Heparin DVT prophylaxis for ICH stroke patients?

[Dimoak]

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Is there any clinical indication for putting intracerebral hemorrhagic stroke pts on heparin given a negative VDUS? If the patient can still move around, wouldn't stockings be sufficient? If vessel integrity, rather than VTE, was the concern for the initial stroke, all the management issues that come with aggressive thrombolysis prevention don't seem worth it if the pt wasn't at a high risk for embolus.

 

[JackADeli]

Is there any clinical indication for putting intracerebral hemorrhagic stroke pts on heparin given a negative VDUS? If the patient can still move around, wouldn't stockings be sufficient? ...

Interesting... Are you a med-student or resident? Based on many of your posts, I am not sure what your background and/or experience is....

Your question ...seems posed with a significant lack of basic knowledge as it relates to DVT/VTE/PTE/etc... risk, prevention and/or treatment. Somewhat convoluted/confusing.... Not sure if you are talking about prophylaxis for DVT/VTE or if you are talking about treatment for an embolism.


For starters.... stockings are NOT regarded as adequate and/or sufficient prophylaxis for DVT in any hospitalized patient.... and especially patients with elevated risk as your described patient is at elevated risk. As with all therapies you would weigh risk vs benefit depending on what you are prophylaxing or treating.... the confusion again. Depending on potential risks and benefit, pneumoboots/SCDs/foot pumps/etc... might be acceptable but that would not equate "adequate" and does not equate to "stockings".

...If vessel integrity, rather than VTE, was the concern for the initial stroke, all the management issues that come with aggressive thrombolysis prevention ...

What?😕

 

[Dimoak]

Interesting... Are you a med-student or resident? Based on many of your posts, I am not sure what your background and/or experience is....

Your question ...seems posed with a significant lack of basic knowledge as it relates to DVT/VTE/PTE/etc... risk, prevention and/or treatment. Somewhat convoluted/confusing.... Not sure if you are talking about prophylaxis for DVT/VTE or if you are talking about treatment for an embolism.

My question is simply whether or not there would be any reason to put a non-clot related stroke patient on heparin. I am certainly not an expert on DVT/VTE/PTE, but that is not the crux of my question. The question is whether or not prophylaxis would be indicated in this case. My opinion is that it wouldn't, but perhaps someone who is an expert on this can explain if or why heparin is indeed indicated in this case.

For starters.... stockings are NOT regarded as adequate and/or sufficient prophylaxis for DVT in any hospitalized patient.... and especially patients with elevated risk as your described patient is at elevated risk. As with all therapies you would weigh risk vs benefit depending on what you are prophylaxing or treating.... the confusion again. Depending on potential risks and benefit, pneumoboots/SCDs/foot pumps/etc... might be acceptable but that would not equate "adequate" and does not equate to "stocking".

In my opinion, for a patient who is moving around, and whose stroke was not caused by a clot, DVT prophylaxis beyond perhaps compression stockings isn't necessary. Can you explain why this patient would still be at an elevated risk for DVT?

What?😕

What I meant to say was if weakness in the vessel, rather than an occlusion, caused the bleed, why would that be an indication for clot prevention?

 

[EMCC]

Is there any clinical indication for putting intracerebral hemorrhagic stroke pts on heparin given a negative VDUS? If the patient can still move around, wouldn't stockings be sufficient? If vessel integrity, rather than VTE, was the concern for the initial stroke, all the management issues that come with aggressive thrombolysis prevention don't seem worth it if the pt wasn't at a high risk for embolus.

Your questions get a few different points which I will try to address...

The doppler would not determine whether a patient gets put on a Heparin analogue s/p ICH. There is pretty good data that TBI can get anticoagulation within 24-48 hours without serious "reprecussions." It is murky, however, when dealing with vascular causes of an ICH. It really does become patient and situation dependent...

Stockings do nothing for VTE prevention. Based on the most recent ACCP guidelines, if a patient is mobile within 48 hours, you don't need any anticoagulation. If, however, the patient is immobile (which head bleeds usually are), then you "must" anticoagulate with low molecular weight heparin as first line, and unfractionated heparin as an option as well.

Academically speaking, it is important to know, "If vessel integrity, rather than VTE, was the concern for the initial stroke," but at the bedside, it is a moot point.

 

[Dimoak]

The doppler would not determine whether a patient gets put on a Heparin analogue s/p ICH. There is pretty good data that TBI can get anticoagulation within 24-48 hours without serious "reprecussions." It is murky, however, when dealing with vascular causes of an ICH. It really does become patient and situation dependent...

Stockings do nothing for VTE prevention. Based on the most recent ACCP guidelines, if a patient is mobile within 48 hours, you don't need any anticoagulation. If, however, the patient is immobile (which head bleeds usually are), then you "must" anticoagulate with low molecular weight heparin as first line, and unfractionated heparin as an option as well.

