Deep Vein : Prevention And Prognosis

Jassin M. Jouria, MD

Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching throughout New York, including King’s County Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serves as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology.

Abstract

Although there are a number of risk factors associated with (DVT), it can strike anyone regardless of age, physical fitness, or other factors. However, DVT has an excellent prognosis when caught early and treated aggressively. Additionally, there are a number of strategies for reducing DVT risk. Nurses should familiarize themselves with these strategies in order to be prepared to advise their patients on lifestyle adjustments and other actions that can lower this risk. This course also aims to increase the awareness and clinical acumen of nurses in their evaluation of deep vein thrombosis. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1 Continuing Nursing Education Course Planners William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster, Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner

Policy Statement

This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities.

Continuing Education Credit Designation This educational activity is credited for 1.5 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity.

Statement of Learning Need Patients with DVT may or may not exhibit symptoms. Its important health professionals help patients understand DVT prevention, risks and symptoms to avoid future complications.

Course Purpose To provide nursing professionals with knowledge of DVT prevention, recognition and treatment options.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 2 Target Audience Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,

Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Activity Review Information

Reviewed by Susan DePasquale, MSN, FPMHNP-BC

Release Date: 1/1/2016 Termination Date: 4/1/2018

Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 3 1. A pulmonary occurs when a clot becomes dislodged and travels to the ______. a. Respiratory system b. Lung c. Digestive system d. Immune system 2. that will be used to treat DVT should be a grade ______. a. 1 b. 2 c. 3 d. 4 3. This is the procedure that injects directly into the blood clot via to dissolve the clot. a. Angioplasty b. Thrombolytic c. Bypass d. Laparoscopy 4. Which of the following is NOT a for DVT? a. b. Strength Training c. d. Age 5. Which of the following is a long-term complication of DVT that causes damage to the vein? a. b. Heart Attack c. Post-Thrombotic Syndrome d. Blockage

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 4 Introduction

Deep vein thrombosis is a blood clot that forms deep in the vein. Most deep vein thrombosis occurs in the lower extremities, but it can also occur in other areas of the body. Deep vein thrombosis is typically the result of lack of movement or vein injury, and is especially common in patients who have recently had surgery.1

Deep vein thrombosis can cause long term damage if not treated properly, but has an excellent prognosis when caught early and treated aggressively.2 While the clot itself is not a concern, the potential complications that it can cause are of concern. Some patients will experience a pulmonary embolism if the clot breaks free and travels to the blood vessels of the lung. When this occurs, the risk of morbidity is high. In some instances, patients will develop post- thrombotic syndrome, which impacts the patient’s mobility and level of basic functioning.

Increasing Patient Awareness Of DVT

Although there are a number of risk factors associated with deep vein thrombosis, it can strike anyone regardless of age, physical fitness, or other factors. However, DVT has an excellent prognosis when caught early and treated aggressively. Additionally, there are a number of strategies for reducing DVT risk. It is important for health care providers to familiarize themselves with these strategies in order to be prepared to advise their patients on lifestyle adjustments and other actions that can lower this risk. The following fact sheet, produced by the Vascular Disease Organization, provides a thorough overview of deep vein thrombosis and the potential complications.3 This fact sheet

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 5 can be distributed to healthcare professionals or patients to increase awareness of deep vein thrombosis.

Deep Vein Thrombosis Fact Sheet Overview Deep vein thrombosis, commonly referred to as “DVT,” occurs when a blood clot or , develops in the large veins of the legs or pelvic area. Some DVTs may cause no pain, whereas others can be quite painful. With prompt diagnosis and treatment, the majority of DVTs are not life threatening. However, a blood clot that forms in the invisible “deep veins” can be life threatening. A clot that forms in the large, deep veins is more likely to break free and travel through the vein. It is then called an embolus. When an embolus travels from the legs or pelvic areas and lodges in a lung , the condition is known as a “pulmonary embolism,” or PE, a potentially fatal condition if not immediately diagnosed and treated.

Symptoms

Approximately one-half of those with a DVT never have recognizable symptoms. The most common symptom is leg pain and tenderness in the calf muscles. One may also observe swelling or a change in color of one leg to purple or blue. These signs and symptoms may appear suddenly or may steadily develop over a short period of time. Symptoms are quite different if the clot breaks loose and travel to the lungs, causing a pulmonary embolism (PE). The symptoms of PE include chest pain, shortness of breath, rapid pulse, or a cough. There may also be a feeling of apprehension, sweating, or fainting. Such symptoms are not specific to a PE, and can occur with pneumonia, heart attack, and other medical conditions.

Underlying Causes Of DVT

Deep vein thrombosis is typically caused by lack of movement or a vein injury. In both instances, DVT will develop if an individual does not take appropriate preventative measures.4

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 6 Lack of Movement

Lack of movement is the most common cause of DVT, yet it is easily preventable. In most instances, the cause is immobility after surgery or during extended periods of travel.5 However, any situation that involves immobility is a potential risk for the development of DVT. Lack of movement causes blood flow to become sluggish, which can result in the development of blood clots.6

 Surgery

Patients are at risk of developing DVT after any type of surgery, but it is most common in instances of lower extremity surgery.7 The following chart shows the three factors most associated with the development of DVT after surgery:8

