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Venous thromboembolism (VTE) prophylaxis: implications for medical-surgical nurses.
Nurses are responsible for continual patient evaluation as they address patient needs, provide essential input into evaluation and risk stratification, and make recommendations regarding prevention-oriented strategies (American Health Consultants, 2002a). As a result, nurses are in a pivotal role to prevent VTE. Education about all aspects of VTE prevention should be included in basic nursing programs and must continue throughout a nurse's career through continuing education, reading, and dissemination of information from current health care literature.
Coaptation splinting for humeral shaft fractures in adults and children: a modified method.
Coaptation splinting is an accepted form of treatment for humeral shaft fractures in both children and adults. However, application may be difficult when working alone or with an uncooperative patient. We describe a modified method, involving supplies easily found in most emergency departments and cast rooms, that mitigates these problems.
Routine chemoprophylaxis for travel-associated thrombosis? No.
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Travel-related thrombosis: is this a problem?
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Vascular skin ulcers of limbs.
On clinical grounds, ulcers of the leg of vascular origin can fairly easily be separated into venous and arterial origins; 85% of ulcers of the leg are caused by venous insufficiency. The ulcers occur mainly around the medial malleolus, are covered by moist granulation tissue, and are surrounded by varying degrees of stasis dermatitis and brown hemosiderin pigmentation. The limb is usually edematous and improves with elevation. In contrast, arterial ulcers of the leg develop more distally on the toes or feet, severe pain is a prominent feature, and the dry crusted ulcers usually lack granulation tissue. Elevation of the leg aggravated the pain of ischemic ulcers, whereas dependency of the limb provides some relief. Both types of ulcers heal faster with occlusive dressings that furnish a moist wound environment. Patients with ulcers caused by venous insufficiency can have coexisting peripheral atherosclerosis. Compression elastic stockings used for venous insufficiency should not be so tight that they induce necrosis of the skin in patients with occult arterial disease.
Deep venous thrombosis prophylaxis with low molecular weight heparin and elastic compression in patients having total hip replacement. A randomised controlled trial.
Seventy-eight patients having elective total hip replacement were randomised into 3 groups A) control; B) low molecular weight heparin: (enoxaparin 40 mg once daily) and C) enoxaparin (40 mg once daily) plus graduated elastic compression (TEDR stockings) for 8-12 days. All patients had a preoperative perfusion lung scan and chest X-Ray and a postoperative perfusion/ventilation scan together with bilateral ascending venography on days 8-12. A blood sample was taken preoperatively, on the 1st, 3rd and 5th postoperative day and at the end of the study. The control group received placebo injections. The venograms and V/Q scans were reported blindly by an independent panel of three and one radiologists respectively. An independent panel of assessors stopped entry in the control group when a total of 45 patients were admitted according to Ethics Committee directives. The study continued with groups B and C. The incidence of DVT (including isolated asymptomatic calf thrombi) was as follows: Group A (n = 14) 93%; Group B (n = 32) 38%; Group C (n = 32) 25% (chi 2; p < 0.001 for group A versus B or C). The incidence of proximal DVT was: Group A 57%; group B 28%; group C 13% (chi 2; p = 0.057 for group A versus B and p < 0.005 for group A versus C). The incidence of silent pulmonary embolism (PE) (new defect on V/Q scan) was 28% (8 out of 29) in patients with and 5% (2 out of 43) in patients without DVT (chi 2; p < 0.02). The combination of high TAT and low anti-Xa activity on the 1st postoperative day identified a high risk group of patients who had a 56% incidence of proximal DVT on the 8th to 12th postoperative day. Further studies are needed to confirm the suggested increased efficacy in prophylaxis by the combination of LMWH and GEC as compared with LMWH alone.
The clinical course of deep-vein thrombosis. Prospective long-term follow-up of 528 symptomatic patients.
