6 Linee guida SPREAD 2010: stroke ischemico Grado B: In pazienti a rischio elevato (pazienti plegici, con alterazione dello stato di coscienza, obesi, con pregressa patologia venosa agli arti inferiori) è indicato l’uso di eparina calcica non frazionata 5000 UI x 2 o eparina a basso peso molecolareIn pazienti non a rischio elevato di trombosi venose profonde, il ricorso sistematico all’eparina comporta un bilancio beneficio/rischio di complicanze emorragiche intracerebrali e/o sistemiche inaccettabile
9 Pharmacological prevention of thrombosis in surgical patients Efficacy of low-dose unfractionated heparin (UFH)in prevention of DVT after major surgerys.c. low-dose UFH pre-operative and b.i.d.post-operative78 ‘high-risk’ patientsPatients with DVT (%)p < 0.001428Kakkar VV et al. Lancet 1972;2:101-6.
10 LMWH for the prevention of VTE in general surgery LMWH vs. no treatment or placebo (8 studies, 5520 patients)RR [CI 95%]DVT (n=513)[0.14–0.54]Clinical PE (n=5456)[0.08–0.79]Clinical VTE (n=4890)[0.11–0.73]Major bleeding (n=5456)[1.37–3.01]Death (n=5142 )[0.27–1.10]Relative risk0.5123LMWH betterPlacebo/No treatment betterMismetti P et al. Br J Surg 2001;88:
11 Guidelines: Prophylaxis of VTE in surgical patients For moderate-risk general surgery patients who are undergoing a major procedure for benign disease, we recommend thromboprophylaxis with LMWH, LDUH, or fondaparinux (each Grade 1A).For higher-risk general surgery patients whoare undergoing a major procedure for cancer,we recommend thromboprophylaxis withLMWH, LDUH three times a day, orFondaparinux (each Grade 1A)1Setting No risk factors Risk factorsGeneral Mechanical Mechanicalsurgery + LMWH or fondaparinuxNICE guidelinesUKGeerts WH et al. Chest 2008Hill J et al BMJ 2007
13 Extended prophylaxis with LMWH after cancer surgery Incidence of Total DVT*Incidence of VTE**p=0.012p=0.0216.3%12.0%10Total DVT (%)VTE (%)7.3%4.8%51 week4 weeks1 week4 weeksENOXACAN II1FAME 2Enoxaparin: n=165Dalteparin: n=34360% cancer surgery in 1 week group56% cancer surgery in 4 weeks group*Deep Vein Thrombosis** Venous ThromboembolismBerqvist D et al. New Engl J Med 2002;346:Rasmussen MS et al. J Thromb Haemost 2006;4:
14 Recommendations: Elective Hip and Knee Replacement We recommend the routine use of one of the following options:(1) LMWH (at a usual high-risk dose);(2) Fondaparinux (2.5 mg);(3) Adjusted dose VKA started preoperatively or the eveningof the surgical day (INR target, 2.5; INR range, 2.0 to 3.0) (all Grade 1A)Geerts et al Chest 2008
16 Timing of the first prophylactic dose of LMWH: results of a meta-analysis 14 Studies patientsEFFICACY19.2%(17-21)DVT %14.4%(12-17)12.4%(10-14)LMWH 12 h preopLMWH periop.LMWH h post-opStrebel, Arch Int Med, 2002
17 Timing of Thromboprophylaxis Initiation For patients receiving LMWH as thromboprophylaxisin major orthopedic surgery, we recommend starting either preoperatively or postoperatively (Grade 1A).For patients receiving fondaparinux as thromboprophylaxis in major orthopedic surgery, we recommend starting either 6 to 8 h after surgery or the next day (Grade 1A).Geerts et al Chest 2008
19 Duration of Thromboprophylaxis For patients undergoing THR, TKR, or HFS, we recommend thromboprophylaxis with one of the recommended options for at least 10 days (Grade 1A).We recommend that thromboprophylaxis be extended beyond 10 days and up to 35 days after surgery (Grade 1A THR, Grade 2B TKR, Grade 1A HFS). The recommended options for extended thromboprophylaxis in THR includeLMWH, a VKA, or fondaparinux.Geerts et al Chest 2008
20 Renal Impairment and Anticoagulant Dosing We recommend that renal function be considered when making decisions about the use and/or the dose of LMWH, fondaparinux, and other antithrombotic drugs that are cleared by the kidneys, particularly in elderly patients, patients with diabetes mellitus, and those at high risk for bleeding (Grade 1A). Depending on the circumstances, we recommend one of the following options in this situation:avoiding the use of an anticoagulant that bioaccumulates in the presence of renal impairment,using a lower dose of the agent,or monitoring the drug level or its anticoagulant effect (Grade 1B).Geerts et al Chest 2008
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