DPT 732SPRING 2009S. SCHERER

Deep Vein Thrombosis

Objectives

Discuss etiology of DVTIdentify signs & symptoms of DVT Discuss diagnostic criteria for DVTIdentify ambulation criteria for patients with

acute DVT

What is a DVT?

Blood clot in a deep veinOccurs due to:

Decreased blood flow rate Damage to vessel wall Hypercoagulability

Complications of DVT

Pulmonary EmbolusSigns/symptoms

Shortness of breath Rapid pulse Sweating Sharp chest pain

Diagnostic Criteria for DVT

Active CancerRecent immobilizationRecently bedridden > 3 days or major

surgery within 4 weeksLocalized tendernessEntire leg swellingCalf swelling > 3 cm Pitting edema Wells, et al

1997

Application of Clinical Decision Rule

Low Pretest Probability

Score of 0 or less

Moderate probability Score of 1-2

High Probability

Score of 3 or more

D-dimer

Ultrasound

Ultrasound

NO DVT

DVT

DVT

negative

negative

negative

positive

positive

positive positive

Ultrasound

NO DVT

DVT

Case Study

41 y.o. female had ACL reconstruction 7 days ago

No post operative anticoagulation therapyPast 2 days sitting in chair or in bedPast 2 days had discomfort in calf and swelling

(4 cm greater than other leg)No history of DVTScore of 1

1 point bedrest, 1 point calf swelling, 1 point tenderness - 2 points for alternate diagnosis (post-op swelling)

Treatment of DVT

Low molecular Weight Heparin or warfarinElastic compression stockingsPneumatic compression devices

When can the Patient Ambulate?

Start therapeutic doses of anticoagulationwalk as soon and as much as possible with

good compression therapy Leads to better outcomes

decreased pain decreased swelling decreased occurrence/severity of postthrombotic

syndrome

(Partsch, 2001).

Other questions

Early ambulation does not increase the incidence of PE in patients with DVT

Bed rest does not decrease incidence of PEBed rest increases size of DVT

How much walking?

RCT of 45 patients treated with dalteparin, 200 IU/kg per body weight

Group 1- rigid bandages 50 mmHg pressure Group 2 thigh high compression stockings (35

mmHg)Group 3 no compressionWalked between 600-12,000 meters/dayAfter 9 days

Leg swelling and pain decreased in compression groups (p < .01)

QOL improved in compression groups No increased incidence of PE

Conclusion

Early ambulation is not associated with an increased risk for pulmonary embolism in anticoagulated patients with acute deep vein thromboses. Ensure patients are anticoagulated Apply compression Encourage walking after 8 hours anticoagulation

ReferencesPartsch, 2000, 2001