Dvt in pulmonary embolism gone gone .ppt

Incidence of DVT in the hospital is 10-40% per month for medical or general surgical patients and 40-60% following major orthopedic surgeries
Incidence of DVT in the hospital is 10-40% per month for medical or general surgical patients and 40-60% following major orthopedic surgeries
Incidence of DVT in the hospital is 10-40% per month for medical or general surgical patients and 40-60% following major orthopedic surgeries
Incidence of DVT in the hospital is 10-40% per month for medical or general surgical patients and 40-60% following major orthopedic surgeries
Incidence of DVT in the hospital is 10-40% per month for medical or general surgical patients and 40-60% following major orthopedic surgeries
Incidence of DVT in the hospital is 10-40% per month for medical or general surgical patients and 40-60% following major orthopedic surgeries
Incidence of DVT in the hospital is 10-40% per month for medical or general surgical patients and 40-60% following major orthopedic surgeries
Incidence of DVT in the hospital is 10-40% per month for medical or general surgical patients and 40-60% following major orthopedic surgeries
Incidence of DVT in the hospital is 10-40% per month for medical or general surgical patients and 40-60% following major orthopedic surgeries
Incidence of DVT in the hospital is 10-40% per month for medical or general surgical patients and 40-60% following major orthopedic surgeries
Incidence of DVT in the hospital is 10-40% per month for medical or general surgical patients and 40-60% following major orthopedic surgeries
Incidence of DVT in the hospital is 10-40% per month for medical or general surgical patients and 40-60% following major orthopedic surgeries
Incidence of DVT in the hospital is 10-40% per month for medical or general surgical patients and 40-60% following major orthopedic surgeries
Incidence of DVT in the hospital is 10-40% per month for medical or general surgical patients and 40-60% following major orthopedic surgeries
Incidence of DVT in the hospital is 10-40% per month for medical or general surgical patients and 40-60% following major orthopedic surgeries
Incidence of DVT in the hospital is 10-40% per month for medical or general surgical patients and 40-60% following major orthopedic surgeries
Incidence of DVT in the hospital is 10-40% per month for medical or general surgical patients and 40-60% following major orthopedic surgeries
Incidence of DVT in the hospital is 10-40% per month for medical or general surgical patients and 40-60% following major orthopedic surgeries
Incidence of DVT in the hospital is 10-40% per month for medical or general surgical patients and 40-60% following major orthopedic surgeries
Incidence of DVT in the hospital is 10-40% per month for medical or general surgical patients and 40-60% following major orthopedic surgeries
Incidence of DVT in the hospital is 10-40% per month for medical or general surgical patients and 40-60% following major orthopedic surgeries
Incidence of DVT i

1. V T E
Venous ThromboEmbolism
Version 2.0 April 2014

2. VTE – aims of this module
To define the terms associated with
VTE and offer evidence-based
guidance to care for patients.
To enable healthcare professionals
to give patients advice so that
patients understand their risks, and
know what they can do to help
reduce their risk of a VTE event.

3. VTE – What does this include?
Deep venous thrombosis (DVT)
Below knee (distal)
Above knee (proximal)
Atypical (e.g. arm)
Pulmonary embolism (PE)
Cerebral venous thrombosis

4. DVT
Migration
PE
Thrombus
Embolus
VTE - deep vein thrombosis (DVT) &
pulmonary embolism (PE)

5. VTE – Why does it happen?
(Virchow’s Triad)

Circulatory stasis (sluggish flow in the
veins)
Endothelial injury to veins (due to
trauma or inflammatory processes)
Hypercoagulable state (inherited or
acquired pro-coagulant factors in the
circulation)

6. VTE – national context
VTE is a major cause of morbidity and
mortality in the UK
VTE deaths are 5 times more than total
deaths from hospital acquired infection,
breast cancer, road traffic accidents and
AIDS.
Cost to NHS is £640 million (2005)
Cost of treating venous leg ulcers around
£400 million a year. 25% of DVT patients
develop Post Thrombotic Syndrome

7. VTE – acute consequences
Acute VTE symptoms in the patient
Painful, swollen leg
Acute breathlessness
Incapacity or sudden death
Time & money spent on
investigation & treatment of a
potentially avoidable condition

8. VTE – chronic consequences
Chronic VTE symptoms in the patient
(25%)

Chronically painful, swollen leg
Leg ulcers & skin changes
Chronic breathlessness
Pulmonary hypertension
High risk of recurrence & therefore
lifelong treatment with warfarin

