Term
| identify clinical risk factors for the development of VTE |
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Definition
SURGERY
TRAUMA
MALIGNANCY
IMMOBILITY
PREVIOUS VTE
CENTRAL VENOUS CATHETER
INCREASING AGE (AGE > 40)
OBESITY
PREGNANCY AND POST-PARTUM
lower extremity paresis
cancer and cancer therapy
venous compression (tumor, hematoma, arterial abnormality)
acute medical illness
estrogen containing OCs or HRT
selective estrogen receptor modulators (SERMs)
erythropoiesis stimulating agents (EPAs)
inherited or acquired thrombophilia
nephrotic syndrome |
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Term
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Definition
| minor surgery, age < 40, and no clinical risk factors |
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Term
| MODERATE level of VTE risk |
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Definition
major or minor surgery, age 40-60 years, and no clinical risk factors
major surgery, age < 40 years, and no clinical risk factors
minor surgery with clinical risk factors
acutely ill (e.g. AMI, ischemic stroke, CHF exacerbation) and no clinical risk factors |
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Term
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Definition
major surgery, age > 60 years, and no clinical risk factors
major surgery, age 40-60 years with clinical risk factors
acutely ill (e.g. AMI, ischemic stroke, CHF exacerbation) with risk factor(s) |
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Term
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Definition
major surgery, age > 60 years, and no clinical risk factors
major surgery, age 40-60 years with clinical risk factors
acutely ill (e.g. AMI, ischemic stroke, CHF exacerbation) with risk factor(s) |
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Term
| HIGHEST level of VTE risk |
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Definition
MAJOR LOWER EXTREMITY ORTHOPEDIC SURGERY
MULTIPLE TRAUMA
SPINAL CORD INJURY OR STROKE WITH LIMB PARALYSIS
hip fracture
major surgery, age > 40 years, and prior history of VTE
major surgery, age > 40 years, and malignancy
major surgery, age > 40 years, and hypercoaguable state |
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Term
| benefits and limitations to non-pharm interventions for VTE prophylaxis: ambulation |
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Definition
patient walking the halls, going for smoke breaks, etc
not just patient is walking to the bathroom when necessary
not just patient thrashing in bed
not patient up in a chair out of bed
not short term walking/ambulation just during physical therapy |
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Term
| benefits and limitations to non-pharm interventions for VTE prophylaxis: graduated compression stockings (GCS) |
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Definition
increase the velocity of venous blood flow
graded amount of pressure - greatest amount of pressure at the ankle
good choice when pharmacological interventions are contraindicated
additive effects when combined with pharmacologic interventions
limitations:
size or shape of legs
patient adherence |
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Term
| benefits and limitations to non-pharm interventions for VTE prophylaxis: intermittent pneumatic compression (IPC) - aka "squeezers"; SCDs, PAS boots |
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Definition
increase velocity of blood flow in the lower extremities by sequential inflation of a series of cuffs wrapped around the patient's legs
cuffs inflate in 1-2 minute cycles throughout the day from ankles to thighs
reduce risk of VTE by ~60% following surgery, neurosurgery, and orthopedic surgery
additive effect when combined with pharmacologic interventions
limitations:
many patients take them off during hospital stay - so patients do not have 24 hour coverage (aka - patient adherence)
more expensive than GCS
relatively cumbersome
may have difficulty wearing while sleeping |
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Term
| benefits and limitations to non-pharm interventions for VTE prophylaxis: inferior vena cava filters (IVC filters) - aka Greenfield filters |
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Definition
insertion of filter into the inferior vena cava (IVC) to prevent embolization of thrombus from lower extremities into the lung (PE)
provide short term protection against PE in very high risk patients when pharmacologic interventions are contraindicated
reserved for patients in whom other prophylactic strategies cannot be used
to reduce long term risk of VTE associated with IVC filters - pharmacologic prophylaxis is necessary and should be gin as soon as the patient is able to tolerate anticoagulation
limitations:
still need therapeutic anticoagulation to maintain long term effectiveness of filters
filters can clot pre and post filter placement
pre clot can lead to post thrombotic syndrome
post clot can dislodge and cause PE
cases of dislodged and broken filters |
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Term
| VTE prophylaxis regimen options |
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Definition
low dose unfractionated heparin (LDUH) 5000 units SQ q 8-12 hours
enoxaparin 40 mg SQ daily or 30 mg SQ q 12 hours
fondaparinux 2.5 mg SQ q 24 hours
dalteparin 2500-5000 units SQ
warfarin (INR 2-3)
dabigatran 220 mg po daily
rivaroxaban 10 mg po daily |
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Term
| clinical considerations for VTE prophylaxis: risk of bleeding complications |
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Definition
active bleeding
platelet level (< 30-50 K)
recent hemorrhage - i.e. intracranial hemorrhage, hemorrhagic stroke, etc.
