VTE

V

enous

T

hrombo

E

mbolism

VTE – aims of this module

 To define the terms associated with VTE and offer maximum care to treat patients.

 To enable patients to have greater understanding of their risks, and how to prevent venous thromboembolism .

VTE – What does this include?

 Deep venous thrombosis (DVT)    Below knee (distal) Above knee (proximal) Atypical (eg arm)  Pulmonary embolism (PE)  Cerebral venous thrombosis

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

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)

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, Ca Breast, RTA and Acquired Immune Deficiency syndrome.

 60,000 die per year from VTE.

 25,000 of these are hospital patients  Cost to NHS is £650 million

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

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

VTE - Who is at risk?

 Most patients admitted to hospital Particularly where there is;     Immobility.

Dehydration.

Obesity Advanced age   Acute & Chronic illness Surgical intervention

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 (eg hydration, mobilization)  Chemical +/- mechanical prophylaxis is highly effective at preventing VTE in high risk patients  It is a DoH requirement

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  Only ½ hospital patients at risk of VTE in the UK are getting targetted prophylaxis

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

VTE – how to scale risk

 Low risk (eg. young, mobile patient)  High risk (eg. Immobile with any risk factor)  Very high risk (history of previous VTE)

What to do about VTE risk at SFT

Is the patient immobile with at least 1 risk factor for VTE?

YES

High

risk Is LMWH contraindicated?

NO

Low

risk No specific action YES Prescribe TEDS NO Very High = Both Prescribe LMWH

VTE – practical prevention

 Adequate hydration.

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

VTE – chemical prevention in patients at high risk

 Low Molecular Weight Heparin (LMWH) Dalteparin 5000iu od @ 18:00  Oral Anticoagulant THR or TKR for 5 weeks or 2 weeks Rivaroxaban 10mg od @ 18:00

VTE – LMWH contraindications

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

VTE – mechanical prevention

 Mechanical compression devices (eg. Sequential compression devices - SCDs) must be used in theatre & can be carried on on the ward provided they are not off for >3hrs  Antiembolic stockings (eg. TEDs) 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 (eg DVT)

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

VTE - the (haemo)dynamic balance risk must be regularly re-assessed – a bleed will physiologically trigger clot formation BLEED CLOT

Document VTE risk assessment here

Prescribe VTE prophylaxis inside the drug chart

VTE - tell your patient about their risk

   Verbally Information leaflet DVD / Video available on request

VTE – more information?

 ICID – “Thromboprophylaxis”  DOH electronic learning tool http://e-lfh.org.uk/projects/vte/launch/  [email protected]

[email protected]

VTE - Help prevent clots!

By kind permission of Richard Curtis and Tony Robinson