Thrombosis prevention
Thrombosis prevention | |
---|---|
Other names | Thrombosis prophylaxis |
ICD-10-PCS | I80-I82 |
ICD-9-CM | 437.6, 453, 671.5, 671.9 |
Thrombosis prevention or thromboprophylaxis is
Blood thinners are used to prevent clots, these blood thinners have different effectiveness and safety profiles. A 2018 systematic review found 20 studies that included 9771 people with cancer. The evidence did not identify any difference between the effects of different blood thinners on death, developing a clot, or bleeding.
There are medication-based
One of the goals of blood clot prevention is to limit
Pathophysiology of blood clot prevention
Medical treatments
Thrombosis prophylaxis is not only used for the prevention of deep vein thrombosis, but can be initiated for the prevention of the formation of blood clots in other organs and circumstances unrelated to deep vein thrombosis:[citation needed]
- cerebral complications
- abortion
- ectopic pregnancy
- molar pregnancy
- pregnancy
- childbirth and the puerperium
- coronary
- portal vein thrombosis
- intracranial, nonpyogenic
- intraspinal, nonpyogenic
- mesenteric
Epidemiology of developing blood clots
The risk of developing deep vein thrombosis, or pulmonary embolism is different than the total risk of the formation of blood clots. This is due to the observation that not all blood clots form in the lower legs. Most hospitalized medical patients have at least 1 risk factor for thrombosis that progresses to thromboembolism and this risk persists weeks after discharge. Those who remain undiagnosed and not treated prophylactically have a 26% chance of developing a fatal embolism. Another 26% develop another embolism. Between 5% and 10% of all in hospital deaths are due to pulmonary embolism (as a consequence of thrombosis). Estimates of the incidence of pulmonary embolism in the US is 0.1% persons/year. Hospital admissions in the US for pulmonary embolism are 200,000 to 300,000 yearly.
The type of surgery performed prior to the formation of blood clots influences the risk. Without prophylactic interventions, the calculated incidence of clot formation in the lower leg veins after surgery is:
- 22% for neurosurgery
- 26% for abdominal surgery
- 45% for 60% in orthopedic surgery
- 14% for gynecologic surgery[13]
As the population of the US ages, the development of blood clots is becoming more common.[14]
General risks and indications for blood clot prevention
Some risk factors for developing blood clots are considered higher that others. One scoring system analyzes the probability for clot formation by assigning a point value system to significant risk factors.[15] The benefit of treating those who are at low risk of developing blood clots may not outweigh the higher risks of significant bleeding.[16]
Risk factors for developing blood clots that are assessed prior to treatments
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Probability and risk estimation for developing blood clots Major risk (=1 point) Minor risk (=2 points) Cancer Family history of
deep vein thrombosisImmobility Hospitalization within
the past 6 monthsCalf swelling superficial vein dilation Recent major surgery redness of area Edema or swelling of only leg Recent trauma
to legTenderness in
the calf and/or thigh
Probability determination and scoring |
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High probability scoring (12–7 points |
3 major points OR 2 major points AND >2 minor points |
Low probability scoring (3–5 points) |
0 major points AND > 2 minor points 1 major point AND >2 minor points 0 major points and >3 minor point 1 major point and more than one minor point |
Moderate probability scoring (varies) |
all other risk combinations |
Risk for subsequent blood clots
Developing blood clots is more probable after the first episode. Risk assessment and intervention for those with one or more episodes of deep vein thrombosis or blood clots in the veins utilizes the Well's test. It has been inconsistently modified by a number of publishers with the results listed below:[28]
Well's and modified Well's risk scoring
Finding | points | references |
---|---|---|
D-dimer abonormal one month after stopping anticoagulants | 2 | [28] |
Age > or = to 50 | 1 | [28] |
male | 1 | [28] |
use of hormone at DVT onset | 1 | [28] |
Adapted for the emergency department
Finding | points | references |
---|---|---|
Malignancy | 1 | [29] |
Age > or = to 50 | 1 | [29] |
cast on lower leg/Paralysis/paresis/ | 1 | [29] |
Recent surgery or immobility | 1 | [29] |
tenderness over deep vein | 1 | [29] |
entire leg swollen | 1 | [29] |
difference of 3 cm between legs | 1 | [29] |
pitting edema of affected leg | 1 | [29] |
Collateral superficial veins | 1 | [29] |
another diagnosis more probable than DVT | −2 | [29] |
Scoring:
- less than 2 points – low risk (3%)
- 2–6 points moderate risk (17%)
- > 6 points high risk (75%)[29]
General interventions
The Centers for Disease Control and Prevention have issued general guidelines describing the interventions that can be taken to reduce the risk of the formation of blood clots:
The Centers for Disease Control and Prevention recommend the following:
- Move around as soon as possible after having been confined to bed, such as after surgery, illness, or injury.
- If you're at risk for DVT, talk to your doctor about:
- Graduated compression stockings (sometimes called "medical compression stockings")
- Medication (anticoagulants) to prevent DVT.
- When sitting for long periods of time, such as when traveling for more than four hours:
- Get up and walk around every 2 to 3 hours.
- Exercise your legs while you're sitting by:
- Raising and lowering your heels while keeping your toes on the floor
- Raising and lowering your toes while keeping your heels on the floor
- Tightening and releasing your leg muscles
- Wear loose-fitting clothes.
