Deep Vein Thrombosis - Essay Example

Case Study Deep Vein Thrombosis 1 Introduction This case study will discuss the problem of Deep Vein Thrombosis (DVT). This research will present basic information about DVT, how it affects the individual and how it impacts overall health. The study will explore current literature on the topic as well as treatments that have been shown to work. It is estimated that at least 1 in 1,000 patients in the UK each year have DVT and about 25,000 people die of blood clots that develop when an individual is in the hospital (Patient UK, 2010). The behavioural changes associated with DVT are those that instruct the patient to stop any activity that will restricts the “free flow of blood within the lower extremities” (Skinner and Moran, 2008). This condition was chosen because it was interesting that there are so many different ways that DVT can develop. 2 Definition of DVT DVT is defined as a blood clot that appears in the thigh or lower leg. (National Health Lung and Blood Institute, 2009). The blood clot goes deep into the body and it is a result of blood thickening and then clumping together. When a blood clot goes deep into a vein, it can break off and move through the individual’s blood stream. Many people have heard about embolisms and this is what the lose clot is called. The blood clot can block blood flow to the lungs and heart at any time When it blocks off blood flow to the lungs, it is called a pulmonary embolism (PE) (National Health Lung and Blood Institute, 2009). PE can become so severe that it can cause damage to other organs and eventually will cause death. 2.1 Causes of DVT There are many situations in which DVT can begin. In some situations, a blood clot can happen after surgery. When an individual leads a very sedentary lifestyle without a lot of movement, the blood flow can become sluggish, which can allow the blood to clot in the veins. Some causes happen because of an inherited condition, hormone therapy, or taking birth control pills (National Health Lung and Blood Institute, 2009). 2.2 Risk Factors Most doctors and researchers say that there are only a few risk factors that they have been able to find in this situation. Some of the risk factors include injury to a deep vein after surgery, obesity, and having heart problems. Also, when people get older, they have a tendency to be more sedentary and DVT has been shown to happen in people over 60. 2.3 Signs and Symptoms of DVT The signs and symptoms of DVT are very subtle and most people will not know that they are ill. The other challenge is that only about 50% of people have symptoms before something larger begins to happen. Some of the signs and symptoms are: 1. Legs swelling or swelling along a vein in the leg. 2. Pain or tenderness in the leg, especially when standing or walking. 3. The leg feels warmer in one area than in the rest of the leg. 4. A read or discoloured area in the skin appears. 5. PE—which can begin with “coughing up blood, an unexplained shortness of breath, pain when deep breathing or rapid breathing with a fast heart rate” (National Health and Lung Institute, 2009). One important issue for people who suspect they have DVT is that they should go to their doctor immediately to check before it is too late. 3 The Literature on DVT There are many articles that have been written on different aspects of DVT and several research studies that have been done. Some of these studies are current and others are later than the last five years. This is a topic that has held interest among the researchers because doctors and researchers are not totally sure how they can stop it. Meissner et al. (2007) examined the various ways that the venous system works and the haemodynamics of haemo-circulation. This was a very helpful article because it explained how the venous system should work. The authors state that the primary function of the venous system is to send blood back to the heart. The venous system has a reservoir that promotes cardiovascular homeostasis as the volume of blood shifts through the venous system. When an individual has a venous system that is working properly, a “central pump, a pressure gradient, a peripheral venous pump and competent venous values” (Meissner et al., 2007, p. 65) work together to pump blood back and forth through the heart. The venous wall will change shape as the pressure, volume and flow change in the veins. Usually, these volume shifts are accommodated easily by the venous system. A dynamic pressure is executed when the heart pumps blood. The largest amount of this pressure will dissipate once it reaches arterial circulation. The rest of the energy that comes from this dynamic pressure will stay