CLINICAL
Guideline Summary:
Prevention of Venous Thromboembolism
PURPOSE
To provide guidance to perioperative team members for developing and implementing a protocol for prevention of
venous thromboembolism (VTE), including prevention of deep vein thrombosis (DVT) by mechanical and pharmacologic
prophylaxis and prevention of pulmonary embolism (PE) as a complication of DVT.
Guideline Summary: Prevention of Venous Thromboembolism1
#
Recommendation
Key Points
I
The health care
organization should
establish and implement a protocol for
the prevention of
VTE.
• The VTE protocol should be developed by an interdisciplinary team, including
o a clinical team leader;
o a quality improvement facilitator;
oprocess owners, including frontline personnel from each discipline (eg, pharmacists, RNs, surgeons, anesthesia professionals);
o information technology and health information system experts; and
o patient representatives.
• The VTE protocol should
o be evidence-based,
o standardize assessment of VTE and bleeding risk,
oprovide clinical decision support for evidence-based prophylaxis based on level of risk for VTE and bleeding
at critical phases of care (eg, admission, transfer of care, post surgery), and
o be easy to use in clinical practice.
• The VTE protocol should include a start time (eg, upon admission, before surgery, after surgery) for all types of
prophylaxis based on the clinical condition of the patient.
• The VTE protocol may include specialty- or procedure-specific (eg, orthopedic, cardiac) clinical decision support for
prophylaxis.
• The health care organization should use a clinical decision support system with alerts to notify clinicians of a
potential lapse in prophylaxis according to the VTE protocol.
II
The perioperative
RN should complete
a preoperative
patient assessment
to determine VTE
risk factors.
• The preoperative patient assessment should include VTE risk factors that contribute to venous stasis, vessel
wall injury, and hypercoagulability, including
o age greater than 40 years,
o cancer (ie, active or occult) or cancer treatment,
o obesity,
o previous history of VTE or stroke,
o prolonged bed rest (> 3 days) or immobilization,
o varicose veins,
o presence of a central venous catheter,
o trauma,
o spinal cord injury,
o inherited or acquired thrombophilia,
o estrogen therapy (ie, oral contraceptive, hormone replacement therapy),
o critical care admission,
o dehydration,
o comorbidities,
o pregnancy and the postpartum period,
o smoking,
http://doi.org/10.1002/aorn.12147
© AORN, Inc, 2018
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Guideline Summary
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Recommendation
Key Points
o steroid therapy,
o American Society of Anesthesiologists physical status classification of 3 or higher,
o recent surgery (ie, within 30 days),
o preoperative hospitalization,
o blood transfusion,
o known non-O blood type,
o obstructive sleep apnea, and
o asplenia.
• The preoperative patient assessment should include procedure-related VTE risk factors, including
oduration of surgery (ie, surgery and general anesthesia time longer than 90 minutes or longer than 60
­minutes for procedures involving the lower limb or pelvis);
othe intraoperative patient position (eg, excessive hip flexion, hyperextension of the knee, reverse
Trendelenburg);
o use of a pneumatic tourniquet, especially during prolonged periods of inflation;
o major orthopedic surgery (eg, hip arthroplasty, knee arthroplasty, hip fracture surgery);
o bariatric surgery;
o cardiothoracic surgery;
o vascular surgery;
o general surgery involving the abdomen or pelvis (eg, hepatic resection);
o urologic surgery involving the abdomen or pelvis (eg, nephrectomy);
o neurosurgery;
o spine surgery;
o immobilizing cast of a lower limb;
o open procedure;
o emergency procedure;
o concurrent procedures;
o transplant surgery;
o cesarean delivery;
o major foot and ankle surgery (eg, Achilles tendon rupture, total ankle arthroplasty, ankle fracture);
o major hand, wrist, or elbow surgery (eg, elbow arthroplasty);
o procedures involving hardware placement; and
o major plastic surgery (eg, body contouring, abdominoplasty, breast reconstruction).
