Sunteți pe pagina 1din 13

Running head: PREVENTING DEEP VEIN THROMBOSIS

Preventing Deep Vein thrombosis


Ashley Kavumkal
University of South Florida

PREVENTING DEEP VEIN THROMBOSIS

Abstract
Clinical Problem: Deep Vein Thrombosis (DVT) is a major health issue especially in hospitalized
post-surgery patients. Statistically 20-30% of the post-surgery patients develop DVT (Kiudelis et
al., 2010). These effects can lead to an increase in the length of hospital stay of the patients and
can affect the patient mentally, physically as well as financially.
Objective: To determine if the use of the combination of mechanical and pharmacological
thromboprophylaxis will reduce the incidence of DVT in post-surgery patients better compared
to the use of either methods alone. PubMed was used to obtain the randomized clinical trials
(RCT) and National Guideline Clearinghouse (NGC) was used to find the guidelines. The key
terms used for searching were deep vein thrombosis, DVT, venous thrombo-embolism, VTE,
DVT prophylaxis and DVT prevention.
Results: Edwards et al. (2008) showed that the combination of a continuous enhanced circulation
therapy (CECT) compression device and low-molecular-weight heparin (LMWH) significantly
reduced the risk of DVT in arthroplasty patients (p=0.018) as compared to CECT alone. Kiudelis
et al. (2010) showed that the combination of intermittent pneumatic compression (IPC) and
LMWH indicated hypo-coagulation effect in the patients compared to patients who used IPC
alone (p=0.0001). Turpie et al. (2007) showed that the combination of fondaparinux and IPC for
abdominal surgery patients reduced DVT by 69.8% compared to IPC alone (p=0.037).
Conclusion: Thus these clinical trials suggest that combining mechanical and pharmacological
thromboprophylaxis in hospitalized post-surgery patients significantly reduces the occurrence of
DVT compared to either method alone.

Preventing Deep Vein Thrombosis

PREVENTING DEEP VEIN THROMBOSIS

According to the Centers for Disease Control and Prevention (2014), DVT is one of the
major problems in hospitalized patients that need to be taken care of as it can lead to fatal
complications such as pulmonary embolism. These effects can lead to an increase in the length of
hospital stay of the patients and can affect the patient mentally, physically as well as financially.
Approximately 20-30% of the post-surgery patients develop DVT (Kiudelis et al., 2010).
Preventing the incidence of DVT results in decreasing the length of hospital stay of the patients
and thereby increases patient satisfaction. Ways to solve the problem include the use of
mechanical devices such as sequential compression devices (SCDs) and/or anti-coagulants to
prevent clot formation. This paper addresses the effectiveness of the combinative use of
thromboprophylaxis. Three supporting RCTs were used along with the guidelines from Scottish
Intercollegiate Guidelines Network (SIGN,2010) which highlights the use of the combination of
mechanical and pharmacological thromboprophylaxis to reduce the occurrence of DVT in
hospitalized post-surgery patients. The initial clinical question was that in hospitalized postsurgery patients, how does the use of combined mechanical and pharmacological
thromboprophylaxis compared to either modality alone affect the rate of occurrence of DVT in
patients over a period of three months? In order to provide the best quality care for their patients,
Sarasota Memorial Hospital (SMH) ensures that they are current on their clinical knowledge.
SMH has developed an evidence based practice clinical team (EBP) to focus on patient outcomes
and safety. The Institutional Review Board (IRB) reviews and approves an EBP which will be
taken over by the department directors to create the infrastructure and educate the healthcare
team on how to implement the protocol at SMH. The same strategy was used to implement the
DVT protocol. To implement this project a collaborative effort of clinical nurses, doctors,
pharmacists and patients is needed. Nurses can educate the patients regarding prophylaxis
methods and implement this in their routine. Doctors prescribe the anticoagulants and

PREVENTING DEEP VEIN THROMBOSIS

mechanical devices that are appropriate for the patients. Pharmacists can give valuable
information on pharmacological prophylaxis such as the mechanism of action, side effects etc.
Literature Search
PubMed was the primary search engine used to obtain the randomized clinical trials
(RCT) and National Guideline Clearinghouse (NGC) was used to find the guideline. The key
terms used for searching were deep vein thrombosis, DVT, venous thrombo-embolism, VTE,
DVT prophylaxis and DVT prevention.
Literature Review
Three RCTs were used to address the effectiveness of the use of combination
thromboprophylaxis compared to either mechanical or pharmacological methods alone (Table 1).
The aim of the study done by Edwards et al. (2008) was to determine the effectiveness of the
combination of a continuous enhanced circulation therapy (CECT) compression device and lowmolecular-weight heparin (LMWH) compared to LMWH alone in total knee (TKA) or hip
arthroplasty (THA). The trial was done on 277 patients out of which 124 were THA and 153
were TKA. Patients were randomized as two groups. All of the patients received LMWH while
one group received CECT. The results showed that in the TKA patients, the rate of
thromboembolism in LMWH group was higher (19.5%) compared to the combination treatment
group (6.6%) with a p value of 0.018. The THA patients also showed a higher rate of
thromboembolism in LMWH group (3.4%) compared to combination treatment group (1.5%)
with a p value of 0.6. The results showed that adding the CECT device to the LMWH
significantly reduced DVT risk in TKA patients but no significant difference was seen in THA
patients.The strength of the study is that it was a randomized controlled trial, with similar
demographics. No deaths occurred in either groups. The weakness was that it was not doubleblinded and the p value of 0.6 in the THA patients is not significant. However, this study

