Friday, January 4, 2008

DVT Prevention

I first posted this on June 19, 2007. I wanted to review it for myself and others. So here it is again with a few small changes. It is an important topic.
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

Current and Emerging Therapies in the Management of Venothromboembolism by Jack E. Ansell MD, Samuel Z. Goldhaber MD, Ajay K. Kakkar MBBS, Graham Turpie MD -- Medscape Article Dec 28, 2007

7 comments:

The Happy Hospitalist said...

Great summary. I am part of our hospitals committee for VTE prevention. I am also part of the SHM national collaborative.

You offer a great summary here. It's nice to see surgeons on board. At my insitution we have a couple stubborn ones who still believe "ambulate four times a day" constitutes adequate prophylaxis.

Happy

rlbates said...

Thanks for your comment. I hope they don't learn the hard way.

Dreaming again said...

I hate those stockings!
I hate the heperin shots to the stomach.

My docs tell me I'd hate not having them more if something went wrong.

rlbates said...

There are some studies being done that show lots of promise for some oral (by mouth) anti-coagulants. Two of them are apixaban and
rivaroxaban. Someday you may not need to do the shots.

Kim said...

My sister was a major trauma patient in 2007 - almost lost both feet and although not ambulatory, she was more active in that wheelchair than I am on two legs.

She was on Lovenox for two months. The doctor said she could go off it as she was constantly moving, transfering, etc and could hardly become immobile.

So off the Lovenox she went.

Only to develop bilateral DVTs and two pulmonary emboli.

She is now on Coumadin.

And, she is walking!

What a year.

Norma said...

My daughter (39) developed a huge DVT in her calf last March. Because she'd had her thyroid removed (cancer) several years before she kept self diagnosing about why her leg was hurting (thinking leg cramps).

Fortunately, her boss (a doctor) insisted she get some tests. It had started to move up the leg. Shots in the abdomen, Coumadin and medical hose, and now seems OK. Not fun, but it beats the alternative.

rlbates said...

Norma, it certainly does beat the alternative. Glad your daughter's boss/doctor pushed her for those tests.