Fitness to Fly

Updated 3/2017 -- all links (except to my own posts) removed as many no longer active.

I noticed this tweet from @doc2doc

In Flight Emergencies http://bit.ly/9N55iG

Enclosed in the link article was the pdf file link for the paper by the working group of the British Medical Cardiovascular Society:   Fitness to fly for passengers with cardiovascular disease.

The portion of the paper I found most interesting was the advise to patients regarding travel, DVT risk, and recent surgery:

Advice to long-distance (air) travelers (>6 h)
1. Low risk
< No history of DVT/VTE.
< No recent surgery (4 weeks).
< No other known risk factor.
It is common sense, given the foregoing, that encouragement be given to keep mobile in so far as is possible, adopt regular flexion and extension exercises of the lower limbs and extremities with the avoidance of dehydration.

The passenger should be well hydrated the day before as well as on the day of the flight. 

Smoking (now generally banned on aircraft) should be avoided.  Also to be avoided are alcohol and/or caffeine, which contribute to dehydration, and hypnotics, particularly in a cramped environment.

2. Moderate risk
< Previous history of DVT/VTE.
< Recent surgery lasting >30 min in the past 2 months but not in the last 4 weeks.
< Known thrombophilia.
< Pregnancy.
< Obesity (BMI >30 kg/m2).

The guidance for low risk should be adopted with the addition of compression stockings which have been shown to reduce risk, although their use has given rise to adverse comment.

3. High risk
< Recent (within 4 weeks) surgery under general anesthesia lasting >30 min.
< Previous DVT with known additional risk factor(s) including known cancer.

The guidance for low and moderate risk should be adopted and low molecular weight heparin considered (ie, subcutaneous enoxoparin 40 mg on the morning of the flight and on the following day).  Although rare compared with unfractionated
heparin, complications including bleeding and thrombocytopenia can occur so it is only recommended in those at high risk.

Co-existent treatment with warfarin is protective and should be continued. Advice should be sought for patients with a plaster cast and consideration given towards a split cast to relieve limb compression.

Similarly, advice is needed following recent (<2 weeks) DVT/VTE. Aspirin had no effect in one study of the prevention of DVT during air travel and its use was associated with gastrointestinal symptoms in 13% of those who used it. It is not currently recommended in this context for DVT/VTE prophylaxis.

I often ask patients of if they have any travel plans when scheduling elective surgery, especially when the surgery is one that is longer than 1 hour.  This has become a routine part of my DVT assessment risk.