Venous thromboembolism: Scope of the problem and the nurse’s role in risk assessment and prevention

VpaR

mfcnaa(yctpehca

tpti

m

PAGE 82 SEPTEMBER 2006JOURNAL OF VASCULAR NURSINGwww.jvascnurs.net

enous thromboembolism: Scope of theroblem and the nurse’s role in risk assessmentnd prevention

uth Morrison, RN, BSN, CVN

Deep vein thrombosis and pulmonary embolism, comprising different manifestations of the same clinical entityreferred to as venous thromboembolism, are a significant cause of morbidity and mortality. Despite pulmonaryembolism being considered the most preventable cause of in-hospital death, the use of appropriate thrombopro-phylaxis remains suboptimal in many patients. Nurses are on the frontline of thrombosis prevention. By playing anessential role in diagnosis and risk assessment, applying timely preventive methods, and providing vital educational andpsychologic support for patients with venous thromboembolism, skilled nursing intervention can save lives. (J Vasc Nurs 2006;
24:82-90)
bsapaihb

WU

amDppVhth

paVii(hamocm

cw

Venous thromboembolism (VTE) is one of the most com-on, yet highly preventable, causes of in-hospital death. Mani-

esting as deep vein thrombosis (DVT) and its potentially fatalomplication pulmonary embolism (PE), the condition is recog-ized as a major national health problem. In the United States,pproximately 1 to 2 million people each year have DVT, and,ccording to the Coalition to Prevent Deep-Vein Thrombosiswww.preventdvt.org), more Americans are thought to die eachear from PE than from breast cancer, acquired immune defi-iency syndrome, and highway fatalities combined. Most pa-ients who have a fatal PE die within the initial 30-minute period,roviding a very small window for effective treatment and thusxplaining the high fatality rate associated with this condition. Itas been estimated that approximately 10% of hospital deathsan be attributed to PE, making VTE the most common prevent-ble cause of hospital death and disability.1,2

VTE places a huge burden on health care resources. In additiono delayed discharge or readmission to hospital, up to 30% ofatients with VTE develop long-term post-thrombotic complica-ions, such as leg pain, swelling, and ulcers, 3 which have a majormpact both on patients’ lives and health care resources.

Primary prevention of VTE is a major focus in health careanagement. The implementation of appropriately targeted throm-

Ruth Morrison is from the Brigham and Women’s Hospital,Boston, Massachusetts.

The author received editorial/writing support in the preparationof this article, funded by sanofi-aventis, New Jersey. The author,however, was fully responsible for content and editorial deci-sions for this article.

Address reprint requests to Ruth Morrison, RN, BSN, CVN,Brigham and Women’s Hospital, 75 Francis Street, Boston, MA02115 (E-mail: [email protected]).

1062-0303/2006/$32.00

Copyright © 2006 by the Society for Vascular Nursing, Inc.

hdoi:10.1016/j.jvn.2006.05.002

oprophylaxis has been described as one of the most importanttrategies for improving in-hospital safety. 4 However, despite thevailability of regularly updated consensus guidelines, thrombopro-hylaxis continues to be underused or inappropriately prescribed in large proportion of medical and surgical patients. 5-8 For example,n the U.S. clinical registry of patients, DVT-FREE, 71% of 5451ospitalized patients received no prophylaxis in the 30-day periodefore the diagnosis of DVT. 9

HY IS VENOUS THROMBOEMBOLISMNDERDIAGNOSED AND UNDERPROPHYLAXED?

Although the health risks posed by VTE are now widelyccepted, many health care providers continue to underesti-ate the extent of the problem. One reason for this is thatVT and PE are often clinically silent. Improved surgicalrocedures mean that the incidence of DVT and PE in theerioperative period is low, and it is rare for surgeons to seeTE in any of their own patients. Furthermore, becauseospital stays are now shorter, the majority of symptomatichromboembolic complications in surgical patients occur afterospital discharge.10

Although VTE was originally considered to be a diseaserimarily seen in surgical patients, many medical patients arelso at high risk of developing thrombosis. The incidence ofTE in general medical patients is 10% to 20%, but the

ncidence is much higher in certain groups, such as criticallyll patients (up to 80%) or patients who have had a stroke20%–50%).11 Current VTE management guidelines clearlyighlight the risk factors for medical patients (eg, immobilitynd chemotherapy) and recommend thromboprophylaxis foredical patients at high risk for thrombosis.11 However, lack

f adherence to guidelines in nonsurgical patients continues toontribute to the problem of inadequate prophylaxis, leavingany patients vulnerable to DVT and PE.5