within the venous system (Meissner et al., 2007). When all of these areas in the venous system are working well, clotting in the veins does not occur; when something blocks the flow at any point, clotting can occur. This information is needed so that people can understand that they have to pay attention to their veins. Matharu and Porter (2010) add to this discussion by describing how DVT happens as a result of major trauma. Trauma can affect people differently and the possible development of venous thrombosis is higher if patients do not receive thromboprophylaxis treatment after the trauma. This development is based on three components: abnormalities in the wall of blood vessels, blood constituents and blood flow. One or all of these components can be damaged in trauma. As an example, individuals who have fractures or who have injuries that come from crashes or penetration injuries can have damage to the walls of their blood vessels. Also, when an individual experiences long periods of immobility as they may experience after a car accident or other debilitating accident, they can experience venous stasis which can put them at increased risk for DVT (Matharu and Porter, 2010). Unfortunately, according to these researchers, there are no specific risk factors that have consistently been found to predict DVT after injury. 4 The Management of Infection When an individual’s immune system is healthy, it can move waste or infection out of the body through physical barriers that include the “skin, mucous membranes, tears, earwax, mucus and stomach acid” (Tunkel, 2008). These physical barriers in the body work to assist the immune system during infection. The body also produces an increase of white blood cells (called neutrophils and monocytes) to “engulf and destroy” the microorganisms that are invading the body. First the neurophils increase to take care of the infection. If the neurophils cannot totally stop the infection, an increase of monocytes happen, especially when the infection continues over a long period of time. Some infections will decrease the white blood cells automatically like cancer or HIV infection. When there is an injury, inflammation will automatically occur to attempt to fight the problem. The body releases substances that tell it to begin to repair itself. The blood supply increases and the infected area becomes warm to the touch. The blood vessel walls are made more porous and this allows the white blood cells to move to the affected areas. The white blood cells will attack the microorganisms and the substances are released that help the inflammation continue. There are other substances that will trigger clotting in the capillaries in the area that is inflamed. The nerves will be stimulated at this point, causing the individual to feel pain (Tinkel, 2008). In looking at how the body works with infection, it is clear to see that when DVT is happening, the immune system is working to try and heal the situation but there may be too many microorganisms or the individual may be immobile for too long a period of time, which causes venous stasis and leads to a blood clot. In responding to injury, the body releases inflammatory chemicals which form adhesions (fibrous scar tissue). In DVT, inflammation can be acute or chronic. When it is acute, it can be the result of an injury that the patient experienced prior to or during DVT (American College of Foot and Ankle Surgeons, 2011). However, infection does not usually occur unless an individual had a previous diagnosis of a disease like diabetes prior to the DVT (Foot Education ,2009). 5 Upper Extremity DVT Joffe et al. (2004) studied upper-extremity DVT in almost 600 patients. As stated previously, DVT generally occurs in the lower extremities so this study shed light on the fact that it can happen anywhere in the body. Upper extremity DVT can happen after pacemaker use or long-term use of a central venous catheter and it can happen as a result of cancer. The point of their study was to examine both lower and upper DVT in their patients. They wanted to understand the “epidemiology, prophylaxis, and initial management” (Joffee et al., 2004 p. 1605). They found that the risk factors are actually different and they found that more research should be done in this area because most research has to do with lower extremity issues. They provided the registry to show a contemporary profile of these patients and to provide research on the topic to add to the literature. Levin (2003) states that upper extremity DVT is actually uncommon but it has been something that is growing in importance. Levin (2003) states that there are three different settings that upper level DVT can happen: in younger