Venous thromboembolism prophylaxis using the Caprini score

Venous thromboembolism (VTE) including pulmonary embolism (PE) and deep vein thrombosis (DVT) is one of the leading causes of preventable cardiovascular disease in the United States (US) and is the number one preventable cause of death following a surgical procedure. Post-operative VTE is associated with multiple short and long-term complications. We will focus on reviewing the many faces of VTE in detail as they represent common challenging scenarios in clinical practice.     

Venous thromboembolism prophylaxis in critically ill patients

Venous thromboembolism (VTE) is a frequent but often silent complication of critical illness that has a negative impact on patient outcomes. The prevention of VTE is an essential component of patient care in the intensive care unit (ICU) setting, and is the focus of this article. The use of anticoagulant thromboprophylaxis significantly decreases the risk of VTE in ICU patients and is discussed at length.     

Venous thromboembolism prophylaxis conversion in nonsurgical inpatients

OBJECTIVE: To provide venous thromboembolism (VTE) prophylaxis according to national consensus guidelines while minimizing associated medication costs. METHODS: Patients admitted to our institution who were receiving VTE prophylaxis with the low-molecular-weight heparin (LMWH) enoxaparin were identified and evaluated for potential conversion to low-dose unfractionated heparin (LDUH). Patients admitted for general medical conditions were targeted for a potential conversion. Factors that excluded patients from conversion were any surgical intervention or evidence of bleeding. For all eligible patients, the treating physician was contacted through written recommendations in an effort to achieve conversion to an LDUH regimen. RESULTS: Throughout a 10-month period, 463 patients were identified as receiving enoxaparin for VTE prophylaxis. Of these, 112 (24%) were candidates for an LDUH regimen. A total of 88 pharmacy recommendations were provided, of which 59 (67%) were accepted. This conversion program resulted in the avoidance of 250 days of enoxaparin prophylaxis and 8495 US dollars of associated medication costs. CONCLUSIONS: Clinical pharmacy programs directed at converting patients from a more costly LMWH regimen for VTE prophylaxis to an LDUH regimen can significantly reduce medication costs while adhering to consensus guidelines.     

Venous thromboembolism: implications for gene-based diagnosis and technology development

Venous thromboembolism is an hypercoagulable state that frequently reflects a complex interplay between inherited, acquired and environmental factors. The overall incidence of venous thromboembolism, which increases with age, is approximately 1:1000 in the US and Western Europe. In addition to known risk factors such as pregnancy and cancer, genetic variants can also increase the venous thromboembolism risk. Once such genetic variant, FV Leiden is characterized by single-point mutation and has been found in approximately 20% of idiopathic venous thromboembolism cases. The discovery of FV Leiden unleashed an increased interest in the genetics of venous thromboembolism as well as other cardiovascular diseases. Because FV Leiden was not only defined by only one common single nucleotide polymorphism but was also widely prevalent, impetus for the development of novel mutation detection methodologies and platforms for DNA analysis in both the clinical and research laboratory was greatly accelerated. An overview of this technology and its relationship to the genetics of venous thromboembolism is reviewed.     

Venous thromboembolism (VTE) risk assessment: Rural nurses' knowledge and use in a rural acute care hospital

It is estimated that about 2000 people die as a result of venous thromboembolism (VTE) each year, with a further 30 000 being hospitalized. Prophylaxis significantly reduces VTE morbidity and mortality, and thus represents a real long‐term health‐care benefit. The aim of this study was twofold: (i) to assess the current level of compliance to VTE risk assessment and prophylaxis best practice guidelines within an Australian rural hospital; and (ii) to determine the effectiveness of nurse education on that compliance. VTE compliance information was obtained from auditing patient notes for a 3‐month period prior to nurse education and was repeated after the education. Nurse knowledge of VTE risk assessment and prophylaxis use was also measured. Both compliance with and knowledge of best practice VTE risk assessment and prophylaxis increased following nurse education. Although the sample size was relatively small, this study has shown nurse education to be effective at increasing VTE compliance and awareness within an Australian rural hospital. This relatively inexpensive and simple intervention bears consideration and could lead to reductions in the morbidity and mortality associated with VTE, as well as reduction in associated health‐care costs.     

Venous thromboembolism prophylaxis guidelines: use by primary care physicians

Venous thromboembolism (VTE), a prevalent, costly medical condition, is one of the most common causes of death in the United States. Although risk factors for VTE are well known, thromboembolic events cannot be predicted because patients are asymptomatic and screening methods have limitations. Anticoagulant therapy (eg, low-molecular-weight heparin, unfractionated heparin, selective factor Xa inhibitors) has proved effective for preventing thromboembolism, including deep vein thrombosis and pulmonary embolism. While quality care for VTE entails prophylaxis for all relevant patients, many high-risk patients are undertreated or treated incorrectly. Both primary and secondary prevention of VTE remain inadequate for several reasons, including lack of awareness of the American College of Chest Physicians guidelines, of the seriousness of VTE, of the benefits of prophylaxis, and of the relatively low risk of bleeding complications. To provide appropriate treatment, physicians must assess the numbers and types of risk factors for each patient, the underlying illness or surgical procedure, and the benefits and risks of possible therapies. The problem of VTE will grow as the US population ages, as surgery is performed on increasingly sick patients, and as the length of hospital stays continues to decrease.     

Diabetic ketoacidosis: implications for the medical-surgical nurse.

Diabetic ketoacidosis (DKA) is an acute complication associated with type 1 diabetes mellitus. DKA accounts for a significant portion of annual health care expenditures and is considered a medical emergency. Previously treated in the ICU, DKA is now treated on general medical-surgical nursing units. To manage this crisis successfully, medical-surgical nurses must have a comprehensive knowledge and understanding of the pathophysiologic mechanisms, clinical manifestations, and treatment protocols. A critical pathway is presented to guide clinical care.     

Venous thromboembolism prophylaxis in a South Australian teaching hospital

BACKGROUND: Venous thromboembolism (VTE) is relatively common among hospitalized patients, is often clinically silent, and is associated with substantial morbidity and mortality. Risk stratification and routine use of thromboprophylaxis for patients at moderate to high risk for VTE are key strategies that can be used to prevent VTE. OBJECTIVE: To assess the appropriateness of the selection and implementation of thromboprophylactic measures for prevention of VTE within a South Australian teaching hospital. METHODS: Guidelines for risk stratification and prophylaxis were compiled from a range of studies, consensus statements, and tertiary references. Using prospective, observational methodology, data collection was performed through case note audit for 130 inpatient admissions over a 4-week period. RESULTS: The decisions regarding the usage of thromboprophylaxis were considered inappropriate in 32% of cases in the study cohort. Suboptimal practices were also observed with respect to factors including the choice between mechanical and pharmacologic methods and the timing of initiation and cessation of thromboprophylaxis. CONCLUSIONS: These findings provide evidence suggesting that the selection and implementation of thromboprophylaxis require improvement and that appropriate means to facilitate this improvement need to be developed and evaluated through future research.