Another reason for the underuse of thrombophylaxis isoncern over the safety of anticoagulant drugs, particularlyith respect to the risk of bleeding complications during
eparin-based thromboprophylaxis. However, there is now
http://www.preventdvt.org

sa(scpom

tmbmrltaibemoi

sabmNcttimif

DA

nvct

Vol. XXIV No. 3 PAGE 83JOURNAL OF VASCULAR NURSINGwww.jvascnurs.net

ubstantial clinical evidence confirming that both unfraction-ted heparin (UFH) and low molecular weight heparinLMWH) provide effective and safe thromboprophylaxis;tudies have shown little or no increase in the rates oflinically important bleeding.11-13 The consequences of un-revented VTE are potentially much more severe and farutweigh any justification for not using effective and recom-ended methods of thromboprophylaxis.

Finally, cost is a factor underlying reluctance to increasehe use of thromboprophylaxis. Pharmacologic and physicalethods of thromboprophylaxis do incur additional expense,

ut effective prevention reduces the number of patient read-issions and the length of hospital stay. Preventing VTE also

educes the risk of long-term morbidity caused by the life-ong complications that can ensue, such as pulmonary hyper-ension, devastating leg ulcers from post-phlebitic syndrome,nd chronic leg pain and swelling from chronic venousnsufficiency.14-16 This presents a delayed burden of throm-osis often overlooked.15 Preventing DVT with the use offfective thromboprophylaxis in high-risk patients and mini-izing the risk of DVT recurrence will reduce the frequency

f such post-thrombotic complications and have an enormous

TABLE I

PREVENTING VENOUS THROMBOEMBOLISM: T

Clinical role● Be alert for signs and symptoms of DVT or PE.● Individual risk assessment on admission and continuing● Encourage early mobilization and leg exercises.● Assessment/fitting of GCS: Assess contraindications by p

stockings. Check integrity of the patient’s skin at regularinformation on how to wear and care for the GCS.

● Fitting IPC devices. Note: Efficacy depends on proper si● Monitor patients for bleeding complications and advise p

event of nose or gum bleeding or hematuria.● Contribute in daily rounds and monitor patient progress.● Accountable for administering pharmacologic measures i

Patient education● Provide patients on oral anticoagulants with information● Provide information on VTE and its prevention. Advise

loss, stopping smoking, regular exercise).● Psychosocial support of patients with VTE via support g● Educating patients and their families, colleagues, and the

DVT and PE.

Guidelines and continuing education● Initiation of, and monitoring compliance with, local VTE● Involvement in the design of written, formal strategies, a● Provide and undertake education and training initiatives.● Assist in meeting quality assurance/JCAHO standards.● Promote interdisciplinary communication—key to succes

DVT, Deep vein thrombosis; PE, pulmonary embolism; GCS, graduainternational normalized ratio; VTE, venous thromboembolism; JCAHO, J

mpact on the quality of life and long-term cost of care. l

The scope of the problem is thus clear: VTE represents aerious clinical condition contributing to significant morbiditynd mortality. But what role can nurses play in reducing theurden of VTE? Over the past 10 years, the channels of com-unication between physicians and nurses have broadened.urses take part in daily rounds and have more input on patient

are decision-making. Nurses and physicians need to workogether to take responsibility and be accountable for the pa-ient’s protection against VTE. Next, we discuss the nurse’s rolen diagnosis and risk assessment, the application of preventiveethods, and the involvement in patient education that positively

mpacts nursing practices. A summary of key nursing practicesor VTE prevention is shown in Table I.

IAGNOSIS OF VENOUS THROMBOEMBOLISM:CLINICAL PROBLEM

Diagnosis of DVT is most frequently performed usingoninvasive vascular ultrasound. This has replaced theenogram, which was invasive and often painful, and in-reased the risk of phlebitis. PE is most often diagnosed withhe noninvasive imaging test, chest computed tomography;

NURSE’S ROLE

sment during hospital stay.

ical assessment, clinical history, and measuring/fittingrvals; provide patients with written and verbal

and application.ts on the importance of notifying care providers in the

ding both oral and injectable medications.

edications/foods that affect INR.ossible lifestyle changes in at-risk patients (eg, weight

s.lic on signs, symptoms, treatment, and prevention of

nagement guidelines.rophylaxis policies.

VTE prevention.

ompression stockings; IPC, intermittent pneumatic compression; INR,ommission on Accreditation of Healthcare Organizations.

