DVT & PE: How early can I mobilize a patient ??Hatoun Al-Abdulkarim

DVT:

Formation of a blood clot in a deep veins as complication of immobility that may contribute to Morbidity & mortality

Signs and symptoms:-Pain

-Tenderness

-Swelling

-Increased warmth & Redness

- Erythema Or Bluish skin discoloration

In Fact,Over 50% of DVTs without Signs & symptoms

US

Pulmonary embolism (PE): Blockage of the main artery of the lung or one of its branches by a substance that has travelled from elsewhere in the body through the bloodstream (Usually DVT)

Signs and symptoms: - Shortness of breath ( suddenly, even at rest) - Chest pain ( worse with deep breathe, cough, or bend) - Cough

Other signs and symptoms may include: - Wheezing - Excessive sweating - Arrhythmia - Weak pulse - Fainting

-PE are reported as many as one third of patients with DVT

-Most pulmonary emboli are multiple, and the lower lobes are involved more commonly than the upper lobes

Lung with PE

Incidence

900,000 PEs/ DVTs in USA in 2002

10-40% in medical or general surgery patients40-60% following major orthopedic surgery10% hospital deaths attributed to PE

*Heit J. ASH Abstract 2005.

Risk Factors

Age (over 40)A past history of DVTA family historyImmobilityRecent surgery or an injury (especially hips or knees)

Obesity PregnancyCancer and its treatments Contraceptive pill that contains estrogen Hormone replacement therapy (HRT)Circulation or heart problems

Methods of ProphylaxisMechanical

Pharmacological

Early ambulationElastic stockingsIntermittent pneumatic compression

Mechanical

Pharmocologic MethodsWarfarin.Unfractionated Heparin.Low Molecular Weight Heparin.

When Can the Patient With DVT Begin to Ambulate?

Medical Approach for Mobilizing pts with a DVT has dramatically changed over the past several years

Partsch and Blattler (2000)

New PE development was similar in a mobile group with graduated compression stockings and a bed rest group. They also found decreased pain and leg edema in the mobile group.

Aschwanden et al (2001)

New PE occurred in 10 % of mobile subjects while new PE occurred in 14 % of immobile subjects.

Romero-Villegas (2008)

2 PEs occurrences in a sample of 105 patients on bedrest and 3 PEs in a sample of 114 patients who received early ambulation.

Compression and walking compared with bed rest in the treatment of proximal DVT during pregnancy 2009

Group A:15 patients with elastic compression bandages and early mobilization

Group B: 17 patients with compression bandages and bed rest.

All patients received heparin therapy.

Subjective Pain was assessed daily with a (VAS)

Objective pain using Lowenberg test. Reduction of edema was recorded initially and on day 2, 4 and 7.

Ultrasound was repeated after 7 days.

RESULTS: Resolution of subjective pain was faster in group A

Objective pain& measurement of leg reduced in group A

There was no pulmonary embolism and progression of thrombus diameter.

A meta-analysis of bed rest vs early ambulation in the management of pulmonary embolism, DVT or both

2009 Sep Department of Cardiology, Cochin Hospital, AP-HP, Ren Descartes Paris V University, Paris, France

METHODS

- Considered all randomized studies and prospective registries that compared the outcomes of patients with DVT, PE, or both, managed with bed rest versus early ambulation, in addition to anticoagulation.

-For each study, data regarding the incidence of new PE, new or progression of DVT, and death from all causes, were used to calculate relative risks (RR) and 95% confidence intervals (CI).

RESULTS

The 5 studies retained in this analysis included a total of 3048 patients. When compared to bed rest, early ambulation was not associated with a higher incidence of a new PE (RR 1.03; 95% ).

Furthermore, early ambulation was associated with a trend toward a lower incidence of new PE and new or progression of DVT than bed rest (RR 0.79; 95% ) and overall mortality (RR 0.79; 95% ).

CONCLUSIONS

It appears that these studies support that early ambulation and mobilization does not increase the risk of PE compared to bedrest and in some cases may result in actual improvement of other factors like pain and edema.

Thank you

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