skin fold between the thumb and forefinger
the skin fold needs to be held throughout the injection
immediately dispose of the syringe in the nearest sharps bin.
Pathophysiology of VTE
(ayska)
1) Large veins (blood clot)
2) Fragile clot or parts of it might break away into the bloodstream --> enters heart and into the lungs
3) Clot blocks a pulmonary artery --> pulmonary embolism
signs and symptoms of VTE
(YanZi)
deep vein thrombosis
swelling/pain in affected limb
red or discolored in affected limb
feeling of warmth in affected limb
pulmonary embolism
sudden shortness of breath
chest pain / chest discomfort
-> can worsen when taking deep breath
-> or when coughing
lightheaded / dizzy / faint
rapid pulse
coughing out blood
How does VTE links to CKD? (lihua)
vice-versa
CKD makes it easier for the body to form blood clots
CKD causes buildup of urea in the blood
which leads to accumulation of "uremic" solute
Can result in cardiovascular toxicity including thrombosis
Blockage of blood flow to kidney can cause damage to kidney and permanent kidney failure
This is known as Renal vein thrombosis
-blockage of renal vein which carries blood away from kidney
What is VTE?
(lihua)
VTE refers to Venous Thromboembolism
Blood clot forms usually in the deep veins
Veins in the leg, groin, or arm is known as DVT
Blood clot in lungs is known as pulmonary embolism (PE)