individuals who are engaging in strenuous exercise like weightlifting, it can also be hereditary when others in the family have had some type of thrombosis, and in patients “with an underlying hypercoagulable state” (Levin, 2003, p. 637) which means that the individual would need anticoagulants in order to help their condition. Often this type of thrombosis is difficult to detect because it has different symptoms than lower extremity DVT. The patient can present with severe pain, some discolouration, and swelling or they can just report mild discomfort, an aching in a certain area and distressing pain. However, The American Thoracic Society (1999) has stated that the use of ultrasonography, contrast venography or magnetic resonance imaging can help to distinguish upper-extremity DVT from other diseases. Meetoo (“In to..” 2010) states that studies have shown that at least 72% of patients using central venous catheter are susceptible to upper-extremity DVT, which means that this is an area that physicians should be aware of when their patients are using these catheters. Meetoo (2010) suggests that there are many therapeutic interventions that can be done to help. The typical way to manage upper extremity DVT is to use unfractionated heparin as soon as the individual is diagnosed and then to follow up with oral anticoagulation with warfarin for a 3-6 month period. Also, some studies have shown that “subcutaneous injections of low-molecular-weight heparin” (p. 469) could work as a bridge to warfarin therapy if needed. Warfarin inhibits the vitamin K-dependent clotting factors and helps the blood stop clotting. Galanaud et al. (2009) studied patients with distal or calf DVT because in other literature it was seen as less severe than other forms of DVT, and this meant that there are no real clinical trials about how interventions could be used to help in this condition. They found that when an individual had cancer, this type of DVT could be more prevalent than in other cases and can be linked to cancer. Spaniolas et al. (2008) state that upper extremity DVT may be an aspect of trauma that is not always diagnosed. There is evidence that supports that there is a growing danger of upper extremity DVT because many people after a traumatic situation have developed a thrombosis but it does not come from lower extremity DVT. They suggest that a routine screening of patients who are at risk for upper extremity DVT should be done in order to detect this problem before it happens. However, there is no way to tell who is at risk or who is not at risk for DVT (Spaniolas et al. 2008). The researchers have used Duplex ultrasonography on a weekly basis to discover DVT in trauma patients. 6 Interventions for DVT There are many interventions that have been seen to assist in work with patients who have DVT. Vedantham (2008) states that the use of anticoagulant drugs are not the best way to treat DVT. Instead, endovascular thrombolysis should be used where possible as long as there is not a risk for bleeding in the patient. This therapy is showing promise according to Vendatham (2008) for improvement in DVT outcomes but it is not known when to use it properly at this time. The author suggests that there needs to be more clinical trials on this measure coming from the United States; perhaps this is because there are more people in the United States who suffer from this disease. Meetoo (2010) suggests that the way to intervene in these instances is to do things that will prevent clotting, prevention of new embolisms and the prevention of recurrent thrombosis. He states that traditional methods of treatment include clinical doses of heparin and the use of “graduated elastic compression stockings” (Meetoo, “In to..” 2010, p. 1026) to reduce the risk of having more thrombosis or continued thrombosis in the area. Prins et al. (2007) state that the challenge with DVT is that there are no clear patterns for how patients deal with DVT so it is unclear when the patient may be able to stop using anticoagulants or other interventions for DVT. Their study also wondered whether some patients, particularly those with secondary DVT should have anticoagulant therapy longer than the three months that is currently recommended (Prins, et al 2007). They state that this is just one of the areas that need to be taken into consideration when prescribing therapy and medication for those people who are experiencing DVT or who may be at risk for experiencing it after certain conditions (Prins et al., 2007). Traditional treatment for DVT is medication that is distributed through a primary doctor or a vascular surgeon, that may include heparin that will be given for five to seven days, and this may be followed up by warfarin for about six months (Society for Vascular Surgery, 2010). 