Prophylaxis in the hospital update

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Prophylaxis in the hospital update Powered By Docstoc
					Prophylaxis in the hospital
     a 2009 update
       Scott Akin MD
• Deep vein thrombosis/ pulmonary
  embolism prophylaxis (VTE prophylaxis)

• Stress ulcer prophylaxis (SUP)

• Contrast nephropathy (CIN) prevention
    Venous Thromboembolism
         (DVT and PE)
• Background
  – Risk of VTE 130 times greater among hospitalized pts
  – 10% of all hospital deaths can be attributed to PE
  – Without prophylaxis, medical pt has VTE risk 5-15%
         – PE = most common preventable cause of hospital death
  – VTE prophylaxis routinely used in surgical patients, but
    not widely practiced in medical pts
     • 40% eligible medical pts got prophylaxis in ENDORSE study
     • 60% in the IMPROVE study
  – Around ¾ PE deaths are medical (not surgical) patients
   VTE Prophylaxis in Medical
• There is no formal, validated risk
  assessment model for medical patient, as
  there is in surgical patients
• Bottom line: generally, medical patients
  who have limited mobility for > 3 days and
  have one RF should get VTE prophylaxis
2004 ACCP Guidelines for VTE
Prophylaxis in Medical Patients
“In acutely ill medical patients who have been
  admitted to the hospital with CHF or severe
  respiratory disease, OR who are confined to
  bed and have one or more additional risk
  factors, we recommend prophylaxis with
  unfractionated heparin (UFH) or low
  molecular weight heparin (LMWH…aka
2004 ACCP Guidelines for VTE
Prophylaxis in Medical Patients

“We recommend, on admission to the ICU, all
 patients be assessed for their risk for VTE.
 Accordingly, most patients should receive
          Risk Factors for VTE
• Malignancy (&             •   Vericose veins
  myeloprolif. Disorders)   •   Previous VTE
• Indwelling catheter       •   Obesity
• CHF                       •   Smoking
• Pregnancy                 •   History of MI
• OCPs/HRT                  •   History of Afib
• IBD                       •   DM
• Paralysis                 •   Thrombiphilias (fact 5 L)
• Nephrotic syndrome
   What Is the Best Drug and
  Dosing for DVT Prophylaxis?
• Short answer: probably low molecular
  weight heparin (enoxaparin/lovenox)…but
  much more expensive than unfractionated

• How about Unfractionated heparin BID vs.
           2007 Meta-analysis
  Wein Et. Al Arch Intern Med 167 (14)
• 36 prospective RCTs including 48,000 pts
• Update on a 2000 meta-analysis with fewer pts
• Conclusions:
   – Both UFH and LMWH (enoxaparin/lovenox) reduce
     DVT & PE in hospitalized patients, but neither affect
   – LMWH (vs. UFH of any dose or frequency) associated
     with reduced risk DVT
  Wein’s 2007 Meta-analysis
-Both LMWH & UFH reduce PE risk about
the same
-Both LMWH & UFH increase the risk of
major bleeding about the same
-No difference in thrombocytopenia
-Injection site hematoma less common with
   Wein’s 2007 Meta-analysis
-Cost of LMWH more, but maybe more cost
  effective in the end because decreases
  number of DVTs.
-UFH dose of TID was more effective than
  the UFH dose of 5000 BID in reducing
  DVT …without any increase risk of
        Another Meta-analysis
        Chest 2007; 131;507-516