Academically speaking, it is important to know, "If vessel integrity, rather than VTE, was the concern for the initial stroke," but at the bedside, it is a moot point.

Thanks for the insight! It seems like the concensus is what I initially suspected before raising this is a concern. I just don't think Heparin should be blanket started on patients when they reach the SICU unless they are immobile, which I agree most will be. But those with rather mild symptoms, who can move around, and didn't have a clot could probably do without the Heparin at all; I was just wondering whether there was any indication for starting it anyway, which there does not appear to be. A recent study actually suggested that stockings have very little noticeable benefit for DVT prevention, but actually increase incidence of blisters, etc., so perhaps there should be movement to not using those as well.

 

[JackADeli]

...was the concern for the initial stroke, all the management issues that come with aggressive thrombolysis prevention...

Never seen or heard of "aggressive thrombolysis prevention".... I'm not sure it even exists as a practice approach as such. Though I could be wrong. The most I have seen is the neurosurgeon holding off on prophylaxis for a couple of days... if one wants to think of that as "aggressive".

...


VIRCHOW'S TRIAD — A major theory delineating the pathogenesis of venous thromboembolism (VTE), often called Virchow's triad..., proposes that VTE occurs as a result of:

• Alterations in blood flow (ie, stasis)
• Vascular endothelial injury
• Alterations in the constituents of the blood (ie, inherited or acquired hypercoagulable state)

A risk factor for thrombosis can now be identified in over 80 percent of patients with venous thrombosis. Furthermore, there is often more than one factor at play in a given patient. As examples:

• Fifty percent of thrombotic events in patients with inherited thrombophilia are associated with the additional presence of an acquired risk factor (eg, surgery, prolonged bed rest, pregnancy, oral contraceptives). Some patients have more than one form of inherited thrombophilia or more than one form of acquired thrombophilia and appear to be at even greater risk for thrombosis...

• In a population-based study of the incidence of venous thromboembolism (VTE), 56 percent of the patients had three or more of the following six risk factors present at the time of VTE: >48 hours of immobility in the preceding month; hospital admission, surgery, malignancy, or infection in the past three months; or current hospitalization.

Accordingly, many patients with VTE fulfill most or all of Virchow's triad of stasis, endothelial injury, and hypercoagulability...

...In my opinion, for a patient who is moving around, and whose stroke was not caused by a clot, DVT prophylaxis beyond perhaps compression stockings isn't necessary. Can you explain why this patient would still be at an elevated risk for DVT?
...if weakness in the vessel, rather than an occlusion, caused the bleed, why would that be an indication for clot prevention?

That is why I asked if you are even in medical school. This is all some of the bare bones basics on this topic. It is a common topic of teaching on medical school teaching rounds by the MS3 level at least. The topic can get quite complicated and debated. However, your questions, opinions and final conclusions/suggestion seems based in a lack of the basics.

Your patient is admitted to hospital
Your patient is Hospitalized
Your patient has some degree of immobility, probably greater then 48 hours
Your patient has some degree of endothelial damage
?did your patient have surgery for head bleed/clot removal

It may be nice academia as to was it a weak vessel that caused the bleed or was it a clot from the ventricle in afib or parodoxic clot from PFO with DVT, etc.... But, ultimately ALL irrelevant when discussion DVT prophylaxis (PFO/AFib scenarios are treatment, etc...). The point is prophylaxis is for prevention in the face of increased risk/etc.... Negative extremity duplex does not impact the decision to prophylax. If you found a clot, you would not prophylax because you would be treating...

...The doppler would not determine whether a patient gets put on a Heparin analogue s/p ICH. There is pretty good data that TBI can get anticoagulation within 24-48 hours without serious "reprecussions." It is murky, however, when dealing with vascular causes of an ICH. It really does become patient and situation dependent...

Agreed. For those without the background or understanding, we are talking about prophylaxtic dose...

...It seems like the concensus is what I initially suspected before raising this is a concern. I just don't think Heparin should be blanket started on patients when they reach the SICU unless they are immobile, which I agree most will be...

If going for generalizations.... then your statement would generally be WRONG. What you suspect would NOT be the general consensus....In conclusion, my question still stands as to what your foundation/background/training is.....😕
Holliday-Inn Express really does not cut it.

 

[Dimoak]

That is why I asked if you are even in medical school. This is all some of the bare bones basics on this topic. It is a common topic of teaching on medical school teaching rounds by the MS3 level at least. The topic can get quite complicated and debated. However, your questions, opinions and final conclusions/suggestion seems based in a lack of the basics.