Factor Description Stasis, or This increases the contact time between blood and vein wall stagnant irregularities. It also prevents naturally occurring blood flow from mixing in the blood. Prolonged bed rest or through veins immobility promotes stasis. Coagulation is encouraged by the presence of tissue debris, collagen or fats in the veins. often releases these materials into the blood system. During hip replacement surgery, reaming and preparing the bone to receive the prosthesis can also release chemical substances (antigens) that stimulate clot formation into the blood stream. Damage to the This can occur during surgery as the physician retracts soft vein walls tissues as part of the procedure. This can also break intercellular bridges and release substances that promote blood clotting.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 7 The above chart provides the three main factors that contribute to the development of DVT in individuals who have had surgery. However, there are other factors that may increase the risk for surgery patients. These factors include the following:9 o Age o Previous history of DVT or pulmonary emboli o Metastatic malignancy o Vein disease (such as ) o Smoking o Estrogen usage or current pregnancy o o Genetic factors

 Long Trips There is a lower risk of developing DVT during travel, but it is still a concern. Recent studies have produced conflicting results. In some instances, studies have shown an increase in the risk of developing DVT during extended periods of travel, while other studies have shown no increased risk.2

In most instances of travel related DVT, the individual has other risk factors that make them more susceptible to DVT, which include:10 o Age o Previous history of DVT or pulmonary emboli o Metastatic malignancy o Vein disease (such as varicose veins) o Smoking

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 8 o Estrogen usage or current pregnancy o Obesity o Genetic factors

In many travel related DVT cases, the individual may have asymptomatic, or mild, DVT. This type of DVT tends to resolve on its own after the patient begins moving again.2

Vein Injury

A patient’s chance of developing DVT increases when the patient’s vein is already damaged from another cause. Damage to the inside of the vein increases the risk of blood clot formation.11 In some instances, damage is caused by a previous DVT. Therefore, a patient who has a history of DVT is at an increased risk of developing another DVT due to the permanent damage caused to the vein.12

Vein damage may also occur as the result of increased from other health conditions or prescription drugs.13 Another cause of vein damage is needle injection, which can occur in a healthcare setting or during injection drug use.3

Diagnosis

Deep vein thrombosis can be difficult to diagnose as it is not easily identifiable upon an initial exam.14 When a patient is at risk of developing DVT, or when a patient presents symptoms of DVT, diagnostic imaging techniques will be used to identify any damage.15

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 9 The following table provides information regarding the diagnostic imaging techniques used in the identification of DVT.1

Imaging Attributes Technique Compression  Sensitivity and specificity exceed 95% and 98% Ultrasonography respectively for symptomatic proximal DVT  Sensitivity of 11–100% and specificity of 90–100% for symptomatic distal DVT  Noninvasive: can be performed relatively rapidly and a portable technique allowing for the bedside ssessment of critically ill patients  Does not visualize the pelvic veins well and cannot be used in obese patients or in patients whose limbs are in plaster casts Computerized  Sensitivity and specificity of 96% and 95% respectively Tomography in a meta-analysis of studies predominantly examining its use for the diagnosis of proximal DVT  Can visualize the pelvic veins, define the upper limit of thrombus extension into the iliac veins and inferior vena cava  Requires the injection of contrast medium, exposes the patient to radiation, may be difficult to interpret when artifact and insufficient venous filling is present, and is more expensive than ultrasonography  Limited by availability and technical expertise Magnetic  Sensitivity and specificity for the diagnosis of Resonance symptomatic DVT is 96% and 93% respectively Imaging  Sensitivity for distal DVT is much lower (about 62%)  Can be performed without the use of contrast medium  Can visualize the pelvic veins, define the upper limit of thrombus extension into the iliac veins and inferior vena cava  Limited by availability and technical expertise

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 10 Venography  Reliably detects isolated distal DVT and thrombosis in (phlebography) the iliac veins and inferior vena cava  Cumbersome to perform, requires the injection of contrast medium, exposes the patient to radiation, may be difficult to interpret when insufficient venous filling is present

Primary Risk Factors For Developing DVT

As noted above, the primary risk factors for developing DVT include lack of movement and vein injury. However, an individual will have an increased risk of developing DVT if he or she has any of the following factors:9  Age  Smoking  Pregnancy  Birth Control Pills  Obesity  High Blood Pressure

While the above factors increase a patient’s risk of developing DVT, not all risk factors are equally problematic. Some risk factors will have a stronger impact on the likelihood of developing DVT than others.

The following table breaks the risk factors into three categories: strong clinical risk factors, moderate clinical risk factors, and weak clinical risk factors.1

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 11 Strong clinical risk factors (odds ratio >10)  Fracture of the hip or lower limb  Hip or knee replacement surgery  Major general surgery  Moderate clinical risk factors (odds ratio 2–9)  Arthroscopic knee surgery Hormonal therapy (i.e., oral contraceptives, hormone replacement therapy)  Pregnancy – postpartum  Paralytic  Previous venous thromboembolism Weak clinical risk factors (odds ratio <2)  Immobilization (i.e., bed rest >3 days, air travel >8 hours)  Pregnancy – antepartum  Obesity  Advancing age

Complications Of DVT

Deep vein thrombosis is not a significant concern on its own. However, it can cause some complications that can be life threatening to the patient. Therefore, any potential complications must be identified and treated early.

