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A Different Strategy to Help Prevent VTE in Trauma Patients

A Different Strategy to Help Prevent VTE in Trauma Patients

Venous thromboembolism (VTE)—consisting of pulmonary embolism (PE) and DVT—is one of the most common and deadliest complications experienced by trauma patients admitted to hospitals. According to recent estimates, trauma is the leading killer of young people in the United States. Other studies suggest that at least 100,000 people die from PE alone every year. In light of the incidence of these events, the AHRQ recently placed interventions to improve VTE prophylaxis on its top 10 list of patient safety practices that are strongly encouraged. Changing the Approach of VTE Prophylaxis “Currently, healthcare practitioners use a complex flow diagram for determining the most appropriate strategies when providing VTE prophylaxis,” explains Elliott R. Haut, MD, FACS. For a study, Dr. Haut and colleagues converted the complex algorithm into a shorter clinical decision support-enabled VTE order set that was built into a computerized provider order entry system (CPOE). The converted algorithm was used at the point of care by trauma services providers at the Johns Hopkins Hospital in the analysis. For the intervention, clinicians checked off appropriate boxes on a short checklist (Table) based on patients’ VTE risk factors and contraindications to pharmacologic VTE prophylaxis. The CPOE system integrated this information into an evidence-based algorithm to stratify patients’ VTE risk. The system then suggested the optimal decision for an appropriate VTE prophylaxis regimen. “Using the order set was mandatory for all adult trauma patients in our study,” adds Dr. Haut, whose research was published in JAMA Surgery. The study team compared compliance with guideline-appropriate VTE prophylaxis during the year prior to implementing the order set with the 3 years after implementation. Increased...
Managing Pulmonary Embolism in the ED

Managing Pulmonary Embolism in the ED

Venous thromboembolism (VTE), which includes DVT and pulmonary embolism (PE), is the third leading cause of cardiovascular death among Americans and is especially fatal if these events go undiagnosed and are not treated promptly. PE is most frequently diagnosed in the ED and is associated with 14- and 30-day mortality rates of about 10% and 20%, respectively. Research has shown that a prompt diagnosis of acute PE—within 48 hours of ED arrival—is associated with improved outcomes. Factors Associated with Delays in PE Diagnosis My colleagues and I previously reported that administra­tion of anticoagulants within 24 hours of ED arrival is as­sociated with reduced mortality. Current guidelines from the American College of Chest Physicians recommend that anticoagulation be initiated even before a confirmed diag­nosis, when the probability of PE is believed to be high. However, studies have indicated that there is potential for significant delays from the time of symptom onset to PE diagnosis in the ED. A prompt diagnosis of acute PE—within 48 hours of ED arrival—is associated with improved outcomes. In an effort to better understand the factors associated with timing of a PE diagnosis in the ED, my colleagues and I conducted a review that was published in the January 2012 Journal of Emergency Medicine. Following univariate and multivariate analyses, we found that the following factors appeared to be associated with delays in PE diagnoses of more than 12 hours: Age older than 65. Concurrent cardiovascular disease (CVD). Morbid obesity (BMI >40 kg/m2). A history of recent immobility (eg, recent surgery) and pre­sentation to the ED with tachycardia were factors associ­ated with a relatively early diagnosis of...

