i pity the fool..

[DancingFajitas]

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question--so i realize pretty much every hospital pt needs to be started on heparin for dvt prophylaxis except if there is a specific CI; but my questions are- 1) should you use LMWH or UH? 2) do you need to hold heparin if the pt is going to have a procedure or go into surgery? 3) should pts also be on ASA or plavix at the same time as heparin? 4) do you follow PTTs when just doing it for prophylaxis?

thanks

 

[SouthernSurgeon]

question--so i realize pretty much every hospital pt needs to be started on heparin for dvt prophylaxis except if there is a specific CI; but my questions are- 1) should you use LMWH or UH? 2) do you need to hold heparin if the pt is going to have a procedure or go into surgery? 3) should pts also be on ASA or plavix at the same time as heparin? 4) do you follow PTTs when just doing it for prophylaxis?

thanks

1) UH - way cheaper (lots of trials comparing the efficacy of LMWH vs UFH for ppx- not much difference)
2) You can give it if it's just the prophylactic dose; if someone is truly being anticoagulated (i.e. therapeutic doses of IV heparin) then you would hold it
3) Sure
4) No

 

[The Angriest Bird]

1) UH. Same efficacy as LMWH. Cheaper. Subcutaneous injection, 5000 units daily

2) Definitely hold it for surgery in the OR. Procedures... depends. If it's something like a simple bedside I&D of 2cm abscess, probably not.

3) If there are indications for ASA and plavix. For people who need long-term anticoagulation therapy, such as those with a-fib, you do a "heparin bridge". It works like this. You start heparin right away, and at the same time start the patient on coumadin. Once coumadin becomes therapeutic (by monitoring PT and INR), you d/c heparin and d/c patient home on coumadin.

4) No. No need to monitor PTT for DVT prophylaxis

 

[Twitch]

Bridge w/lovenox so pt can go home and f/u o/p (assuming reasonable pt compliance). While the individual cost of the drug UH < LMWH, keep in mind the cost of the hospital stay x5 days till warfarin kicks in and INR bumps up.
If the pt's ambulatory & willing - how about using the old fashioned dvt ppx - let them walk. Given the choice of getting poked (if no line/access) or worry about HIT or have to wear scd's, folks may prefer (if able & willing) the natural dvt ppx.

 

[The Angriest Bird]

While the individual cost of the drug UH < LMWH, keep in mind the cost of the hospital stay x5 days till warfarin kicks in and INR bumps up.

Compliance is another big problem with Levonox.

 

[Rendar5]

yes, all hospital patients need DVT prophylaxis. This is either walking, stockings, compression devices, or daily subcutaneous injections of heparin. If a patient is ambulatory there's no need to give em injections, and if you're that concerned just put TEDs on them. Hell, most patients should not be getting injections, they should be forced to walk or wear devices. sc hep has potentially bad side effects.

Now this is not IV heparin we're talking about. That is something else entirely, is limited in its use to patients you need immediate anticoagulation on or need to bridge to coumadin. that's another topic for another thread.

 

[Gute]

Compliance is another big problem with Levonox.

Yep, we had a pt. who bounced back after developing a PE. He was unable to afford enoxaparin. SW really dropped the ball.