- You can reduce your risk by maintaining a healthy weight, avoiding a sedentary lifestyle, and following your doctor's recommendations based on your individual risk factors.[7]
Interventions during travel
Seat-edge pressure from the seat on an airplane on the
Interventions for those hospitalized
Compression devices
Mechanical compression devices are used for prevention of thrombosis and are beneficial enough to be used by themselves with patients at low to moderate risk.
The application of
Assessment
There has been some success in preventing blood clots by an early risk assessment upon admission to the hospital, which is a strategy recognized by the Centers for Disease Control and Prevention. Hospitals that have participated in this effort to reduce the incidence of thrombosis found that rates of DVT decreased in some instances.[34] Some hospitals developed a mandatory assessment quantifying the risk for developing blood clots and a plan of care developed from the results. The person's risk for developing blood clots is entered into their record, 'following' them through their treatment regime. If the hospital stay exceeds three days, the person will be reassessed for risk. Clinicians are then able to apply protocols for prevention based upon best clinical practices.[35][36]
Interventions to treat immobility
Immobility is a significant risk factor in the development of thrombosis.[37][38][22][25] Immediate post-surgical interventions, such as out of bed orders (OOB), are typically ordered by the physician to prevent thrombosis. These orders, typically delegated to a nurse, but may include the participation of a physical therapist and others trained to perform the intervention, are to perform range of motion (ROM) activities that include: muscle contractions of the lower legs for those who are very weak, moving the feet, wiggling the toes, bending the knees, raise and lower the legs. In addition, changes in positioning prevents immobility and shifts areas of venous stasis. If the person is too weak to perform these preventative activities, hospital personnel will perform these movements independently. Exercise of the lower extremities is a post-operative method of prophylaxis. Nursing personnel will often perform range of motion exercises and encourage frequent moving of the legs, feet, and ankles. Frequent positioning changes and adequate fluid intake. After a surgical procedure, ambulation as soon as possible is prophylactic in preventing the formation of blood clots.[38][22][25]
Early ambulation also prevents venous stasis and physicians order OOB activities on the same day of surgery. This is accomplished in increments. The progression of increasing mobility proceeds by: raising the head of the bed, sitting up in bed, moving to the edge of the bed, dangling the legs off the bed and then ambulating to a close chair.[19][25]
Patient education and compliance reduces the risk of developing blood clots. These exercises and use of equipment and follow up by clinicians reduces the risk of developing blood clots.[25]
Note that if a blood clot has already formed in the deep veins of the leg, bedrest is usually prescribed and the treatment to prevent bloods with physical intervention is contraindicated.[citation needed]
Medication
Anticoagulants and antiplatelets
Thromboprophylaxis, such as anticoagulants or perioperative heparin, is effective for hospitalized patients at risk for VTE.[2][39] Additional risk factors such as obesity, disease, malignancies, long surgeries, and immobility may influence the prescribed dosage. Anticoagulant medications may prevent the formation of blood clots in people who are at high risk for their development.[4] Treating blood clots that have already formed is managed by the use of anti-hemolytic ("clot busters"). Despite its effectiveness, the use of thromboprophylaxis remains under-utilized, though alerts (computer or human) in hospitals are associated with increased prescription and reductions in symptomatic VTE.[39] The list below describes some of the more common medications used to prevent blood clots.[24] Note that generally since blood clotting is inhibited, a side effect typically is increased bleeding, though it can be reversed by administering a medication that stops the bleeding or by discontinuation of the medication itself. Anti-coagulant administration is often given before the start of the operation.[25] Medications that inhibit blood clot formation include:
Medications used to prevent blood clots
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Heparins
Adding heparin to the use of compression stockings may prevent thrombosis for those of higher risk.[4][47]
This section may require cleanup to meet Wikipedia's quality standards. The specific problem is: Unclear colors and separation. (December 2022) |
The discontinuation of contraceptives also prevents blood clots.[15]
Herbal interactions
The therapeutic effects of warfarin may be decreased by
Dietary interactions
By containing significant content of
Contraindications
Preventing blood clots with medication is not considered safe in the following circumstances:
- uncooperative patient
- recent childbirth
- gastrointestinal bleeding
- reproductive system
bleeding - genitourinary system
bleeding - hemorrhagic blood dyscrasias
- peptic ulcers
- alcoholism
- infection
- eye surgery
- brain surgery
- spinal cord surgery
- recent cerebrovascular hemorrhage[1]: 877
Research
An international registry and risk assessment calculator is being used to centralize data on post-surgical venous thrombosis and its prevention.[53] Hospitals are implementing a multi-disciplinary approach to prevent of blood clots. This includes adequate assessment of the risks, follow up on missed doses of medication and instituting a 'patient-centered' approach endorsed by the Joint Commission.[34] Recommendations regarding the prevention of blood clots vary widely between clinicians and treatment facilities. Research continues to clarify these discrepancies.[5] The metabolic state of hypercoagulability (the tendency to form blood clots) tests are being developed. These include the evaluation of the thrombin–antithrombin complexes (TAT), low levels of the anticoagulants ATIII and protein C, but these tests are not yet widely available.[13]
References
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- ^ "Talk with Your Doctor about Taking Aspirin Every Day". US Preventive Services Task Force. April 2016. Retrieved December 29, 2016.
- ^ "Dipyridamole" at Dorland's Medical Dictionary
- ^ a b c "Recommended Use of Aspirin and Other Antiplatelet Medications Among Adults, National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, United States, 2005–2008". Centers for Disease Control and Prevention. June 15, 2012. Retrieved December 29, 2016.
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