Pulmonary Embolism

A pulmonary embolism is caused by a blood clot that travels from a region in the body to the lungs. The blood clot blocks one of the blood vessels in the lung, causing potential problems.16 A pulmonary embolism is extremely dangerous and can be life threatening if not identified and treated immediately.17 Therefore, a treating provider

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 12 should be aware of the following signs and symptoms of a pulmonary embolism:18  Unexplained sudden onset of shortness of breath  Chest pain or discomfort that worsens with a deep breath or cough  Feeling lightheaded or dizzy, or fainting  Rapid pulse  Sweating  Coughing up blood  A sense of anxiety or nervousness

Deep vein thrombosis is the most common cause of a pulmonary embolism. Once a clot has formed, usually in the leg, it may immediately break off and travel to the lungs, or it may not happen for a number of days after the formation of the clot.19 It is important to identify the problem as soon as possible as early treatment can reduce the likelihood that the embolism will be life threatening.20 The following diagnostic procedures are often used to identify a pulmonary embolism:16

Chest X-ray: A type of diagnostic radiology procedure used to assess the lungs, as well as the heart. Chest X-rays may provide important information regarding the size, shape, contour, and anatomic location of the heart, lungs, bronchi, great vessels (aorta and pulmonary ), and mediastinum (area in the middle of the chest separating the lungs). Ventilation-perfusion scan (V/Q scan): A type of nuclear radiology procedure in which a tiny amount of a radioactive substance is used during the procedure to assist in the examination of the lungs. A ventilation scan evaluates ventilation, or the movement of air into and out of the bronchi and bronchioles. A perfusion scan evaluates blood flow within the lungs.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 13 Pulmonary angiogram: An x-ray image of the blood vessels used to evaluate various conditions, such as aneurysm, stenosis (narrowing of the blood vessel), or blockages. A dye (contrast) will be injected through a thin flexible tube placed in an artery. This dye makes the blood vessels visible on X-ray. Spiral computed tomography (also called CT or CAT scan): A diagnostic procedure that uses a combination of x-rays and computer technology to produce cross-sectional images (often called slices). CT with contrast enhances the image of the blood vessels in the lungs. Contrast refers to a substance injected into an intravenous (IV) line that causes the particular or tissue under study to be seen more clearly. Magnetic resonance imaging (MRI): A diagnostic procedure that uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body. Duplex ultrasound (US): A type of vascular ultrasound procedure done to assess blood flow and the structure of the blood vessels in the legs. Blood clots from the legs often dislodge into the lung. Since the treatment of DVT or deep and PE are the same, US is a portable, less risky and cheaper alternative that gives your doctor the same information. Laboratory tests: Blood tests to check the blood's clotting status. Other blood work may include testing for genetic (inherited) disorders that may contribute to abnormal clotting of the blood. In addition, arterial blood gases may be checked to determine the amount of oxygen in the blood. Electrocardiogram (ECG or EKG): One of the simplest and fastest procedures used to evaluate the heart. Electrodes (small, plastic patches) are placed at certain locations on the chest, arms, and legs. When the electrodes are connected to an ECG machine by lead wires, the electrical activity of the heart is measured, interpreted, and printed out for the physician's information and further interpretation.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 14 Early detection and treatment is imperative in instances of deep vein thrombosis and pulmonary embolism. Therefore, the Surgeon General released the following fact sheet to be distributed to individuals to increase awareness about the relationship between the two conditions.21 The following fact sheet should be provided to all patients who are at risk of developing either condition.

Fact Sheet: Deep Vein Thrombosis and Pulmonary Embolism

Who is at risk for Deep Vein Thrombosis and Pulmonary Embolism? Almost anyone can have deep vein thrombosis or pulmonary embolism. In most cases, deep vein thrombosis or pulmonary embolism develops in a person who has an inherited blood clotting disorder or other risk factor, and who experiences a triggering event. The risk increases even more for someone who has more than one risk factor at the same time.

Factors that increase risk are:  Certain inherited blood disorders or factors that make your blood thicker or more likely to clot as well as a family history or previous deep vein thrombosis or pulmonary embolism  Overweight and obesity  and its treatment  Pregnancy and  In women, use of hormones for birth control or menopause  Smoking  Age: those aged 50 or older are more likely to develop deep vein thrombosis  Ethnicity: African Americans and Whites are more likely than other groups to develop deep vein thrombosis

How can Deep Vein Thrombosis and Pulmonary Embolism be prevented? If you're at risk, you can help prevent blood clots from forming by:  Seeing your doctor for regular checkups  Taking all medicines your doctor prescribes nursece4less.com nursece4less.com nursece4less.com nursece4less.com 15  Getting out of bed and moving around as soon as possible after surgery or illness  Exercising your lower leg muscles during long trips  Exercising regularly, maintaining a healthy weight, and not smoking  If you have had deep vein thrombosis or pulmonary embolism before, you can help prevent future blood clots by following the above steps and: o Taking all medicines, such as blood thinners, that your doctor prescribes to prevent or treat blood clots o Using graduated compression stockings (sometimes called support hose or medical compression stockings) as your doctor directs to help prevent blood from pooling and clotting in the lower leg o Following up with your doctor for tests and treatment o In some cases, blood-thinning and compression stockings might also be used in individuals considered at high risk but without a history of deep vein thrombosis

Contact your doctor at once if you have any signs or symptoms:  Swelling in one leg or along a vein in the leg  Pain or tenderness in one leg (might be felt only when standing or walking)  Warmth in one leg in the swollen or painful areas  Red or discolored skin in one leg  Unexplained shortness of breath or difficulty breathing  Coughing up blood

Tips for travelers: Your risk of developing deep vein thrombosis while traveling is small. The risk increases if the travel time is longer than 4 hours, or if you have other risk factors for deep vein thrombosis.