HE

asses

hysinte

zingatien

nclu

on mon p

rouppub

mand p

sful

ted coint C

ung scans are used less frequently although still relied on if

teboeorVssmw

spnmsapt

i


he patient is allergic to contrast dye. The patient should alsoxpect to have an electrocardiogram, a chest x-ray film, andlood work including a D-dimer. However, routine screeningf patients for VTE is neither clinically nor economicallyfficient.11 This is where the physical examination and thor-ugh family history are crucial, and where nurses have a vitalole in screening for signs and symptoms associated withTE. Diagnosis presents a clinical challenge; VTE has few

pecific symptoms and is clinically silent in many patients,uch that diagnosis can prove difficult and unreliable. Nursesust be vigilant for the few signs and symptoms associated

TABLE II

SIGNS AND SYMPTOMS OF VENOUS THROMBO

Condition: Deep vein thrombosis

Signs and symptoms: Calf pain, tenderness, or bothSwelling (with/without pitting

edema)Swelling (below knee � distal

vein thrombosis; up togroin � proximal veinthrombosis)

WarmthErythema and discolorationDilated superficial veinsCyanosis

Tacbr

DysTacPleuCyaHemSudCouSwe

bpm, Beats per minute.

TABLE III

RISK FACTORS FOR VENOUS THROMBOEMBOL

Predisposing (inherent) factors

Increasing age (� 40 y)ObesityHistory of smokingPregnancy (and postpartum period)History of VTEFamily history of VTECancerHeart or respiratory failureInflammatory bowel diseaseDiabetes mellitusNephrotic syndromeThrombophiliaNeurological disease with extremity paresisVaricose veins/vein stripping

S

TImPCCAEHSMPH

VTE, Venous thromboembolism.

ith VTE (Table II). t

Diagnosis of PE is also difficult because classic signs andymptoms are often absent in patients. A thorough history andhysical examination often provide the first clue for early diag-osis of PE (Table II). With increasing age of the patient, PEay masquerade as other illnesses, such as acute coronary

yndromes or exacerbation of chronic lung disease, meaning thatccurate diagnosis of PE is particularly difficult when patientsresent with concurrent illnesses, such as pneumonia or conges-ive heart failure.

Although recognition of the symptoms or signs of early VTEs important, it will not prevent all clinically important symp-

BOLISM AND POST-THROMBOTIC SYNDROME

ulmonary embolism Post-thrombotic syndrome

ea (respiratory rate � 20s/min)

rdia (heart rate � 100 bpm)or central chest pain

sysiscollapse

g

Leg painLower limb swellingVenous leg ulcerationVaricose veinsSuperficial thrombophlebitisVenous hypertension

11

Exposing (acquired) risk factors

y (particularly major orthopedic surgery, cancer surgery,osurgery)a (major or lower limb)

bilitysisr therapy (chemotherapy, radiotherapy, hormonal therapy)l venous catheterization/pacemakermedical illness (eg, pneumonia, sepsis)en-containing oral contraceptivesne replacement therapy

ive estrogen receptor modulatorsproliferative disorderssmal nocturnal hemoglobinuria

talization

EM

P

hypneathpneahycariticnosiopt

denghatin

ISM

urgerneurraummo

aralyanceentracutestrogormoelectyelo

aroxyospi

omatic thromboembolic events. With routine diagnostic screen-

FED


VENOUS THROMBOEMBOLISM RISK ASSESSMENT MODELFOR SURGICAL AND MEDICAL PATIENTS

STEP 1: EXPOSING RISK FACTORS ASSOCIATED WITH CLINICAL SETTING

Assign 1 factor Assign 2 factors Assign 3 factors Assign 5 factorsMinor surgery Major surgery Major surgery (2-3 hr) Elective major lower extremity

Immobilizing plaster cast (> 60 min) arthroplasty

Medical patient Arthroscopic surgery Hip, pelvis, or leg fracture (< 1 month)

currently at bedrest (> 60 min) Stroke (< 1 month)

Sepsis (< 1 month) Laparoscopic surgery Multiple trauma (< 1 month)

Acute myocardial (> 60 min) Acute spinal cord injury (< 1 month)

infarction (< 1 month) Central venous access Major surgery lasting over 3 hours

Congestive heart failure(< 1 month)Serious lung diseaseinc. pneumonia (< 1 month)Abnormal pulmonary function(COPD)History of prior major surgery

BASELINE RISK FACTOR SCORE (If score = 5, go to step 4):