9. VTE - Who is at risk?
Most patients admitted to hospital are at
risk. Particularly where there is:
immobility
dehydration
obesity
advanced age
acute & chronic illness
surgical intervention

10. VTE – Why risk assess?
Documented Risk Assessment is vital as …
it alerts both the patient & healthcare
team to VTE risk & triggers practical VTE
prevention measures (e.g. hydration,
mobilisation)
chemical +/- mechanical prophylaxis is
very effective at preventing VTE in high
risk patients
it is a mandatory national CQUIN: 95%
patients admitted to hospital to be risk
assessed for VTE

11. VTE – What is the risk?
Without thromboprophylaxis VTE may
develop in:
Up to 50% medical patients
Up to 40% orthopaedic patients
Up to 20% surgical patients
VTE affects about 1 in 100,000 women of
childbearing age.

It is up to 10 times more
common in pregnant than in non-pregnant
women of a similar age

12. VTE – we forget because although
the risk is high it is not immediate
Mean time to develop a VTE after
elective hip surgery? 22 days.
Mean time to develop a VTE after
elective knee surgery? 10 days

13. VTE – how to scale risk
Low risk (e.g. young, mobile patient, no
risk factors)
High risk (e.g. reduced mobility with any
risk factor)

14. What to do about VTE risk?
Is the patient
immobile with at least
1 risk factor for VTE?
yes no
Low risk High risk
Give patient advice re
early mobilisation
and hydration
Are there
contraindications to
chemical prophylaxis?
Prescribe LMWH
Prescribe antiembolic
stockings
Previous history of
VTE?
yes
no
= very high
risk
∴
prescribe
both

15. VTE – practical prevention
Adequate hydration

Mobilisation as soon as possible
Regular leg exercises
Good positioning / posture / avoid
hypothermia

16. VTE – chemical prevention in
patients at high risk
Low Molecular Weight Heparin
(LMWH) Dalteparin 5000iu od @
18:00

17. VTE – LMWH contraindications
Dalteparin is absolutely contraindicated
in:
Patients at high risk of a serious or life
threatening bleed
Major inherited bleeding disorders
Previous Heparin-induced
thrombocytopenia
Other contraindications are relative
(ie. balance of risk / benefit)

18. VTE – mechanical prevention
Mechanical compression devices (e.g.
sequential compression devices - SCDs) must
be used in theatre & can be continued on the
ward provided they are not off for >3hrs
Antiembolic stockings should be used in high
risk patients who cannot have chemical
prevention or as an additional measure for
patients who have previously damaged leg
veins (e.g. DVT)

19. VTE – contraindications to
antiembolic stockings
Leg ulcers, peripheral vascular disease,
peripheral neuropathy, lymphoedema
*** Badly fitted / applied stockings in
patients with poor peripheral
circulation can result in leg
amputation

20. VTE - the (haemo)dynamic
balance
risk must be regularly re-
assessed – a bleed will
physiologically trigger clot
formation
Clot
Bleed

21. Document VTE
risk assessment
here Contraindications
to chemical
prophylaxis here

22. Prescribe VTE prophylaxis on
the drug chart

DALTEPARIN
5000
UNITS
OD
SC
Dr Doctor
1234
1/1/
13

23. Weight adjusted dalteparin
VTE thromboprophylaxis
Always consider relative risk of bleeding/thrombus formation before
using weight adjusted dosing
Patients <50kg may be considered for a reduced dose of 2500 units
once daily if they also have other bleeding risk factors
Please refer to separate guidance on ICID for obstetric patients
Weight (kg)50 - 99 100 - 150 > 150
Dose of
dalteparin
5000 units
once daily
5000 units
twice daily
7500 units
twice daily
Weight adjusted dosing of dalteparin is not included in the product
licence for dalteparin but the following dosing schedule is supported by
the Thrombosis Committee:
 For Bariatric patients only (BMI>40kg/M
2
or are 40kg above ideal body weight).

24. VTE - tell your patient about
their risk
verbally
offer an information leaflet
DVD / video available on
request

25. VTE – more information?
ICID – “VTE”
DOH electronic learning tool
www.e-lfh.org.uk/projects/vte/
VTE prevention England
www.vteprevention-nhsengland.org.uk/
SFT VTE website
www.vte.salisbury.nhs.uk
Email:
[email protected]
[email protected]

26. VTE - Help prevent clots!
By kind permission of Richard Curtis and Tony Robinson