During long trips, it may help to:  Frequently walk up and down the aisles of the bus, train, or airplane. If traveling by car, stop about every hour and walk around  Move your legs and flex and stretch your feet often while you’re sitting by:  Raising and lowering your heels while keeping your toes on the floor  Raising and lowering your toes while keeping your heels on the floor

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 16  Tightening and releasing your leg muscles  Wear loose and comfortable clothing  Drink plenty of fluids, especially water, and avoid alcohol and caffeine  If you're at high risk for deep vein thrombosis, your doctor may also recommend wearing compression stockings during travel or taking a blood-thinning medicine before traveling.

Post-Thrombotic Syndrome

Post-thrombotic syndrome, also referred to as post phlebitic syndrome, is a long-term complication of deep vein thrombosis. It occurs when DVT is left untreated, thereby causing damage to the calf tissue.22 Damage occurs as the result of increased flow and pressure of diverted blood into other veins.23 Approximately two-thirds of individuals with untreated DVT will develop post-thrombotic syndrome.24 Post-thrombotic syndrome can occur as the result of DVT in any area of the lower extremity, but it is most common in instances where the DVT occurs in a thigh vein or when it extends into a thigh vein from a calf vein.25 It is especially common in overweight individuals, as well as those with multiple deep vein thromboses.26

In a normal vein, the blood flows freely. However, in a vein with a deep vein thrombosis, the clot prevents the free circulation of the blood. The clot causes blood to be diverted into other areas, thereby causing complications. The symptoms of post-thrombotic syndrome, which range from mild to severe, include:22

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 17  Calf pain  Discomfort  Swelling of the legs ()  Leg pain  Skin discoloration  Rashes  Ulcer on the skin of the calf (only in severe instances)

Diagnosis

Post-thrombotic symptoms can be caused by a number of other unrelated factors, so it is important to properly identify and diagnose post-thrombotic syndrome before administering treatment.27 Typically, the syndrome is diagnosed using the following diagnostic techniques:

 Compression ultrasound:

Compression ultrasound is a simple and easy test to determine if there is a clot in the veins. It is generally the first type of test that a physician will use because it works best soon after thrombosis has occurred.

 Continuous-wave doppler ultrasound:

This test is a simple and fast way to detect whether the valves in veins are working properly and the blood is flowing normally.

 Color duplex scanning:

This test uses color scans to visualize blood vessels and uses Doppler ultrasound to detect the direction of blood flow. It is a

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 18 test that takes longer than doppler ultrasound but it can also measure how much damage there is to the veins and exactly where the damage is located.22

Treatment

When a patient is diagnosed with post-thrombotic syndrome, it is important to begin treatment immediately to prevent further damage. Treatment typically includes one or more of the following:28

 wearing elastic compression stockings  exercising regularly  elevating leg(s) while resting  medication ( or diuretics), rarely used

Heart Attack and Stroke

Heart attacks and are not commonly associated with deep vein thrombosis, as they occur as the result of clots in the arteries instead of the veins.29 However, recent studies have shown that there is a connection between the development of clots in deep veins and the development of subsequent clots in arteries.30 When compared to patients who have never had deep vein thrombosis or a pulmonary embolism, those who had a history of the conditions showed an increase in the incidence of heart attack and stroke.31 In fact, the risk of heart attack or stroke in patients with deep vein thrombosis or pulmonary embolism was thirty percent higher than it was in those who had never had the condition.30

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 19 In patients with deep vein thrombosis or pulmonary embolism, heart attacks and strokes occur most frequently in the first year following an incident of DVT or pulmonary embolism. Patients are two times more likely to experience a stroke and three times more likely to experience a heart attack in the year following a DVT.4 The risk decreases after the first year, but still remains twenty to forty percent higher than it is for an individual with no history of DVT or pulmonary embolism.1

DVT Prevention

Once a patient develops deep vein thrombosis, he or she is at risk of developing additional complications. In addition, both deep vein thrombosis and pulmonary embolism can be difficult to detect, as they are often asymptomatic. Therefore, prevention is very important. Most practitioners will focus on prevention in instances where there is a risk of DVT or pulmonary embolism, using both pharmaceutical and mechanical strategies. In instances where preventative strategies are used, a patient’s risk of developing DVT or pulmonary embolism decreases from eighty percent to less than twenty percent.25

Prevention is a multifaceted approach and includes both mechanical and pharmaceutical strategies. In most instances, a number of strategies will be used together. However, in some situations, a patient may only require one strategy. Specific strategies will depend on the level of risk and the type of situation. Some prevention strategies will be used for a short duration, while other strategies may extend for a number of months. Common prevention strategies include:

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 20  Anticoagulants  Movement  Compression stockings

In each situation, the provider will assess the patient and develop a prevention plan that best meets the patient’s needs.

Anticoagulants

Anticoagulants are often used to prevent clot formation, especially after surgery. However, while anticoagulants are effective at preventing clot formation, they also increase the risk of bleeding, which can be problematic in some patients.32 Therefore, each patient is assessed before being administered anticoagulants. The following table provides information regarding the three most common anticoagulants:8

Anticoagulant Description Aspirin Aspirin is easy to administer, costs little, has few bleeding complications, and does not need to be monitored. However, it has not been proven more effective than other agents and may not be advisable for all patients. Studies have shown that aspirin has a greater protective effect for men than for women.

