Hospital Acquired Venous
Thromboembolism
Beverley Hunt
Simon Noble
Hospital- acquired VTE
Estimates
•
VTE in the UK -an estimated 60,,000 deaths: at least 32,000 due to hospital admission of
which 25,000 are preventable
•
More people die from VTE than breast cancer, HIV and road traffic accidents combined
•
Hospital acquired VTE causes more deaths than hospital -acquired infection (MRSA & C
difficile, peaked at 10,000)
Facts
•
Definition includes any VTE within 90 days of discharge
•
Hospital-acquired clots account for 2/3 of all VTE
•
Registered deaths due to VTE in England in 2007 -19,000- but under diagnosed…….(House
of Commons Question summer 2009)
•
Autopsy data suggests reported incidences are markedly underestimated. Baglin et al J Clin
Path 1997; 50: 609-10
Death due to PE in England and Wales
from the National Statistics office
Cause of
death
Age
group
2005
2006
2007
2008
0-10
0
0
0
0
11-20
11
9
5
6
21-30
33
42
35
28
31-40
114
101
96
111
41-50
248
267
252
292
Underlying 0-10
3
4
4
3
Or
11-20
13
11
10
12
Contrib
21-30
61
68
65
62
cause
31-40
200
184
170
205
41-50
454
467
452
477
Postoperative risk of VTE in middle aged
women: prospective cohort study
Sweetland et al. BMJ 2009; 339: 583
1 in 140 middle aged
women (55+/-4.6) post
surgery will be admitted
with a VTE during
12/52 post surgery
1 in 45 after hip/knee
surgery
1 in 85 after cancer
surgery
Relative
risk
0-6
weeks
6-12
weeks
In patient 70
20
Day
patient
5
10
“WE DON’T see it anymore, a disease of the
past” Anon consultant
BUT VTE is a “silent disease”
• -80% of DVT subclinical
• -<50% of PE detected prior to death
• 10% of hospital deaths due to PE
• Post surgery the average VTE events occur:
• DVT on day 7
• PE on day 21
•
Warwick D 2009
Thromboprophylaxis political
momentum
Consistent investment and a coherent
strategy leads to Department of Health
taking ownership for VTE prevention
2004
2005
2006
2007
2008
2009
2010
NICE guidelines published Jan 24th 2010:
Venous thromboembolism: reducing the
risk of VTE in patients admitted to hospital
General advice
• Do not allow the patients to become
dehydrated unless clinically indicated
• Encourage patients to mobilise as soon
as possible
• Do not regard aspirin or other
antiplatelet drugs as adequate
prophylaxis for VTE
Risk assessment of VTE (NICE)
• Reassess patient’s risk of bleeding and
VTE within 24 hours of admission, and
whenever the clinical situation changes,
to:
• Ensure that the methods are suitable
• Ensure it is being used correctly
• Identify adverse events
Mechanical VTE prophylaxis
• Base the choice of mechanical VTE
prophylaxis on individual patient factors
including clinical conditions, surgical
procedure and patient preference.
Choose any one of the following:
• Anti-embolism stockings (thigh or knee
length)
• Foot impulse devices
• Intermittent pneumatic compression
devices (thigh or knee length)
Mechanical VTE prophylaxis
• Base the choice of mechanical VTE
prophylaxis on individual patient factors
including clinical conditions, surgical
procedure and patient preference.
Choose any one of the following:
• Anti-embolism stockings (thigh or knee
length)
• Foot impulse devices
• Intermittent pneumatic compression
devices (thigh or knee length)
Anti-embolism stockings
Do not offer stockings to patients who have:
• Suspected peripheral arterial disease
• Peripheral arterial bypass grafting
• Peripheral neuropathy or other causes of sensory impairment
• Any local condition in which stockings may cause damage
• Known allergy to material of manufacture
• Cardiac failure/severe leg oedema
• Unusual leg size or shape
• If arterial disease suspected seek expert opinion
Encourage them to wear them day and night until they no longer have reduced
mobility
Remove daily for hygiene purposes and to inspect skin 2-3 times a day for integrity
or sensory impairment and discontinue if problems develop.
