The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [128]
The use of antiembolic compression stockings.
The use of prophylactic anticoagulation.
Early mobilization after surgery.
External compression and decompression devices in those who cannot mobilize.
(Dolan and Fitch 2007, House of Commons Health Select Committee 2005, NICE 2007)
On admission or preferably prior to admission, all patients should have a risk assessment to assess both their individual risk for developing VTE and any risk factors for preventive therapies (National Clinical Guidelines Centre 2009).
Risk factors for the development of VTE
Active cancer or cancer treatment.
Age over 60 years.
Critical care admission.
Dehydration.
Known thrombophilias.
Obesity (Body Mass Index >30 kg/m2).
One or more significant co-morbidities.
Individual history or first-degree relative with a history of VTE.
Use of hormone replacement therapy.
Use of oestrogen-containing contraceptive therapy.
Varicose veins with phlebitis.
Pregnancy and up to 6 weeks following birth (special considerations).
(National Clinical Guidelines Centre 2009)
Antiembolic stockings (Graduated elastic compression stockings)
Graduated compression (antiembolic) stockings promote venous flow and reduce venous stasis not only in the legs but also in the pelvic veins and inferior vena cava (National Clinical Guidelines Centre 2009, NICE 2007, Roderick et al. 2005).
Thigh-length graduated compression/antiembolic stockings should be fitted from the time of admission to hospital unless contraindicated, for example peripheral arterial disease or diabetic neuropathy (NICE 2007) and until the patient has returned to their usual level of mobility. For details on measurement and fitting, see Chapter 14.
The use of prophylactic anticoagulation with low molecular weight heparin
Heparin interrupts the clotting cascade and can prevent clots. Different types of heparin affect clotting at varying levels and work in slightly dissimilar ways, depending on whether they are unfractionated heparin (UH) or low molecular weight heparin (LMWH). In addition, factor Xa inhibitors prevent the formation and development of thrombi.
Unfractionated heparin and LMWH are comparable in preventing VTE, but the advantage of LMWH over UH is that it has been shown to have a better side-effect profile with fewer adverse events (Lechler et al. 2006). Patients also rarely need to have regular clotting tests that are recommended for those on UH. The side-effects of LMWH include thrombocytopenia, liver abnormalities, skin rashes and minor bruising and so it should be used cautiously in patients who have renal failure (Dolan and Fitch 2007, National Clinical Guidelines Centre 2009, NICE 2007, Wilson 2007).
Patients who are at risk from VTE and are assessed as being able to receive LMWH should commence prophylactic treatment as soon as they have been assessed as at risk and continue with it as long as the risk remains. Patients will receive an injection which is administered subcutaneously once a day. There are several LMWH preparations available for use in the UK and Europe. Many patients will continue with LMWH on discharge from hospital and will therefore need to be taught how to self-administer or, if unable to undertake this, their family or a professional carer will need to administer the once-daily dose (National Clinical Guidelines Centre 2009, NICE 2007).
Intermittent pneumatic compression devices
Pneumatic compression devices, usually in the form of a calf boot attached to an external pump which constantly inflates and deflates, are used to promote venous return. They are most useful in patients who have been assessed as having high risk factors and are immobile following surgery or critical illness. The device can be used in combination with VTE compression stockings and LMWH.
The device is often applied in theatre or in critical