Warfarin is the most commonly used agent for hip and knee (also called replacement patients. Warfarin interferes with Coumadin) metabolism in the liver to prevent formation of certain clotting factors. Because warfarin takes at least 36 hours to start working, and four to five days to reach its maximum effectiveness, it is usually started the day before surgery.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 21 Low doses are used because higher doses can cause episodes of bleeding, but the dose response is difficult to predict and warfarin must be administered through an outpatient clinic. Warfarin can cause fetal damage.

Heparin is a naturally occurring substance that inhibits the clotting cascade. It can come in high (standard unfractionated heparin) or low (fractionated heparin) molecular weights.

Recent emphasis has been on low molecular weight (LMWH) because they are more predictable and effective, with fewer bleeding complications than standard unfractionated heparin. LMWH is effective after both hip and knee joint replacement , but there is a higher incidence of bleeding when it is used after knee replacement surgery. The most commonly used and researched LMWH are enoxaparin, ardeparin, dalteparin, and fraxiparine. Heparin works much faster than warfarin, so it is often administered initially and followed by warfarin therapy, or administered as a single agent.

Movement

Movement is a common prevention strategy for deep vein thrombosis and pulmonary embolism. Movement is crucial to prevention as it keeps the blood circulating throughout the body. Since DVT is often caused by increased immobility, it is important to ensure that a patient moves around as frequently as possible.33 This may be difficult with patients who are immobile due to surgery or other health complications. However, even modified movements and stretching can decrease the risk of developing deep vein thrombosis.6 When nursece4less.com nursece4less.com nursece4less.com nursece4less.com 22 movement is restricted, circulation is interrupted, thereby causing DVT.34

Compression Stockings

In many instances, a patient will be prescribed compression stockings as a preventative measure. This is especially true if the patient has a history of deep vein thrombosis, as compression wear will reduce the risk of recurrent DVT.35 Most patients are advised to wear compression stockings for two or more years, or until the risk of developing a clot has been eliminated.36

Compression stockings are specially made to provide different levels of pressure at different regions of the leg, which helps move fluid in the appropriate direction. The stockings use special elastic to apply various amounts of pressure to the leg. They are available in different grades, depending on the amount of pressure needed. However, while the amount of pressure differs between grades, the stockings still use the same pressure pattern. Stockings are tightest at the ankle, and the pressure gradually decreases as the stocking moves up the calf. This helps to move fluid up the leg and prevent it from collecting in different areas.

Patients will require specially fitted compression stockings that are intended to prevent the formation of a blood clot. In some instances, the patient will require a prescription to purchase compression stockings from a medical supply store. However, some compression stockings can be purchased over the counter at a pharmacy.37

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 23 There are two different types of compression stockings that are used to treat or prevent deep vein thrombosis.37

1. To reduce the risk of deep leg vein thrombosis in people who are at high risk. This kind of compression stocking is less expensive than those used to help treat existing deep leg vein thrombosis.

2. To relieve symptoms associated with existing deep leg vein thrombosis, especially swelling and pain, and prevent post- thrombotic syndrome. This type of stocking may also help prevent new clots from forming, although this is not its primary function.

Treatment

Once deep vein thrombosis is identified, it is important to administer treatment as soon as possible to prevent severe, long-term complications from developing. The specific treatment will vary depending on the location of the clot, the severity of the clot and any other health conditions the patient may have. Typically, treatment will involve a combination of different specifically tailored to the patient’s needs.

Some treatment will be administered in an outpatient capacity, while other forms of treatment will require a short hospital stay with constant monitoring.20 The primary goal of treatment is to prevent a pulmonary embolism and reduce the risk of morbidity.5

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 24 Anticoagulants

In addition to helping prevent DVT, anticoagulants are also effective in treating deep vein thrombosis. Once a clot has formed, anticoagulants are used to break it apart and increase blood flow.38 However, since anticoagulants can also cause excessive bleeding, they should be used with caution.39 The previous table on anticoagulants provides information regarding the three most common anticoagulants.8

Thrombolytic Therapy

Thrombolytic therapy dissolves blood clots using medications that are administered via catheter directly into the area where the clot has formed.40 However, thrombolytic therapy is not used in mild cases of deep vein thrombosis as the medication must be administered by a team of trained physicians, nurses and technicians.41 Instead, is used to treat large clots that are causing severe symptoms and that pose a risk to the patient. Thrombolytic therapy is also used to treat clots that cause massive swelling or occur in the lungs.40 Thrombolytics increase the risk of bleeding, so they should only be used in extreme situations after a patient has been assessed.42

Thrombolytics are administered via catheter in a catheterization laboratory using specialized equipment. In most situations, the patient will be sedated prior to the procedure.43 Once the patient is sedated, the catheter is inserted into the area where the clot is located, and thrombolytics are infused directly into the clot, thereby dissolving it.40

It can take a number of hours or a number of days for the clot to dissolve completely.41 The patient is monitored using a genogram or duplex ultrasound.40 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 25 Compression

In many instances, compression stockings are used to treat deep vein thrombosis. Compression stockings reduce the risk of developing post- thrombotic syndrome, and they also help prevent the patient from developing additional deep vein thrombosis.44 As mentioned earlier, typically, treatment with compression stockings will continue for at least two years to ensure that the deep vein thrombosis has been resolved and to prevent further complications.36 Some patients may be advised to wear compression stockings indefinitely after experiencing a bout of deep vein thrombosis.33

While compression stockings are used for both prevention and treatment of deep vein thrombosis, the type of stockings used for treatment differs for each. As stated above, there are two types of compression stockings that are used to treat or prevent deep vein thrombosis:37

1. To reduce the risk of deep leg vein thrombosis in people who are at high risk. This kind of compression stocking is less expensive than those used to help treat existing deep leg vein thrombosis.