_______________________________________________________________________________________STEP 2: PREDISPOSING RISK FACTORS ASSOCIATED WITH PATIENT

PATIENT RISK FACTORS Assign 1 factor unless otherwise noted

MOLECULAR__________________CLINICAL SETTING INHERITED ACQUIREDAge 41 to 60 years (1 factor) Factor V Lei den (3 factors) Positive Lupus anticoagulant (3 factors)

Age 60 to 74 years (2 factors) Positive Prothrombin 20210A Elevated anticardiolipin antibodies (3 factors)

Age over 75 years (3factors) (3 factors) Heparin-induced thrombocytopenia

History of SVT, DVT/PE Elevated serum homocysteine (3 factors)(3 factors) (3 factors)Family history of DVT/PE (3 factors) Other thrombophilia (3 factors)

Previous malignancy (2 factors)

Active malignancy or chemotherapy(3 factors)Varicose veins

Swollen legs (current)

History of inflammatory bowel disease

Obesity (BMI > 30)

Obesity (BMI > 40) (2 factors)

Obesity (BMI > 50) (3 factors)

Oral contraceptive orhormonal replacement therapyHistory of unexplained stillborn infant,recurrent spontaneous abortion ( 3),premature birth with toxemia or growth-restricted infantPregnancy or postpartum (< 1 month)

TOTAL ADDITIONAL PREDISPOSING RISK FACTORS SCORE:______________________________________________________________________________________________________

STEP 3: TOTAL RISK FACTORS (EXPOSING + PREDISPOSING):____STEP 4: RECOMMENDED PROPHYLACTIC REGIMENS FOR EACH RISK GROUP

Low Risk (1 factor) Moderate Risk (2 factors) High Risk (3-4 factors) Highest Risk (5 or more factors)

No specific measures LDUH (q 12 h) LDUH (q 8 h), or Pharmacological: LMWH, LDUH (q 8 h),Early ambulation or IPC or GCS, IPC, or LMWH alone, oral anticoagulants, or fondaparinux

or LMWH or in combination with alone or in combination with IPC or GCSIPC or GCS

Abbreviations: LMWH, low molecular weight heparin; LDUH, low-dose unfractionated heparin; IPC, intermittent pneumatic compression;GCS, graduated compression stockings.

igure 1. Example of an easy-to-use, practical thrombosis risk-assessment model (RAM). Updated from Caprini JA, Arcelus JI, Reyna JJ.ffective risk stratification of surgical and nonsurgical patients for venous thromboembolic disease. Semin Hematol 2001;38(2 Suppl 5):12-9.
ata courtesy of J. A. Caprini, 2006.

ira

VA

R

pVeic

cbrprnp

A

p(

FDC


ng accepted to be inefficient, individualized assessment of VTEisk offers a logical and effective way to identify and appropri-tely prophylax at-risk patients.

ENOUS THROMBOEMBOLISM RISKSSESSMENT

isk factors for venous thromboembolism

The risk of VTE varies greatly according to the individualatient and the clinical situation. A number of risk factors forTE have been identified (Table III), which can be considered as

ither predisposing factors relating to the patient (eg, age, inher-ted thrombophilia, and underlying illness such as cancer or

RISK FACTORS1 Personal history of DVT or

PENo = 0

2 Family history of DVT or PE(any blood relative)

No = 0

3 Malignancy: current orprevious

No = 0

4 Personal history of recent MIor stroke ( 1 month)

No = 0

5 Recent major surgery lasting>60 min ( 1 month)

No = 0

6 Currently on BCP, HRT, orhormonal therapy for breastor prostate cancer

No = 0

7 Current or recent acuteinflammatory orinfectious process (< 1month)

No = 0

8 Currently immobile (unableto ambulate in the inpatientsetting)

No = 0

9 History of unexplainedstillborn infant,recurrent spontaneousabortion, premature birthwith preeclampsia, orgrowth-restricted infant

No = 0

10 Swollen legs No = 011 Varicose veins No = 012 Obesity (BMI 30 kg/m2) No = 013 Age 40 =

Total DVT risk score ______

igure 2. Deep vein thrombosis risk-assessment questionnaire to beVT, deep vein thrombosis; HRT, hormone replacement therapy; Maprini, 2006.

hronic lung disease) or exposing risk factors caused by the b

linical situation (eg, duration/type of surgery, prolonged immo-ility, and trauma). Many hospitalized patients have several VTEisk factors, and the effects are cumulative.17 For example, aatient admitted for surgical resection of lung cancer is at highisk of VTE because of the operation, the presence of malig-ancy, the period of immobility after surgery, and potentially therothrombotic effects of cancer chemotherapy.