• 8000 patients, 12 studies
• BID vs. TID unfractionated heparin
• TID heparin showed a trend toward a
  decrease in pulmonary embolism
• Significant decrease in the incidence of the
  combined outcome of proximal DVT or PE
• BUT significant increase in major bleeding
  events with TID dosing (especially in elderly
  and thin)
  – Yes, that conflicts with the previous meta-analysis
      2008 Chest Guidleines
• “There is no compelling evidence that
  unfractionated heparin (UFH) should be
  administered three times daily in
  preference to twice daily in medical
  patients, although these two regimens
  have never been directly compared.”
      2008 Chest Guidelines
• “In a metaanalysis that included almost
  8,000 patients, three-times-daily UFH
  was associated with significantly more
  major bleeding events, while there was
  a nonsignificant trend toward more
  thromboembolic events with twice-daily
   TID Vs. BID…will We Ever
         Really Know?
• Probably not…

• Randomized controlled trial would take
  a study of 150,000 to show a
  difference...And given heparin is generic
  there is no financial incentive to do it.
What Are We Doing at CCRMC?
• First do no harm: “default” order for DVT
  prophylaxis will be heparin 5000 units SQ BID
• If patient has multiple DVT risk factors consider
  heparin 5000 units SQ TID or Enoxaparin 40 units
  daily….But only IF patient is low bleeding risk:
      - Not “old” (>65-70??)
      - Not “low body weight” (< 50kg…??)
      - Stable Hemoglobin
      - No history of bleeds
     VTE prophylaxis summary
• Assess every patient for VTE prophylaxis based
  on their mobility status and risk factors
• Encourage early ambulation
• LMWH may be better than UFH…but $$$$
• Generally stick with BID UFH…unless multiple
  DVT risk factors and low bleeding risk
• Stay tuned for guidelines on extended prophylaxis
  in the high risk patient
       Next topic: Stress ulcer
• Background:
  – Stress ulcers= stomach (but sometimes duodenal or
    distal esophagus) erosions that can bleed (usually
    “ooze,” but if deeper can cause massive hemorrhage).
  – Physiology: Disruption of balance between acid
    production (increases) and glycoprotein mucosal
    protection barrier (breaks down from refluxed bile
    salts/build up of uremic toxins)
  – In shock/trauma: Perfusion impaired  ischemia
    mucosal barrier breakdown
     Stress Ulcer Risk Factors

-Kidney/Liver failure
-Trauma (especially head/spine)
-Severe burns
-Organ transplant
-History of PUD or UGIB
      SUP Official Guidelines
• 1999 American Society of Health System
  Pharmacists…SUP recommended in:
  – All ICU patients with a coagulopathy or pts intubated >
    48 hours
  – Pts with Hx GIB w/in 1 yr PTA
  – Pts with two of the following: Sepsis, ICU stay > 1
    week, occult bleeding > 6 days, high dose steroids
  – GCS <10
  – Burn patients (>35%BSA)
  – Consider in: Some trauma pts (ISS >16), Post
    transplant pts, Liver failure, Spinal cord injury pt
   SUP guidelines (continued)
• 1999 American Society of Health System
  – “SUP is not recommended for adult patients in
    non-ICU settings”
            SUP since 1999
• Since then SUP has become much more
  common in general medicine (non-ICU)
  patients with little evidence to support such
  – Inadvertently continuing SUP after acute reason
    for its initiation has resolved (extubated and
    transferred to floor…all meds continued).
  – Extrapolating ICU data to no-ICU patients
    Downside of inappropriate SUP
•   Giving a patient a med that is not indicated
•   Cost
•   Increase risk of C-diff related disease
•   Increase risk of drug-drug interactions
•   Potential increase risk of Pneumonia
    – Rise in gastric PH may promote growth of
      bacteria in stomach (GN bacilli in duodenum)
    – Studies have been conflicting
     10 years since 1999
    Who should get SUP???