Your patient is admitted to hospital
Your patient is Hospitalized
Your patient has some degree of immobility, probably greater then 48 hours
Your patient has some degree of endothelial damage
?did your patient have surgery for head bleed/clot removal

It may be nice academia as to was it a weak vessel that caused the bleed or was it a clot from the ventricle in afib or parodoxic clot from PFO with DVT, etc.... But, ultimately ALL irrelevant when discussion DVT prophylaxis (PFO/AFib scenarios are treatment, etc...). The point is prophylaxis is for prevention in the face of increased risk/etc.... Negative extremity duplex does not impact the decision to prophylax. If you found a clot, you would not prophylax because you would be treating...

In conclusion, my question still stands as to what your foundation/background is.....😕Agreed. For those without the background or understanding, we are talking about prophylaxtic dose...If going for generalizations.... then your statement would generally be WRONG. What you suspect would NOT be the general consensus....

Are you even reading my posts attentively, or just trying to get what you want out of them? The point, was that giving heparin to a patient not at risk for a clot, and so not needing prophylaxis (as in, is mobile within the first 48 hours). This is not a generalized case where the patient probably may or not may have had a clot that caused the stroke, but a case where the patient did not have a clot, and so should not receive DVT prophylaxis. Again, I was not asking how to prophylax, but rather saying it was not necessary. If a patient does not have an increased risk, then there is no reason to prophylax.

If going for generalizations.... then your statement would generally be WRONG. What you suspect would NOT be the general consensus....

Who's going for generalizations? I cited a specific example in the very first post in this thread.

Patient with ICH, but no clot. Patient is mobile within 48 hours of admission. No sign of clot. So then no, heparin as long as <3 risk factors are present.

 

[JackADeli]

...just trying to get what you want out of them? The point, was that giving heparin to a patient not at risk for a clot, and so not needing prophylaxis (as in, is mobile within the first 48 hours).
...Patient with ICH, but no clot. Patient is mobile within 48 hours of admission. No sign of clot. So then no, heparin as long as <3 risk factors are present.

I am probably wasting my time replying to you.
First, I am not "just trying to get what you(I) want". I don't want anything.... cause I got it. I went to school. I studied this topic. I use this topic everyday.
Second, Your generalized/generic example should you prefer, arguably IS at increased risk... even if the blood in the head was not an embolism and the duplex of the legs was negative...
Based on past experiences with your posting, I suspect you will start to absorb some replies and modify your explanation of the original question as if it was all as you meant to say originally....

 

[Dimoak]

I am probably wasting my time replying to you.

If you feel that way, then you don't have to reply. Either way, I appreciate whatever attempt you made at answering my question.

First, I am not "just trying to get what you(I) want". I don't want anything.... cause I got it. I went to school. I studied this topic. I use this topic everyday.
Second, Your generalized/generic example should you prefer, arguably IS at increased risk... even if the blood in the head was not an embolism and the duplex of the legs was negative...
Based on past experiences with your posting, I suspect you will start to absorb some replies and modify your explanation of the original question as if it was all as you meant to say originally....

And who exactly would be harmed if I "absorbed replies and modified my explanation of my original question"? If it was unclear, then I attempt to explain my question so it can be answered. If you suspect that I'm just trying to come across being "smarter" or more "credible" than I am on a topic, this is really not the case. Neither in this thread, nor in the previous ones you appear to cite, did I actually change my original statement or question based on what the replies were. My question and position on the topic did not change through the course of this thread. I was merely asking whether the case I described would warrant heparin, or not (and I stated before that it wouldn't). There really was nothing more "insidious" to the motives behind my question, or any further posts I made in the thread.

 

[JackADeli]

...a patient not at risk for a clot, and so not needing prophylaxis (as in, is mobile within the first 48 hours). ...the patient did not have a clot...
...Patient with ICH, but no clot. Patient is mobile within 48 hours of admission. No sign of clot...

Just to assure clarification for those new to the topic of DVT prophylaxis...
The quote above may be confusing if not deceptive and is in general innacurate.

1. Being hospitalized is in and of itself a risk for DVT
2. Lack of apparent acute emboli is NOT a consideration of risk for DVT when considering prophylaxis. I dare say, the vast majority of folks at increased risk and/or receiving SQ prophylaxis have no known emboli.
3. Lack of apparent acute DVT is NOT a consideration of risk for DVT when considering prophylaxis. I dare say, the vast majority of folks at increased risk and/or receiving SQ prophylaxis have no "sign of clot".
4. Being mobile and numbers 2 & 3 above do NOT equal a patient not at risk for a clot.
5. As for 2 & 3 above, the presence of emboli or the presence of "clot" are indicaters for treatment not prophylaxis.

...A risk factor for thrombosis can now be identified in over 80 percent of patients with venous thrombosis. Furthermore, there is often more than one factor at play in a given patient....