PREVENTING DEEP VEIN THROMBOSIS

supports the PICOT question as its results indicate a better reduction of thromboembolism with
the combination prophylaxis compared to LMWH alone.
Kiudelis et al. (2010) conducted a study to evaluate the effect of the combination of
intermittent pneumatic compression (IPC) and LMWH on DVT prevention compared to IPC
alone during and after laparoscopic fundoplication. The trial was done on 20 patients who were
randomly divided to receive IPC during operation (group one) or IPC during and LMWH before
operation (group two). Plasma prothrombin fragment F1+2 (F1+2), thrombin-antithrombin
complex (TAT) markers of thrombogenesis and plasma free tissue factor pathway inhibitor
(fTFPI) a marker of hypocoagulation effect were measured one hour before, during, and after
the laparoscopic operation. The F1+2 (nmol/L) results before, during and after the procedure
were 1.07, 1.0 and 1.85 respectively in group one and 1.11, 1.01 and 1.44 in group two. The TAT
(ug/L) results were 1.5, 6.5 and 9.1 in group one and 2.5, 4.8 and 4.7 in group two. The fTFPI
(ng/mL) results were 13.7, 13.7 and 11.3 in group one and 13.4, 27.9 and 21.3 in group two
respectively. The results indicated hypo-coagulation effect in the patients who used combination
prophylaxis methods which was not observed in patients who used IPC alone thereby showing
that combination prophylaxis is better than IPC alone (p =0.0001). The strength of this study is
that it was a randomized controlled trial done on patients with similar medical conditions in one
clinical setting. Statistical analysis found a significant difference between groups. A limitation of
the study is that the population used for this study is small (20 patients). However, this could be a
good resource for the project because this study matches the PICOT question as it uses both
combination prophylaxis method and single method as intervention and comparison.
Turpie et al. (2007) performed a study to compare the effect of the combination of
fondaparinux and IPC with IPC alone after abdominal surgery. The trial was done on 1309
patients aged 40 years and above who were randomized to receive 2.5mg fondaparinux or

PREVENTING DEEP VEIN THROMBOSIS

placebo subcutaneously six to eight hours after the surgery for five to nine days. All the patients
received IPC. Follow-up was done for 32 days. The outcome showed venous thromboembolism
(VTE) for up to ten days. The number of patients that were evaluable were 842. The VTE rate
was 1.7% in the patients who were treated with fondaparinux and 5.3% in placebo treatment
(p=0.004). The DVT rate was reduced from 1.7% to 0.2% in the fondaparinux patients
(p=0.037). Thus results showed that fondaparinux 2.5 mg in combination with IPC reduced the
DVT rate by 69.8% as compared to pneumatic compression alone, with a low bleeding risk as
compared to placebo. The strength of this study is that it was a randomized, double-blind
controlled trial. A weakness is that a major bleeding rate of 1.6% was found among the
population with fondaparinux and 0.2% with placebo. Also, eight patients who received
fondaparinux, and five patients who received placebo died by day 32. However, this study
matches the PICOT question as it uses combined prophylaxis to either one alone. The protocol
used at SMH for DVT prevention suggests using the combination of mechanical and
pharmacological prophylaxis methods rather than either one alone for high risk patients-who are
post-surgery patients which is similar to the national guideline (SIGN, 2010). Thus the SMH
protocol as well as the guideline for DVT prevention supports the PICOT question.
Synthesis
The three RCTs and the clinical guideline for DVT prevention appeared to be very
similar. Edwards et al. (2008) showed that the combination of a continuous enhanced circulation
therapy (CECT) compression device and low-molecular-weight heparin (LMWH) significantly
reduced the risk of DVT in arthroplasty patients (p=0.018). Kiudelis et al. (2010) showed that the
combination of intermittent pneumatic compression (IPC) and LMWH indicated hypocoagulation effect in the patients compared to patients who used IPC alone (p=0.0001). Turpie et
al. (2007) showed that the combination of fondaparinux and IPC for abdominal surgery patients