7 Conclusion Deep vein thrombosis is a problem that many people do not know that they have because there are no symptoms. According to Patient UK (2010), it affects one in one thousand people each year. This can happen after surgery, especially when there is trauma (Matharu and Porter, 2010) or when someone is using a venous catheter, or when pace maker is used over time (Meetoo 2010). The challenge is that there are no real risk factors that can predict if and when an individual will have DVT. When the blood is sluggish, when some women use birth control pills or when there is surgery, the patient can have DVT, but not every patient in these conditions will have it (National Health Lung and Blood Institute, 2009). More research has to be done on upper extremity DVT because most of the literature is connected to lower extremity DVT (Joffe et al. 2004; Levin, 2003; Meetoo, 2010). However, both types of DVT have different ways of expression and they are different in their symptoms. The best thing that people can do is to have an duplex ultrasound after their surgery and to have this checked several times a year to make sure that they are not being bothered by this issue. Otherwise, it can lead to death if it goes undetected. References AMERICAN COLLEGE OF FOOD AND ANKLE SURGEONS. (2011). Foot health facts: Acute Inflammation. [Online]. Available from http://www.footphysicians.com/footankleinfo/inflammation.htm [Accessed 2 July 2011]. FOOT EDUCATION. (2009). Surgical complications. [Online]. Available from http://www.footeducation.com/foot-and-ankle-surgical-complications#dvt [Accessed 2 July 2011]. GALANAUD, J.P., QUENET, S., RIVRON-GUILLOT, K., QUERE, I., SANCHEZ MUNOZ-TORRERO, J.F., TOLOSA, C., MONTREAL, M., and THE RIETE INVESTIGATORS. Comparison of the clinical history of symptomatic isolated distal deep-vein thrombosis vs proximal deep vein thrombosis in 11,086 patients. Journal of Thrombosis and Haemostasis, Vol. 7, pp. 2028-2034. [online]. Available from doi:10.1111/j.1538-7836.2009.2034. [Accessed 17th June 2011] JOFFEE, H.V., KUCHER, N., TAPSON, M.D. AND GOLDHABER, S.Z. (2004). Upper extremity deep vein thrombosis: A perspective registry of 592 patients. Circulation, Vol. 110, pp. 1605-1611 [online]. Available from doi: 10.1116/o1.CIR.0000142289.94369.D7 [Accessed 18th June 2011]. LEVIN, M. (2003). Upper-extremity deep vein thrombosis: limits and frontiers. SoutherMedical Journal, Vol. 96, pp. 637-638. Available from MEDLINE database. [Accessed 18th June 2011]. MATHARU, G.S. and PORTER, K.M. (2010. Deep vein thrombosis in major trauma. Trauma, Vol. 12, pp. 161-169 [online]. Available from doi:10.1177/1460408610374148. [Accessed 17th June 2011] MOTTO, D. (2011). Clues to DVT pathogenesis. Blood, Vol. 117 (4), pp. 11006-1107. [online] Available from doi://10.1182/blood-2010-11-315879. [Accessed 17th June 2011]. MEETOO, D.L. [2010]. The management of upper-extremity deep vein thrombosis. Nurse Prescribing, Vol. 8 (10), pp. 466-472 [online]. Available from CINAHL with Full Text database. [Accessed 20th June 2011]. MEETOO, D. L. (2010). In too deep: understanding, detecting and managing DVT. British Journal of Nursing. Vol. 19 (16), p p1021-1027. [online] Available from CINAHL with Full Text database. [Accessed 20th June 2011]. NATIONAL HEALTH LUNG AND BLOOD INSTITUTE. (2009). What is deep vein thrombosis? Available from http://www.nhlbi.nih.gov/health/dci/ Diseases/Dvt/DVT_WhatIs.html [online]. [Accessed 19th June 2011]. PATIENT UK. (2010). Deep vein thrombosis. Available from http://www.patient.co.uk/health/Deep-Vein-Thrombosis.htm [Accessed 20th June 2011] PRINS, M.H., LENSING, A.W., GHIRARDUZZI, A., AGENO,W., IMBERTI, D., SCANNAPIECO, G., AMBROSIO, G.B., PESAVENTO, R., CUPPINI, S., QUINTAVALLA, R., AND AGNELLI, G. (2007). Residual Thrombosis on Ultrasonography to Guide the Duration of Anticoagulation in Patients With Deep Venous Thrombosis. Annals of Internal Medicine, Vol. 150 (9), pp577-W:102. [online]. Available from Academic Search Premier database. [Accessed 22nd June 2011]. SKINNER, N. AND MORAN, P. (2008). CMAG: Deep vein thrombosis (DVT). [online], Available from www.cmsa.org/portals/0/pdf/CMAG_DVT.pdf [Acessed 2nd July 2011]. SOCIETY FOR VASCULAR SURGERY. (2010). Deep vein thrombosis. Vascular Web. Available from http://www.vascularweb.org/vascularhealth/Pages/deep-vein-thrombosis-(-dvt-)-.aspx [Accessed 22nd June 2011]. SPANIOLAS, K., VELMAHOS, G.C., WICKY, S., NUSSBAUMER, K., PETROVICK, L., GERVASIN, A., DE MOYA, M., AND ALAM, H. (2008). Is Upper Extremity Deep Venous Thrombosis Underdiagnosed in Trauma Patients?. American Surgeon, