Deep Vein Thrombrosis Prevention

American Association of Critical Care Nurses- December 2005Download the .pdf

Expected Practice:

  •  Assess all patients upon admission to the ICU for risk factors of deep vein thrombosis (DVT) and anticipate orders for DVT prophylaxis based on risk assessment. Clinical eligibility and regimens for DVT prophylaxis include:
    • Moderate-risk patients including medically ill and postoperative patients—on low dose unfractionated heparin or low-molecular-weight heparin (LMWH)
    • Higher risk patients including major trauma or orthopedic surgery—LMWH
    • Patients with high risk for bleeding—on mechanical prophylaxis including graduated compression stockings and/or intermittent pneumatic compression devices
    • Mechanical prophylaxis may also be anticipated in conjunction with anti-coagulant based prophylaxis regimens.
  • Review daily with the physician and during multidisciplinary rounds each patient’s current DVT risk factors including clinical status, necessity for central venous catheter (CVC), current status of DVT prophylaxis, risk for bleeding, and response to treatment.
  • Maximize patient mobility whenever possible and take measures to reduce the amount of time the patient is immobile because of the effects of treatment (eg, pain, sedation, neuromuscular blockade, mechanical ventilation).
  • Ensure that mechanical prophylaxis devices are fitted properly and in use at all times except when being removed for cleaning and/or inspection of skin.

Supporting Evidence

  •  Multiple medical and surgical risk factors leading to DVT formation have been identified.1 Iatrogenic risk factors for DVT include immobilization, sedation/neuromuscular blockade, CVCs, surgery, sepsis, mechanical ventilation, vasopressor administration, heart failure, stroke, malignancy, previous DVT, and renal dialysis; a vast majority of patients in critical care units have 1 or more major risk factors.1-4 In 5 prospective studies, the rate of DVT in patients in critical care not receiving prophylaxis ranged from 13% to 31%.5-8 Because signs and symptoms of DVT are frequently silent and can lead to fatal pulmonary embolism, AHRQ (Agency for Healthcare Research and Quality) and ACCP (American College of Chest Physicians) recommend DVT prophylaxis for at-risk patients.1,9-17
  • Randomized trials indicate that both low dose unfractionated heparin and LMWH are efficacious in preventing DVT in moderate-risk critical care patients.5-8, 18 For patients at higher risk, such as those who have major trauma or have had orthopedic surgery, LMWH has been shown to provide superior protection over low dose unfractionated heparin.1 Direct thrombin inhibitors can be used in place of low molecular weight heparin or unfractionated heparin for patients with documented or suspected heparin induced thrombocytopenia.1, 19,20 Numerous studies suggest that aspirin alone is not an efficacious means of DVT prophylaxis for any patient group.21-25
  • Although examined less rigorously than anticoagulant based methods, mechanical methods of prophylaxis (including graduated compression stockings, intermittent compression devices, and venous foot pumps) have been shown to reduce the risk of DVT.26-36 One study involving non-lower extremity trauma patients compared the efficacy of intermittent pneumatic compression devices and venous foot pumps. DVT rates among the venous foot pump group were 3 times greater when compared with the rates of the intermittent pneumatic compression group. The researchers concluded that intermittent pneumatic compression devices provided superior prophylaxis in this patient population.34
  • In general, mechanical prophylaxis is less efficacious when compared to anticoagulation based therapy.31-33, 35,36 Reduction in risk of death or pulmonary embolism has not been attributed to mechanical methods of prophylaxis.1 In 1 study involving below-the-knee graded stockings, 98% of commercially available stockings failed to produce an ideal pressure gradient and 54% were found to produce a dangerous reverse pressure gradient. 37 Mechanical prophylaxis methods are a desirable option because they do not pose bleeding concerns.1 A combination of mechanical prophylaxis and chemoprophylaxis is thought to potentiate overall efficacy but this combination has not been tested in the critical care setting.38
  • Written policies for DVT prophylaxis in conjunction with either preprinted or computerized ICU admission orders have been shown to increase compliance with prophylaxis measures. 39 One study found that implementation of a daily goals form, which included DVT prophylaxis in the ICU, resulted in a significant improvement in the percentage of residents and nurses who understood the patient’s daily goals for care and decreased ICU length of stay by 1.1 days.40
  • The presence of a CVC is an independent risk factor for upper extremity DVT in the general population.41
  • Several studies involving a variety of patient populations with diagnostically confirmed DVT have identified immobility either as a comorbidity or independent risk factor.42-44
  • Improperly fitted graduated compression stockings producing a reversed pressure gradient were associated with a statistically significantly higher incidence of DVT compared with stockings that produced a proper gradient.35 Studies evaluating compliance with intermittent pneumatic compression devices demonstrated rates of non-compliance ranging from 22% to 81% in at-risk patients.

What You Should Do:

  •  Ensure that your unit has a written policy for DVT prophylaxis that is updated regularly to reflect emerging evidentiary findings in addition to preprinted or computerized ICU admission orders.
  • Ensure that your unit has an organized process for developing and communicating patient goals (which include DVT prophylaxis) to members of the multidisciplinary team.
  • Establish a process to educate and routinely evaluate all staff in the use of mechanical prophylaxis devices.
  • Review orders of patients discharged from the ICU to ensure that transfer orders include a plan for DVT prophylaxis.
  • Monitor your unit’s compliance with DVT prophylaxis policies and rates of DVT and pulmonary embolism. Initiate quality improvement initiatives involving a multidisciplinary team as necessary.

Need More Information or Help?

Talk with a clinical practice specialist for additional information / assistance at www.aacn.org then select PRN.

References:

  1. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest. 2004;126(Suppl):338S-400S.
  2. Geerts W, Cook D, Selby R, et al. Venous thromboembolism and its prevention in critical care. J Crit Care. 2002;17,95-104.
  3. Cook D, Attia J, Weaver B, et al. Venous thromboembolic disease: an observational study in medical-surgical intensive care unit patients. J Crit Care. 2000;15,127-132.
  4. Cook DJ, Crowther M, Meade M, et al. Deep venous thrombosis in medical-surgical ICU patients: prevalence, incidence and risk factors [abstract]. Crit Care. 2003;7(Suppl):S54.
  5. Cade JF. High risk of the critically ill for venous thromboembolism. Crit Care Med. 1982;10:448-450.
  6. Fraisse F, Holzapfel L, Couland JM, et al. Nadroparin in the prevention of deep vein thrombosis in acute decompensated COPD. Am J Respir Crit Care Med. 2000;161:1109-1114.
  7. Kapoor M, Kupfer YY, Tessler S. Subcutaneous heparin prophylaxis significantly reduces the incidence of venous thromboembolic events in the critically ill [abstract]. Crit Care Med. 1999;27(Suppl):A69.
  8. Goldhaber SZ, Kett DH, Cusumano CJ, et al. Low molecular weight heparin versus minidose unfractionated heparin for prophylaxis against venous thromboembolism in medical intensive care unit patients: a randomized controlled trial [abstract]. J Am Coll Cardiol. 2000;35(Suppl):325A.
  9. Lindblad B, Eriksson A, Bergqvist D. Autopsy-verified pulmonary embolism in a surgical department: analysis of the period from 1951 to 1968. Br J Surg. 1991;78:849-852.
  10. Sandler DA, Martin JF. Autopsy proven pulmonary embolism in hospital patients: are we detecting enough deep vein thrombosis? J R Soc Med. 1989;82:203-205.
  11. Geerts WH, Heit JA, Clagett GP, et al. Prevention of venous thromboembolism. Chest. 2001;119(Suppl):132S-175S.
  12. Prevention of fatal pulmonary embolism by low doses of heparin; International Multicentre Trial. Lancet. 1975;2:45-51.
  13. Sevitt S, Gallagher NG. Prevention of venous thrombosis and pulmonary embolism in injured patients: a trial of anticoagulant prophylaxis with phenindione in middle-aged and elderly patients with fractured necks of femur. Lancet. 1959;ii:981-989.
  14. Sagar S, Massey J, Sanderson JM. Low-dose heparin prophylaxis against fatal pulmonary embolism. BMJ. 1975;2:257-259.
  15. Halkin H, Goldberg J, Modan M, et al. Reduction of mortality in general medical inpatients by low-dose heparin prophylaxis. Ann Intern Med. 1982;96:561-565.
  16. Collins R, Scrimgeour A, Yusuf S, et al. Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of subcutaneous heparin: overview of results of randomized trials in general, orthopedic, and urologic surgery. N Engl J Med. 1988;318:1162-1173.
  17. Agency for Healthcare Research and Quality. Making health care safer: a critical analysis of patient safety practices. Evidence Report/Technology Assessment No. 43. Available at: http://www.ahrq.gov/clinic/ptsafety Accessed September 19, 2006.
  18. Iorio A, Agnelli G. Low-molecular-weight and unfractionated heparin for prevention of venous thromboembolism in neurosurgery: a meta-analysis. Arch Intern Med. 2000;160:2327-2332.
  19. Heit JA. The potential role of direct thrombin inhibitors in the prevention and treatment of venous thromboembolism. Chest. 2003;124(Suppl):40S-48S.
  20. DiNisio M, Middeldorp S, Buller HR. Direct thrombin inhibitors. N Engl J Med. 2005; 353:1028-1040.
  21. Pulmonary Embolism Prevention Trial. Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin. Lancet. 2000;355:1295-1302.
  22. Butterfield WJ, Hicks BH, Ambler AR, et al. Effect of aspirin on postoperative venous thrombosis. Lancet. 1972;2:441-445.