PREVENTING DEEP VEIN THROMBOSIS

reduced DVT by 69.8% compared to IPC alone (p=0.037). The clinical guideline also
recommended the use of both prophylaxis methods together for high risk patients (see Table 1).
The RCTs used similar methods in terms of randomly dividing the samples in which one
group received both prophylaxis and the other received either one alone. However, none of these
studies mentioned about the exceptional DVT situations. No information was given on an
alternative solution or its effectiveness in case of not being able to use the combination therapy
compared to the clinical guidelines.
Proposed Practice Change
The proposed change of this project is the use of combination therapy for DVT
prevention. The current DVT protocol at SMH also uses the combination therapy which includes
the mechanical and pharmacological thromboprophylaxis. Thus, the proposed practice change is
similar to the current protocol used at SMH. Educating the team more about how to handle the
exceptional cases as mentioned in the synthesis is recommended. Also, apart from the initial
assessment for DVT in patients, the reassessments should also be done thoroughly to watch the
change in DVT scores (SIGN, 2010).
Change Strategy
Communication is the key factor in promoting effective team management. Everyone in
the team should be up to date on their knowledge about DVT management. Keeping track of the
data is important to follow up on the effectiveness of the protocol. Educators must stress upon
the importance of proper assessment and proper documentation (SIGN, 2010).
SMH uses the IOWA model to adopt and implement EBP. Based on this model, SMH
first identifies the problem, forms a team, reviews the evidence, and clarifies whether there is
sufficient evidence to change practice, evaluate the practice change and share the information
(Melnyk & Fineout-Overholt, 2011).
Roll Out Plan

PREVENTING DEEP VEIN THROMBOSIS


Step
Step 1

Timeframe

Definition

January 2015

Step 2

January 2015

Step 3

January-March
2015

Step 4

April 2015

Prepare and assess the need for change within SMH


Identify DVT as a problem
Combine the triggers
questions,observations,risk, financial, change
in standard, new research for DVT prophylaxis
Consider if DVT prophylaxis is a priority topic
for SMH
Collect relevant evidence
Form a team
Search and collect reliable literature on DVT
prophylaxis
Use relevant RCTs within 5yrs as evidence
Evaluate and combine the evidence collected
Confirm that the evidence is sufficient to
support the change
Pilot the change for proper DVT prevention
methods
Collect baseline data documentation of nurses
and physicians
Design EBP guidelines supporting the use of
both pharmacologic and mechanical prophylaxis
Implement EBP on pilot units
Evaluate process and outcomes- difference in
DVT rate
Modify practices guidelines here
Identity if the change is appropriate for
adoption in practice- significant decrease in DVT
rate
Institute the change and continue to monitor
the change
Disseminate results
Display the results suggesting that
combination therapy is better for DVT prophylaxis
Department heads release information and
educate clinicians, nurses, staff, patients and
families
and also they take the information out to research
conferences to spread the new study.

The Iowa Model of Evidence-Based Practice (Melnyk & Fineout-Overholt, 2011, p. 252)
Project Evaluation

PREVENTING DEEP VEIN THROMBOSIS

Specific data will be collected on hospitalized post-surgery patients. Assessments and


reassessments for DVT scores (score one being low risk and three or more being high risk) will
be done on these patients. Those patients who are at high risk for DVT will be provided with the
combination therapy of mechanical and pharmacological prophylaxis methods. Results of the
combination therapy will be compared with the results of patients who received either
prophylaxis method alone. Results showing a decrease in DVT rates by at least 50% for patients
with combination therapy compared to the single one will indicate the success of the project. The
decrease in length of patients hospital stay could also be a parameter that indicates success. The
data will be collected using nurses and physician documentations.
Dissemination of EBP
The EBP can be disseminated by the clinical leaders and educators to all the units at
SMH by setting up educational programs which includes power point presentations and handouts
with detailed information about the project. Educators could share the information at regional or
national research conferences or at health awareness programs. They could also be guest
speakers at colleges or universities to share it with future physicians, nurses, pharmacist etc.
Karen Reynolds- the nurse team leader and educator as well as Jan Mauck- the chief nursing
officer are the department heads who are in charge of educating and spreading the information at
SMH.

PREVENTING DEEP VEIN THROMBOSIS

10

References
Center for Disease Control and Prevention. (2014). Deep vein thrombosis/ pulmonary embolism
- blood clot forming in a vein. Retrieved from http://www.cdc.gov/ncbddd/dvt/facts.html
Edwards, J. Z., Pulido, P. A., Ezzet, K. A., Copp, S. N., Walker, R. H., & Colwell, C. W. (2008).
Portable compression device and low-molecular-weight heparin compared with lowmolecular-weight heparin for thromboprophylaxis after total joint arthroplasty. The
Journal of Arthroplasty, 23(8), 1122-1127. doi:10.1016/j.arth.2007.11.006
Kiudelis, M., Gerbutavicius, R., Gerbutaviciene, R., Grinite, R., Mickevicius, A., Endzinas, Z.,
& Pundzius, J. (2010). A combinative effect of low-molecular-weight heparin and
intermittent pneumatic compression device for thrombosis prevention during
laparoscopic fundoplication. Medicina, 46(1), 18-23.