• In a population-based study of the incidence of venous thromboembolism (VTE), 56 percent of the patients had three or more of ...six risk factors present at the time of VTE....

You are very likely to identify risk factors in retrospect. Thus, 80% of those with thrombosis had "A risk factor" for thrombosis. You really do not want to be identifying factors after the event, that is why we prophylax. Note, "A" risk factor. IF 56% of the patients with VTE had 3 or more of the listed risk factors...that means 44% had less then 3 of these six listed factors...

DVT is serious. Its complications are serious. While mobility (ambulation specifically) is a crucial component to decrease risk, it is not the only factor. DVTs often occur well after a patient has been discharged from the hospital. Numerous surgical patients are "mobile" in less then 24 hours... and still develop DVT and/or PE. The vast majority of patients admitted to a hospital have any number of factors for increased risk of DVT. There are likely more beyond the six listed that we do not even know. Do not hang your hat on the fact that your patient is ambulatory and has no DVT that you know of....

PS: Yes, I left out his added statement of "So then no, heparin as long as <3 risk factors are present."... For any number of reasons not the least of which being the over simplification, lack of specificity and unclear application in his original generic example. IMPO, A patient being admitted to a hospital with a hemorrhagic stroke is NOT going to be applicable to this adendum.

 

[Dimoak]

Way to completely take my statements out of context. 👍

So what you're saying, is that if you were managing a patient with an ICH that was unrelated to a clot, you'd still put them on heparin? By that logic, just about any hospitalized patient, moving or not, should be on heparin?

You've made quite a few assumptions, specifically that this is a surgical case, which not all ICHs are. But during observation, is there a reason to give heparin? Not in all cases, and as such, it shouldn't be blanket-applied. In my opinion, just as not all hospitalized patients are going to be put on heparin, not all ICH patients (especially if not surgical) should be put on heparin.

 

[JackADeli]

...what you're saying, is that if you were managing a patient ....unrelated to a clot, you'd still put them on heparin? By that logic, just about any hospitalized patient, moving or not, should be on heparin?...

Yes. But, this is of course all my opinion based on actual and fairly extensive formal medical training.

As the critical care attending said in conference recently, "You would be hard pressed to find any hospitalized patient that did NOT warrant SQ [heparin] DVT prophylaxis".

 

[Dimoak]

As the critical care attending said in conference recently, "You would be hard pressed to find any hospitalized patient that did NOT warrant SQ [heparin] DVT prophylaxis".

I agree completely; my statement was simply that there are cases, such as a fairly small ICH, say a non-operated small hematoma and a mobile patient, where heparin would not be necessary and could do more harm than good. My question was whether this could be a reasonable position to take, or whether heparin should always be used regardless of the bleed-related pathology. Since it appears that I am indeed wrong, I will defer to your superior understanding of the subject matter and advanced training. Thanks for taking the time to teach.

 

[skiz knot]

PGY N Ortho
HD #X

AF VSS
blah blah blah
blah blah

A/P
Blah Blah
DVT prophy per primary team



----------------------------------------------------
That answers that debate, at least from my perspective😉

 

[JackADeli]

I have a few moments this AM.
I think this topic is important and worth the effort to eliminate potential confusion and/or deception (deliberate or not).
So, I am going to attempt to again delineate the point and explain what is either confusion in the OP or something else...

First:

PGY N Ortho
....DVT prophy per primary team...

That almost always works well, is recommended.

Now for the OP; I will take it point by point...

Is there any clinical indication for putting intracerebral hemorrhagic stroke pts on heparin given a negative VDUS?...

If the question is about "prophylaxis", the VDUS is irrelevant. It has no bearing whatsoever to the decision to prophylax a patient acutely admitted to the hospital. Thus, VDUS are not routinely employed at admission.

If one is concerned of a paradoxical emboli, VDUS may show some clot... but may NOT. If you are concerned patient has embolic event, you would assess bleed status and make determination on when you would initiate "therapeutic" heparin (or other such).

If the patient can still move around, wouldn't stockings be sufficient?

No. As mentioned throughout. Further, a point that is worth emphasizing, ambulating and having no clot (as seems to be the emphasis of the OP), does not equate risk free or acceptable criteria to forego standard SQ prophylaxis.

If vessel integrity, rather than VTE, was the concern for the initial stroke,

See the earlier answers above. You have a patient with hemorrhagic stroke admitted to the hospital. You would discuss with neuro (surge or med) risk and benefit and timing of such prophylaxis. However, by definition, as the patient is described by the original OP, with no other information, this patient has at least 2 risk factors for developing DVT.

all the management issues that come with aggressive thrombolysis prevention don't seem worth it if the pt wasn't at a high risk for embolus.