BACKGROUND AND OBJECTIVE: In contrast to the extensive documentation on the short-term outcome of patients with acute deep vein thrombosis (DVT) of the lower extremities, little is known about the long-term clinical course of this disease. To determine the clinical course of patients with a first episode of symptomatic DVTn over an 8-year follow-up period. The primary aims were to assess the long-term incidence of recurrent venous thromboembolism and that of the post-thrombotic syndrome. In addition, we determined mortality and evaluated potential risk factors for all these outcomes. METHODS: This was designed as a prospective cohort follow-up study. Consecutive symptomatic outpatients with a first episode of venography proven DVT were treated with an initial course of full-dose (low molecular weight) heparin, followed by at least three months of oral anticoagulants. After discharge, they were instructed to wear compression elastic stockings for at least two years. Follow-up assessments were scheduled at three and six months, and then every six months up to eight years. Diagnosis of recurrent venous thromboembolism was made according to standard criteria. The presence of post-thrombotic syndrome was evaluated using a standardized scale. RESULTS: A total of 528 consecutive patients with a first episode of venography confirmed DVT were included in the study. The cumulative incidence of recurrent venous thromboembolism after two, five and eight years was 17.2, 24.3 and 29.7%, respectively. Malignancy and impaired coagulation inhibition increased the risk of recurrent venous thromboembolism (RR = 1.48 and 2.0, respectively). In contrast, surgery and recent trauma or fracture were associated with a diminished risk of recurrent venous thromboembolism (RR = 0.65 and 0.39, respectively). The cumulative incidence of post-thrombotic syndrome after two, five and eight years was 24.5, 29.6 and 29.8%, respectively. The development of ipsilateral recurrent DVT was strongly associated with the risk for post-thrombotic syndrome (risk ratio, 2.4). Survival after eight years was 69%. The presence of malignancy increased the risk of death remarkably (risk ratio, 7.1). INTERPRETATION AND CONCLUSIONS: Symptomatic DVT carries a high risk for recurrent venous thromboembolism that persists for many years, especially in patients without transient risk factors for DVT. The post-thrombotic syndrome occurs in almost one-third of patients and is strongly related to recurrent ipsilateral DVT. Our findings challenge the widely adopted short course of anticoagulation in patients with symptomatic DVT.
[Comparison of ambulatory and inpatient treatment of acute deep venous thrombosis of the leg: subjective and economic aspects].
The frequency of clinical recurrence and pulmonary embolism in patients with acute deep venous thrombosis is reduced to the same extent by hospital treatment (with unfractionated heparin) as by treatment at home (with low-molecular-weight heparin). Very few data on subjective parameters of effectiveness have been published. We performed a prospective randomized trial comparing outpatient with in-hospital treatment in 28 patients. Six clinical and quality-of-life related parameters of effectiveness were assessed quantitatively: clinical course (with a score system), pain of venous congestion of the calf muscles (with Lowenberg's test), subjective perception of pain and general well-being (with visual analogue scales), satisfaction with the care provided, and absence from work. Subjective effectiveness was compared with the costs of each form of treatment. Outpatient treatment was significantly more effective than in-hospital treatment with regard to the objective parameters. It was, however, associated with less well-being and more pain than in-hospital treatment. The discrepancy is explained by eventually insufficient adjuvant treatment measures (which consisted of external leg compression by stockings and forced walking) and by anxiety brought on by the information that potentially lethal pulmonary embolism could occur despite anticoagulant therapy. Outpatient treatment was less costly. On the average and per patient it was CHF 3944 less expensive than treatment in hospital. An estimation reveals that the Swiss health care system would save about CHF 25 million per year if the 85% of patients with deep-vein thrombosis suitable for home care were given this form of treatment. We conclude that outpatient management is subjectively cost-effective but should be optimised to eliminate certain drawbacks associated with it.
[Chronic venous insufficiency and compression therapy].
INTRODUCTION: Disorders of venous circulation are among most frequent diseases in the human population. During recent years there has been increased interest in physiopathology of chronic venous insufficiency (CVI), due to development of more accurate diagnostic methods and new therapeutic techniques. Considering patophysiology of CVI and its consequences the crucial points are stasis and reflux of blood flow, with increase of intravascular pressure. CLASSIFICATION AND THERAPY OF CVI: Empirical experience and theoretical models suggest that progression of the disease can be stopped or reverted by correction of stasis. Today, this is the main direction in all therapeutic approaches. Compression therapy represents the most successful conservative technique. In this article we are presenting basic principles of the compression therapy of CVI. Evidence for the physiologic effect of compression therapy are decrease of edema, softening of lipodermatosclerosis, acceleration of venous flow, decrease in venous volume, blood shift into central compartments, reduction of venous refluxes, influence on arterial flow and improvement of microcirculation and lymph drainage. There are several types of compression devices: elastic stockings, elastic bandages, inelastic bandages, intermittent pneumatic compression devices. Other advantages of compression therapy are decrease of hospital treatment and better quality of life for patients with CVI.
Incidence of venous thromboembolism in patients undergoing craniotomy and motor mapping for glioma without intraoperative mechanical prophylaxis to the contralateral leg.
