VTEVTEVVenousenous T ThrombohromboEEmbolismmbolism

VTE – aims of this moduleVTE – aims of this module

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

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

VTE – What does this VTE – What does this include?include?

Deep venous thrombosis (DVT)Deep venous thrombosis (DVT) Below knee (distal)Below knee (distal) Above knee (proximal)Above knee (proximal) Atypical (eg arm)Atypical (eg arm)

Pulmonary embolism (PE)Pulmonary embolism (PE)

Cerebral venous thrombosisCerebral venous thrombosis

DVT

Migration

PE

Thrombus

Embolus

VTE - deep vein thrombosis VTE - deep vein thrombosis (DVT) & pulmonary embolism (DVT) & pulmonary embolism

(PE)(PE)

VTE – Why does it VTE – Why does it happen? (Virchow’s happen? (Virchow’s

Triad)Triad)

Circulatory Stasis. (sluggish flow in Circulatory Stasis. (sluggish flow in the veins)the veins)

Endothelial injury to veins. (due to Endothelial injury to veins. (due to trauma or inflammatory processes)trauma or inflammatory processes)

Hypercoagulable state. (inherited Hypercoagulable state. (inherited or acquired pro-coagulant factors or acquired pro-coagulant factors in the circulation)in the circulation)

VTE – national contextVTE – national context

VTE is a major cause of morbidity and VTE is a major cause of morbidity and mortality in the UK mortality in the UK

VTE deaths are 5 times more than total VTE deaths are 5 times more than total deaths from Hospital Acquired Infection, deaths from Hospital Acquired Infection, Ca Breast, RTA and Acquired Immune Ca Breast, RTA and Acquired Immune Deficiency syndrome.Deficiency syndrome.

60,000 die per year from VTE.60,000 die per year from VTE.

25,000 25,000 of these are of these are hospital patientshospital patients

Cost to NHS is £650 million Cost to NHS is £650 million

VTE – acute VTE – acute consequencesconsequences

Acute VTE symptoms in the patientAcute VTE symptoms in the patient Painful, swollen legPainful, swollen leg Acute breathlessnessAcute breathlessness Incapacity or sudden deathIncapacity or sudden death

Time & money spent on investigation Time & money spent on investigation & treatment of a potentially & treatment of a potentially avoidable conditionavoidable condition

VTE – chronic consequencesVTE – chronic consequences

Chronic VTE symptoms in the patient (25%)Chronic VTE symptoms in the patient (25%) Chronically painful, swollen legChronically painful, swollen leg Leg ulcers & skin changesLeg ulcers & skin changes Chronic breathlessnessChronic breathlessness Pulmonary hypertensionPulmonary hypertension

High risk of recurrence & therefore lifelong High risk of recurrence & therefore lifelong treatment with warfarintreatment with warfarin

VTE - Who is at risk?VTE - Who is at risk? Most patients admitted to hospital Most patients admitted to hospital

Particularly where there is;Particularly where there is;

Immobility.Immobility.

Dehydration.Dehydration.

ObesityObesity

Advanced ageAdvanced age

Acute & Chronic illnessAcute & Chronic illness

Surgical interventionSurgical intervention

VTE – Why risk assess?VTE – Why risk assess?DocumentedDocumented RRisk isk AAssessment is ssessment is vital vital as …as …

It alerts both the patient & healthcare team to VTE risk It alerts both the patient & healthcare team to VTE risk & triggers practical VTE prevention measures (eg & triggers practical VTE prevention measures (eg hydration, mobilization)hydration, mobilization)

Chemical +/- mechanical prophylaxis is highly effective Chemical +/- mechanical prophylaxis is highly effective at preventing VTE in high risk patientsat preventing VTE in high risk patients

It is a DoH requirementIt is a DoH requirement

VTE – What is the risk?VTE – What is the risk?

Without thromboprophylaxis VTE Without thromboprophylaxis VTE may develop in:may develop in: Up to 50% medical patientsUp to 50% medical patients Up to 40% orthopaedic patientsUp to 40% orthopaedic patients Up to 20% surgical patientsUp to 20% surgical patients

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

VTE – we forget because VTE – we forget because although the risk is high it is although the risk is high it is

not immediatenot immediate

Mean time to develop a Mean time to develop a VTE after VTE after

elective elective hiphip surgery? surgery? 22 days.22 days.