As I stated in previous answer, the concept as posed in the question...."aggressive thrombolysis prevention"; I have never heard of nor do I think it exists! It makes for interesting use of verbage. But, you treat the initial injury. You are not aggressively preventing thrombolysis...

Now for some of the additions as this went on:

My question is simply whether or not there would be any reason to put a non-clot related stroke patient on heparin. ...The question is whether or not prophylaxis would be indicated in this case. My opinion is that it wouldn't...

Again the emphasis on this not being an acute clot... A concept that seems lost on the OP. Generally speaking, lack of acute clot has no berring on the decision of prophylaxis. Really, that emphasis is at best a red herring.

...In my opinion, for a patient who is moving around, and whose stroke was not caused by a clot, DVT prophylaxis beyond perhaps compression stockings isn't necessary...

This statement is crucial in recognizing the significant lack of basic understanding. The opinion based on the information given thus far is quite incorrect. As mentioned and will be mentioned throughout.... the lack of acute clot in this patient desciption is irrelevant to the question of prophylaxis. Ambulation (or lack of immobility) is really the only positive given on this patient at this point. As mentioned, the patient as described/created by the OP arrives at the hospital with at least two risk factors... that is before one even looks closely or does a complete H&P.

...if weakness in the vessel, rather than an occlusion, caused the bleed, why would that be an indication for clot prevention?

in prophylaxis, you are NOT treating the bleed cause. You are preventing additional pathology from arrising. Further, you could argue that a ruptured vessel equates to... endothelial damage. Thus, increasing risk for clot elswhere in the body. To our understanding, their is a homeostasis between clotting and "declotting".... If someone has an abnormal bleeding situation, inflamation, etc.... the homeostasis is broken and things generally move towards increased clotting and hemostasis.

...It seems like the concensus is what I initially suspected before raising this is a concern...

This statement is crucial in recognizing the significant lack of basic understanding and thus the difficulty in understanding the explanations to this point. Again wrong and again not understanding what has been said.

...I just don't think Heparin should be blanket started on patients when they reach the SICU unless they are immobile, which I agree most will be. But those with rather mild symptoms, who can move around, and didn't have a clot could probably do without the Heparin at all; ...any indication for starting it anyway, which there does not appear to be....

Fortunately for the patients in the SICU, you are not making these decisions. At this point the example patient is really becoming fairly artificial: i.e. Hemorrhagic stroke + SICU + ambulating AND somehow at low risk for DVT. I would argue such a bird does not exist. Again, you emphasize the red herring that the patient does not currently have an acute clot.

... I cited a specific example in the very first post in this thread.

Patient with ICH, but no clot. Patient is mobile within 48 hours of admission. No sign of clot. So then no, heparin as long as <3 risk factors are present.

Yes (you did), patient/circumstance specifics given that lean towards the improbable if not impossible. Again the emphasis on the lack of an acute DVT or emboli. This is of course the first point in which "<3 risk factors are present" is cited. The problem is, we already know from just the generalized patient description that he/she has at least two risk factors to begin with. It starts to get odd, if not ludicrous to say the patient in question is admitted to SICU and has "<3 risk factors are present" after a complete H&P is performed. This really is the point where one could just make a blanket argument and say, "I have patient X, he/she has no indications for prophylaxis, would you prophylax them?" You can try to define a patient out of a therapy if you choose. But, that is not the example/scenario given.

...My question and position on the topic did not change through the course of this thread...

Actually, if it hasn't changed then it devolved.... as pieced together in this reply.

...So what you're saying, is that if you were managing a patient with an ICH that was unrelated to a clot, you'd still put them on heparin? By that logic, just about any hospitalized patient, moving or not, should be on heparin?

Again the emphasis/fixation on mobility and lack of acute DVT/emboli at presentation as the main determinants for prophylaxis.

...You've made quite a few assumptions, specifically that this is a surgical case, which not all ICHs are..

No, I did not assume the patient had a procedure. I believe there is a question mark before my statement in that reply. That was to further assess you representation on this patient. You had mentioned the patient being in the SICU.

...is there a reason to give heparin? Not in all cases, and as such, it shouldn't be blanket-applied. In my opinion, just as not all hospitalized patients are going to be put on heparin, not all ICH patients (especially if not surgical) should be put on heparin.

As for the reasons, answered at length previously. DVT SQ prophylaxis is NOT a primarily surgical patient matter.

I think my previous statement/quote is really the answer:
As the critical care attending said in conference recently, "You would be hard pressed to find any hospitalized patient that did NOT warrant SQ [heparin] DVT prophylaxis".

