Efficacy of IVC filters.

[Sparda29]

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I was doing some chart reviews the other day for my final presentation at this rotation. Came across an 82 YO patient who had an MI + DVT on May 31. She was given Lovenox to start and Plavix as well. No ASA because of a severe allergy.

They also installed an IVC filter but did not start her on warfarin therapy. She was discharged from the main hospital on 6/11 and brought to our rehab facility. Everything regarding the MI + DVT was proceeding well but she developed a gallbladder infection over the weekend.

WBC went from 7000 to 23000 in 3 days and her BP dropped to 90/40, ultrasound confirmed the infection and we started her on Primaxin. She was transferred out of our facility and back to the hospital for the infection care.

My question: Is an IVC filter good enough to replace warfarin therapy, or did they really mess this up?

 

[psychoandy]

Generally you don't see IVC filters used unless there's a contraindication to anticoag or if it fails, but it seems like a decent intervention. Not a very frequent one tho bc you want to avoid unnecessary invasive interventions, plus i'm sure IR charges an arm and a leg. Are you associating cholecystitis with IVC filter placement? I don't think they go anywhere near the GI tract when placing one.

Also, any idea on LFTs or bili or s/sx of jaundice? Any stones in the gallbladder, cystic duct, or bile duct? I'm not a GI person but that severe of an infection seems more like cholangitis than cholecystitis.

 

[Sparda29]

Generally you don't see IVC filters used unless there's a contraindication to anticoag or if it fails, but it seems like a decent intervention. Not a very frequent one tho bc you want to avoid unnecessary invasive interventions, plus i'm sure IR charges an arm and a leg. Are you associating cholecystitis with IVC filter placement? I don't think they go anywhere near the GI tract when placing one.

Also, any idea on LFTs or bili or s/sx of jaundice? Any stones in the gallbladder, cystic duct, or bile duct? I'm not a GI person but that severe of an infection seems more like cholangitis than cholecystitis.

I'm not connecting the two together. I was looking for a patient who was currently on antibiotic treatment. LFTs were normal. So while going through the chart on the patient, I went through it rather fast, so I didn't see that they had placed an IVC filter. Saw that they started Lovenox but didn't see Warfarin so went into panic mode to try and figure out where the hell Warfarin was, and if they made a replacement for it. That's when I read this little note about IVC filter being placed. Googled IVC filter, and found out its used in contraindications to anticoag therapy. Also found that it is not always effective.

Charts at this hospital are a bit disorganized, I've been told to get used to it.

 

[WVUPharm2007]

Those things suck. Usually you use pharmacological methods. But I don't know the whole story. I got an idea...ask your preceptor. I'm sure s/he's a smart lad/y.

 

[Sparda29]

Those things suck. Usually you use pharmacological methods. But I don't know the whole story. I got an idea...ask your preceptor. I'm sure s/he's a smart lad/y.

That's what she told me also. They are alright but don't have the greatest success rate. It is out of our hands now since the patient was transferred back to the main hospital. Decided to go with a patient who has a VRE bacteremia and end stage renal disease.

 

[Praziquantel86]

That's what she told me also. They are alright but don't have the greatest success rate. It is out of our hands now since the patient was transferred back to the main hospital. Decided to go with a patient who has a VRE bacteremia and end stage renal disease.

Look up the literature on daptomycin synergy. It's pretty interesting.

 

[njac]

She's 82. Do you want your 82yo grandma on warfarin? We place filters in most of our trauma patients who have contraindications to chemical anticoagulation.

 

[Sparda29]

She's 82. Do you want your 82yo grandma on warfarin? We place filters in most of our trauma patients who have contraindications to chemical anticoagulation.

We have plenty of other people her age here who are on warfarin with pretty much the same disease progression. Gonna have to look through the file again on Monday and try to find that absolute contraindication to Warfarin, with the handwriting as bad as it is in this place, very likely that I missed something. (Geriatrics is pretty depressing IMO, basically a look into the future on how life is gonna be like for you in 70 years. I'd rather work in NICU or PICU.)

 

[WVUPharm2007]

She's 82. Do you want your 82yo grandma on warfarin?

Yes.

 

[aboveliquidice]

She's 82. Do you want your 82yo grandma on warfarin? We place filters in most of our trauma patients who have contraindications to chemical anticoagulation.

Vs MI, stroke, or PE? Yeah... Nobody wants to be on anticoags - but the alternatives blow. Just ask Phil from the deadliest catch.

 

[ucrx]

Is she a fall risk? Once she is home, will she be able to manage taking the warfarin properly? Is there any reason she would not be able to be treated in case of a major bleed or overdose (like refusing blood products)? I didn't think IFC filters were great choices, but sometimes one is the best choice for a specific patient even in the absence of absolute contraindications.

 

[Rebel78]

She's 82. Do you want your 82yo grandma on warfarin? We place filters in most of our trauma patients who have contraindications to chemical anticoagulation.

Is warfarin contraindicated in the elderly?

I don't know nearly enough about the pt to make a recommendation, but generally, anitcoag therapy is the better choice vs. the filter.

I had a lady in the coag clinic just the other day who said she was gonna find a new cardiologist who would treat with the filter b/c she was "tired" of taking Coumadin. She had a DVT history.

 

[patmcd]

An IVC might not be perfectly effective, but its a far shot better than nothing in a patient that can't take oral anticoagulants.

 

[njac]

Is warfarin contraindicated in the elderly?

I don't know nearly enough about the pt to make a recommendation, but generally, anitcoag therapy is the better choice vs. the filter.

I had a lady in the coag clinic just the other day who said she was gonna find a new cardiologist who would treat with the filter b/c she was "tired" of taking Coumadin. She had a DVT history.

it would be contraindicated in a patient who has a significant fall risk, or dementia such that they would be unlikely to take the warfarin properly.

 

[Sparda29]

Is she a fall risk? Once she is home, will she be able to manage taking the warfarin properly? Is there any reason she would not be able to be treated in case of a major bleed or overdose (like refusing blood products)? I didn't think IFC filters were great choices, but sometimes one is the best choice for a specific patient even in the absence of absolute contraindications.

She's only a fall risk if she stands up. They had her as completely immobile at this facility.

 

[Rebel78]

it would be contraindicated in a patient who has a significant fall risk, or dementia such that they would be unlikely to take the warfarin properly.

Your right there. Of course, virtually any elderly person is a "fall risk", but without a specific dx (severe vertigo, hip replacement, etc), not sure how much weight I'd put on it.

 

[KUMoose]

She's only a fall risk if she stands up. They had her as completely immobile at this facility.

Why? That's a more interesting issue to work up (at least from the information provided).