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Deep Vein Thrombosis in Hospitalized Patients a Review of Evidence-Based Guidelines for Prevention

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Deep Vein Thrombosis in Hospitalized Patients a Review of Evidence-Based Guidelines for Prevention Clinical DIMENSION Deep Vein Thrombosis in Hospitalized Patients A Review of Evidence-based Guidelines for Prevention Wendy Kehl-Pruett, ARNP, MSN, CCRN Deep vein thrombosis affects many hospitalized patients because of decreased activity and therapeutic equipment. This article reviews known risk factors for developing deep vein thrombosis, current prevention methods, and current evidence-based guidelines in order to raise nurses’ awareness of early prevention methods in all hospitalized patients. Early prophylaxis can reduce patient risk of deep vein thrombosis and its complications. Keywords: Deep vein thrombosis, Thrombosis, Embolism, Risk factors, Prevention [DIMENS CRIT CARE NURS. 2006;25(2):53/59] Venous thromboembolism results from a combination including high-dose anticoagulants and thrombolytics, of venous stasis, vein injury, and increased coagulation, may be contraindicated in certain inpatient popula- otherwise known as Virchow’s triad.1 Venous stasis tions; therefore, other methods of preventing DVT are occurs when patients are immobile and blood pools imperative. in the extremities, usually the leg veins. Vein injury can be the result of surgery, intravenous therapy, and phle- botomy. Increased coagulability is seen in inflamma- Deep vein thrombosis is a tory conditions and some infectious disease processes. complication of prolonged To prevent venous thromboembolism, the 3 compo- immobilization in hospital patients. nents of Virchow’s triad must be minimized during hospitalization. Deep vein thrombosis (DVT), a form of venous throm- boembolism, is a complication of prolonged immobiliza- Patients in critical care units may be at risk of de- tion in hospital patients. Hospitalized patients are at veloping DVT and its complications. Critical care nurses increased risk of developing DVT due to immobility, must understand the risk factors for DVT and the vari- advanced age, acute medical illness, and central venous ous methodologies used to prevent this potentially life- catheters.2 Individuals who develop DVT are at fur- threatening condition. This article contains a review of ther risk for serious complications such as pulmo- risk factors and current methods for prevention of DVT nary embolism and death. Patients who develop DVT in hospitalized patients in order to raise clinician aware- can also have increased lengths of stay, which can ness of this preventable complication. The purpose of equate to increased avoidable costs. Treatment options, this article is to review risk factors for DVT, prophylaxis March/April 2006 53 Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Deep Vein Thrombosis in Hospitalized Patients Y options, and current evidence-based guidelines for DVT These studies and meta-analysis,5 7 illustrate that prophylaxis, so that nurses may advocate for the initia- despite known risk factors and available prevention tion of early prevention measures in all hospitalized methods, medical patients are less likely to receive pro- patients. The guidelines presented are recommendations phylaxis than surgical patients. Researchers have also for early prevention that can reduce DVT occurrence noted that 75% of venous thromboembolism occurs in and prevent serious complications. medical patients.2,8 These statistics show an alarming trend toward underutilization of DVT prevention in PREVALENCE OF DEEP VEIN THROMBOSIS medical and surgical patients requiring hospitalization. The prevalence of DVT in the general population is 0.1%, which translates to 2 million people experiencing RISK FACTORS FOR DEEP VEIN DVT each year.1 Approximately one in every 1,000 per- THROMBOSIS IN HOSPITALIZED PATIENTS sons will experience DVT in the United States this year.3 Although all hospitalized patients have a possibility of Unfortunately, the incidence of DVT in hospitalized developing venous thromboembolism, certain factors Y medical patients has only been documented in clinical increase the risk of developing DVT (see Table 1).1,2,9 14 trials where prevention techniques were being studied. These risk factors include decreased mobility, age, obe- This rate has been reported at approximately 15%.4 sity, estrogen therapy, surgery, central venous catheters, General medical and surgical patients have a 10% to previous history of DVT, and many acute and chronic 40% risk of developing DVT while hospitalized, where- medical conditions that lead to hospital admission. as orthopedic surgery patients have a 40% to 60% risk.2 Medical conditions that can lead to increased risk in- The Deep Vein Thrombosis Free (DVT FREE) reg- clude cancer, inflammatory