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Tell me about DVT Prophylaxis

Author:Lengyel J.
on 02 Dec, 2007

Last edited by: Lengyel J. on 02 Dec, 2007
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Tell me about DVT Prophylaxis
 
See this link for all listed NICE guidelines April 2007. http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11006 
 
Choose this link for 25 page PDF summary.
 
 
 
MCQ examples
 
Which one of these are not accepted as methods of diagnosing DVT
a)     Radioiodine (125I) fibrinogen uptake
b)     Impedence Plethysmography
c)     Doppler Ultrasound
d)     Magnetic resonance imaging
e)     Venography
 
Answer (b)
 
 
What is the risk of Venous thromboembolism in surgical patients?
 
Type of surgery
Incidence DVT
Incidence of Symptomatic PE
 
 
 
General
24%
1%
Orthopaedic ( elective hip)
44%
4%
Gynaecological
16%
0%
 
 
 
Taken from data 2003/04 ( NICE guidleines)
 
 
Some interesting facts that may come up
  • Smoking is associated with a lower risk of DVT
  • OCP- increases your risk of DVT by approximately 2
    • Combined OCP
      •  stop for major surgery
      • No need to stop for elective day case surgery
    • POP – no need to stop for any surgery
  • HRT – there were no studies in surgical patients.
    • No need to stop providing DVT prophylaxis is used
  •  Regional anaesthesia reduces the risk DVT
  •  Heparin reduces DVT 55% and PE by 30%
  •  MWH reduces DVT 51% and PE by 64%
  • TEDS reduce DVT 51% ( No difference between knee and thigh length)
  • IPC = Intermittent Pneumatic compression reduces DVT by 56% ( PE no difference)
  • Although NICE recommend that patients mobilise early and we should avoid dehydration, there is not one RCT to support this. This is therefore level 4 evidence.
    •  Early mobilisation is ‘good practice’ but there are no RCT to prove or refute the fact that it reduces the risk DVT / PE.
    • The only 1 RCT looking at hydration suggested hydration increased the risk DVT
  • Vena caval filters should be considered for patients undergoing surgery within 1 month if anticoagulation is contraindicated
 
KEY Recommendations

Patients should be assessed to identify their risk factors for developing venous thromboembolism( Box 1 below)

  • Patients having general surgery should be offered mechanical prophylaxis.
  •  Patients having general surgery with one or more risk factors for VTE (see box 1) should be offered mechanical prophylaxis and either LMWH or fondaparinux

 

Healthcare professionals should inform patients that the immobility associated with continuous travel of more than 3 hours in the 4 weeks before or after surgery may increase the risk of VTE

 

Healthcare professionals should advise patients to consider stopping combined oral contraceptive use 4 weeks before elective surgery   
 
 
 
Individual patient-related risk factors for venous thromboembolism
 

 

BOX 1

_ Active cancer or cancer treatment

_ Active heart or respiratory failure
_ Acute medical illness
_ Age over 60 years
_ Antiphospholipid syndrome
_ Behcet’s disease
_ Central venous catheter in situ
_ Continuous travel of more than 3 hours approximately 4 weeks before or after surgery
_ Immobility (for example, paralysis or limb in plaster)
_ Irritable bowel disease (for example, Crohn’s disease or ulcerative colitis)
_ Myeloproliferative diseases
_ Nephrotic syndrome
_ Obesity (body mass index X 30 kg/m2)
_ Paraproteinaemia
_ Paroxysmal nocturnal haemoglobinuria
_ Personal or family history of VTE
_ Pregnancy or puerperium
_ Recent myocardial infarction or stroke
_ Severe infection
_ Use of oral contraceptives or hormonal replacement therapy
_ Varicose veins with associated phlebitis
_ Inherited Thrombophilias for example:
_ High levels of coagulation factors (for example, Factor VIII)
_ Hyperhomocysteinaemia
_ Low activated protein C resistance (for example, Factor V Leiden)
_ Protein C, S and antithrombin deficiencies
_ Prothrombin 2021A gene mutation
 
 
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