Last week the National Institute for Health and Clinical Excellence (Nice) published it’s report calling for DVT screening of all patients admitted to the hospital in Great Britain. You can read the Quick Reference Guide here (pdf file). Seems like a good time to review the subject.
From the prevention side in surgical patients, here are a few things to remember. Patients are ranked into risk categories. These are:
- Low: Minor procedure, Patient less than 40 yrs old, No other risk factors
- Moderate: Minor procedure, Age between 40-60 yrs, No other risks factors
- High : Non-minor (major) procedure, More than 60 yrs, No other risks factors
Or Age between 40-60 yrs with other risks factors
- 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) during the surgical procedure.
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)
2. Prevention of Venous Thromboembolism in the Plastic Surgery Patient; Plastic and Reconstructive Surgery, Vol 114 (3) September 1, 2004, pp 43e-51e.
3. 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.
4. 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
5. 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
6. The Efficacy of Prophylactic Low-Molecular-Weight Heparin to Prevent Pulmonary Thromboembolism in Immediate Breast Reconstruction Using the TRAM Flap; Plastic and Reconstructive Surgery:Volume 123(1)January 2009pp 9-12; Kim, Eun Key M.D.; Eom, Jin Sup M.D., Ph.D.; Ahn, Sei Hyun M.D., Ph.D.; Son, Byung Ho M.D., Ph.D.; Lee, Taik Jong M.D., Ph.D.
7. Executive Summary: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition); Chest June 2008 133:71S-109S; doi:10.1378/chest.08-0693