Generally only critically ill ICU patients who are:
– Intubated > 48 hours
– Coagulopathic

Consider in ICU patient with multiple other risk
     Stress Ulcer Risk Factors

Mechanical ventilation
-Kidney/Liver failure
-Trauma (especially head/spine)
-Severe burns
-Organ transplant
-History of PUD or UGIB
OK, so they REALLY qualify for
 SUP…what do you give them?
• Antacids: Not ideal because you have to give
  them every 1-2 hours
• Sucralfate: The most rigorous RTC comparing to
  ranitidine, showed more GIBs with sucralfate (Crit
  care medicine 2005 33:760)
• H2 Blockers: Efficacy for SUP well documented,
  generally well tolerated**
• PPIs: Data on efficacy less extensive than for the
  above, but well tolerated, side effects for short
  term use are rare, and PO is now generic.
           “expert opinion”
• Oral PPI for those who can take them
  (better than H2 blockers for decreasing PH)
• IV H2 Blockers in those who cannot eat
  (“expert” opinion that the “far greater cost
  of IV PPIs outweighs the nominally greater
  efficacy that may exist”)
Don’t forget to feed your patient
• Entral nutrition may reduce incidence of
  stress ulcers/GIB
• Protective effect of nutrition is NOT due to
  change in gastric PH…it is due to
  preventing the loss of energy stores of the
  gastric epithelium (suggested by the fact
  that TPN patients have less stress ulcers).
  Next Topic: Contrast Induced
  Nephropathy (CIN) Prevention
• Definition: 0.5mg/dl or 25% increase in creatinine
  following contrast administration (within 24
  hours, up to 5 days later)
• 3rd most common cause of ARF in hospital
• 4-11% incidence of CIN in mild-mod CRI
• Higher rates in DM patients, or pt with RFs
• Generally no prevention measures necessary when
  Cr<1.5 or GFR >50-60…remember, serum Cr
  may overestimate GFR in older, thiner, patients
             CIN risk factors
•   DM
•   Age >75
•   Periprocedural volume depletion
•   CHF
•   Cirrhosis
•   CRI
•   NSAID use
            CIN Prevention
• Do they really need contrast?
• Can you do a u/s, or MRI?
• Avoid high Osmolal agents (1400-1800)
• Use “iso-osmolal” (290) agents rather than
  “low osmolal” (500-850…still increased
  osm compared to plasma)
  NSAIDS, and nephrotoxins
CIN Prevention: Meds/IVF prior
• Multiple conflicting are just 2:
  – NEJM 2006; 354:4 “additional fluids should be
    given, although the optimal regimen is
    uncertain” … “N-acetylcystine is not
  – Circulation 2007; 115:1211(REMEDIAL trial):
    Bicarb + NAC is superior to saline + NAC or
    saline + NAC + ascorbic acid.
 7 CIN Studies: Sodium Bicarb
     vs. Sodium Chloride
• Five prospective trials (REMEDIAL was
  the largest) each concluded that bicarb is
  superior to NS
• Two concluded there was no difference
• Differences in design, definitions of CIN,
  and patient populations make direct
  comparisons difficult
• Overall bicarb comes out ahead…I guess
        CIN prevention: UTD
• “we recommend isotonic IVF prior to and
  continued for several hours after contrast
  administration…optimal type of IVF and timing
  are not well established”
  – Isotonic bicarb (3 amps in 850ml D5W) at 3 ml/kg for
    one hr prior, then at rate of 1ml/kg for 6 hours after
    procedure OR NS at 1ml/kg for at least 2, ideally 6-12
    hrs pre and 6-12 hrs post
  – NAC 1200 mg PO BID day before and day of
 CIN prevention: Clinical pearl
• Before ordering NAC and/or IVF/Bicarb,
  ask yourself: Is this intervention which is
  supported by weak evidence (at best) going
  to DELAY a study…and possibly DELAY
  patient care??
• Assess ALL your patients daily for need of DVT
• Ditto for Peptic ulcer disease prophylaxis, BUT
• PUD prophylaxis should almost always be stopped
  once transferred out of ICU
• Prior to contrast CT, check a creatinine, and if
  >1.5, consider risks and benefits of the CT scan.
  If really needed, make sure they are hydrated and
  consider giving them Bicarb+D5W and/or NAC

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