Thrombosis prevention

Pathophysicology of blood clot prevention

The development of blood clots can be interrupted and prevented by the use of medication, changing risk factors and other interventions. Some risk factors can be modified. These would be losing weight, increasing exercise and the cessation of oral contraceptives. Moving during periods of travel is a modifiable behavior. Preventing blood clots includes the use of medications that interrupt the complex clotting cascade and changing the proteins that are needed for clotting. Antiplatelet drugs also have an affect in preventing the formation of clots.

If a blood clot has aleady formed in a blood vessel, treatment will differ significantly from clot prevention. Hemolytic medications are used. These are medications that will help dissolve the clot. Physical interventions then become contraindicated due to the risk of the clot migrating to distant locations like the heart, brain, and lungs. Once a clot has formed, a person will be prescribed bed rest and remain relatively immobile until it the clot is undetectable.

Medical treatments

Thrombosis prophylaxis is not only used for the prevention of deep vein thrombosis, but can be initiated for the prevention of the formation of blood clots in other organs and circumstances unrelated to deep vein thrombosis:

Epidemiology of developing blood clots

The risk of developing deep vein thrombosis, or pulmonary embolism is different than the total risk of the formation of blood clots. This is due to the observation that not all blood clots form in the lower legs. Most hospitalized medical patients have at least 1 risk factor for thrombosis that progresses to thromboembolism and this risk persists weeks after discharge. Those who remain undiagnosed and not treated prophylacticly have a 26% chance of suffering a fatal embolism. Another 26% develop another embolism. Between 5% and 10% of all in hospital deaths are due to pulmonary embolism (as a consequence of thrombosis). Estimates of the incidence of pulmonary embolism in the US is 0.1% persons/year. Hospital admissions in the US for pulmonary embolism are 200,000 to 300,000 yearly. Thrombosis that develops into DVT will affect 900,000 people and kill up to 100,000 in the US. On average 28,726 hospitalized adults aged 18 and older with a VTE blood clot diagnosis die each year. Risk of thrombosis is related to hospitalization. In 2005 the UK the Parliamentary Health Select Committee determined the annual rate of death due to thrombosis was 25,000 with at least 50% being hospital-acquired.

The type of surgery performed prior to the formation of blood clots influences the risk. Without prophylactic interventions, the calculated incidence of clot formation in the lower leg veins after surgery is:

As the population of the US ages, the development of blood clots is becoming more common.

General risks and indications for blood clot prevention

Some risk factors for developing blood clots are considered higher that others. One scoring system analyzes the probability for clot formation by assigning a point value system to significant risk factors. The benefit of treating those who are at low risk of developing blood clots may not outweigh the higher risks of significant bleeding.

Risk for subsequent blood clots

Developing blood clots is more probable after the first episode. Risk assessment and intervention for those with one or more episodes of deep vein thrombosis or blood clots in the veins utilizes the Well's test. It has been inconsistently modified by a number of publishers with the results listed below:

Adapted for the emergency room

Scoring:

General interventions

The Centers for Disease Control and Prevention have issued general guidelines describing the interventions that can be taken to reduce the risk of the formation of blood clots:

Interventions during travel

Seat-edge pressure from the seat on an airplane on the popliteal area may contribute to vessel wall damage as well as venous stasis. Coagulation activation may result from an interaction between cabin conditions (such as hypobaric hypoxia) and individual risk factors for the formation of blood clots. Studies of the pathophysiologic mechanisms for the increased risk of Venous thrombosis embolism or VTE after long-distance travel have not produced consistent results, but venous stasis appears to play a major role; other factors specific to air travel may increase coagulation activation, particularly in passengers with individual risk factors for VTE.

Compression devices

The use of fitted intermittent pneumatic compression devices before, during and after procedures is another way to It consists of an air pump and inflatable auxiliary compartments that sequentially inflates and deflated to provide an external 'pump' that returns venous blood toward the heart. The use of intermittent pneumatic compression is common. These devices are also placed on a surgical patient in the operating room (the intra-surgical period) and remain on the person while recovering from the surgery.

The application of antiembolism stockings (TED stockings) can be used to prevent thrombosis. The correct use and properly fitted graded compression stockings can reduce the rate of thrombosis by 50%. Contraindications for the use of antiembolism stockings include the presence of advanced peripheral and obstructive arterial disease, septic phlebitis, heart failure, open wounds, dermatitis and peripheral neuropathy. Differences between the use of thigh-high compression stockings and shorter types to prevent blood clots exist, but remain inconsistent.

