Tuesday, June 19, 2007

Deep Venous Thrombosis Prevention

For me the prevention of DVT (deep venous thromboembolism) is more important than the diagnosis. As I read several sources of medical literature, it seems the family physicians are more concerned with the diagnosis, and that is probably as it should be. For them often the presentation of DVT may be a symptom of some under-lying illness (ie cancer). For surgeons, we want to prevent being the cause of DVT’s in our patients, because for us DVT is a complication not just a disease process. I (we) don’t like complications. Just different perspectives, as we all work towards the goal of the patient’s good health.

From the prevention side, here are a few things to remember. Patients are ranked into risk categories. These are:
  1. Low: Minor procedure, Patient less than 40 yrs old, No other risk factors
  2. Moderate: Minor procedure, Age between 40-60 yrs, No other risks factors
  3. High : Non-minor (major) procedure, More than 60 yrs, No other risks factors
    Or Age between 40-60 yrs with other risks factors
  4. Highest: Major procedure, Multiple risk factors, Hip/knee arthroplasty, Hip fracture surgery, Major trauma, Spinal cord injury

    Other risks factors include: recent pregnancy (less than one month ago) [This is why, along with the recent blood loss of delivery, and often anemia of pregnancy that women should never have a tummy tuck at the time of their C-section. The risks are too high for complications.], varicose veins, overweight, personal or family history of blood clots, personal history of cancer, use of birth control or hormone replacement, recent travel (long flights or car rides without movement), etc. Recall the journalist who died after sitting in a tank for long hours with little to no movement.

Preventive Therapy consists of:
All surgical patients should have intermittent pneumatic compression devices used (unless the procedure will be less than 1 hour).

  • Low Risk (less than 2 %)
    Ambulate three times daily for 5 minutes minimum each time
    Flex and extend ankles often

  • Moderate Risk (10-20%)
    1. Ambulate as above
    2. Flex and extend ankles often
    3. TED stockings

  • High Risk (20-40%)
    1. Same as moderate (1-3)
    2. Lovenox (enoxaparin sodium) SQ for 7-14 days

  • Highest Risk (40-80%)
    1. Same as high risk
    2. Lovenox, Fondaparinux SQ, Heparin or Warfarin (will depend on the procedure being done and on patient history)

REFERENCES

Prevent DVT.org

Prevention of Venous Thromboembolism in the Plastic Surgery Patient; Plastic and Reconstructive Surgery, Vol 114 (3) September 1, 2004, pp 43e-51e.

Deep Venous Thrombosis Prophylaxis Practice and Treatment Strategies among Plastic Surgeons: Survey Results, Plastic and Reconstructive Surgery; Vol 119 (1) January 2007, pp 157-174.

Current Diagnosis of Venous Thromboembolism in Primary Care: A Clinical Practice Guideline from the American Academy of Family Physicians and the American College of Physicians

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