PREVENTING DEEP VEIN THROMBOSIS

11

Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in


nursing & healthcare: A guide to best practice (2nd ed.). Philadelphia,
PA: Wolters Kluwer Lippincott Williams & Wilkins.
Scottish Intercollegiate Guidelines Network. (2010). Prevention and management of venous
thromboembolism. A national clinical guideline. Retrieved from
http://www.guideline.gov/content.aspx?id=25639
Turpie, A. G., Bauer, K. A., Caprini, J. A., Comp, P. C., Gent, M., & Muntz, J. E. (2007).
Fondaparinux combined with intermittent pneumatic compression vs. intermittent
pneumatic compression alone for prevention of venous thromboembolism after
abdominal surgery: A randomized, double-blind comparison. Journal of Thrombosis &
Haemostasis, 5(9), 1854-1861. doi:10.1111/j.1538-7836.2007.02657.x

Table 1
Literature Review
Reference

Aims

Design and
Measures

Sample

Outcomes / statistics

PREVENTING DEEP VEIN THROMBOSIS

12

To determine
the
effectiveness of
the combination
of a continuous
enhanced
circulation
therapy (CECT)
compression
device and lowmolecularweight heparin
(LMWH)
compared to
LMWH alone
in total knee
(TKA) or hip
arthroplasty
(THA).

RCT, sample
with similar
demographic
-randomly
chosen to
receive
LMWH
alone or
LMWH+CE
CT

277
patients
out of
which 124
were THA
and 153
were
TKA.

In TKA patients, higher


thromboembolism rate
in LMWH group
(19.5%) compared to
the combination
treatment group (6.6%)
with a p value of 0.018.
The THA patients also
showed a higher rate of
thromboembolism in
LMWH group (3.4%)
compared to
combination treatment
group (1.5%) with a p
value of 0.6.

Kiudelis,
M., Gerbutavicius,
R., Gerbutaviciene,
R., Grinite,
R., Mickevicius,
A., Endzinas, Z.,
& Pundzius, J. (2010).
A combinative effect
of low-molecularweight heparin and
intermittent pneumatic
compression device
for thrombosis
prevention during
laparoscopic
fundoplication.
Medicina, 46(1), 1823.

To evaluate the
effect of the
combination of
intermittent
pneumatic
compression
(IPC) and
LMWH on
DVT prevention
compared to
IPC alone
during and after
laparoscopic
fundoplication.

RCT, similar
demographic
under same
clinical
setting
randomly
chosen to
receive
LMWH
alone or
LMWH+
IPC

20
patients
randomly
divided to
receive
IPC
during
operation
(group
one) or
IPC
during and
LMWH
before
operation
(group
two).

hypo-coagulation effect
in the patients who
used combination
prophylaxis methods
which was not observed
in patients who used
IPC alone (p=0.0001)

Turpie, A. G., Bauer,


K. A., Caprini, J. A.,
Comp, P. C., Gent, M.,
& Muntz, J. E. (2007).
Fondaparinux
combined with
intermittent pneumatic

to compare the
effect of the
combination of
fondaparinux
and IPC with
IPC alone after
abdominal

RCT, doubleblinded
sample
randomly
chosen to
receive IPC
alone or

1309
patients
aged 40
years and
above
who were
randomize

VTE rate 1.7% in the


patients treated with
fondaparinux and 5.3%
in placebo treatment
(p=0.004). DVT rate
reduced from 1.7% to
0.2% in the

Edwards, J. Z., Pulido,


P. A., Ezzet, K.
A., Copp, S.
N., Walker, R. H.,
& Colwell, C. W.
(2008).
Portable compression
device and lowmolecular-weight
heparin compared
with low-molecularweight heparin for
thromboprophylaxis
after total joint
arthroplasty. The
Journal of
Arthroplasty, 23(8),
1122-1127.
doi:10.1016/j.arth.200
7.11.006

PREVENTING DEEP VEIN THROMBOSIS


compression vs.
intermittent pneumatic
compression alone for
prevention of venous
thromboembolism
after abdominal
surgery: A
randomized, doubleblind comparison.
Journal of Thrombosis
& Haemostasis, 5(9),
1854-1861.
doi:10.1111/j.15387836.2007.02657.x

surgery

IPC+
Fondaparinu
x

13
d to
fondaparinux patients
receive
(p=0.037).
2.5mg
fondaparin
ux or
placebo
subcutane
ously six
to eight
hours after
the
surgery
for five to
nine days