2. To relieve symptoms associated with existing deep leg vein thrombosis, especially swelling and pain, and prevent post- thrombotic syndrome. This type of stocking may also help prevent new clots from forming, although this is not its primary function.

Patients will require specially fitted compression stockings that are intended to prevent the formation of a blood clot. Patients should not

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 26 purchase compression stockings for DVT treatment over the counter at a pharmacy, as accurate sizing and measurement is imperative when using them for treatment.44 In most instances, patients are advised to wear grade three strength stockings, as these have the best level of compression for the reduction of deep vein thrombosis.45 However, some patients will be unable to tolerate grade three stockings due to the amount of squeezing force they produce. In these instances, patients will be prescribed grade two stockings, which are not as effective as the grade three stockings.44

Prognosis

The prognosis for deep vein thrombosis depends on the severity of the DVT and the condition of the patient. In most instances, deep vein thrombosis will resolve quickly and without any additional complications.10 However, many patients will experience recurring deep vein thrombosis once they have had an initial case of it.46 Recurring deep vein thrombosis is often the result of vein damage caused by the initial incidence, but it can also be caused by secondary health conditions or lifestyle habits.9

Deep vein thrombosis does not pose a risk of morbidity.30 However, if DVT causes a pulmonary embolism, patients have a high risk of short- term morbidity.16 Overall, pulmonary account for 300,000 deaths annually.19 Long-term morbidity is typically associated with post phlebitic syndrome, which causes a number of complications for the patient.23

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 27 When treated, the prognosis for deep vein thrombosis is quite positive. Most patients will experience no long-term complications and will be able to resume normal activities and level of function quickly.47 Most patients will recover completely, although the risk of recurrence will always be a concern. This risk can be minimized if the patient wears compression stockings. However, if a patient develops a pulmonary embolism or post phlebitic syndrome, the prognosis is not as positive.

Post Phlebitic Syndrome

Post phlebitic syndrome, also referred to as post-thrombotic syndrome, is a long-term complication of deep vein thrombosis. It occurs when DVT is left untreated, thereby causing damage to the calf tissue.22 Damage occurs as the result of increased flow and pressure of diverted blood into other veins.23 Approximately two-thirds of individuals with untreated DVT will develop post phlebitic syndrome.24 Post phlebitic syndrome can occur as the result of DVT in any area of the lower extremity, but it is most common in instances where the DVT occurs in a thigh vein or when it extends into a thigh vein from a calf vein.25 It is especially common in overweight individuals, as well as those with multiple deep vein thromboses.26

Post phlebitic syndrome typically develops within two years of an episode of deep vein thrombosis and will range in severity. In extreme instances, it will cause painful leg ulcers, which will require continuous medical care.24 Patients with less severe cases will still experience lack of function and long term mobility issues.23

The risk of developing post phlebitic syndrome increases if any of the following factors are present:22

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 older age  obesity  history of previous ipsilateral DVT  iliac-femoral location of the current thrombosis  failure to recover promptly from the acute symptoms  insufficient quality of oral therapy

Summary

Deep vein thrombosis is a blood clot that forms deep in the vein of the lower extremity typically as the result of lack of movement or vein injury. DVT can strike anyone regardless of age, physical fitness, or other factors; however, it is especially common in patients who have recently had surgery. It can cause long-term damage if not treated properly and has an excellent prognosis when caught early and treated aggressively. While the clot itself is not a concern, the potential complications that it can cause are of concern. Some patients will experience a pulmonary embolism if the clot breaks free and travels to the blood vessels in the lung. When this occurs, the risk of morbidity is high. In some instances, patients will develop post-thrombotic syndrome, which impacts the patient’s mobility and level of basic functioning.

Although there are a number of risk factors associated with deep vein thrombosis, it can strike anyone regardless of age, physical fitness, or other factors. However, DVT has an excellent prognosis when caught early and treated aggressively. Additionally, there are a number of strategies for reducing DVT risk. It is important for health care nursece4less.com nursece4less.com nursece4less.com nursece4less.com 29 providers to familiarize themselves with these strategies in order to be prepared to advise their patients on lifestyle adjustments and other actions that can lower this risk.

Recent studies have shown that there is a connection between the development of clots in deep veins and the development of subsequent clots in arteries. When compared to patients who have never had deep vein thrombosis or a pulmonary embolism, those who had a history of the conditions showed an increase in the incidence of heart attack and stroke. The risk of heart attack or stroke in patients with deep vein thrombosis or pulmonary embolism has been found to be thirty percent higher than it was in those who had never had the condition.

There are a number of strategies for reducing DVT risk. It is important for health care providers to familiarize themselves with these strategies in order to be prepared to advise their patients on lifestyle adjustments and other actions that can lower this risk. Prophylaxis for DVT can often prevent disease and avoid complications later on. Nurses are able to educate colleagues and patients in health practice settings where the risk of DVT is known to be at higher risk to occur. The key to prevent DVT is to recognize who is at risk and to start preventive measures.

Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation.

Completing the study questions is optional and is NOT a course requirement.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 30 1. A pulmonary embolism occurs when a clot becomes dislodged and travels to the ______. a. Respiratory system b. Lung c. Digestive system d. Immune system

2. Compression stockings that will be used to treat DVT should be a grade ______. a. 1 b. 2 c. 3 d. 4

3. This is the procedure that injects medication directly into the blood clot via catheter to dissolve the clot. a. Angioplasty b. Thrombolytic Therapy c. Bypass d. Laparoscopy

4. Which of the following is NOT a risk factor for DVT? a. Smoking b. Strength Training c. Pregnancy d. Age

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 31 5. Which of the following is a long-term complication of DVT that causes damage to the vein? a. Pulmonary Embolism b. Heart Attack c. Post-Thrombotic Syndrome d. Blockage

CORRECT ANSWERS:

1. b 2. c 3. b 4. b 5. c

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 32 References Section

The reference section of in-text citations include published works intended as helpful material for further reading. Unpublished works and personal communications are not included in this section, although may appear within the study text.

1. Deep Vein Thrombosis: Risks and Diagnosis [Internet]. Available from: http://www.williampoh.com/Documents/AFPDVT0710.pdf 2. Kesieme E, Kesieme C, Jebbin N, Irekpita E, Dongo A. Deep vein thrombosis: a clinical review. J. Blood Med. 2011;2:59–69. 3. Deep Vein Thrombosis [Internet]. Available from: http://vasculardisease.org/flyers/deep-vein-thrombosis-flyer.pdf 4. Bandyopadhyay G, Roy SB, Haldar S, Bhattacharya R. Deep vein thrombosis. J. Indian Med. Assoc. 2010;108:866–7. 5. Lottenberg R, Soucie JM, Grant AM, Atrash HK, Raskob GE, Silverstein R, et al. Surveillance for Deep Vein Thrombosis and Pulmonary Embolism. Am. J. Prev. Med. 2010. p. S502–S509. 6. Eikelboom JW, Karthikeyan G, Fagel N, Hirsh J. American Association of Orthopedic Surgeons and American College of Chest Physicians guidelines for venous thromboembolism prevention in hip and knee arthroplasty differ: what are the implications for clinicians and patients? Chest. American College of Chest Physicians; 2009 Feb 1;135(2):513–20. 7. Yamaki T, Hamahata A, Soejima K, Kono T, Nozaki M, Sakurai H. Factors predicting development of post-thrombotic syndrome in patients with a first episode of deep vein thrombosis: preliminary report. Eur. J. Vasc. Endovasc. Surg. 2011;41:126–33.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 33 8. Deep Vein Thrombosis -OrthoInfo - AAOS [Internet]. Available from: http://orthoinfo.aaos.org/topic.cfm?topic=a00219 9. Eichinger S, Heinze G, Jandeck LM, Kyrle PA. Risk assessment of recurrence in patients with unprovoked deep vein thrombosis or pulmonary embolism: the Vienna prediction model. Circulation. 2010 Apr 13;121(14):1630–6. 10. Yamaki T, Nozaki M, Sakurai H, Takeuchi M, Soejima K, Kono T. Presence of Lower Limb Deep Vein Thrombosis and Prognosis in Patients with Symptomatic Pulmonary Embolism: Preliminary Report. Eur. J. Vasc. Endovasc. Surg. 2009;37(2):225–31. 11. Halvorson JJ, Anz A, Langfitt M, Deonanan JK, Scott A, Teasdall RD, et al. Vascular injury associated with extremity trauma: initial diagnosis and management. J. Am. Acad. Orthop. Surg. American Academy of Orthopaedic Surgeons; 2011 Aug 1;19(8):495–504. 12. Deroo S, Deatrick KB, Henke PK. The vessel wall: A forgotten player in post thrombotic syndrome. Thromb. Haemost. 2010;104:681–92. 13. Tovey C, Wyatt S. Diagnosis, investigation, and management of deep vein thrombosis. BMJ Br. Med. J. 2003;326:1180–4. 14. Scarvelis D, Wells PS. Diagnosis and treatment of deep-vein thrombosis. CMAJ. 2006 Oct 24;175(9):1087–92. 15. Wells PS, Owen C, Doucette S, Fergusson D, Tran H. Does this patient have deep vein thrombosis? JAMA. American Medical Association; 2006 Jan 11;295(2):199–207. 16. Pulmonary Embolism [Internet]. Available from: http://medicalcenter.osu.edu/patientcare/healthcare_services/lun g_diseases/lung/embolism/Pages/index.aspx

