The grades of the strength and consistency of evidence (A1, A2, B1, B2, C1, C2, D) are defined at the end of the "Major Recommendations" field.
Definitions
Venous thrombi: "intravascular deposits composed predominantly of fibrin and red cells, with a variable platelet and leukocyte component". They often happen in the presence of stasis. These are commonly known as "blood clots."
Deep veins: This discussion is limited to the deep veins of the lower extremity. They include: posterior tibial, anterior tibial, peroneal, popliteal, femoral (common femoral, superficial femoral, profunda femoris), and iliac veins.
Pulmonary embolism: A thrombus that becomes mobile and travels to the pulmonary vasculature obstructing pulmonary circulation.
Anticoagulant: A substance that inhibits, prevents, or suppresses clotting of blood.
Individuals at Risk for Deep Vein Thrombosis
All surgical patients are considered at some degree of risk for development of deep vein thrombosis (DVT). This guideline focuses on the prevention of deep vein thrombosis in the elderly surgical patient. Advancing age is a known risk factor.
See Appendix A in the original guideline document for a comprehensive review of individuals at risk for the development of DVT and the effect of aging on DVT.
Assessment Criteria
Refer to the "Target Population" field of this summary for a listing of patients who are likely to benefit the most from use of this evidence-based guideline:
Description of Intervention
- Risk factor assessment should be completed for every patient upon admission to the hospital for all unplanned admissions (see "Thrombosis Risk Factor Assessment for Surgical and Medical Patients" in Appendix B of the original guideline document for an example).
- Risk factor assessment should be completed pre-operatively for every patient whose surgical admission is planned (Caprini et al., 1991. Evidence Grade = C1).
- Thorough education is provided for patient and family members regarding the importance of DVT prophylaxis and their role in assuring compliance. Provide written as well as verbal information regarding the basic physiology about how blood flows to and from the heart, and the role of muscles in this process. Empower patients to be active participants in exercise, ambulation (if not contraindicated), and in the use of mechanical devices (Blondin & Titler, 1996. Evidence Grade = D).
- Appropriate prophylaxis should be initiated as soon as medically possible for unplanned admissions (Hamilton, Hull, & Pineo, 1994. Evidence Grade = A1).
- Appropriate prophylaxis should be initiated preoperatively for planned same-day admissions or on admission to the inpatient unit for those patients admitted on any day preceding their scheduled surgery (Hamilton, Hull, & Pineo, 1994. Evidence Grade = A1).
- Patients arriving to nursing units without orders for DVT prophylaxis: nursing staff should immediately notify responsible physician.
- All patients should have a plan for active and passive lower extremity activity unless contraindicated including flexion and extension of the ankle (ankle pumps), knees and hips. Involve Physical Therapy as appropriate. Provide written instructions, with pictures as well as a demonstration.
- Early and aggressive ambulation for all patients if not contraindicated by condition.
- If the following regimens are ordered, follow these guidelines:
- Graduated Compression Stockings (GCS): wear at all times except when removed for skin care or bathing. Replace within 30 minutes (Sigel et al., 1975).
- Measure each patient; do not "guess" size.
- Consider knee high GCS for patients unable to wear thigh high due to size, injury, or physician preference.
- Avoid stockings that threaten a "garter" effect at the calf, posterior knee or thigh.
- Re-measure postoperatively for patients undergoing lower extremity surgery.
- Note manufacturer's list of "contraindications for use" accompanying product prior to applying.
- Intermittent Pneumatic Compression Devices (IPCD): wear at all times when inactive. This includes when patient is in bed, resting in the chair, or at lengthy tests.
- Measure each patient; do not "guess" size.
- Consider knee high IPCD for patients unable to wear thigh high due to size, injury, or physician preference.
- Note manufacturer's list of "contraindications for use" accompanying product prior to applying.
- Foot Pumps: wear at all times when inactive. This includes when patient is in bed, resting in the chair, or at lengthy tests.
- Note manufacturer's list of "contraindications for use" accompanying product prior to applying.
- Anticoagulant Therapy per physician order.
- Continue GCS use after discharge for period of relative immobility (Caprini, Scurr, & Hasty, 1988; Clagett & Reisch, 1988. Evidence Grade = A1). This definition is variable and needs to be determined at your institution. A good rule of thumb is "up more than down". Hamilton, Hull, & Pineo, (1994) defined this as ambulating three to four hours per day (Evidence Grade = A1).
- Continue anticoagulant therapy after discharge per Licensed Independent Practitioner (LIP) order.
- Monitor for clinical signs and symptoms of DVT (50% confidence) such as calf pain or tenderness, palpable cords, increased circumference, positive Homan's sign (Hamilton, Hull, & Pineo, 1994. Evidence Grade = A1).
Definitions:
Evidence Grading
A1 = Evidence from well-designed meta-analysis or well-done systematic review with results that consistently support a specific action (e.g. assessment, intervention, or treatment)
A2 = Evidence from one or more randomized controlled trials with consistent results
B1 = Evidence from high quality evidence-based practice guideline
B2 = Evidence from one or more quasi experimental studies with consistent results
C1 = Evidence from observational studies with consistent results (e.g. correlational, descriptive studies)
C2 = Inconsistent evidence from observational studies or controlled trials
D = Evidence from expert opinion, multiple case reports, or national consensus reports
