Post-Operative Complications: Deep Vein Thrombosis

Post-Operative Complications: Hemorrhage and Deep Vein Thrombosis

Deep Vein Thrombosis (DVT)

• Blood clot in a deep vein, most serious complication
• Clot can dislodge and travel to the lungs, a medical emergency
• Range in size from 1 mm in diameter to a mass that can completely obstruct the vein
• Deep veins are thin walled and run parallel to arteries with unidirectional flow back to the heart

Venous Thrombus (Clot)

• Composed of RBC, WBC, Platelets, Fibrin, and a tail-like appendage
• Tail grows or propagates in the direction of blood flow
• Likes valves of veins where venous stasis occurs
• Can occlude lumen

Contributing Factors (Virchow's Triad)

• Stasis of the blood/alterations in blood flow
• Endothelial injury/vessel wall injury
• Altered blood coagulability

Predisposing Factors for DVT

• Venous Stasis:
  • Bedrest, bedridden, immobilization
  • Obesity
  • History of varicosities
  • Heart failure/shock
  • Veins dilated with certain medications
  • Spinal cord injury (SCI)
  • Age
  • Surgery (past 3 months)
  • Anesthesia
  • Cast
  • Driving/flying
• Vessel Wall Injury:
  • Fractures and dislocations
  • Diseases of veins
  • Trauma
  • Chemical irritation
  • Central venous catheters
  • Repetitive motion injury
• Altered Blood Coagulability:
  • Blood dyscrasia
  • Oral contraceptives (OCP)
  • Hormone replacement therapy (HRT)
  • Polycythemias
  • Deficient blood volume
  • Stress response
• Others:
  • Pregnancy
  • Cancer
  • Smoking
  • Height
  • Family history
  • History of DVT + PE

Upper Extremity Venous Thrombosis

• Less common than lower extremity
• Reasons: IV catheters, disease states, trauma, dialysis catheters, central lines, and effort thrombosis

Prophylaxis (Prevention)

• Doctor's orders
• Anticoagulation:
  • Unfractionated Heparin (UFH) or Low Molecular Weight Heparin (LMWH)
  • Can decrease risk of DVT by up to 50%
• Mechanical:
  • Intermittent pneumatic compression device
  • Graduated compression stockings

Clinical Manifestations

• Superficial Veins:
  • Pain/tenderness
  • Redness
  • Warmth
  • Most dissolve spontaneously
• Deep Vein Thrombosis (DVT):
  • No symptoms to nonspecific
  • Tenderness affected limb
  • Pain
  • Edema/Swelling
  • Discoloration or redness
  • Increased skin temperature
  • Superficial veins prominent

Suspected DVT

• Report immediately
• Nurse can elevate leg but avoid pressure on suspected thrombus area
• No massage area
• Homan's Sign on calf pain or dorsiflexion contraindicated when DVT suspected

Diagnostics

• Duplex Ultrasonography
• D-dimer Blood Test
• Contrast Venography
• MRI/CT

Goal of DVT Management

• Stop the clot from getting any bigger
• Prevent the clot from breaking loose and causing a pulmonary embolism (PE)
• Reduce the chance of deep vein thrombosis again
• Prevent Post-Thrombotic Syndrome (PTS)

Treatment Options

• Pharmacological Therapy:
  • Anticoagulant Therapy
  • Thromboembolytic Therapy
• Surgical Management:
  • Thrombectomy
  • Catheter-Directed Thrombolysis
  • IVC filter
  • Ligation, clips

Anticoagulation Agents

• Unfractionated Heparin (UFH)
  • Prevent extension or development of new thrombi
  • Intermittent or continuous IV infusion for 5 days
• Low Molecular Weight Heparin (LMWH)
  • Used for some DVTs, prevents extension or new thrombi
  • Longer half-life, given SQ, decreased risk of HIT
• Fondaparinux (Arixtra)
  • Synthetic inhibitor of factor Xa
  • Treats and prevents DVT and PE
  • No reversal agent, never causes HIT

Anticoagulation Therapy Monitoring

• Bleeding
• Thrombocytopenia
• Heparin induced thrombocytopenia (HIT)
• Regular monitoring of blood levels, counts, and INR

Teaching

• Self-injections – site and technique
• Avoid injury
• Signs and symptoms to report
• Medications interactions
• Diet
• Routine monitoring required
• Communicate anticoagulation to all other HCP

Client Comfort and Healing

• Adjuncts to therapy: activity, elevation, warm moist packs, analgesics
• Walking preferred over sitting/standing
• Bed exercises
• Hydration

Pulmonary Embolism (PE)

• Collection of particulate matter (solids, liquid, gaseous) enters systemic venous circulation and lodges in pulmonary vessels
• Obstructs pulmonary circulation causing impaired gas exchange, constriction of regional blood vessels, and bronchioles
• Decreases oxygenation
• Can be fatal
• Caused by blood clot, foreign body, tumor, fat emboli, amniotic fluid, pus

PE Risk Factors

• Immobilization/paralyzed
• Surgery
• Trauma
• Increased blood coagulation
• History of varicose vein(s)
• Obesity, smoking, pregnancy, OCP, CHF, stroke
• History
• Age
• Septic
• Cancer + therapy

PE Pathway

• Deep veins of the legs
• Most lethal from femoral or iliac veins
• Right side of heart and upper extremities
• Pelvic veins

Signs and Symptoms (PE)

• Dyspnea
• Tachypnea
• Tachycardia
• Chest pain/chest wall tenderness
• Syncope
• Diaphoresis
• Anxiety/apprehension
• Cough/hemoptysis
• Hemoptysis

Diagnostic Tests and Assessment

• Computed tomographic pulmonary angiography
• Ventilation-perfusion scan (V/Q)
• Pulmonary angiography
• MRI
• CXR
• ECG
• Peripheral vascular studies
• ABG's

Interventions

• Goals: increase alveolar gas exchange, improve tissue perfusion, get rid of embolism, prevent complications
• Pharmacological Therapy:
  • Anticoagulation
  • Thrombolytics
• Surgical Management:
  • Embolectomy
  • Clips
  • Filter