Transcript VTE Presentation - American Association of Critical

Venous Thromboembolism
Prevention
August 2010
Expected Practice
Assess all patients upon admission to
the ICU for risk factors of venous
thromboembolism (VTE) and anticipate
orders for VTE prophylaxis based on
risk assessment
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Expected Practice
Moderate-risk patients (medically ill and
postoperative patients): low dose
unfractionated heparin, low-molecular-weight
heparin (LMWH), or fondaparinux
High risk patients (major trauma, spinal cord
injury, or orthopedic surgery): LMWH,
fondaparinux, or oral vitamin K antagonist
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Expected Practice
Patients with high risk for bleeding:
mechanical prophylaxis
 Graduated compression stockings
 Intermittent pneumatic compression devices
Mechanical prophylaxis may also be
anticipated in conjunction with anticoagulant based prophylaxis regimens
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Expected Practice
Review daily each patient’s current
VTE risk factors including
 clinical status
 necessity for central venous catheter
 current status of VTE prophylaxis
 risk for bleeding
 response to treatment.
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Expected Practice
Maximize patient mobility to reduce the
amount of time the patient is immobile
Ensure that mechanical prophylaxis
devices are fitted properly and in use at
all times
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Problem Scope and Impact
Most hospitalized patients have at least
one risk factor for VTE.
VTE is common and contributes to
excess length of stay, excess charges,
and mortality.
Primary thromboprophylaxis reduces
the morbidity and mortality associated
with deep vein thrombosis and
pulmonary embolism.
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Supporting Evidence
 The majority of critical care patients have one or more risk
factors leading to VTE formation
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Immobilization
sedation/neuromuscular blockade
CVC’s
Surgery
sepsis
mechanical ventilation
vasopressor administration
heart failure
Stroke
Malignancy
previous VTE
renal dialysis
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Supporting Evidence
Signs and symptoms of VTE are
frequently silent and can lead to fatal
pulmonary embolism, VTE prophylaxis
is recommended for at-risk patients.
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Supporting Evidence
Low dose unfractionated heparin and LMWH
are efficacious in preventing VTE in moderaterisk critical care patients.
For patients at higher risk major trauma or post
orthopedic surgery, LMWH has been shown to
provide superior protection over low dose
unfractionated heparin.
Direct thrombin inhibitors can be used in place
of low molecular weight heparin or
unfractionated heparin in patients with heparin
induced thrombocytopenia.
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Supporting Evidence
Mechanical methods of prophylaxis have
been shown to reduce the risk of VTE
 graduated compression stockings
 intermittent compression devices
 venous foot pumps
Mechanical prophylaxis is less efficacious
when compared to anticoagulation based
therapy.
Mechanical prophylaxis methods do not
pose bleeding concerns.
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Supporting Evidence
Written policies for VTE prophylaxis along
with either standing ICU admission orders
increase compliance with prophylaxis
measures
A daily goals form, which included VTE
prophylaxis, resulted in a significant
improvement in increased staff
understanding the patient’s daily goals for
care and decreased ICU length of stay
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Supporting Evidence
The presence of a CVC is a risk factor for
upper extremity VTE population
Several studies identified immobility either as
a co-morbidity or independent risk factor.
Compliance monitoring with intermittent
pneumatic compression devices demonstrated
rates of non-compliance ranging from 22% to
81% in at-risk patients
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Supporting Evidence
Improperly fitted compression stockings
producing a reversed pressure gradient
were associated with a significantly higher
incidence of VTE compared with stockings
that were properly fitted
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Actions for Nursing Practice
Ensure that your unit has a written policy for VTE
prophylaxis that is updated regularly to reflect
emerging evidentiary findings
Ensure that preprinted or computerized
admission orders are available and current
Ensure that your unit has an organized process
for developing and communicating patient goals
(including VTE prophylaxis) to members of the
multidisciplinary team
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Actions for Nursing Practice
Educate and routinely evaluate all staff
in the use of mechanical prophylaxis
devices
Review orders of patients discharged
from the ICU to ensure a continuation
plan for VTE prophylaxis
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Actions for Nursing Practice
Monitor
 compliance with VTE prophylaxis policies
 rates of VTE and pulmonary embolism
 initiate quality improvement initiatives
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Need More Information?
For more information or further
assistance, please contact a
clinical practice specialist with the
AACN Practice Resource Network.
Email:
[email protected]
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