• The perioperative RN should consult and collaborate with perioperative team members regarding the need for
and selection of prophylaxis based on the organizational protocol and the individual patient’s VTE risk factor
assessment.
III
The perioperative
RN should implement mechanical
VTE prophylaxis in
a safe and effective manner as
prescribed.
• When prescribed, an intermittent pneumatic compression device should be functioning and graduated compression stockings should be applied before the administration of regional or general anesthesia.
• The perioperative RN should perform interventions for safe and effective use of an intermittent pneumatic
compression device.
• The perioperative RN should assess the patient for potential contraindications related to use of the intermittent pneumatic compression device, including
o any leg condition (eg, dermatitis, recent skin graft, gangrene) that pneumatic compression may exacerbate,
o known allergy or sensitivity to the sleeve or tubing material,
o cardiac failure or pulmonary edema from congestive heart failure,
o any factor that prevents correct fitting of sleeves (eg, exceeding the size limit, severe leg edema, deformity),
o preexisting DVT, and
o severe arteriosclerosis or other ischemic vascular disease.
• The perioperative RN should notify the prescriber and anesthesia professional of any identified contraindications related to use of the intermittent pneumatic compression device.
• Sleeves for the intermittent pneumatic compression device should be applied according to the manufacturer’s
instructions for use.
• When the manufacturer’s instructions for use require the use of stockinet, graduated compression stockings,
or other material under the sleeves, the material should be wrinkle-free when applied to the skin.
• During application of the sleeve, the tubing on the external surface of the sleeve should be placed facing away
from the patient’s skin and away from locations that may create a pressure injury.
• The perioperative RN should verify that the sleeves for the intermittent pneumatic compression device are
applied correctly, connected to the device pump, and operating and that the tubing is away from locations that
may create a pressure injury after the patient is transferred to the OR bed or repositioned.
(continued)
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Guideline Summary
June 2018, Vol. 107, No. 6
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Recommendation
Key Points
• When intermittent pneumatic compression is used, interventions should be implemented to prevent unplanned
hypothermia.
• Sleeves for an intermittent pneumatic compression device used on the sterile field should be sterile.
• An intermittent pneumatic compression device used during a procedure with intraoperative magnetic resonance imaging should be nonferromagnetic.
• The intermittent pneumatic compression device should remain on for a minimum of 18 hours daily during the
intraoperative and immediate postoperative period unless removal is necessitated by patient care needs.
• The intermittent pneumatic compression device should be portable.
• The intermittent pneumatic compression device should be capable of recording wear time.
• The perioperative RN should perform interventions for safe and effective use of graduated compression stockings.
• The perioperative RN should assess the patient for potential contraindications related to the use of graduated
compression stockings, including
o any skin conditions (eg, dermatitis, recent skin graft, leg ulcer) that stockings may exacerbate,
oany vascular conditions (eg, peripheral vascular disease, peripheral arterial bypass grafting, severe arteriosclerosis) that stockings may exacerbate,
o severe peripheral neuropathy or other sensory impairment,
o gangrene,
o known allergy or sensitivity to stocking material,
o cardiac failure or pulmonary edema from congestive heart failure, and
oany factor that prevents correct fitting of stockings (eg, exceeding the size limit, severe leg edema, deformity).
• The perioperative RN should notify the prescriber and anesthesia professional of any identified contraindications related to the use of the graduated compression stockings.
• The perioperative RN should assess the patient’s ability to wear thigh-high graduated compression stockings
in accordance with the manufacturer’s instructions for use and the patient’s preference for length (ie, thigh or
knee length). When thigh-length graduated compression stockings are contraindicated based on the patient
assessment, the perioperative RN should collaborate with the prescriber to determine whether knee-length
graduated compression stockings may be substituted for thigh-length stockings.
• Graduated compression stockings should be fitted to the individual patient. The patient’s legs should be measured separately and according to the manufacturer’s written instructions.