Reducing VTE Risk After Hip & Knee Replacement

Venous thromboembolism (VTE), which encompasses deep vein thrombosis (DVT) and pulmonary embolism (PE), is one of the most common reasons for readmission following primary hip or knee replacement surgery. However, recent studies suggest that only 0.7% to 0.9% of patients undergoing hip or knee replacements require rehospitalization because of VTE in the first 3 months after surgery. “These surgeries put patients at risk for thromboembolic disease because they affect multiple aspects of Virchow’s triad,” explains Joshua J. Jacobs, MD. Virchow’s triad consists of hypercoagulability, venous stasis, and injury to the vascular endothelium. All three components of the triad can be present following hip or knee replacement surgery and predispose individuals to thrombosis, according to Dr. Jacobs. “DVT occurs in about 37% of patients following primary hip or knee replacement surgery who have not been treated with prophylactic agents. The rate of clinically symptomatic VTE events is far less, but VTE should be an important concern of orthopedic surgeons performing these procedures.” New Guidelines on Preventing VTE Dr. Jacobs chaired a workgroup that updated guidelines from the American Academy of Orthopaedic Surgeons (AAOS) on preventing VTE in patients undergoing elective hip and knee arthroplasty. The guidelines were released on September 24, 2011 and are available for free at www.aaos.org/guidelines. “The AAOS felt it was necessary to update these guidelines for the first time since 2007 because of the increasing availability of study data that impacted the previous recommendations and to maintain inclusion in the AHRQ’s National Guideline Clearinghouse, which requires an update every 5 years,” says Dr. Jacobs. The American College of Chest Physicians has also published guidelines on VTE...
Conference Highlights: ISET 2012

Conference Highlights: ISET 2012

New research was presented at ISET 2012, the annual International Symposium on Endovascular Therapy, on January 15-19 in Miami Beach. The features below highlight just some of the studies that emerged from the meeting. » A New Approach to Managing Unstoppable Nosebleeds  » Cryoablation Deemed Effective in Ovarian Cancer » MS Patients Report Benefits With Angioplasty » Fibromuscular Dysplasia Frequently Undiagnosed Treating DVT in Pregnant Women The Particulars: Studies have shown that DVT is four to six times more common in pregnant women than in non-pregnant women. Research suggests that many pregnant women with DVT often forgo the most effective treatments—surgery or catheter-directed thrombolysis—because they fear that doing so may harm their unborn children. Data Breakdown: In a study of 11 pregnant women with DVT, two underwent surgery to remove the clot, and nine were treated with a bath of thrombolytic medications delivered directly into the clot. Removal of the clot was successful in all cases, and all but one pregnancy resulted in successful birth. One woman who miscarried 1 week after treatment suffered from antiphospholipid antibody syndrome, which the researchers believe likely caused the miscarriage. Take Home Pearl: Aggressive treatment with surgery or catheter-directed thrombolysis for pregnant women with DVT appears to be safe. Aggressive treatment was also shown to prevent serious complications and death.     A New Approach to Managing Unstoppable Nosebleeds [back to top] The Particulars: Unstoppable nosebleeds can cause anemia and may lead to other more serious complications, including heart attack. When packing the nose with gauze, inflating a balloon to stop blood flow, or cauterizing the vessels in the nose fail, surgery or embolization are the...

Catching the Warning Signs of DVT

In the United States, more people die each year from pulmonary embolism (PE) than motor vehicle accidents, breast cancer, or AIDS. Most PEs are complications of deep vein thrombosis (DVT). In fact, more than 2 million Americans suffer from DVT each year, with over half of these individuals developing their DVT complications in the hospital or in the 30 days after hospitalization. While the connection between the risk of DVT, cancer, and cancer treatment is not fully understood, the literature suggests that approximately 10% of individuals who present with DVT or PE will have a cancer diagnosis within 2 years of the thrombotic episode. Other factors that increase the risk of DVT in patients with cancer are those whose disease has metastasized and those who are receiving chemotherapy. Furthermore, it has been reported that the probability of death within about 6 months of initial hospital admissions is over 94% for those who had venous thromboembolism and malignant disease compared with a rate of less than 40% for those with cancer alone. What Oncology Nurses Can Do From an historical perspective, DVT has been more closely related to surgical conditions. As such, routine attention to DVT risk has been given primarily to surgical patients; these individuals would be given compression stockings, prophylaxis, or other treatment. Now, there is heightened awareness that medical patients are also at risk for DVT. In addition to a cancer diagnosis, multiple risk factors and triggering events are associated with DVT, including increasing age, immobility, stroke, paralysis, previous DVT, major surgery, trauma, obesity, and inherited clotting predisposition, among others. Oncology nurses should be aware of risk...
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