  23. McKenna R, Galante J, Bachmann F, et al. Prevention of venous thromboembolism after total knee replacement by high-dose aspirin or intermittent calf and thigh compression. BMJ. 1980;280:514-517.
  24. Powers PJ, Gent M, Jay RM, et al. A randomized trial of less intense postoperative warfarin or aspirin therapy in the prevention of venous thromboembolism after surgery for fractured hip. Arch Intern Med. 1989;149:771-774.
  25. Westrich GH, Sculco TP. Prophylaxis against deep venous thrombosis after total knee arthroplasty: pneumatic planter compression and aspirin compared with aspirin alone. J Bone Joint Surg Am. 1996;78:826-834.
  26. Coe NP, Collins RE, Klein LA, et al. Prevention of deep vein thrombosis in urological patients: a controlled, randomized trial of low-dose heparin and external
    1. pneumatic compression boots. Surgery. 1978;83:230-234.
  27. Turpie AG, Hirsh J, Gent M, et al. Prevention of deep vein thrombosis in potential neurosurgical patients: a randomized trial comparing graduated compression stockings alone or graduated compression stockings plus intermittent pneumatic compression with control. Arch Intern Med. 1989;149:679-681.
  28. Vanek VW. Meta-analysis of effectiveness of intermittent pneumatic compression devices with a comparison of thigh-high to knee-high sleeves. Am Surg. 1998;64:1050-1058.
  29. Warwick D, Harrison J, Glew D, et al. Comparison of the use of a foot pump with the use of low-molecular-weight heparin for the prevention of deep-vein thrombosis after total hip replacement. J Bone Joint Surg Am. 1998;80:1158-1166:
  30. Agu O, Hamilton G, Baker D. Graduated compression stockings in the prevention of venous thromboembolism. Br J Surg. 1999;86:992-1004.
  31. Freedman KB, Brookenthal KR, Fitzgerald RH, et al. A meta-analysis of thromboembolic prophylaxis following elective total hip arthroplasty. J Bone Joint Surg Am. 2000;82:929-938.
  32. Westrich GH, Haas SB, Mosca P, et al. Meta-analysis of thromboembolic prophylaxis after total knee arthroplasty. J Bone Joint Surg Br. 2000;82:795-800.
  33. Amarigiri SV, Lees TA. Elastic compression stockings for prevention of deep vein thrombosis [abstract]. Cochrane Database Syst Rev. Available at: http://www.update-software.com/abstracts/ab001484.htm. Accessed December 9, 2005.
  34. Elliot CG, Dudney TM, Egger M, et al. Calf-thigh sequential pneumatic compression compared with plantar venous pneumatic compression to prevent deep-vein thrombosis after non-lower extremity trauma. J Trauma. 1999;47(1):25-32.
  35. Hull RD, Raskob GE, Gent M, et al. Effectiveness of intermittent pneumatic leg compression for preventing deep vein thrombosis after total hip replacement. JAMA. 1990;263:2313-2317.
  36. Blanchard J, Meuwly JY, Leyvraz PF, et al. Prevention of deep-vein thrombosis after total knee replacement: randomised comparison between a low-molecular-weight heparin (nadroparin) and mechanical prophylaxis with a foot-pump system. J Bone Joint Surg Br. 1999;81:654-659.
  37. Best AJ, Williams S, Crozier A, et al. Graded compression stockings in elective orthopaedic surgery: an assessment of the in vivo performance of commercially available stockings in patients having hip and knee arthroplasty. J Bone Joint Surg Br. 2000;82:116-118.
  38. Geerts WH, Selby R. Prevention of venous thromboembolism in the ICU. Chest. 2003;124(Suppl):357S-363S.
  39. Levi D, Kupfter Y, Seneviratne C, et al. Computerized order entry sets and intensive education improve the rate of prophylaxis for deep vein thrombophlebitis [abstract]. Chest. 1998;114(Suppl):280S.
  40. Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving communication in the ICU using daily goals. J Crit Care. 2003;18(2):71-5.
  41. Heit JA, Silverstein MD, Mohr DN, et al. Risk factors for deep vein thrombosis and pulmonary embolism: a population-based case-control study. Arch Intern Med. 2000;160:809-815.
  42. Goldhaber SZ, Tapson VF. Prospective registry of 5,451 patients with ultrasound confirmed deep vein thrombosis. Am J Cardiol. 2004;15;93(2):259-62.
  43. Weill-Engerer S, Meaume, S, Lahlou A, et al. Risk factors for deep vein thrombosis in inpatients aged 65 and older: a case-control multicenter study. J Am Geriatr Soc. 2004;52(8):1299-304.
  44. Landefeld CS, McGuire E, Cohen AM. Clinical findings associated with acute proximal deep vein thrombosis: a basis for quantifying clinical judgment. Am J Med. 1990;88(4):382-8.
  45. Cornwell EE, Chang D, Velmahos G, et al. Compliance with sequential compression device prophylaxis in at-risk trauma patients: a prospective analysis. Am Surg. 2002;68:470-473. 4 of 4 Issued 12/2005
  46. Comerota AJ, Katz ML, White JV. Why does prophylaxis with external pneumatic compression for deep vein thrombosis fail? Am J Surg. 1992;164:265-268.