CURRENT Essentials of Critical Care.pdf

Chapter 1 Monitoring & Support 7Deep Venous Thromobosis,Prevention in Surgical Patients■ Essential Concepts• Highest deep venous thrombosis (DVT) and pulmonary embolism(PE) risk after hip fracture, total hip or knee replacement(40–70%); postoperative surgery patients (25%)■ Essentials of Management• LDUH subcutaneous low-dose heparin, 5000–7000 units, 2–3times daily; LMWH subcutaneous low molecular weight heparin;ES elastic stockings; SCD sequential compression device;ADW adjusted-dose warfarin• General surgery, low risk (age 40; minor procedure): earlyambulation; moderate risk (minor procedure with risk factors;minor surgery age 40–60, no risks; major surgery age 40, norisks): LDUH, LMWH, ES, or SCD• General surgery: high risk with bleeding likely: ES or SCD; veryhigh risk for DVT: LDUH or LMWH plus ES or SCD• Gynecologic surgery, major, benign: LDUH twice/daily; orLMWH or SCD before and after surgery; extensive, malignant:LDUH three times/day plus ES or SCD; or higher dose LMWH• Urologic surgery, brief, minor: early ambulation; major open:LMWH, LDUH, ES, or SCD; highest-risk: LDUH or LMWHplus ES with or without SCD• Total hip replacement: LMWH (12 hours before or 12 to 24hours after; or half usual high-risk dose 4 to 6 hours after, usualhigh-risk dose following day); or ADW therapy (INR 2.5),started pre- or immediately postoperatively• Total knee replacement: LMWH or ADW (INR 2.5); alternative,optimal use of SCD• Hip-fracture surgery: LMWH or ADW (INR 2.5)• Intracranial neurosurgery: SCD with or without ES; LDUH orpostoperative LMWH• Head trauma, thrombosis risk: LMWH as soon as safe; if delayedor contraindicated, ES and SCD; if suboptimal prophylaxis,look for DVT; IVC filter if found• Acute spinal cord injury: LMWH plus ES and SCD; if contraindicated,ES and SCD■ PearlEpidural or spinal anesthesia in anticoagulated patients may causeparaspinous hematomas, which can lead to long-term neurologicaldeficits.ReferenceGeerts WH et al: Prevention of venous thromboembolism. Chest 2001;119(1Suppl):132S. [PMID: 11157647]