1. VTE Venous ThromboEmbolism

2. VTE – aims of this module To define the terms associated with VTE and offer maximum care to treat patients. 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. To enable patients to have greater understanding of their risks, and how to prevent venous thromboembolism.

3. VTE – What does this 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 thrombosis Cerebral venous thrombosis

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

5. VTE – Why does it happen? (Virchow’s Triad) Circulatory Stasis. (sluggish flow in the veins) Circulatory Stasis. (sluggish flow in the veins) Endothelial injury to veins. (due to trauma or inflammatory processes) Endothelial injury to veins. (due to trauma or inflammatory processes) Hypercoagulable state. (inherited or acquired pro-coagulant factors in the circulation) Hypercoagulable state. (inherited or acquired pro-coagulant factors in the circulation)

6. VTE – national context VTE is a major cause of morbidity and mortality in the UK 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. 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. 60,000 die per year from VTE. 25,000 of these are hospital patients 25,000 of these are hospital patients Cost to NHS is £650 million Cost to NHS is £650 million

7. VTE – acute consequences Acute VTE symptoms in the patient Acute VTE symptoms in the patient Painful, swollen leg Painful, swollen leg Acute breathlessness Acute breathlessness Incapacity or sudden death Incapacity or sudden death Time & money spent on investigation & treatment of a potentially avoidable condition Time & money spent on investigation & treatment of a potentially avoidable condition

8. VTE – chronic consequences Chronic VTE symptoms in the patient (25%) Chronic VTE symptoms in the patient (25%) Chronically painful, swollen leg Chronically painful, swollen leg Leg ulcers & skin changes Leg ulcers & skin changes Chronic breathlessness Chronic breathlessness Pulmonary hypertension Pulmonary hypertension High risk of recurrence & therefore lifelong treatment with warfarin High risk of recurrence & therefore lifelong treatment with warfarin

9. VTE - Who is at risk? Most patients admitted to hospital Particularly where there is; Most patients admitted to hospital Particularly where there is; Immobility. Immobility. Dehydration. Dehydration. Obesity Obesity Advanced age Advanced age Acute & Chronic illness Acute & Chronic illness Surgical intervention Surgical intervention

10. 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) 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 Chemical +/- mechanical prophylaxis is highly effective at preventing VTE in high risk patients It is a DoH requirement It is a DoH requirement

11. VTE – What is the risk? Without thromboprophylaxis VTE may develop in: Without thromboprophylaxis VTE may develop in: Up to 50% medical patients Up to 50% medical patients Up to 40% orthopaedic patients Up to 40% orthopaedic patients Up to 20% surgical patients Up to 20% surgical patients Only ½ hospital patients at risk of VTE in the UK are getting targetted prophylaxis Only ½ hospital patients at risk of VTE in the UK are getting targetted prophylaxis

12. 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 hip surgery? 22 days. Mean time to develop a VTE after elective knee surgery? 10 days Mean time to develop a VTE after elective knee surgery? 10 days

13. VTE – how to scale risk Low risk (eg. young, mobile patient) Low risk (eg. young, mobile patient) High risk (eg. Immobile with any risk factor) High risk (eg. Immobile with any risk factor) Very high risk (history of previous VTE) Very high risk (history of previous VTE)

14. Is the patient immobile with at least 1 risk factor for VTE? YESNO Low risk No specific action High risk Is LMWH contraindicated? YESNO Prescribe LMWHPrescribe TEDS What to do about VTE risk at SFT Very High = Both

15. VTE – practical prevention Adequate hydration. Adequate hydration. Mobilisation as soon as possible Mobilisation as soon as possible Regular leg exercises Regular leg exercises Good positioning / posture / avoid hypothermia Good positioning / posture / avoid hypothermia

16. VTE – chemical prevention in patients at high risk Low Molecular Weight Heparin (LMWH) Dalteparin 5000iu od @ 18:00 Low Molecular Weight Heparin (LMWH) Dalteparin 5000iu od @ 18:00 Oral Anticoagulant Oral Anticoagulant THR or TKR for 5 weeks or 2 weeks Rivaroxaban 10mg od @ 18:00

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

18. 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 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) 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)

19. VTE – contraindications to antiembolic stockings Leg ulcers, peripheral vascular disease, peripheral neuropathy, lymphoedema Leg ulcers, peripheral vascular disease, peripheral neuropathy, lymphoedema *** Badly fitted / applied stockings in patients with poor peripheral circulation can result in leg amputation *** Badly fitted / applied stockings in patients with poor peripheral circulation can result in leg amputation

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

21. Document VTE risk assessment here

22. Prescribe VTE prophylaxis inside the drug chart

23. VTE - tell your patient about their risk Verbally Verbally Information leaflet Information leaflet DVD / Video available on request DVD / Video available on request

24. VTE – more information? ICID – “Thromboprophylaxis” ICID – “Thromboprophylaxis” DOH electronic learning tool DOH electronic learning toolhttp://e-lfh.org.uk/projects/vte/launch/ tamara.everington@salisbury.nhs.uk Sue.snoxall@salisbury.nhs.uk tamara.everington@salisbury.nhs.uk Sue.snoxall@salisbury.nhs.uk tamara.everington@salisbury.nhs.uk Sue.snoxall@salisbury.nhs.uk tamara.everington@salisbury.nhs.uk Sue.snoxall@salisbury.nhs.uk

25. VTE - Help prevent clots! By kind permission of Richard Curtis and Tony Robinson