Page 391 - Essential Haematology

Chapter 27 Thrombosis and antithrombotic therapy / 377

Mechanical m ethods of

Table 27.8 Recommendations on the
management of bleeding and excessive p rophylaxis of DVT , PE
anticoagulation by the British Committee for
Standards in Haematology (third edition Graduated c ompression s tockings
1998; 2005 update).

These are used postoperatively, past - partum and

INR 3.0 – 6.0 (target Reduce warfarin dose during long aeroplane flights to reduce the risk of
INR 2.5) or stop DVT. After a DVT, if worn for 1 – 2 years they
reduce the risk of the post - thrombotic syndrome.
INR 4.0 – 6.0 (target Restart warfarin when

Knee high stockings are sufficient in the vast major-
INR 3.5) INR < 5.0

ity of cases. They should be compression class II and
INR 6.0 – 8.0 Stop warfarin * worn except when the patient is recumbent.
No bleeding or minor Restart when INR < 5.0
bleeding Intermittent c ompression d evices
INR > 8.0 Stop warfarin * Intermittent pneumatic compression and mechani-
No bleeding or minor Restart warfarin when cal foot pumps are used in some hospitals in high
bleeding INR < 5.0 risk patients in whom bleeding as a result of LMWH
If other risk factors for is likely.
bleeding give
0.5 – 2.5 mg vitamin K Inferior v ena c ava fi lter

orally
This can provide protection against pulmonary

Major bleeding Stop warfarin
embolism when a DVT in the legs is diagnosed but
Give prothrombin
anticoagulation is contraindicated (e.g. ongoing or
complex concentrate
very recent intracranial or gastrointestinal bleeding
50 units/kg, in
preference or where there is recurrent PE despite adequate
FFP 15 mL/kg (when anticoagulation).
available)
Give 5 mg vitamin K Fibrinolytic a gents
(i.v. or oral)

Two fibrinolytic agents, streptokinase and tissue
FFP, fresh frozen plasma; INR, international normalized plasminogen activator, are most frequently used to
ratio; i.v., intravenous. lyse fresh thrombi, although other agents are avail-
* 1 mg vitamin K may be given orally to rapidly reduce
the INR to the therapeutic range within 24 hours in all able. Th ese drugs may be used systemically for
patients with an INR above the therapeutic range and no patients with acute myocardial infarction, major PE
bleeding. or iliofemoral thrombosis, and locally in patients
with acute peripheral arterial occlusion.
Administration of thrombolytic agents has been
simplified with standardized dosage regimens. Th e

therapy is most effective in the first 6 hours after

symptoms begin but is still of benefit up to 24

Post - t hrombotic s yndrome
hours. Aspirin therapy is also given and the value

Thrombi that persist destroy venous valves and of additional heparin therapy is under study.
venous return is impaired. There is venous hyper- The use of laboratory tests for monitoring and

tension which is responsible for fl uid accumulation control of short - term thrombolytic therapy is now
in the extravascular space, with oedema and in the considered unnecessary. However, certain clinical
long - term skin atrophy, melanin pigmentation and, complications exclude the use of thrombolytic
in severe cases, skin ulceration. agents (Table 27.9 ).