ssessing risk

Accurate, individual risk assessment allows thrombopro-hylaxis to be targeted appropriately. Risk assessment modelsRAMs) have been developed to predict the level of throm-

Yes = 3 NA = 0

Yes = 3 NA = 0

Yes = 2 NA = 0

Yes = 1 NA = 0

Yes = 2 NA = 0

Yes = 1 NA = 0

Yes = 1 NA = 0

Yes = 1 NA = 0

Yes = 1 NA = 0

Yes = 1Yes = 1Yes = 141–60 = 1 61– 74 = 2 75 = 3

ered by the patient. BCP, birth control pill; BMI, body mass index;yocardial infarction; PE, pulmonary embolism. Courtesy of J. A.

0___

answI, m

otic risk in a given patient from the number and type of risk

foedpoalsbFcewc

fpmopr

M

orvLmts

mapphpratpwmictit

rTtaarI

agbbcdAplracct

P

instrvpphcA

feabnHt

W

rumaaaraAsfrrp

C


actors with which the patient presents. With informationbtained from the patient’s clinical history and physicalxamination, current RAMs offer nurses a simple tool thatirectly links VTE risk to specific recommendations for VTErevention. An example RAM is shown in Figure 1.18 Scoringf VTE risk factors allows the level of risk to be categorizedccording to the American College of Chest Physicians guide-ines (low, moderate, high, or highest) and matched withpecific recommendations for prophylaxis.11 There are clearenefits in making the patient an active partner in this process.igure 2 represents a simple patient history questionnaire thatan be completed by the patient at the time of the initialncounter. Nurses are central to facilitating this process—orking with the patient in this way greatly simplifies data

ollection and subsequent assessment.Every hospitalized patient should be assessed for VTE risk

actors and prescribed prophylactic measures included in theatient’s admission orders. Most hospitals use a nursing assess-ent form. This form serves as a catalyst for achieving the

bjectives of the hospitalization and implementing patient carelans. Ideally, the risk assessment for VTE should be incorpo-ated into the initial nursing assessment form.

ethods of prevention

Nurses execute the orders for VTE prophylaxis, regardlessf which modality or combination of modalities, and will beesponsible for ongoing administration and monitoring. Pre-ention methods can be either pharmacologic (eg, UFH,MWH, fondaparinux, or warfarin) or mechanical (eg, earlyobilization, graduated compression stockings, or intermit-

ent pneumatic compression devices). Current methods areummarized in Table IV.11,19,20

Nurses are accountable for administering pharmacologiceasures including both oral and injectable medications. Unless

nticoagulants are contraindicated, heparin-based thrombopro-hylaxis (ie, with UFH or LMWH) is currently the mainstay ofharmacologic prophylaxis for patients at moderate, high, orighest risk of VTE who require rapid, safe, and effectiverophylaxis before, during, or after a period of increased VTEisk, such as surgery or prolonged immobilization. Vitamin Kntagonists, such as warfarin, have been used safely and effec-ively for many years in VTE treatment and for secondaryrevention in patients at high risk for recurrence. However,arfarin is considered by many nurses to be a problematicedication; a narrow therapeutic window requires frequent mon-

toring and dose adjustment, whereas numerous factors canontribute to over- or undertreatment, including medical condi-ions and concomitant therapies, variations in dietary vitamin Kntake, alcohol use, dosing errors, and patient adherence toreatment.19

Most mechanical methods of thromboprophylaxis aim toeduce venous stasis and thus the propensity for clot formation.hey find particular use in patients at low risk of VTE and in

hose with a contraindication to pharmacologic therapy, and canlso be used as an adjunct to pharmacologic therapy in patientst very high thromboembolic risk. The nurse will have an activeole in the implementation of mechanical prophylaxis methods.
n the first instance, the nurse will encourage able patients to C
mbulate as early as possible and avoid prolonged bedrest. Ifraduated compression stockings are recommended, they shoulde prescribed by the health care provider and the patient shoulde measured accurately by the nurse for a correct fit. At dis-harge, specific compression is prescribed depending on theegree of symptoms, such as pain, swelling, or discoloration.pplication and troubleshooting of intermittent pneumatic com-ression devices (which work by rhythmically compressing theower extremities to increase venous flow) are also nursingesponsibilities. Studies have shown such devices to be effective,lthough their usefulness can be limited by incorrect use, poorompliance, and the inability to continue after hospital dis-harge.11 Nurses are well positioned to educate the patient onheir use and benefits, and thus improve compliance.