Can you create an artificial patient scenario declaring them risk free and then argue no prophylaxis? Yes. In such a case, there would be no argument. However, in real life, the clinician would need to thoroughly review the patient and history. Given the almost universal increased risk nature of patients admitted to the hospital, you would need to clearly identify convincing reason why the patient did not require prophylaxis. With the given example, you would be hard pressed to identify a lack of increased risk. However, you should identify if the prophylaxis itself posed significant risk. You would not be saying the patient was at little or no risk for DVT/VTE, you would just be determining that you needed to live with that risk given the alternative....

 

[Dimoak]

I have a few moments this AM.
I think this topic is important and worth the effort to eliminate potential confusion and/or deception (deliberate or not).
So, I am going to attempt to again delineate the point and explain what is either confusion in the OP or something else...

First:That almost always works well, is recommended.

Now for the OP; I will take it point by point...
If the question is about "prophylaxis", the VDUS is irrelevant. It has no bearing whatsoever to the decision to prophylax a patient acutely admitted to the hospital. Thus, VDUS are not routinely employed at admission.

If one is concerned of a paradoxical emboli, VDUS may show some clot... but may NOT. If you are concerned patient has embolic event, you would assess bleed status and make determination on when you would initiate "therapeutic" heparin (or other such).No. As mentioned throughout. Further, a point that is worth emphasizing, ambulating and having no clot (as seems to be the emphasis of the OP), does not equate risk free or acceptable criteria to forego standard SQ prophylaxis. See the earlier answers above. You have a patient with hemorrhagic stroke admitted to the hospital. You would discuss with neuro (surge or med) risk and benefit and timing of such prophylaxis. However, by definition, as the patient is described by the original OP, with no other information, this patient has at least 2 risk factors for developing DVT.As I stated in previous answer, the concept as posed in the question...."aggressive thrombolysis prevention"; I have never heard of nor do I think it exists! It makes for interesting use of verbage. But, you treat the initial injury. You are not aggressively preventing thrombolysis...

Now for some of the additions as this went on:Again the emphasis on this not being an acute clot... A concept that seems lost on the OP. Generally speaking, lack of acute clot has no berring on the decision of prophylaxis. Really, that emphasis is at best a red herring.This statement is crucial in recognizing the significant lack of basic understanding. The opinion based on the information given thus far is quite incorrect. As mentioned and will be mentioned throughout.... the lack of acute clot in this patient desciption is irrelevant to the question of prophylaxis. Ambulation (or lack of immobility) is really the only positive given on this patient at this point. As mentioned, the patient as describedcreated by the OP arrives at the hospital with at least two risk factors... that is before one even looks closely or does a complete H&P.in prophylaxis, you are NOT treating the bleed cause. You are preventing additional pathology from arrising. Further, you could argue that a ruptured vessel equates to... endothelial damage. Thus, increasing risk for clot elswhere in the body. To our understanding, their is a homeostasis between clotting and "declotting".... If someone has an abnormal bleeding situation, inflamation, etc.... the homeostasis is broken and things generally move towards increased clotting and hemostasis.

So then with all of the wonderful presumptions and mental gymnastics on what is or isn't lost on someone, you would give heparin?

 

[JackADeli]

in reference to mild ICH... but with stroke???

...Intracerebral hemorrhage is more likely to be fatal than ischemic stroke. The hemorrhage is usually large and catastrophic, especially in people who have chronic high blood pressure. More than half of the people who have a large hemorrhage die within a few days. Those who survive usually recover consciousness and some brain function over time. However, most do not recover all lost brain function....

Absolute risk of DVT in Hospitalized patients
....
Medical 10-20%
....
Stroke 20-50%
....
Critical Care Patients 10-80%....

Again, all this would have to be weighed against risk vs benefit and what are the real particulars of a given patient...

So ... you would give heparin?

I would need more clarification on your generic patient. But, looking at the text on stroke

...Prophylactic heparin and enoxaparin have not been shown to increase hemorrhage size in patients with ICH. DVT prophylaxis should be initiated 24 hours after admission once it has been ascertained that the patient does not have an underlying coagulopathy...

 

[Dimoak]

Can you create an artificial patient scenario declaring them risk free and then argue no prophylaxis? Yes. In such a case, there would be no argument. However, in real life, the clinician would need to thoroughly review the patient and history. Given the almost universal increased risk nature of patients admitted to the hospital, you would need to clearly identify convincing reason why the patient did not require prophylaxis. With the given example, you would be hard pressed to identify a lack of increased risk. However, you should identify if the prophylaxis itself posed significant risk. You would not be saying the patient was at little or no risk for DVT/VTE, you would just be determining that you needed to live with that risk given the alternative....

Ah, this is the answer I was looking for.

So then:
50-59yo. M
yes for DM
bp under control
no hx of ca
no hx of previous dvt
no hx of a-fib
no previous acute ischemic events
no hx of varicose
no hx of surgery
not obese
mobile

Does this qualify as low risk factors for DVT?