OBJECT: Evidence-based reviews support the use of venous thromboembolism (VTE) prophylaxis in the form of compression devices and/or stockings for patients undergoing craniotomy. In patients undergoing craniotomy with motor mapping for glioma, the contralateral lower extremity should remain visible so that motor responses can be accurately identified. As a consequence, these patients could be placed at a higher risk to develop VTE. The authors have quantified the incidence of VTE in patients undergoing craniotomy with motor mapping and have shown that there is no increased risk of developing a VTE in the contralateral lower extremity when compression devices are not used. METHODS: One hundred eighty consecutive cases (1997-2000) of craniotomy with motor mapping for glioma were retrospectively reviewed to determine the incidence and location of VTEs during the early postoperative course. Intraoperative VTE prophylaxis in all patients consisted of ipsilateral (that is, ipsilateral to the hemisphere being mapped) lower-extremity mechanical prophylaxis (antiembolism stocking plus compression device). Postoperatively, all patients received bilateral mechanical prophylaxis. Patients were observed until discharge and received clinical follow up. Venous thromboembolism, classified as deep venous thrombosis (DVT) or pulmonary embolism (PE) occurring within 6 weeks postoperatively, was confirmed by Doppler ultrasonography, spiral computerized tomography scanning, or both. The average duration of postoperative hospitalization was 5 days (range 2-59 days). Six patients (3.3%) experienced VTE. Of those, in four (2.2%) the DVT was localized to the contralateral (three patients) or ipsilateral (one patient) lower extremity. Two other patients (1.1%) only had PE. There were no deaths from thromboembolic complications and no statistically significant predisposition to VTE in the contralateral lower extremity among patients not receiving intraoperative prophylaxis. CONCLUSIONS: The incidence of VTE in patients undergoing craniotomy with motor mapping is comparable to that in patients receiving bilateral lower-extremity mechanical VTE prophylaxis. The practice of leaving the contralateral lower extremity free from intraoperative prophylaxis does not appear to place patients at a higher risk for developing VTE. There appears to be no preferential distribution of VTE in contralateral lower extremities that do not receive immediate preoperative and intraoperative mechanical prophylaxis.
Objectification of compression therapy haemodynamic effect by means of light reflex rheography.
Light reflex rheography (LRR) is one of the non-invasive diagnostic methods which makes it possible to examine venous haemodynamics. Through the use of this method we wanted to prove the positive influence of compression therapy on varices of the lower extremities in the 2nd degree chronic insufficiency. In all, 32 patients were examined (39 extremities), and evaluations were done on them of the initial venous refilling time-Ti, i.e. a segment of the LRR curve during the first three seconds after the cessation of muscle work (12 dorsal flexions sitting). Measurements were made without stockings and with the use of the 2nd compression class stockings made by Loana and with the use of Cambren the 1st compression class stockings. With the 1st compression class stockings, measurements were made with one and two stockings simultaneously. The arithmetic mean of the values measured in the individual groups was evaluated by Student's t-test. Our results confirmed the anticipated prolongation of the initial time (Ti) segment in the monitored patients, even when the 1st class Cambren C stockings were used. Especially when two of these stockings were used simultaneously, the Ti period was fully comparable to the Ti values when the 2nd class compression stockings were used. It has been demonstrated that when two lower compression class stockings are used simultaneously, there is a significantly increased compression effect and an improvement of the function parameters, even in patients with varices and the 2nd degree chronic venous insufficiency.
Successful methods of treating leg ulcers. The tried and true, plus the novel and new.
The cause of a leg ulcer should be determined before a course of treatment is undertaken, and this often can be accomplished through history taking, physical examination, and use of simple noninvasive testing. Most leg ulcers are caused by venous disease, arterial insufficiency, neuropathy, or a combination of these factors. Complete management should address the patient's general health as well as specific findings, and treatment of any underlying cause is paramount. In venous ulcers, compression is the cornerstone of treatment, and a variety of effective stockings and other compression devices are available. Arterial ulcers usually require reestablishment of an adequate vascular supply, often through surgery. Neuropathic ulcers need thorough debridement to allow good granulation and epithelialization. Five types of occlusive dressings are available that achieve debridement less painfully but also more slowly than the surgical approach. Several adjunctive methods are now available that facilitate successful therapy in these ulcers, which have often been considered nonhealing wounds.
Intermittent sequential pneumatic compression of the legs and thromboembolism-deterrent stockings in the prevention of postoperative deep venous thrombosis.
One hundred fifty patients over the age of 30 who had undergone major abdominal operations were stratified according to the risk of deep venous thrombosis and randomized into three groups to receive different prophylactic regimens: group A, electrical calf stimulation; group B, low-dose subcutaneous heparin; group C, intermittent sequential compression and thromboembolism-deterrent (TED) stockings. All the patients were scanned with the 125I-fibrinogen test for the whole stay in hospital. The incidence of 125I-fibrinogen detected deep venous thrombi was 18% in group A, 9% in group B, and 4% in group C. The results indicate that the regimen of intermittent sequential compression and TED stockings is as effective as low-dose subcutaneous heparin. Electrical calf stimulation is less effective.
Techniques for preventing hypotension during spinal anaesthesia for caesarean section.