recent bleeding ulcers/GI bleed
fall risk |
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Term
| clinical considerations for VTE prophylaxis: renal dysfunction or renal failure |
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Definition
ENOXAPARIN requires dose adjustment when CrCl < 30 ml/min and is contraindicated in hemodialysis patients
FONDAPARINUX is contraindicated with CrCl < 30 ml/min
DABIGATRAN and RIVAROXABAN require dose adjustment with CrCl 30-50 ml/min and contraindicated in CrCl < 30 ml/min
FRED
UFH and dalteparin - no adjustment for renal insufficieny |
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Term
| clinical considerations for VTE prophylaxis: obesity |
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Definition
based on bariatric surgery trials - enoxaparin 40 mg SQ q 12 hours may be an option for patients > 140 kg
controversial data and no clear recommendations for patients > 140 kg |
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Term
| clinical considerations for VTE prophylaxis: neuraxial anesthesia/analgesia or peripheral nerve block - aka epidural anesthesia, peripheral nerve block, etc. |
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Definition
RISK OF RARE BUT POTENTIALLY DEVASTATING SPINAL OR EPIDURAL HEMATOMA IS INCREASED WITH CONCOMITANT USE OF ANTITHROMBOTIC DRUGS
removal of epidural catheter in the presence of anticoagulation also increases the risk of hematoma
Guideline Recommendations:
waiting 8-12 hours after SQ dose of heparin or a twice daily prophylactic dose of LMWH to insert a catheter
waiting at least 18 hours after a once daily prophylactic dose of LMWH to insert a catheter
removal of catheter should be done just before the next dose of VTE prophylaxis when anticoagulant effect is at a minimum
VTE prophylaxis dose should be delayed for at least 2 hours after removal of a spinal needle or epidural catheter
if VTE prophylaxis with warfarin - avoid altogether or use for < 48 hours |
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Term
| VTE prophylaxis for orthopedic surgery |
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Definition
TOTAL HIP REPLACEMENT (THR) AND TOTAL KNEE REPLACEMENT (TKR):
duration: 10-35 days post surgery
recommended options:
LMWH* (FIRST LINE)
fondaparinux
dabigatran
rivaroxaban
LDUH
VKA
ASA
HIP FRACTURE SURGERY (HFS):
duration: 10-35 days post surgery
recommended options:
LMWH* (FIRST LINE)
fondaparinux
LDUH
VKA
ASA |
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Term
| VTE prophylaxis for LOW RISK patients |
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Definition
general risk assessment:
minor surgery, age < 40 years, and no clinical risk factors
prophylaxis therapy options:
ambulation
non-pharmacologic interventions - GCS, IPC |
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Term
| VTE prophylaxis for MODERATE RISK patients |
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Definition
general risk assessment:
major or minor surgery, age 40-60 years, and no clinical risk factors
major surgery, age < 40 years, and no clinical risk factors
minor surgery with clinical risk factors
acutely ill (e.g. AMI, ischemic stroke, CHF exacerbation) and no clinical risk factors
prophylaxis therapy options:
UFH 5000 units SQ q 8-12 hours
enoxaparin 40 mg SQ q 24 hours
dalteparin 2500 units SQ q 24 hours
IPC
GCS |
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Term
| VTE prophylaxis for HIGH RISK patients |
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Definition
general risk assessment:
major surgery, age > 60 years, and no clinical risk factors
major surgery, age 40-60 years, with clinical risk factors
acutely ill (e.g. AMI, ischemmic stroke, CHF exacerbation) with risk factor(s)
prophylaxis therapy options:
UFH 5000 units SQ q 8 hours
enoxaparin 40 mg SQ q 24 hours
dalteparin 5000 units SQ q 24 hours
fondaparinux 2.5 mg SQ q 24 hours
IPC |
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Term
| VTE prophylaxis for the HIGHEST RISK patients |
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Definition
general risk assessment:
major lower extremity orthopedic surgery
hip fracture
multiple trauma
major surgery, age > 40 years, and prior history of VTE
major surgery, age > 40 years, and malignancy
major surgery, age > 40 years, and hypercoaguable state
