In bedridden hospitalized patients, which is most effective in prevention of venous thromboembolism,

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In bedridden hospitalized patients, which is
most effective in prevention of venous
thromboembolism, sequential compression devices
or Lovenox/Heparin?
Student Presenters Temequah Breckenridge RN,
Nancy Hancin LPN, Shannon Rials RN, Dana Stipes
RN
University of Oklahoma College of Nursing
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A Preventable Problem

• Venous Thromboembolism (VTE) is the most common
  preventable cause of hospital death.
  Pharmacologic methods to prevent VTE are safe,
  effective, cost effective, and advocated by
  authoritative guidelines. However, studies have
  shown that these preventive methods are
  significantly underutilized.
• AHRQ, 2008

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Venous ThromboembolismComposed of Deep Vein
Thrombosis (DVT)and Pulmonary Embolism (PE)
Thrombus in one of the deep veins
Embolus
Perfusion defect
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Venous thromboembolism DVT PE
Deep Vein Thrombosis
Pulmonary Embolism
Embolus that originated in the femoral vein of
the leg, removed from a pulmonary artery
Large thrombus in the femoral vein of the leg
https//secure.pharmacytimes.com/lessons/200309-01
.asp
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VTE-The Facts

• Hospitalization rate 250,000 per year
• Affected rate 2 million per year
• Incidence varies from 56100,000 to 182100,000
• Incidence in the United States 100100,000
• Possibly most preventable cause of
  hospital-associated death.
• High cost avoided with prophylaxis

Goldhaber, 2003
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VTE-The Facts

• 2 million affected
• 1 in 10 die from PE
• gt 200,000 deaths annually
• More than combination of
• Breast Cancer
• AIDS
• Traffic Accidents

Goldhaber, 2003
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WHY WORRY?

• Preventive strategies helped 90 of patients
  avoid VTE
• Death r/t PE reduced 60-70 with preventive
  strategy
• 300 bed facility 150 cases of VTE/year
• Screening for VTE upon hospital admission is
  cost-effective
• Cost of hospital-acquired DVT 10,000
• Cost of hospital-acquired PE 20,000

Maynard, 2008
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VTE The Silent Killer
Over 70 PE are detected POSMORTEM
Between 50- 80 of DVTs are clinically silent
(Stein,1995), (Lethen, 1997)
http//www.lemonwheel.com/site/Alaska.php
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NBCs David Bloom Dies of DVT/PE in 2003

• Died unexpectantly from a PE-DVT in the leg from
  limited mobility while covering a story in Iraq.
• Wife, Melanie, now a crusader for VTE awareness.
• www.unitedjustice.com/david-bloom.html

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Not Just a Surgical Problem
Events
Geerts, 2004
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• The rationale for Risk Stratification

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Acquired Risk Factors for VTE7th ACCP Guidelines

• Increasing age (gt40)
• Prolonged immobility
• Previous VTE
• Cancer
• Major surgery
• Trauma
• Obesity
• Acute medical illness
• Hormone therapy

• Smoking
• Varicose veins
• Cardiac or
• Pulmonary failure
• Central venous catheters
• IBS
• Nephrotic syndrome
• Pregnancy/postpartum
• Geerts, 2004

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Risk of VTE Increases With the Number of Risk
Factors
Proportion of patients with VTE ()
Risk factors
Anderson, 2003
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Is Chemical Prophylaxis or Mechanical Prophylaxis
better?
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What is the Evidence?

• Arthroscopy Knee Surgery
• SCDs vs. LMWH
• 7 day study
• Conclusion
• 2.3 higher incidence of VTE, and death in
  patients who only wore SCDs
• Camporese, 2008

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What is the Evidence

• Craniotomy for Brain Tumor
• 2 Groups
• Enoxaparin (lovenox) 40 mg/day with SCDs
• Unfractionated Heparin 5,000 u BID with SCDs
• Conclusion
• No symptomatic VTE with either group
• 9.3 frequency of asymptomatic VTE

Goldhaber, 2002
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What is the Evidence

• Combined SCD and pharmacological prophylaxis
• Recommend combined methods in high
  risk
• groups.
• Mechanical methods in groups with higher
• propensity of bleeding
• Shown combined methods significantly
• decrease incidence of VTE.

Kakkos, 2008
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What is the Evidence

• Medenox Trial
• 14 day trial using 866 patients
• VTE in placebo group 14.9
• VTE in Lovenox group 5.5
• Represents a relative risk reduction of 63
• Revealed lt 1 rate of major bleeds

Samama, 1999
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What is the Evidence

• The-Prince Study
• 10 2 day study using 451 patients
• VTE in Heparin group 10.4
• VTE in Lovenox group 7.9
• Lovenox less bleeding, less S/Es, less deaths

Kleber, 2003
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Why are Mechanical VTE prophylaxis strategies not
used?
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Sequential Compression Devices

• Evidence limited
• Compliance poor
• Bleeding risk none
• Safety issues

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Safety Hazard
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Increase Safety and Satisfaction
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Mechanical Disadvantages

• Foot pumps
• Complaints of being too noisy
• Complaints of irritation
• SCDs
• Safety hazard
• Limits mobility

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Mechanical Disadvantages

• Early ambulation
• Difficult to obtain sufficient distance
• Patient resistance or outright refusal
• TED hose
• Hard to fit properly
• Complaints of being too tight

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Chemical Prophylaxis Strategies

• Aspirin (ASA) oral antiplatelet
• Coumadin (Warfarin) oral anticoagulant
• Heparin SQ/IV anticoagulant
• Lovenox (Enoxaprin) SQ anticoagulant