atient education and awareness

It is recommended that the patient becomes an active partnern the prophylaxis decision-making process, and this is where theurse can play a vital role. Not only must nurses be vigilant forigns and symptoms in their patients, but it is important to ensurehe patient is aware of signs and symptoms to encourage self-eporting. Nurses also discuss lifestyle modifications and pre-entable risk factors (eg, smoking, obesity), educating both theatients and their families. Ensuring the patient is informed isarticularly important in light of the trend toward shortenedospital stays or treatment as an outpatient. Such time constraintsan be very frustrating for the patient as well as for the nurse:dvocate for your patients and be proactive.

For a patient informed of increased thromboembolic risk oror those who have previously experienced an event, psychologicffects may be apparent, presenting in some cases as extremenxiety or a constant fear of death (often expressed as a “timeomb waiting to happen”). Support groups led by physicians andurses, such as the one established at Brigham and Women’sospital, Boston, can provide invaluable support to patients and

heir families at this time.

ider education: Coalition to fight the killer

As a response to the mounting public health crisis, in Feb-uary 2003 more than 60 organizations assembled to discuss thergent need to make DVT a top public health priority. At thiseeting, co-hosted by the American Public Health Association

nd Centers for Disease Control, participants agreed to establishcoalition of organizations committed to educating the public

nd health care community about DVT and the importance ofecognizing risk factors and implementing early measures. Co-lition members include the American Nurses Association,merican Academy of Nurse Practitioners, and American As-

ociation of Managed Care Nurses. One of the early outcomesor the coalition was the development of a White Paper, a usefulesource that describes in simple terms the scope of the problem,isk factors, and practical measures for prevention (visit www.reventdvt.org to download a copy).

onsensus guidelines and continuing education

The current consensus guidelines published by the American
ollege of Chest Physicians highlight the need for a coordinated


TABLE IV

SUMMARY OF CURRENT AMERICAN COLLEGE OF CHEST PHYSICIANS’ RECOMMENDED METHODS FOR PREVENTION OFVENOUS THROMBOEMBOLISM11,19,20

Method Mode of action Strategy Patient population Benefits Disadvantages

Pharmacologic*

UFH Indirect thrombininhibitor (Factors Xaand ILa)

Primary prevention Moderate- or high-risksurgical patients

At-risk medical patients

● Effective prevention ofDVT and PE

● Lower acquisition costsrelative to LMWH

● No need for coagulationmonitoring atprophylactic doses

● Risk of HIT● Risk of osteoporosis (with

long-term use)● Vigilance recommended in

those with severe renalimpairment, low bodyweight, or very highbleeding risk

● Twice- or three-times dailydosing schedule

LMWH Indirect thrombininhibitor (Factors Xaand ILa)

Primary preventionSecondary prevention

Moderate-, high-, andhighest-risk surgicalpatients

At-risk medical patientsPatients with cancer at

risk of recurrence


● Once-daily dose suitablefor outpatient therapy,which may bringconvenience and costbenefits

● No need for coagulationmonitoring

● Risk of HIT or osteoporosiswith long-term use; althoughlower relative to UFH

● Vigilance recommended inthose with severe renalimpairment, low bodyweight, or very highbleeding risk

● Higher acquisition costrelative to UFH

Vitamin K antagonists(eg, warfarin)

Inhibits synthesis ofvitamin K- dependentclotting factors

Primary preventionSecondary prevention

Highest-risk patients:surgery, trauma, SCI

Patients at risk ofrecurrence

● Effective prevention ofrecurrent VTE

● No risk of HIT orosteoporosis (with long-term use)

● Convenient oraladministration

● Suitable for long-termprophylaxis

● Low acquisition costsrelative to heparins

● Regular monitoring and doseadjustments required tomaintain therapeutic INR

● Inter-patient dose variability● Lag of � 4 days until

therapeutic coagulationlevels achieved

● May require periprocedural“bridging” with LMWH orUFH

● Significant interactions withrange of drugs and foods

● Contraindicated in patientswith active bleeding orhypersensitivity, onNSAIDs, and duringpregnancy

● Dose sensitivity in geriatricpatients with increasedmajor bleeding

PAG

E88

SEPT

EM

BE

R2006

JOU

RN

AL

OF

VA

SCU

LA

RN

UR

SING

ww

w.jvascnurs.net

TABLE IV

(CONTINUED)