spinal cord injury or stroke with limb paralysis
prophylaxis therapy options:
IPC + UFH 5000 units SQ q 8 hours
enoxaparin 30 mg SQ q 12 hours
dalteparin 5000 units SQ q 24 hours
fondaparinux 2.5 mg SQ q 24 hours
warfarin (INR 2-3)
[for THR or TKR - also can consider use of dabigatran or rivaroxaban] |
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Term
| VTE prophylaxis for acutely ill |
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Definition
low risk: ambulation
moderate to high risk: LMWH, LDUH, fondaparinux |
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Term
| VTE prophylaxis for critically ill (ICU) |
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Definition
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Term
| VTE prophylaxis for abdominal pelvic surgery |
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Definition
very low risk: ambulation
low risk: IPC
moderate risk: LMWH, LDUH
high risk: use both pharmacologic (LMWH, LDUH) and mechanical (IPC) |
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Term
| VTE prophylaxis for cardiac surgery |
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Definition
| use both pharmacologic (LMWH, LDUH) and mechanical (IPC) |
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Term
| VTE prophylaxis for throacic surgery |
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Definition
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Term
| VTE prophylaxis for major trauma |
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Definition
low to moderate risk: LMWH, LDUH
high risk: use both pharmacologic (LMWH, LDUH) and mechanical (IPC) |
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Term
| identify risk factors for the development of stress ulcers |
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Definition
MECHANICAL VENTILATION (only proven situation where stress ulcer prophylaxis is useful)
SEPSIS
BURN PATIENTS
RECENT H/O GASTRIC ULCERS/BLEED
HEAD TRAUMA/HEMORRHAGE
coagulopathy/anticoagulation
renal failure
age > 65 yo
corticosteroids/NSAIDs
SBP < 100 mmHg for > 1 hours
major surgery |
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Term
| advantages and disadvantages of pharmacologic strategies for preventing stress ulcers: sucralfate |
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Definition
complexes with gastric secretions forming a viscous past like adhesive substance protecting the mucosa from gastric secretions
helps maintain functional and structural integrity of the GI tract
advantages:
decreased risk of aspiration pneumonia
inexpensive
disadvantages:
inferior to H2RAs in preventing stress ulcers - per randomized, double blind placebo controlled trail in patients requiring mechanical ventilation > 48 hours
no IV formulation - PO only |
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Term
| advantages and disadvantages of pharmacologic strategies for preventing stress ulcers: histamine receptor antagonists (H2RAs) = FIRST LINE OPTION FOR STRESS ULCER PROPHYLAXIS |
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Definition
competitive inhibition of histamine 2 receptors in parietal cells promotes reduction in gastric acid secretion and hydrogen ion concentration
antisecretory activity increases gastric pH
advantages:
both IV and PO administration
AS EFFECTIVE AS PPIS FOR STRESS ULCER PROPHYLAXIS
cost effective
disadvantages:
increased risk of aspiration pneumonia
DOSAGE ADJUSTMENT NEEDED FOR MODERATE TO SEVERE RENAL IMPAIRMENT
overuse
continuation upon hospital discharge without indication |
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Term
| advantages and disadvantages of pharmacologic strategies for preventing stress ulcers: proton pump inhibitors (PPIs) |
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Definition
bind and irreversible inhibition of Na/K ATPase pump of parietal cells
prevents secretion of gastric acid
advantages:
IV, PO, NG/OG administration options
most rapid and potent suppressor of gastric acid, although no proven clinical superiority over H2RAs
once daily administration
no dosage adjustment for renal impairment
few interactions
disadvantages:
cost - especially IV preparations
overuse
continuation upon hospital discharge without indication
decreases effectiveness of clpidogrel??
increases risk of community acquired and hospital acquired pneumonia??