Assessment

There has been some success in preventing blood clots by an early assessment risk upon admission to the hospital. This strategy for preventing blood clots is the Centers for Disease and prevention's program that recognizes procedural prevention. Hospitals participated in this effort to reduce the incidence of thrombosis. In some instances, the rates of DVT were decreased. Some of the hospitals developed a mandatory assessment quantifying the risk for developing blood clots and a plan of care developed from the assessment. The person's risk for developing blood clots is entered into their record, ‘following’ them through their treatment regime. If the hospital stay exceeded three days, the person was reassessed for risk. Clinicians were then able to apply protocols for prevention based upon best clinical practices.

Interventions to treat immobility

Immobility is a significant risk factor in the development of thrombosis. Immediate post-surgical interventions,(out of bed orders (OOB), are typically ordered by the physician to prevent thrombosis. These orders are typically delegated to a nurse, but may include the participation of a physical therapist and others trained to perform the intervention. are to perform range of motion (ROM) activities that include: muscle contractions of the lower legs for those who are very weak, moving the feet, wiggling the toes, bending the knees, raise and lower the legs. In addition, changes in positioning prevents immobility and shifts areas of venous stasis. If the person is too weak to perform these preventative activities, hospital personnel will perform these movements independently. Exercise of the lower extremeties is a post-operative method of prophlaxsis. Nursing personnel will often perform range of motion exercises and encourage frequent moving of the legs, feet, and ankles. Frequent positioning changes and adequate fluid intake. After a surgical procedure, ambulation as soon as possible is prophylactic in preventing the formation of blood clots.

Early ambulation also prevents venous stasis and physicians order OOB activities on the same day of surgery. This is accomplished in increments. The progression of increasing mobility proceeds by: raising the head of the bed, sitting up in bed, moving to the edge of the bed, dangling the legs off the bed and then ambulating to a close chair.

Patient education and compliance reduces the risk of developing blood clots. These excerises and use of equipment and follow up by clinicians reduces the risk of developing blood clots.

Note that if a blood clot has already formed in the deep veins of the leg, bedrest is usually prescribed and the treatment to prevent bloods with physical intervention is contraindicated.

Anticoagulants and antiplatelets

Thrombosis prophylaxis is often prescribed for hospitalized patients routinely by a number of means. Anticoagulants are often prescribed. Pre-operatively some patients receive low-molecular-weight heparin once a day. Additional risk factors such as obesity, disease, malignancies, long surgeries, and immobility may influence the prescribed dosage. Anticoagulant medications prevent the formation of blood clots in people who are at high risk for their development. Treating blood clots that have already formed is managed by the use of anti-hemolytic ("clot busters"). The list below describes some of the more common medications used to prevent blood clots. Note that generally that since blood clotting is inhibited, a side effect typically is bleeding, though it can be reversed by administering a medication that stops the bleeding or by discontinuation of the medication itself. Anti-coagulant administration is often given before the start of the operation. There are concerns with the potential of increased risk of bleeding and so many surgeons start giving anti-coagulants the first 6 hours after surgery.Medications that inhibit blood clot formation include:

The discontinuation of contraceptives also prevents blood clots.

Herbal interactions

The therapeutic effects of warfarin may be decreased by valerian. Anticoagulants can be affected by chamomile. Dong quai, garlic, ginger, Ginkgo biloba, bilberry and feverfew can increase bleeding time. These same herbal supplements taken with warfarin increased prothrombin time.

Dietary interactions

Some foods act as antagonists to antiplatelet and anticolgulant medications. These foods contain Vitamin K (which is also given to treat bleeding): soybean oil, green leafy vegetables like spinach, legumes, and broccoli.

Contraindications

Preventing blood clots with medication is not considered safe in the following circumstances:

Adding heparin to the use of compression stockings may prevent thrombosis.

Research

An international registry and risk assessment calculator is being used to centralize data on post-surgical venous thrombosis and its prevention. Hospitals are implementing a multi-disciplinary approach to prevent of blood clots. This includes adequate assessment of the risks, follow up on missed doses of medication and instituting a 'patient-centered' approach endorsed by the Joint Commission. Recommendations regarding the prevention of blood clots vary widely between clinicians and treatment facilities. Research continues to clarify these discrepancies. The metabolic state of hypercoagulability (the tendency to form blood clots) tests are being developed. These include the evaluation of the thrombin–antithrombin complexes (TAT), low levels of the anticoagulants ATIII and protein C, but these tests are not yet widely available.