1. DVT & PE: How early can I mobilize a patient ??11
DVT & PE: How early can I mobilize a patient ??
Hatoun Al-Abdulkarim

2. DVT:
Formation of a blood clot in a deep veins as complication of immobility that may contribute to Morbidity & mortality

3. Signs and symptoms: -Pain -Tenderness -Swelling
-Increased warmth & Redness
- Erythema Or Bluish skin discoloration

4. Over 50% of DVTs without Signs & symptoms
In Fact,
Over 50% of DVTs without Signs & symptoms

5. 55 US

6. Pulmonary embolism (PE):
Blockage of the main artery of the lung or one of its branches by a substance that has travelled from elsewhere in the body through the bloodstream (Usually DVT)

7. Signs and symptoms: - Shortness of breath ( suddenly, even at rest)
- Chest pain ( worse with deep breathe, cough, or bend)
- Cough
Other signs and symptoms may include:
- Wheezing
- Excessive sweating
- Arrhythmia
- Weak pulse
- Fainting

8. -PE are reported as many as one third of patients with DVT88
-PE are reported as many as one third of patients with DVT
-Most pulmonary emboli are multiple, and the lower lobes are involved more commonly than the upper lobes

9. 99
Lung with PE

10. Incidence *Heit J. ASH Abstract 2005. 900,000 PEs/ DVTs in USA in 2002
Incidence
900,000 PEs/ DVTs in USA in 2002
10-40% in medical or general surgery patients
40-60% following major orthopedic surgery
10% hospital deaths attributed to PE
*Heit J. ASH Abstract 2005.

11. Risk Factors Age (over 40) A past history of DVT A family history
Risk Factors
Age (over 40)
A past history of DVT
A family history
Immobility
Recent surgery or an injury (especially hips or knees)

12. Obesity
Pregnancy
Cancer and its treatments
Contraceptive pill that contains estrogen
Hormone replacement therapy (HRT)
Circulation or heart problems

13. Methods of Prophylaxis
Methods of Prophylaxis
Mechanical
Pharmacological

14. Mechanical Early ambulation Elastic stockings
Mechanical
Early ambulation
Elastic stockings
Intermittent pneumatic compression

15. Pharmocologic Methods
Pharmocologic Methods
Warfarin.
Unfractionated Heparin.
Low Molecular Weight Heparin.

16. When Can the Patient With DVT Begin to Ambulate?
When Can the Patient With DVT Begin to Ambulate?

17. Medical Approach for Mobilizing pts with a DVT has dramatically changed over the past several years

18. Partsch and Blattler (2000)
Partsch and Blattler (2000)
New PE development was similar in a mobile group with graduated compression stockings and a bed rest group.
They also found decreased pain and leg edema in the mobile group.

19.
Aschwanden et al (2001)
New PE occurred in 10 % of mobile subjects while new PE occurred in 14 % of immobile subjects.

20.
Romero-Villegas (2008)
2 PEs occurrences in a sample of 105 patients on bedrest
and
3 PEs in a sample of 114 patients who received early ambulation.

21.
Compression and walking compared with bed rest in the treatment of proximal DVT during pregnancy

22. 15 patients with elastic compression bandages and early mobilization
Group A:
15 patients with elastic compression bandages and early mobilization
Group B:
17 patients with compression bandages and bed rest.
All patients received heparin therapy.

23. Objective pain using Lowenberg test.
Subjective Pain was assessed daily with a (VAS)
Objective pain using Lowenberg test.
Reduction of edema was recorded initially and on day 2, 4 and 7.
Ultrasound was repeated after 7 days.

24. RESULTS: Resolution of subjective pain was faster in group A
RESULTS:
Resolution of subjective pain was faster in group A
Objective pain& measurement of leg reduced in group A
There was no pulmonary embolism and progression of thrombus diameter.

25.
A meta-analysis of bed rest vs early ambulation in the management of pulmonary embolism, DVT or both
2009 Sep
Department of Cardiology, Cochin Hospital, AP-HP, René Descartes Paris V University, Paris, France

26.
METHODS
- Considered all randomized studies and prospective registries that compared the outcomes of patients with DVT, PE, or both, managed with bed rest versus early ambulation, in addition to anticoagulation.
-For each study, data regarding the incidence of new PE, new or progression of DVT, and death from all causes, were used to calculate relative risks (RR) and 95% confidence intervals (CI).

27.
RESULTS
The 5 studies retained in this analysis included a total of 3048 patients.
When compared to bed rest, early ambulation was not associated with a higher incidence of a new PE (RR 1.03; 95% ).

28. overall mortality (RR 0.79; 95% ).
Furthermore, early ambulation was associated with a trend toward a lower incidence of new PE and new or progression of DVT than bed rest (RR 0.79; 95% )
and
overall mortality (RR 0.79; 95% ).

29.
CONCLUSIONS

30.
It appears that these studies support that early ambulation and mobilization does not increase the risk of PE compared to bedrest and in some cases may result in actual improvement of other factors like pain and edema.

31. Thank you