 

[JackADeli]

50-59yo. M
yes for DM
bp under control
no hx of ca
no hx of previous dvt
no hx of a-fib
no previous acute ischemic events
no hx of varicose
no hx of surgery
not obese
mobile

Does this qualify as low risk factors for DVT?

While the list can get excessively lengthy, additional risk factors include

Smoking
heart failure
Pacemaker
central line
picc line
family history.

 

[JackADeli]

Ah, this is the answer I was looking for....
...Does this qualify as low risk factors for DVT?

I sense the enthusiasm on this. I am not sure what your goal is at this point. Are you trying to define a patient out of SQ DVT prophylaxis?

As I stated/quoted previously... "A" risk factor for thrombosis can now be identified in over 80 percent. IF 56% of the patients with VTE had 3 or more of the listed risk factors...that means 44% had less then 3 of these six listed factors... Note, you can find even more risk factors then the ones we have listed. I could ask you some additional questions. Would I just get another "no" as we proceed to define the patient out of prophylaxis?

Your patient as described in my opinion has at least two risk factors for DVT. In addition he is in an SICU. You are increasingly making an argument that he has minimal contra-indication to the theraupy. As noted, as much as 44% of VTE patients have two or less risk factors. You patient has two at least. Unfortunately, we do not know all the risk factors for DVT. Of further misfortune, we often make the diagnosis of increased risk in a retrospective fashion after the patient has an adverse event... often in patients we think have no risk factors. I would follow:

...Prophylactic heparin and enoxaparin have not been shown to increase hemorrhage size in patients with ICH. DVT prophylaxis should be initiated 24 hours after admission once it has been ascertained that the patient does not have an underlying coagulopathy...

The way you have described and/or refined your patient into stability increases the question "why wouldn't you give SQ prophylaxis". I think that is the question to be answered.

Regards,
JAD

PS: A Hx or lack of A-Fib isn't really relavent to DVT prophylaxis... AFib would be a matter of Embolism and/or therapeutic anticoagulation.

 

[Dimoak]

-Not a smoker
-No hx CHF or any cardiovascular abnormalities
-Only plain venous access for fluids and med drips
-no coagulopathy family hx
-yes for hx of high cholesterol which was controlled by vytorin and pt has been off antilipidemic for 6+ months
-only previous hospitalization was for DM exacerbation 15+ years ago.

The way you have described and/or refined your patient into stability increases the question "why wouldn't you give SQ prophylaxis". I think that is the question to be answered.

Pt presented initially to ED with mild ICH. Hematoma <3cmx3cm around right bg, but deep, no brainstem compromise. Pt was responsive and aware, no obvious memory loss, neuro exam demonstrated diffuse left sided weakness and numbness, otherwise no remarkable findings. Pt moving within 24 hours. I thought that the risk of hemorrhage and thrombocytopenia would outweigh the benefit of SQ heparin, and that perhaps other DVT prophylaxis such as stockings would be more appropriate (although I've sinced read some literature suggesting stockings don't demonstrate an obvious benefit for DVT prevention).

 

[paiute]

-Not a smoker
-No hx CHF or any cardiovascular abnormalities
-Only plain venous access for fluids and med drips
-no coagulopathy family hx
-yes for hx of high cholesterol which was controlled by vytorin and pt has been off antilipidemic for 6+ months
-only previous hospitalization was for DM exacerbation 15+ years ago.


Pt presented initially to ED with mild ICH. Hematoma <3cmx3cm around right bg, but deep, no brainstem compromise. Pt was responsive and aware, no obvious memory loss, neuro exam demonstrated diffuse left sided weakness and numbness, otherwise no remarkable findings. Pt moving within 24 hours. I thought that the risk of hemorrhage and thrombocytopenia would outweigh the benefit of SQ heparin, and that perhaps other DVT prophylaxis such as stockings would be more appropriate (although I've sinced read some literature suggesting stockings don't demonstrate an obvious benefit for DVT prevention).

I have seen a person die from hemorrhage after being put on standard DVT prophylaxis. I think your question is very important. The degree of mobility, perhaps, is the critical factor here. Does the patient walk up and down the hall 3 times a day?

 

[JackADeli]

I have seen a person die from hemorrhage after being put on standard DVT prophylaxis...

I'm sure you have. Thank you for playing.

As for the original and subsequent questions and variations. I think safe to say, asked & answered.

...The way you have described and/or refined your patient into stability increases the question "why wouldn't you give SQ prophylaxis"?...

...50-59yo. M... DM... bp under control...mild ICH...diffuse left sided weakness and numbness... Pt moving within 24 hours...

...a patient with hemorrhagic stroke admitted to the hospital [SICU]. You would discuss with neuro (surge or med) risk and benefit and timing of such prophylaxis...