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Why are Chemical VTE prophylaxis strategies not
used?
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Chemical Disadvantages

• ASA
• Slow onset
• Coumadin
• Frequent blood draws
• Difficult to maintain therapeutic INR level
• Heparin
• 3 SQ injections daily
• Frequent blood draws
• Difficult to maintain therapeutic PTT level
• Lovenox
• Cannot be used in high risk bleeding

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VTE Prophylaxis Efficacy(least to greatest)

• Early ambulation
• ASA and Coumadin (Warfarin)
• TED hose
• Foot pumps
• Heparin
• SCDs
• Lovenox (Enoxaprin)

Goldhaber, 2003
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RECOMMENDED PROPHYLAXIS

• __________________________________________________
  _____________
• Low risk Moderate risk High risk
  Highest risk
• __________________________________________________
  _____________
• Early ambulation LDUH (q12h) LDUH
  (q8h) LMWH
• LMWH LMWH
  Oral anticoagulants
• SCD SCD
  SCD/ESLMWH/LDUH
• ES
• __________________________________________________
  ____________________
• LDUH low-dose unfractionated heparin
• LMWH low-molecular-weight heparin
• SCD Sequential Compression Device
• ES elastic stockings
• 7th ACCP Guidelines on Antithrombotic and
  Thrombolytic Therapy
  
  
• 
  
  Geerts, 2004

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Conclusion

• In patients who have been admitted to the
  hospital, with congestive heart failure or severe
  respiratory disease, or who are confined to bed
  and have more than one additional risk factors
• Recommended Prophylaxis
• LMWH or
• LDUH
• Geerts, 2004

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Conclusion

• The American Public Health Association has
  stated that the disconnect between evidence and
  execution as it relates to DVT prevention amounts
  to a public health crisis.

AHRQ, 2008
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Conclusion

• Deep vein thrombosis (DVT) prophylaxis is the
  number one strategy to improve patient safety in
  hospitals. 
• "The first manifestation of VTE DVT/PE may be
  fatal PEAccordingly, prophylaxis against VTE
  remains the most appropriate strategy to reduce
  this sequelae..."

Geerts, 2004
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Conclusion

• Best result - combination of mechanical
  chemical
• Added preventive effect
• Recommended in higher risk groups
• Cannot always use SCDs due to leg injury
• Cannot always use Lovenox due to bleeding

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Conclusion

• Screening for VTE upon hospital admission is
  cost-effective and necessary. When using a
  preventive strategy
• Mechanical/chemical should be individualized
  based on patient risk factors.
• VTE can be prevented in 90 of surgical/trauma
  patients without additional risk factors
• Risk of VTE and death related to PE in high risk
  surgical and trauma patients is significantly
  reduced by 60-70

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References

• Anderson, F A.., Spencer, F.A., MD, (2003). Risk
  factors for venous thromboembolism. Circulation,
  107 (23Suppl 1) 19-16.
• Caprini, J., Arcelus, J., Reyna, J. (2001).
  Effective risk stratification of surgical and
  nonsurgical patients for venous thromboembolic
  disease. Seminars in Hematology, 38(2)Suppl
  512-19.
• Camporese G., Bernardi E., Prandoni P., et al
  (2008). Low-molecular-weight-heparin (LMWH)
  versus compression stockings for
  thromboprophylaxis after knee arthroscopy A
  randomized trial. Annals of Internal Medicine,
  149 73-82.
• Geerts, W. H., Pineo, G.F., Heit, J.A., et al
  (2004). Prevention of venous thromboembolism the
  seventh ACCP conference on antithrombotic and
  thrombolytic therapy. Chest,126(suppl)338S
  400S.
• Goldhaber, S.Z., Tapson, V.F., Uri, E. Gideon B.,
  Comp, P.C. et al (2003). Prophylaxis of venous
  thromboembolism (VTE) in the hospitalized medical
  patient. Hospital Medicine Consensus Reports,
  (5), 1-20.

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References

• Goldhaber, S.Z., Dunn, K., Gerhard-Herman M.,
  Park, J., Black, P. (2002). Low rate of venous
  thromboembolism after craniotomy for brain tumor
  using multimodality prophylaxis. Chest,
  122(6)1933-7.
• Kakkos, S.K., Caprini, J.A., Geroulakos, G.,
  Nicolaides, A.N., Standsby, G.P., Reddy, D.J., et
  al. (2008). Combined intermittent pneumatic leg
  compression and pharmacological prophylaxis for
  prevention of venous thromboembolism in high-risk
  patients. International Angiology, 25(2) 101-61.
• Kleber, F. X., Witt, C., Vogel, G., Koppenhagen,
  K., Schomaker, U., Flosbach, C.W., (2003).
  THE-PRINCE study group Randomized comparison of
  enoxaparin with unfractionated heparin for the
  prevention of venous thromboembolism in medical
  patients with heart failure or severe respiratory
  disease. American Heart Journal, 145614 621.
• Maynard, G., Stein, J. (2008). Preventing
  hospital-acquired venous thromboembolism A guide
  for effective quality improvement. Agency for
  Healthcare Research and Quality, No. 08-0075,
  1-50.

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References

• Samama, M.M., Cohen, A.T., Darmon, J.Y., et al
  (1999). Prophylaxis in medical patients with
  enoxaparin study group A comparison of
  enoxaparin with placebo for the prevention of
  venous thromboembolism in acutely ill medical
  patients. New England Journal of Medicine, 341
  793-800.