Clinical Question of the Day 4/20/12

[gotdrugs]

Very short case:

Okay, you have a patient, in the ICU, will be immobile for days, one signficant thing in PMH is ESLD. Baseline INR is 2.3.

Does this patient "need" VTE prophylaxis?

You have basically 3 general choices when asked what to do.

One has risks if you choose it , One would be generally considered safe, one is debatable on the risk/benefit ratio.

Which do you choose?

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[PharmDstudent]

What is the platelet count?

 

[rxlea]

Why is the patient in the hospital?

His liver isn't producing normal amounts of clotting factors. I'll look some stuff up but I want a bit more info.

Comorbidities? Renal function?

 

[janeno]

The increased INR in patients with ESLD does not automatically confer anticoagulation. Longer stay of hospital can contribute to development VTE. Based on the limited information, I would recommend adding VTE prophylaxis with enoxaparin or heparin assuming that patient is not having any variceal bleeding. It would be nice to see patient's albumin since malnutrition could possibly contribute to clotting in ESLD patients.

As mentioned above, more information would be useful. This answer is based on the limited info available.

 

[habeansha]

are compression stockings the safe option?

 

[gotdrugs]

Good question all, don't over think though, just generalized answers.

But - platelets are 150K, Albumin 2.9, no bleeding, CrCl 50. In the hospital for HCAP.

 

[bacillus1]

The guy might have that high of INR because of his liver, where clotting factors are made. Anticoagulants work in the liver, and if the liver's shot, don't think that they'll be too helpful. I like the idea of compression stockings.

 

[VCU07]

Good question all, don't over think though, just generalized answers.

But - platelets are 150K, Albumin 2.9, no bleeding, CrCl 50. In the hospital for HCAP.

no prophylaxis except stockings

 

[PharmDstudent]

Good question all, don't over think though, just generalized answers.

But - platelets are 150K, Albumin 2.9, no bleeding, CrCl 50. In the hospital for HCAP.

INR is variable in liver disease. So no warfarin.

If the platelets are that high, then thrombin is available so prophylaxis is needed. I would also go with enoxaparin or heparin.

The guy might have that high of INR because of his liver, where clotting factors are made. Anticoagulants work in the liver, and if the liver's shot, don't think that they'll be too helpful. I like the idea of compression stockings.

This case study from 2000 suggests that compression stockings are not adequate enough.

 

[Its Z]

The increased INR in patients with ESLD does not automatically confer anticoagulation. Longer stay of hospital can contribute to development VTE. Based on the limited information, I would recommend adding VTE prophylaxis with enoxaparin or heparin assuming that patient is not having any variceal bleeding. It would be nice to see patient's albumin since malnutrition could possibly contribute to clotting in ESLD patients.

As mentioned above, more information would be useful. This answer is based on the limited info available.

+1. Lmwh or heparin unless there are other risks for bleed.

 

[lactonerx]

Per AT9:

Risk factors for DVT in this pt: +3 points for reduced mobility, +1 point for elderly age(?), +1 point for respiratory failure

However, strongest risk factors for bleeding include hepatic failure.

LMWH/LDUH in critically ill pts is only a level 2C recommendation.
In this patient it is reasonable to do only mechanical thromboprophylaxis with graduated compression stockings.

 

[lactonerx]

(score of 4+ is high risk for VTE)