INCREASED RISK OF C. DIFFICILE COLITIS - FDA just put out a WARNING for this
long term use - increases risk of osteoporosis and HYPOMAGNESEMIA (NEW RECOMMENDATIONS FROM FDA TO CHECK MAGNESIUM LEVELS YEARLY FOR PATIENTS ON PPIS) |
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Term
| recommend a regimen for stress ulcer prophylaxis based on patient specific factors, clinical risk factors, and clinical considerations |
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Definition
assess daily for risk factors and need to continue therapy (if on mechanical ventilation)
if need to continue - consider IV to PO interchange if possible
if patient on H2RA or PPI at home, then generally continue as inpatient therapy (i.e. medication reconciliation) |
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Term
| define glycemic goals for hospitalized patients |
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Definition
ICU:
140-180 mg/dL
non-ICU:
preprandial: < 140 mg/dL
random: < 180 mg/dL |
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Term
| recommend a schedule intermittent insulin regimen for a hospitalized patient based on baseline insulin needs |
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Definition
2 components of scheduled insulin: BASAL insulin (long acting insulin) and PRANDIAL insulin (rapid acting insulin)
what is the total daily dose I need to start with?
if the patient on insulin at home: consider total daily dose of home insulin and adjust for changes in nutritional intake, metabolic stress, medications, renal failure, etc.
if patient requiring frequent and consistent supplemental/correctional insulin: calculate total daily SQ requirements = total daily dose
BASAL INSULIN:
options - glargine, detemir, NPH
40-50% total daily dose of insulin
glargine - daily (usually q HS)
detemir - once or twice daily
NPH - divided BID with breakfast and supper
PRANDIAL INSULIN:
options:
for patient on a regular PO diet - lispro
for patient on continuous nutrition (tube feeds or TPN) - lispro or regular
50-60% of total daily dose divided
for patient on regular PO diet divide lispro dose to TID given 15 minutes before meals
for patient on continuous nutrition (tube feed or TPN):
lispro - divide dose to be given q 4 hours
regular - divide dose to be given q 6 hours
alternatively can provide majority of needs with basal |
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Term
| recommend an insulin regimen for a hospitalized patient transitioning from continuous insulin infusion to a schedule intermittent insulin regimen |
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Definition
begin transition when:
patient hemodynamically stable
patient begins to eat regular meals or stable on continuous nutrition
patient transferring to a lower intensity of care
general approach:
calculate total daily IV requirements (units/hr x 24 hours = total daily dose)
daily SQ requirements: ~75-80% of total daily IV
40-50% = basal insulin SQ
50-60% = prandial that is divided among meals
other considerations:
FIRST DOSE OF SQ SHOULD BE GIVEN BEFORE IV INSULIN IS DISCONTINUTED
if intermediate or long acting insulin is used alone, administer 2-3 hours before DC of IV insulin
if combination of basal + prandial insulin basal can be initiated at any time of day; administer short or rapid acting insulin 1-2 hours prior to DC of IV insulin |
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Term
| explain the role of the pharmacist in transition of care |
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Definition
MEDICATION RECONCILIATION:
what medications is the patient taking home?
is the patient being sent home on the same medications?
any new medications that the patient was not on prior to this hospitalization?
any medications that were discontinued during hospitalization?
should the patient be continued on home medications that were DC'd during this hosptialization?
does this patient need counseling on changes in medications?
GREAT TIME TO ASSESS OR REASSESS:
appropriateness of medications that have been initiated in the hospital (i.e. does this patient still need to be on this medication?)
IV to PO interchanges
medication dosing (i.e. is the renal failure better or worse?)
can we start patient's home medications? |
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