...It really does become patient and situation dependent...

...I would follow:

...Prophylactic heparin and enoxaparin have not been shown to increase hemorrhage size in patients with ICH. DVT prophylaxis should be initiated 24 hours after admission once it has been ascertained that the patient does not have an underlying coagulopathy...

Anymore finesse would require formal training and a broader understanding of the subject matter.

Regards,
JAD

 

[Dimoak]

Does the patient walk up and down the hall 3 times a day?

The patient began walking within around 48 hours, and began physical therapy the following day. I don't think he was walking around that much during the first 24 hours, however.

 

[JackADeli]

...The question is whether or not prophylaxis would be indicated in this case. My opinion is that it wouldn't...

In my opinion, for a patient who is moving around, and whose stroke was not caused by a clot, DVT prophylaxis beyond perhaps compression stockings isn't necessary...

...I just don't think Heparin should be blanket started on patients when they reach the SICU unless they are immobile, which I agree most will be. But those with rather mild symptoms, who can move around, and didn't have a clot could probably do without the Heparin at all; I was just wondering whether there was any indication for starting it anyway, which there does not appear to be...

To answer my earlier/openning question/s:

Interesting... Are you a med-student or resident? Based on many of your posts, I am not sure what your background and/or experience is....

Your question ...seems posed with a significant lack of basic knowledge as it relates to...

I found your previous posts:

...I'm not in med school yet (hopefully I will be some day)...

...I know the topic of MD/JDs has been discussed before ... Are there any people here doing a different MSTP at Illinois and can give me some of their impressions or feelings on how the program is run?

Your enthusiasm for medical knowledge may be appreciated by some.... But, internet sparring and hypotheticals of this nature are NOT an appropriate substitution for formal education and training. If you are seeking medical advice for yourself or a loved one, I would suggest IMHO your approach (in this and other threads) is not the way to go about it.

Based on these posts (5/2006), it is reasonable to conclude you have limited if any formal medical school training. Thus your ascersions and comments on the appropriate course of treatment of any patient, and in particularly a patient in the SICU are IMHO innapropriate and could deceive lay-persons that troll the internet.

In general, the answer, IMPO as to DVT/PTE prophylaxis in stroke is as follows...

...Prophylactic heparin and enoxaparin have not been shown to increase hemorrhage size in patients with ICH. DVT prophylaxis should be initiated 24 hours after admission once it has been ascertained that the patient does not have an underlying coagulopathy...

JAD

 

[Dimoak]

Incase anyone reading is also interested in this topic, there's a really nice free presentation available from Vindico on DVT Prophylaxis in a Surgical Setting.

 

[JackADeli]

Incase anyone reading is also interested in this topic, there's a really nice free presentation available from Vindico on DVT Prophylaxis in a Surgical Setting.

Not sure what the point is... i.e. just trying to keep this discussion going or something. Whatever the case, it would seem you continue to confuse the issues.

The link is interesting and as it is a presentation for discussion of POST-OPERATIVE, ORTHOPEDIC joint patients and it appears they are using TREATMENT dose levels (i.e. INR > 2) of anticoagulation in the papers they discuss, it might be better suited in the ortho discussion section.

Their guidelines and/or discussions are not really applicable guidelines to "your patient". As, you make it quite clear your patient 1. has a stroke and 2. has not had surgery. Further, "we" have been discussing prophylaxtic as opposed to treatment dose care.... or so I thought. In a patient with a neurologic "injury", I would follow the guidelines/recommendations (for prophylaxis) within said field (i.e. stroke recs) and/or consult neurology or neurosurgery if unclear on best practice. I would not be consulting ortho hip surgeons.....

JAD

 

[Dimoak]

Not sure what the point is... i.e. just trying to keep this discussion going or something. Whatever the case, it would seem you continue to confuse the issues.

The link is interesting and as it is a presentation for discussion of POST-OPERATIVE, ORTHOPEDIC joint patients and it appears they are using TREATMENT dose levels (i.e. INR > 2) of anticoagulation in the papers they discuss, it might be better suited in the ortho discussion section.

Their guidelines and/or discussions are not really applicable guidelines to "your patient". As, you make it quite clear your patient 1. has a stroke and 2. has not had surgery. Further, "we" have been discussing prophylaxtic as opposed to treatment dose care.... or so I thought. In a patient with a neurologic "injury", I would follow the guidelines/recommendations (for prophylaxis) within said field (i.e. stroke recs) and/or consult neurology or neurosurgery if unclear on best practice. I would not be consulting ortho hip surgeons.....

JAD

This link was not in regard to the original case being discussed in this thread which you've already explained, but rather additional information on the topic as I didn't feel it to be necessary to start a brand new thread on DVT but wanted to share the link.

 

[skiz knot]

Why is this thread still going on???