• Graduated compression stockings should be applied according to the manufacturer’s written instructions. After
application, the perioperative RN should verify that the
o stockings are not rolled up the foot or down the leg,
o stockings are smooth when fitted,
o toe holes lie underneath the toes,
o heel patches are in the correct position, and
o thigh gussets are positioned on the patient’s inner thighs.
• The perioperative RN should verify that the graduated compression stockings have not rolled up the foot or
down the leg during transfer to and from the OR bed or during procedural positioning.
• Patients who develop postoperative leg edema should have their stockings removed, legs remeasured, and
stockings refitted.
• Elastic bandages should not be used as a replacement for graduated compression stockings.
• Graduated compression stockings and intermittent pneumatic compression devices may be used on patients in
the lithotomy position.
• The perioperative RN should assess the patient for adverse effects related to the use of mechanical VTE prophylaxis, including
o skin injury;
o hypothermia from use of the intermittent pneumatic compression device;
o numbness, tingling, discomfort, or pain;
o proximal indentation from knee-length graduated compression stockings; and
o ischemia.
• The VTE protocol should specify when mechanical VTE prophylaxis (ie, intermittent pneumatic compression
device, graduated compression stockings) should be removed for patient assessment and patient care activities
(eg, ambulation, before discharge, transfer of care).
• When evidence of complications related to the use of mechanical VTE prophylaxis is present, the perioperative
RN should
o remove the stocking and compression device,
o notify the physician and anesthesia professional, and
o document actions taken.
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Guideline Summary
(continued) Guideline Summary: Prevention of Venous Thromboembolism1
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Recommendation
Key Points
• When patient injury or equipment failure occur during the use of an intermittent pneumatic compression device,
o the intermittent pneumatic compression device should be removed from service;
o all sleeve and tubing accessories should be retained if possible; and
othe adverse event details, including device identification and maintenance and service information, should
be reported according to the health care organization’s policy and procedures.
• The patient should ambulate as soon as possible after surgery.
• The perioperative RN should instruct the patient to perform postoperative foot and ankle exercises.
IV
The perioperative
RN should implement pharmacologic
VTE prophylaxis in
a safe and effective
manner.
• The perioperative RN should assess the patient for potential contraindications related to the use of pharmacologic VTE prophylaxis, including
o active bleeding;
o previous major bleeding;
o known, untreated bleeding disorder;
o severe renal or hepatic failure;
o thrombocytopenia;
o acute stroke;
o uncontrolled systemic hypertension;
olumbar puncture or epidural or spinal anesthesia within the previous 4 hours or planned within the next 12 hours;
o concomitant use of anticoagulants, antiplatelet therapy, or thrombolytic drugs;
oprocedures in which bleeding complications may have especially severe consequences (eg, craniotomy,
spinal surgery, spinal trauma, reconstructive procedures involving a free flap);
o bacterial endocarditis;
o allergy to medication;
o pregnancy;
o ophthalmic surgery; and
o prosthetic heart valve.
• The perioperative RN should notify the prescriber of any identified contraindications.
• The perioperative RN should assess the patient for adverse effects related to the use of pharmacologic VTE
prophylaxis, including
o bleeding;
o hematoma formation;
o thrombocytopenia;
o osteoporosis and osteopenia;
o skin necrosis;
o calciphylaxis;
o atheroembolism; and
o injection site irritation, pain, bruising, bleeding, or itching.
• The perioperative RN should notify the prescriber and anesthesia professional of any identified adverse
events.
V
The perioperative
RN should provide
the patient and the
patient’s designated
caregiver(s) with
instructions regarding prevention of
VTE and prescribed
prophylactic
measures.