NB WE SHOULD BE USING TEDs. SARAH & QUEEN ward are trialling Saphena
Medical patients
• “Assess all patients on admission to identify those who are at
increased risk of VTE”
• At increased risk if reduced mobility for 3 days or more OR
• Are expected to have ongoing reduced mobility relative to their
normal state and one or more risk factor shown in Box 1
Box 1 Risk factors for VTE
• Active cancer or cancer Rx
•>60 years
•Critical Care admission
•Dehydration
•Known thrombophilias
•Obesity- BMI>30
•Significant medical co-morbidity
•Personal history or 1st degree relative with VTE
•COC or HRT
•Varicose veins with phlebitis
Medical patients con’t
• Assess all pts for risk of bleeding before offering
pharmacological agents. Do not offer
pharmacological prophylaxis unless the risk of VTE
outweighs the risk of bleeding- risk factors in Box 2
Box 2 risk factors for bleeding
•Active bleeding
•Acquired bleeding disoreders (e.g acute liver failure)
•Concurrnet use of anticoagulants
•LP/epidural/spinal anaesthesia expected within next 4 hours
•LP/epidural/spinal anaesthesia within the previous 4 hours
•Acute stroke
•Thrombocytopenia <75x109/l
•Uncontrolled hypertension (>230/120)
•Untreated inherited bleeding disorders (e.g haemophilia)
Reducing the risk of VTE in medical patients
Those at risk offer:
• Fondaparinux sodium
• LMWH
• UFH (renal failure)
Start as soon as possible after risk
assessment is completed and continue
until the patient is no longer at
increased risk of VTE
Stroke patients
Do not offer anti-embolism stocking
Consider pharmacological if
• Haemorrhagic stroke excluded
• The risk of bleeding (NB haemorrhagic transformation) is low
AND
• The patient has one of more of
- Major restriction of mobility
- Prev history of VTE
- Dehydration
- Comorbidities e.g cancer
Continue until the acute event is over and the patient’s condition is
stable
Until the patient can have pharmacological prophylaxis consider
offering a foot impulse or intermittent pneumatice compression
Surgical patients
Offer thromboprophylaxis to
those assess to be at
increased risk :
• Surgical procedure total
anaesthetic & surgical time
>90mins or 60 mins if surgery
involves pelvis or lower limb
• Acute surgical admission with
inflammatory or intraabdominal condition
• Expected significant reduction
in mobility
• One of more of the risk factors
in box 1
Box 1 Risk factors for VTE
Active cancer or cancer Rx
>60 years
Critical Care admission
Dehydration
Known thrombophilias
Obesity- BMI>30
Significant medical co-morbidity
Personal history or 1st degree
relative with VTE
COC or HRT
Varicose veins with phlebitis
Reducing the VTE risk after surgery
• Combined mechanical and
pharmacological for those at risk
• Enoxaparin 40mg or UFH 5,000 TDS in
renal failure
• Extended thromboprophylaxis of 28-35
days after cancer and hip fracture
• (NB need trials after renal tx)
Total hip and knee replacement
• Offer combined mechanical and
pharmacological
• Start mechanical on admission
• We are using dabigatran etexilate
Predictable anticoagulant effect
Fixed dose
No need for monitoring
• Continue for 10-12 days after TKR and 28-35
days after THR
General recommendation in surgical
patients
• Stop COC or HRT 4 weeks before elective surgery
and provide alternative contraceptive advice if
necessary
• Assess the risks and benefits of stopping pre-existing
antiplatelet therapy 1 wek before surgery. Consider
involving the multidisciplinary team in the assessment
• Consider using regional anaesthesia as it carries a
lower risk of VTE and plan the timing to minimise the
risk of epidural haematoma (Dr Thomson’s bridging
clinic)
• Do not offer thromboprophylaxis in surgery with local
anaesthesia with no limitation of mobility
“all patients, both medical and surgical,
who are admitted to hospital should
undergo a risk assessment for venous
thrombosis”
(House of Commons Health Committee The Prevention of Venous
Thromboembolism in Hospitalised Patients Second Report of Session 2004–05)
This needed mandating!
Being updated! No 2 will probably disappear…
Lifeblood: the thrombosis charity
www.thrombosis-charity.org.uk