2. DEFINITIONS
PE: obstruction of the PA or one of its branches by material
(eg, thrombus, tumor, air, or fat) that originated elsewhere in
the body.
Massive PE causes hypotension, defined as a systolic blood
pressure <90 mmHg or a drop in systolic blood pressure of
≥40 mmHg from baseline for a period >15 min.
All acute PE not meeting the definition of massive PE are
considered submassive PE.
Saddle PE is a PE that lodges at the bifurcation of the main
pulmonary artery into the right and left pulmonary arteries
18. LOW MOLECULAR WEIGHT HEPARIN
We recommend LMWH for most hemodynamically stable
patients with acute PE, rather than UFH.
Dosing:
Enoxaparin :1 mg/kg of actual body weight every 12 hours.
Dalteparin :150-200 IUKg OD(Max. 18,000 IU)
Monitoring :The therapeutic anti-Xa target ranges 0.6 to
1.0 units/m .
19. SC FONDAPARINUX
Dosing: 5 mg for patients <50 kg, 7.5 mg for patients 50 to
100 kg, and 10 mg for patients >100 kg SCOD.
CI in patients with severe renal insufficiency (CrCl <30
mL/minute) or Cr≥1.8
N0 antidote
Can be used in HIT
In pregnancy better to use LMWH
To be stopped 2-4 days before elective surgery
20. UNFRACTIONATED HEPARIN
Indications:
1-Persistent hypotension due to acute PE
2-Increased risk of bleeding
3-Thrombolysis is being considered
4-Concern about SC absorption (eg, morbid obesity)
Dosing: IV bolus of 80 units/kg, followed by an infusion at 18 units/kg
Hr. SC 333 IUkg, followed by SC 250 IU kg very 12 hours
Monitoring : the therapeutic aPTT is 1.5 to 2.5 times the control aPTT .
21. WARFARIN
Vit. K antagonists, which suppress production of the
vitamin K-dependent clotting factors (II, VII, IX, and
X).
Should be overlapped with heparin for a minimum of 5
days and until the(INR) has been within the
therapeutic range (2.0 to 3.0)
22. Anticoagulants other than heparin
and warfarin
DIRECT THROMBIN INHIBIT
Bivalirudin: ACS
Argatroban: ACS
Dabigatran:(VTE) orally active direct thrombin inhibitor
FACTOR XA INHIBITORS
Rivaroxaban: (VTE)orally available direct factor Xa inhibitor
23. COMPLICATIONS
Bleeding
HIT: C later
DURATIONOFTTT:
First episode of PE:
Reversible RF = 3 ms
Unprovoked = 3ms then reasses
Recurrent PE = 3ms then reasses
24. CANCER+PE
In patients with malignancy and VTE, we suggest the
continued use of LMWH after initial treatment rather
than vitamin K antagonists (VKAs) for 3-6 ms(Grade
2B). Oral anticoagulation with VKAs is preferred over
no therapy.
27. PREVENTION
Non-hospitalized,Hospitalized antenatally for non-delivery
reasons ,Postpartum : we suggest observation rather than
pharmacologic prophylaxis . We suggest pharmacologic prophylaxis for
patients with a history of a single idiopathic, pregnancy-associated VTE,
and in those with a history of multiple VTEs, regardless of the cause
After CS and have no RF for VTE, we suggest early ambulation or the
use of mechanical devices rather than pharmacologic prophylaxis . If
additional risk factors for VTE, we suggest the use of both.
Antepartum prophylaxis should be continued until delivery. We
suggest that postpartum prophylaxis be continued for 6-12 w. Following
cesarean section, thromboprophylaxis is continued until the patient is
ambulatory.
28. TTT
ANTICOAGULATION :LMWH
Labor : LMWH should be discontinued at least 24 hr prior to
delivery if the delivery time is predictable (eg, induction of
labor, planned CS).OR shift to UFH at 36 w of gestation and
monitor with PTT
After delivery : LMWH should be restarted 12 hr after a
cesarean delivery or 6 hours after a vaginal birth, assuming
that significant bleeding has not occurred. Options for long-
term anticoagulant therapy include SC LMWH, SC UFH, or
an oral vitamin K antagonist (warfarin).
Duration: 3-6 ms if no addittional RF
IVC
THROMBOLYSIS
33. Thrombolytic Agents
tPA (Altepase) : 100 mg IV over two hours.
Streptokinase : 250,000 units IV over the initial 30
minutes, then 100,000 units/hour for 24 hours.
Monitor closely for hypotension, anaphylaxis, asthma,
and allergic reactions. Mild adverse reactions may
respond favorably to a decreased infusion rate.