diseases, acute infections, istry is a national registry for patients who have ultra- heart failure, stroke, and chronic lung disease. sound-confirmed DVT.5 The registry’s purpose is to Decreased mobility is a major risk factor that affects study the epidemiology of patients with DVT and eval- most hospitalized patients, because few patients are as uate current management of prophylaxis. In a prospec- active while hospitalized as they were at home. DVT tive study of data from this registry,5 the DVT FREE risk is higher in hospitalized patients because bedrest is Steering Committee reviewed data from 5,451 patients frequently ordered. Even those patients permitted to get enrolled within a 6-month period and found that 2,726 out of bed, remain in bed far more than they would at developed DVT while hospitalized. Of those patients, 1,362 were medical patients and 1,364 were surgical patients. Seventy-one percent of these combined medical TABLE 1 Risk Factors for DVT in and surgical patients had not received any type of DVT Hospital Patients prophylaxis 30 days prior to diagnosis. Researchers General Risk Factors confirmed that routine preventive measures were not provided to 58% of medical patients.5 Unfortunately, Decreased mobility because this is a retrospective review, reasons for Age absence of DVT prophylaxis were not given. Obesity Another large (n = 4,011) prospective registry of Smoking patients with confirmed venous thromboembolism was created to assess current DVT prevention methods and Previous history of DVT patient outcomes.6 A review of data obtained over a Acute medical illness 17-month period found that surgical patients received Central venous catheters DVT prophylaxis 66% of the time, whereas nonsurgical Surgery, orthopedic, or abdominal patients were given DVT prophylaxis only 23% of the time. It was further noted that even in the presence of Estrogen therapy known risk factors, most medical patients had not re- Cancer and cancer therapy ceived prophylaxis. Inflammatory conditions Researchers conducted a meta-analysis of 14 studies Acute infectious processes from 1994 to 2002 that assessed the use of DVT pre- vention in critical care patients.7 They concluded that Heart failure only 69% of 3,654 combined patients received some Chronic lung disease form of DVT prophylaxis. Even with improved tech- Stroke niques in prevention, 31% of patients still did not Varicose veins receive adequate screening or prevention. 54 Dimensions of Critical Care Nursing Vol. 25 / No. 2 Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Deep Vein Thrombosis in Hospitalized Patients home because of monitoring equipment, intravenous lines, motherapy, inflammatory disease, acute infectious dis- drainage tubes, catheters, and other necessary medical ease, estrogen therapy, heart failure, and chronic lung equipment. Decreased venous circulation and vascular disease.2,9,10,12 Another important risk factor for DVT disease, including prior history of venous thromboem- in hospital patients is the use of central venous bolism and varicose vein, are also considered risk fac- catheters.2 These catheters lead to venous injury when tors in DVT.9,10,12 inserted and, if inserted in the femoral vein, can further Increasing age is another important risk factor for restrict activity levels. DVT. In a 21-year analysis of records from the National All of these risk factors should be considered when Hospital Discharge Survey, researchers found an in- determining patient risk for developing venous throm- creased incidence of DVT as subjects aged.13 Elderly boembolism. Although individual risk factors are im- patients have higher DVT rates as compared to younger portant in considering the need for DVT prophylaxis, persons, with DVT rates doubling with each increase in multiple risk factors lead to an even greater risk.2 There- decade of life.9,13 Especially at risk are patients over age fore, all patients should be screened for DVT risk upon 75,2,10,13 although some recommend evaluating all in- admission.2,9 Specific screening should include de- dividuals older than 60 years.12 Eighty-year-old patients creased mobility, age, obesity, and medical conditions are 100 times more likely than patients under 40 to that increase DVT risk. DVT prevention techniques develop DVT.1 This is important as the Centers for should then be initiated based on risk assessment. Disease Control and Prevention population projections predict that the population of 65- to 85-year-olds will increase by 44% over the next 15 years.15 This means AMERICAN COLLEGE OF CHEST that hospitals will have greater numbers of elderly PHYSICIAN GUIDELINES patients at increased risk of DVT. Also noted in the Since 1986, the American College of Chest Physicians analysis of discharge records was that although pulmo- (ACCP) has produced evidence-based guidelines
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