Fondaparinux Indirect thrombininhibitor (Factor Xa)

Primary prevention Highest-risk orthopedicsurgery patients


● Once-daily injection● No need for coagulation

monitoring

● Vigilance recommended inthose with severe renalimpairment, low bodyweight, or very highbleeding risk

Mechanical

Ambulation (early and“aggressive”)

Reduces venous stasis Primary prevention Low-risk patients ● Cheap and easy toimplement in ablepatients

● Limited efficacy● Limited in patients with

impaired mobility

Graduated compressionstockings

Physical reduction ofvenousstasis/promotion ofvenous return

Primary prevention Low-risk patients, or ascombinationtherapy withLMWH or UFH inhigh-risk patients,or in patientscontraindicated topharmacologictherapy

● No increased risk ofbleeding complications

● Useful adjunct topharmacologic therapy

● May help prevent post-thrombotic syndrome(known to minimize and/or prevent venous stasisulcers)

● Inexpensive

● Limited efficacy (notsuitable for high or highest-risk patients)

● Efficacy can be reduced bypoor fitting

● May aggravate peripheralarterial disease

IPC Rhythmic compressionof the lowerextremities toincrease both meanand peak venousflow

Primary prevention Low-risk patients or ascombinationtherapy withLMWH or UFH inhigh-risk patients,or in thosecontraindicated topharmacologictherapy


● Useful adjunct topharmacologic therapy

● Relatively low-cost,reusable devices

● Use limited by poorcompliance, incorrect use,and the inability to be usedafter hospital discharge

● May aggravate peripheralarterial disease

IVC filters Physical barrier to filterthrombotic debris

Secondary preventionin patients withPEor pulmonaryhypertension

Patients at high risk forPE withcontraindication toanticoagulation orin whomanticoagulation isineffective


● Effective measure inselected high-riskpatients

● Filters can become blockedover time

● Venous collaterals developaround the IVC

DVT, Deep vein thrombosis; GCS, graduated compression stockings; HIT, heparin-induced thrombocytopenia; INR, international normalized ratio; IPC, intermittent pneumatic compression; IVC, inferiorvena cava; LMWH, low molecular weight heparin; NSAID, nonsteroidal anti-inflammatory drug; PE, pulmonary embolism; SCI, spinal cord injury; UFH, unfractionated heparin; VTE, venousthromboembolism *All pharmacologic anthithrombotic agents are associated with an increased bleeding risk.

Vol.

XX

IVN

o.3

PAG

E89

JOU

RN

AL

OF

VA

SCU

LA

RN

UR

SING

ww

w.jvascnurs.net

aEocttnspctgrpdApduan

C

Bcmvfaoqwcsc

R

1

1

1

1

1

1

1

1

1

1

2

2

2


pproach to the detection, prevention, and treatment of DVT.11

very hospital should have a thromboprophylactic policy basedn the clinical evidence in consensus guidelines. Integratedlinical care pathways are one way of achieving this. As struc-ured, multidisciplinary care plans, they are designed to supporthe implementation of clinical guidelines and help reduce un-ecessary variations in patient care and outcomes. They can alsoupport the development of care partnerships and empoweratients and health care professionals. Central to this are localontinuing medical and nursing education initiatives that are keyo improving awareness and adherence to VTE managementuidelines. Hospital audits have shown that thromboprophylaxisates significantly improve after educational programs have beenut in place, particularly when local hospital data on the inci-ence of VTE are used to highlight the need for prophylaxis.21,22

lso take time to educate yourself: Review recent literature andublished research in treatment and prevention, be familiar withiagnostic modalities to explain test procedures accurately, andnderstand preventive modalities to optimize care. Overallwareness of VTE prophylaxis and well-educated physicians andurses should help to decrease the incidence of VTE.

ONCLUSIONS

Nurses are on the frontline in the prevention of thrombosis.oth DVT, and its potentially life-threatening complication PE,an have long-term effects on patient health and their futureanagement. Skilled nursing intervention can save lives through

igilance for clinical signs and symptoms that arouse suspicionor acute VTE, and assessment of a patient’s VTE risk ondmission and throughout their hospital stay. As an essential partf a multidisciplinary team, nurses will help meet and maintainuality assurance standards and compliance to guidelines thatill directly translate into improved patient care. Through edu-

ating patients, their families, colleagues, and, indeed, them-elves, nurses can make a real impact on a largely preventableondition that is one of the nation’s leading causes of death.