Mean time to develop a Mean time to develop a VTE after VTE after

elective elective kneeknee surgery? surgery? 10 days10 days

VTE – how to scale riskVTE – how to scale risk

Low risk (eg. young, mobile patient)Low risk (eg. young, mobile patient)

High risk (eg. Immobile with any risk High risk (eg. Immobile with any risk factor)factor)

Very high risk (history of previous Very high risk (history of previous VTE)VTE)

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

YES NO

Low riskNo specific action

High riskIs LMWH contraindicated?

YES NO

Prescribe LMWHPrescribe TEDS

What to do about VTE risk at SFT

Very High = Both

VTE – practical preventionVTE – practical prevention

Adequate hydration.Adequate hydration.

Mobilisation as soon as possibleMobilisation as soon as possible Regular leg exercisesRegular leg exercises Good positioning / posture / avoid Good positioning / posture / avoid

hypothermia hypothermia

VTE – chemical prevention VTE – chemical prevention in patients at high riskin patients at high risk

Low Molecular Weight Heparin Low Molecular Weight Heparin (LMWH) (LMWH) Dalteparin 5000iu od @ Dalteparin 5000iu od @ 18:0018:00

Oral Anticoagulant Oral Anticoagulant

THR or TKR for 5 weeks or 2 weeksTHR or TKR for 5 weeks or 2 weeks

Rivaroxaban 10mg od @ 18:00Rivaroxaban 10mg od @ 18:00

VTE – LMWH VTE – LMWH contraindicationscontraindications

Dalteparin is absolutely contraindicated Dalteparin is absolutely contraindicated in:in: Patients at high risk of a serious / life Patients at high risk of a serious / life

threatening bleedthreatening bleed Major inherited bleeding disordersMajor inherited bleeding disorders Previous Heparin-induced thrombocytopeniaPrevious Heparin-induced thrombocytopenia

Other contraindications are relative (ie. Other contraindications are relative (ie. balance of risk / benefitbalance of risk / benefit

VTE – mechanical VTE – mechanical preventionprevention

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

Antiembolic stockings (eg. TEDs) should be Antiembolic stockings (eg. TEDs) should be used in High risk patients who cannot have used in High risk patients who cannot have chemical prevention chemical prevention oror as an additional as an additional measure for patients who have previously measure for patients who have previously damaged leg veins (eg DVT) damaged leg veins (eg DVT)

VTE – contraindications to VTE – contraindications to antiembolic stockingsantiembolic stockings

Leg ulcers, peripheral vascular Leg ulcers, peripheral vascular disease, peripheral neuropathy, disease, peripheral neuropathy, lymphoedemalymphoedema

*** Badly fitted / applied stockings in *** Badly fitted / applied stockings in patients with poor peripheral patients with poor peripheral circulation can result in leg circulation can result in leg amputationamputation

VTE - the (haemo)dynamic VTE - the (haemo)dynamic balancebalance

risk must be regularly re-risk must be regularly re-assessed – a bleed will assessed – a bleed will

physiologically trigger clot physiologically trigger clot formationformation

CLOT BLEED

Document VTE risk

assessment here

Prescribe VTE prophylaxis Prescribe VTE prophylaxis inside the drug chartinside the drug chart

VTE - tell your patient about VTE - tell your patient about their risktheir risk

VerballyVerbally Information leafletInformation leaflet DVD / Video available on DVD / Video available on

requestrequest

VTE – more information?VTE – more information?

ICID – “Thromboprophylaxis”ICID – “Thromboprophylaxis”

DOH electronic learning toolDOH electronic learning tool

http://e-lfh.org.uk/projects/vte/launch/http://e-lfh.org.uk/projects/vte/launch/

tamara.everington@salisbury.nhs.uktamara.everington@salisbury.nhs.uk Sue.snoxall@salisbury.nhs.ukSue.snoxall@salisbury.nhs.uk

VTE - Help prevent clots!VTE - Help prevent clots!

By kind permission of Richard Curtis and Tony Robinson