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 34 17. Acute Pulmonary Embolism — NEJM [Internet]. Available from: http://www.nejm.org/doi/full/10.1056/NEJMra0907731 18. Headley CM, Melander S. When it may be a pulmonary embolism. Nephrol. Nurs. J. 2011;38:127–37. 19. Humenberger M, Lang IM. Pulmonary embolism. Hamostaseologie. 2008;28:40–3. 20. Brenner B, Hoffman R. Emerging options in the treatment of deep vein thrombosis and pulmonary embolism. Blood Rev. 2011;25:215–21. 21. (OSG) O of the SG. Fact Sheet: Deep Vein Thrombosis and Pulmonary Embolism. 22. The facts on post-thrombotic syndrome [Internet]. Available from: http://www.inate.org/en/1/2/6/23/default.aspx 23. Brenner B, Greer IA, Kahn SR. The post thrombotic syndrome. Thromb. Res. 2011;127:S89–S92. 24. Galanaud JP, Holcroft CA, Rodger MA, Kovacs MJ, Betancourt MT, Wells PS, et al. Predictors of post-thrombotic syndrome in a population with a first deep vein thrombosis and no primary venous insufficiency. J. Thromb. Haemost. 2013 Mar;11(3):474– 80. 25. Guanella R, Kahn SR. Post-thrombotic syndrome: current prevention and management strategies. Expert Rev. Cardiovasc. Ther. 2012;10:1555–66. 26. Elman EE, Kahn SR. The post-thrombotic syndrome after upper extremity deep venous thrombosis in adults: A systematic review. Thromb. Res. 2006;117(6):609–14. 27. Roumen-Klappe EM, Janssen MCH, Van Rossum J, Holewijn S, Van Bokhoven MMJA, Kaasjager K, et al. Inflammation in deep vein thrombosis and the development of post-thrombotic

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 35 syndrome: a prospective study. J. Thromb. Haemost. 2009 Apr;7(4):582–7. 28. Morling JR, Yeoh SE, Kolbach DN. Rutosides for treatment of post-thrombotic syndrome. Cochrane Database Syst. Rev. 2013;4:CD005625. 29. Rathbun S. Cardiology patient pages. The Surgeon General’s call to action to prevent deep vein thrombosis and pulmonary embolism. Circulation. 2009 Apr 21;119(15):e480–2. 30. Goldhaber SZ, Bounameaux H. Pulmonary embolism and deep vein thrombosis. Lancet. 2012 May 12;379(9828):1835–46. 31. Naccarato M, Chiodo Grandi F, Dennis M, Sandercock PA. Physical methods for preventing deep vein thrombosis in stroke. Cochrane database Syst. Rev. 2010 Jan;(8):CD001922. 32. Franchini M, Mannucci PM. A new era for anticoagulants. Eur. J. Intern. Med. 2009;20:562–8. 33. Galanaud J-P, Laroche J-P, Righini M. The history and historical treatments of deep vein thrombosis. J. Thromb. Haemost. 2013. p. 402–11. 34. Friedman RJ, Gallus AS, Cushner FD, FitzGerald G, Jr FAA, Investigators for the GOR. Physician compliance with guidelines for deep-vein thrombosis prevention in total hip and knee arthroplasty. Informa UK Ltd UK; 2007 Nov 19; 35. MJ C, S H, E J, A E, M K. Compression stockings for preventing deep vein thrombosis (DVT) in airline passengers. John Wiley and Sons, Ltd. for The Cochrane Collaboration; 2010. 36. Kahn SR, Shbaklo H, Lamping DL, Holcroft CA, Shrier I, Miron MJ, et al. Determinants of health-related quality of life during the 2 years following deep vein thrombosis. J. Thromb. Haemost. 2008 Jul;6(7):1105–12.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 36 37. Sachdeva A, Dalton M, Amaragiri S V, Lees T. Elastic compression stockings for prevention of deep vein thrombosis. Cochrane database Syst. Rev. 2010 Jan;(7):CD001484. 38. Mavrakanas T, Bounameaux H. The potential role of new oral anticoagulants in the prevention and treatment of thromboembolism. Pharmacol. Ther. 2011;130(1):46–58. 39. Gross PL, Weitz JI. New anticoagulants for treatment of venous thromboembolism. Arterioscler. Thromb. Vasc. Biol. 2008 Mar 1;28(3):380–6. 40. Schermerhorn M, Mewissen MW. Thrombolysis for Lower- Extremity Deep Vein Thrombosis. Semin. Vasc. Surg. 2010;23(4):228–34. 41. L W, MP A. Thrombolysis for treatment of acute deep vein thrombosis. John Wiley and Sons, Ltd. for The Cochrane Collaboration; 2010. 42. Gogalniceanu P, Johnston CJC, Khalid U, Holt PJE, Hincliffe R, Loftus IM, et al. Indications for Thrombolysis in Deep Venous Thrombosis. Eur. J. Vasc. Endovasc. Surg. 2009;38(2):192–8. 43. Comerota AJ. Thrombolysis for deep venous thrombosis. J. Vasc. Surg. 2012;55(2):607–11. 44. Aschwanden M, Jeanneret C, Koller MT, Thalhammer C, Bucher HC, Jaeger KA. Effect of prolonged treatment with compression stockings to prevent post-thrombotic sequelae: A randomized controlled trial. J. Vasc. Surg. 2008;47(5):1015–21. 45. Kahn SR. The post-thrombotic syndrome. Hematology Am. Soc. Hematol. Educ. Program. 2010 Jan 1;2010(1):216–20. 46. Jiménez D, Aujesky D, Díaz G, Monreal M, Otero R, Martí D, et al. Prognostic Significance of Deep Vein Thrombosis in Patients

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 37 Presenting with Acute Symptomatic Pulmonary Embolism. American Thoracic Society; 2012 Dec 20; 47. Spencer FA, Gore JM, Lessard D, Douketis JD, Emery C, Goldberg RJ. Patient outcomes after deep vein thrombosis and pulmonary embolism: the Worcester Venous Thromboembolism Study. Arch. Intern. Med. American Medical Association; 2008 Feb 25;168(4):425–30.

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