• The perioperative RN should provide the patient and the patient’s designated caregiver(s) with verbal and
written instructions on the prevention of VTE, including
ocommon signs and symptoms of DVT or PE (eg, leg pain, swelling, unexplained shortness of breath, wheezing, chest pain, palpitations, anxiety, sweating, coughing up blood);
othe importance of seeking medical help and whom to contact if the patient suspects DVT, PE, or an adverse
event;
o the importance of adhering to the entire duration of prescribed VTE prophylaxis;
o whom to contact if the patient has any problems using the prescribed VTE prophylaxis;
o the importance of mobilization, including ambulation and foot and ankle exercise;
o maintaining adequate hydration;
o preventive measures to use when traveling long distances after surgery;
o elevating the legs;
o avoiding clothing that constricts the lower extremities;
o avoiding sitting with knees bent or leg crossed for long periods of time; and
o avoiding sitting or standing for long periods of time.
• The perioperative RN should provide the patient receiving mechanical prophylaxis and the patient’s designated
caregiver(s) with preoperative and postoperative instructions, including
o the benefits of mechanical prophylaxis;
o the importance of compliance;
(continued)
AORN Journal
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Guideline Summary
June 2018, Vol. 107, No. 6
(continued) Guideline Summary: Prevention of Venous Thromboembolism1
#
Recommendation
Key Points
othe importance of wearing sized, graduated compression stockings in accordance with the manufacturer’s
instructions for use;
o instructions for removal, laundering, and reapplication of graduated compression stockings;
oinstructions for removal and reapplication of the intermittent compression device immediately after ambulation;
o the importance of postoperative ambulation;
o potential complications; and
o whom to contact if the patient has any problems using the prescribed mechanical prophylaxis.
• The perioperative RN should provide the patient receiving pharmacologic VTE prophylaxis and the patient’s
designated caregiver(s) with preoperative and postoperative instructions, including
o the importance of following through with medication-related laboratory tests;
o the importance of continuing medication post discharge as prescribed;
owhom to contact if the patient has any problems self-administering the prescribed pharmacologic prophylaxis;
o the importance of not stopping medication or of not starting a new medication;
o potential adverse effects and when to seek medical attention;
ointeractions with herbal and other over-the-counter preparations (eg, ginger, ginkgo biloba, ginseng, garlic,
chamomile);
o reporting signs of bleeding;
o reporting signs of epidural hematoma if the patient underwent any spine procedures;
o avoiding eating large amounts of food high in vitamin K such as green, leafy vegetables;
o avoiding certain activities (eg, contact sports);
o using an electric razor when shaving;
o using a soft toothbrush and waxed dental floss gently;
oinforming health care workers about pharmacologic prophylaxis before undergoing any procedures (eg,
dental work, laboratory tests);
ocarrying or wearing medical identification to let health care providers know that the patient takes anticoagulation therapy; and
o informing the physician if the patient is breastfeeding.
VI
Documentation
should reflect activities for prevention
of VTE.
• Documentation should be recorded in a manner consistent with the health care organization’s policies and
procedures and should include
o pharmacologic prophylaxis administration (eg, medication, dose, time, route),
o presence of VTE risk factors,
o contraindications to mechanical or pharmacologic prophylaxis and actions taken,
o adverse effects from mechanical or pharmacologic prophylaxis and actions taken,
o patient education provided,
o the reason for any variance from the VTE protocol,
othe type and size of intermittent pneumatic compression sleeves and graduated compression stockings applied,
oresults of a fall risk assessment and measures taken to prevent patient falls during postoperative ambulation,
o application and removal times for all mechanical prophylactic measures,
ointermittent pneumatic compression device identification (eg, serial or biomedical number) and settings, and
o results of a patient skin assessment for mechanical prophylactic measures.
Reference
1. Guideline for prevention of venous thromboembolism. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2018:773-798.
AORN has developed this Guideline Summary as a service to AORN members. The summary is intended to be
an adjunct to the complete guideline upon which it is based and is not intended to be a replacement for that
document. Individuals who are developing and updating organizational policies and procedures should review
and reference the full guideline.
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AORN Journal
Reproduced with permission of copyright owner. Further reproduction
prohibited without permission.