Monday, March 02, 2009

VTE management pearls

Tracy Minichiello, MD, associate professor of medicine at the University of California, San Francisco, and chief of the San Francisco VA’s Anticoagulation Services is a frequent speaker on venous thromboembolism at Bob Wachter’s conflicted, commercially biased, pharma funded, superb hospital medicine course.

Today’s Hospitalist recently published excerpts from one of her recent talks. Some of the pearls and FAQs she covered:

Risk stratify all patients with a diagnosis of acute PE.

While low molecular weight heparins are generally advantageous consider unfractionated heparin in special circumstances, such as massive or submassive PE and in patients with renal impairment or extremes of weight.

How do you transition from one form of heparin go another?

It’s not uncommon, she pointed out, for hospitalists to receive a patient who was started on unfractionated heparin in the emergency department but will be transitioned to LMWH once admitted. “Our service is often asked how to make this transition,” she said.In an ideal world—one with adequate nursing staff—the best strategy would be to stop heparin one to two hours before starting the LMWH. But Dr. Minichiello said that because she can’t be sure that a nurse will get back to a patient in that short amount of time, she usually starts the LMWH at the same time she orders the unfractionated heparin to be discontinued.And how do you transition a patient from LMWH to unfractionated heparin? Dr. Minichiello said she recommends discontinuing the LMWH and starting a weight-based IV unfractionated heparin drip, without a bolus, one or two hours before the next LMWD dose is due.

Finally, regarding IVC filters:

Given concerns about long-term complications, retrievable filters are now quite commonly used. “But retrievable filters are only temporary if practitioners remember to remove them,” she said.This can be a challenge, particularly for hospitalists who see patients for only a short time and rarely follow patients after discharge. “If you order an IVC filter to be placed,” she said, “you should really own it until it comes out, or make sure you specifically hand off that responsibility, just as you would the follow-up of any other critical test or procedure. Develop a process for follow-up to be sure that removal actually happens. ”

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