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26/12/2021 at 16:11 น. #18569Sawettachai JaitaBlocked
Question 3; she will travel to South Korea. What would you suggest for her?
ANS:
This patient is considered to have a moderate to high risk of VTE related to long haul flight due to
1.Previous history of VTE ( DVT)
2.Old Age (age above 40 y/o
3.The duration of direct flight from Bangkok to Seoul is estimated to be 5-6 hours. ( >4 hours)Therefore, the preventive measures are strongly recommended as followed.
1.Sitting at aisle seat ; more space for frequent ambulation.
2.Performing Calf muscle exercise every 1-2 hours during the flight.
3.Avoiding drinking beverages with diuretic effect i.e. alcohol, soft drink, coffee.
4.Wearing below-knee stocking with pressure of 15-30 mmHg
5.Primary prophylaxis with anticoagulant may be recommended based on shared decision-making between the treating physician and the patient. Although LMWH is the conventional treatment to prevent travel-related VTE, current data suggests that DOACs may be used instead of LMWH because of the convenience. However, due to its limited data and concern of bleeding complication, decisions to prescribe an anticoagulant must always be considered based on a balance between risk of thrombosis and bleeding in individual basis.Ref:
1.CDC Yellow book,Chapter : Deep vein thrombosis & Pulmonary embolism.
2.Chamnanchanunt S, Rojnuckarin P. Direct Oral Anticoagulants and Travel-related Venous Thromboembolism. Open Med (Wars). 2018 Nov 27;13:575-582. -
26/12/2021 at 15:18 น. #18568Sawettachai JaitaBlocked
Question 2; Doppler ultrasonography reveals thrombosis of both distal legs and no mass demonstrated in the abdomen. What is the proper duration of warfarin treatment in this patient?
Ans: At this point, the patient need to be investigated for possible primary causes of DVT i.e. malignancy / inflammatory or autoimmune diseases / acquired hypercoagulable state. Furthermore, pulmonary embolism should be excluded by using CTPA as well (Tachypnea may suggest PE in this case).
According to the recommendation of ASH2020; guidelines for managements of VTE, any DVT cases (both provoked/unprovoked DVT) should be initially prescribed with a short course of anticoagulant. Thus, this patient should be advised to be initially treated with LMWH for 3-5 days and then continue the treatment with warfarin for 3-6 months as a primary treatment.
After finishing the primary treatment, the patient will be subsequently evaluated by the doctor whether she needs the further indefinite antithrombotic therapy for secondary prevention or not. The decision will be made based on the type of DVT. ( The DVT and/or PE patients with transient risks factors usually do not require antithrombotic therapy after completion of primary treatment. However, for unprovoked DVT/PE cases or those with known chronic risk factors i.e. autoimmune disease, inflammatory bowel disease, the ASH guidelines suggest the use of indefinite antithrombotic therapy in order to prevent recurrent VTE.
Ref: Thomas L. Ortel et al,American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism. Blood Adv 2020; 4 (19): 4693–4738. doi: https://doi.org/10.1182/bloodadvances.2020001830
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25/12/2021 at 23:07 น. #18566Sawettachai JaitaBlocked
Q1:
1.Bilateral swelling of both legs.
2.Tachypnea 25/min = may suggest PE. a
3.Both legs have non-pitting edema.
4.Hyperpigmentation and thickening of the affected limbs.
5.High D-dimer level : 800 mg/dL (cut-off point <500 mg/dL)
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