EFERENCES

1. Sandler DA, Martin JF. Autopsy proven pulmonary embo-lism in hospital patients: are we detecting enough deep veinthrombosis? JR Soc Med 1989;82:203-5.

2. Lindblad B, Eriksson A, Bergqvist D. Autopsy-verifiedpulmonary embolism in a surgical department: analysis ofthe period from 1951 to 1988. Br J Surg 1991;78:849-52.

3. Prandoni P, Lensing AW, Cogo A, et al. The long-termclinical course of acute deep venous thrombosis. Ann InternMed 1996;125:1-7.

4. Shojania KG, Duncan BW, McDonald KM, et al. Makinghealth care safer: a critical analysis of patient safety practices.Evid Rep Technol Assess (Summ) 2001;(43):i-x,1-668.

5. Anderson Jr, FA, Tapson VF, Decousus H, et al. IMPROVE,a multinational observational cohort study of practices inprevention of venous thromboembolism in acutely ill med-ical patients: a comparison with clinical study patient pop-ulations. Blood 2003;102:3l9a.

6. Stratton MA, Anderson FA, Bussey HI, et al. Prevention of
venous thromboembolism: adherence to the 1995 American
College of Chest Physicians consensus guidelines forsurgical patients. Arch Intern Med 2000;160:334-40.

7. Arnold DM, Kahn SR, Shrier I. Missed opportunities forprevention of venous thromboembolism: an evaluation ofthe use of thromboprophylaxis guidelines. Chest 2001;120:1964-71.

8. Bergmann JF, Mouly S. Thromboprophylaxis in medicalpatients: focus on France. Semin Thromb Hemost 2002;28(Suppl 3):51-5.

9. Goldhaber SZ, Tapson VF. A prospective registry of 5,451patients with ultrasound-confirmed deep vein thrombosis.Am J Cardiol 2004;93:259-62.

0. White RH, Romano PS, Zhou H, et al. Incidence and timecourse of thromboembolic outcomes following total hip orknee arthroplasty. Arch Intern Med 1998;158:1525-31.

1. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venousthromboembolism: the Seventh ACCP Conference on Anti-thrombotic and Thrombolytic Therapy. Chest 2004;126(3Suppl):338S-400S.

2. Koch A, Bouges S, Ziegler S, et al. Low molecular weightheparin and unfractionated heparin in thrombosis prophy-laxis after major surgical intervention: update of previousmeta-analyses. Br J Surg 1997;84:750-9.

3. Kakkar VV, Cohen AT, Edmonson RA, et al. Low molec-ular weight versus standard heparin for prevention of venousthromboembolism after major abdominal surgery. TheThromboprophylaxis Collaborative Group. Lancet 1993;341:259-65.

4. Bergqvist D, Jendteg S, Johansen L, et al. Cost of long-termcomplications of deep venous thrombosis of the lower ex-tremities: an analysis of a defined patient population inSweden. Ann Intern Med 1997;126:454-7.

5. Kahn SR. The post-thrombotic syndrome: the forgottenmorbidity of venous thrombosis. J Thromb Thrombolysis2006;21(1):41-8.

6. Eberhardt RT, Raffetto JD. Chronic venous insufficiency.Circulation 2005;111:2398-409.

7. Wheeler HB. Diagnosis of deep vein thrombosis. Review ofclinical evaluation and impedance plethysmography. Am JSurg 1985;150(4A):7-13.

8. Caprini JA, Arcelus JI, Reyna JJ. Effective risk stratificationof surgical and nonsurgical patients for venous thromboem-bolic disease. Semin Hematol 2001;38(2 Suppl 5):12-9.

9. Ansell J, Hirsh J, Poller L, et al. The pharmacology andmanagement of the vitamin K antagonists: the SeventhACCP Conference on Antithrombotic and ThrombolyticTherapy. Chest 2004;126(3 Suppl):204S-33S.

0. Bauer KA. Fondaparinux: a new synthetic and selectiveinhibitor of Factor Xa. Best Pract Res Clin Haematol 2004;17:89-104.

1. Anderson Jr, FA Wheeler HB, Goldberg RJ, et al. Changingclinical practice. Prospective study of the impact of continu-ing medical education and quality assurance programs onuse of prophylaxis for venous thromboembolism. Arch In-tern Med 1994;154:669-77.

2. Peterson GM, Drake CI, Jupe DM, et al. Educational cam-paign to improve the prevention of postoperative venous
thromboembolism. J Clin Pharm Ther 1999;24:279-87.

Documents

Venous thromboembolism: Scope of the problem and the nurse’s role in risk assessment and prevention