BACKGROUND: Maternal hypotension is the most frequent complication of a spinal anaesthetic for caesarean section with an incidence approaching 100%. Most workers define hypotension as a maternal systolic blood pressure below 70-80% of baseline recordings and/or an absolute value of < 90 -100mmHg. The frequent occurrence and rapid onset of hypotension during spinal anaesthesia has encouraged anaesthetists to try and prevent or minimise the associated maternal symptoms of nausea and vomiting during the establishment of the block. Untreated, severe hypotension can also pose serious risks to both mother (unconsciousness, pulmonary aspiration, apnoea or even cardiac arrest) and baby (impaired placental perfusion leading to hypoxia, fetal acidosis and neurological injury). A range of strategies is currently used to prevent or minimise hypotension but there is no established ideal technique. OBJECTIVES: To assess the relative efficacy and side effects of prophylactic interventions for hypotension following spinal anaesthesia for caesarean section. SEARCH STRATEGY: The Cochrane Pregnancy and Childbirth Group Trials Register, the Cochrane Controlled Trials Register, other databases and bibliographies of relevant papers are searched according to the strategy developed for the Pregnancy and Childbirth Group as a whole. Date of last search: May 2001. SELECTION CRITERIA: All published or unpublished randomised controlled trials that compare use of an intervention to prevent hypotension with placebo or alternative treatment in patients having spinal anaesthesia for caesarean section. DATA COLLECTION AND ANALYSIS: Trials identified from searching are assessed for inclusion by the same two reviewers independently. Studies are excluded from review for the following reasons: hypotension is not an outcome measure or clearly defined prior to administering a rescue treatment; randomisation is unsatisfactory; the spinal anaesthetic technique or dose of local anaesthetic is not controlled-for; and the intervention is implemented in response to a fall in blood pressure rather than for prevention. Statistical analyses use the Review Manager software for calculation of the treatment effect as represented by the relative risks and proportional and absolute risk reductions. MAIN RESULTS: Twenty trials meet the criteria for inclusion. Four of the twelve interventions reviewed are shown to reduce the incidence of hypotension under spinal anaesthesia for caesarean section: (1) crystalloid 20ml/kg vs control, Relative Risk (RR) 0.78 (95% confidence interval (CI) 0.6, 1.0); (2) pre-emptive colloid administration vs crystalloid, (RR) 0.54 (95% CI 0.37, 0.78); (3) ephedrine vs control, RR 0.70 (95% CI 0.57, 0.85); and (4) lower limb compression vs control, RR 0.75 (95% CI 0.59, 0.94). There are no significant differences in maternal or neonatal side effects in any of the comparisons studied. REVIEWER'S CONCLUSIONS: No studied intervention has been shown to eliminate the need to treat maternal hypotension during spinal anaesthesia for caesarean section. We are unable to draw any conclusions regarding adverse effects of the studied interventions, due to their probable low incidence and the small number of women studied. Further randomised controlled trials are recommended, in particular assessing a combination of the beneficial interventions, i.e. colloid or crystalloid preloading, parenteral ephedrine administration and leg compression with bandages, stockings or inflatable boots.
Elvarex compression garments in the management of lymphoedema.
Lymphoedema is a progressive and debilitating disorder, caused by malfunction of the lymphatic system. It is characterized by chronic swelling, usually of a limb but it can also affect other parts of the body. It is not curable but can be reduced and controlled. The mainstay of management is physical decongestive treatment, of which compression therapy is one of the four elements. The simplest and most cost-effective method of applying compression is with elastic compression garments. Essential for their success are a perfect fit and appropriate selection of compression class and stocking material. Elvarex, manufactured by JOBST, is a range of custom-made compression garments for both upper and lower limbs, available in a wide variety of styles and options. The flat knitting process provides superior fit and effective long-term management of lymphoedema.
A pressure profile for elastic stockings.
Special equipment to measure the circumferential compression exerted by an elastic stocking was used to determine the "pressure-girth profiles" of several types of elastic stocking. Once the pressure-girth profile has been determined, the pressure exerted at the ankle, calf, and thigh can be predicted for any size of limb without further pressure measurements. An excellent correlation (r = 0.96) was obtained when this method was compared with another well-established one of measuring the pressures exerted by stockings. The method has several potential applications in quality control during stocking manufacture and, clinically, in determining whether a stocking exerts a graduated pressure on a particular limb.
[Importance of elastic compression of the lower limbs in the prevention of venous thrombosis in digestive surgery].
A group of 25 patients having to undergo laparotomy were prescribed thrombo-embolic preventive stockings of graduated elasticity to be worm from 48 hours before the operation until 9 days afterwards. This group was compared to another group of 25 patients. The thromboses were detected using the fibrinogen test and the Doppler. This study demonstrates the efficiency of prophylactic anti-thrombotic stockings using graduated compression.