DPT 732 SPRING 2009 S. SCHERER Deep Vein Thrombosis

Objectives Discuss etiology of DVT Identify signs & symptoms of DVT Discuss diagnostic criteria for DVT Identify ambulation criteria for patients with acute DVT

What is a DVT? Blood clot in a deep vein Occurs due to:  Decreased blood flow rate  Damage to vessel wall  Hypercoagulability

Complications of DVT Pulmonary Embolus Signs/symptoms  Shortness of breath  Rapid pulse  Sweating  Sharp chest pain

Diagnostic Criteria for DVT Active Cancer Recent immobilization Recently bedridden > 3 days or major surgery within 4 weeks Localized tenderness Entire leg swelling Calf 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 NO DVT DVT negative positive Ultrasound NO DVT DVT

Case Study 41 y.o. female had ACL reconstruction 7 days ago No post operative anticoagulation therapy Past 2 days sitting in chair or in bed Past 2 days had discomfort in calf and swelling (4 cm greater than other leg) No history of DVT Score 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 warfarin Elastic compression stockings Pneumatic compression devices

When can the Patient Ambulate? Start therapeutic doses of anticoagulation walk 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 PE Bed 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 compression Walked between ,000 meters/day After 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 References Partsch, 2000, 2001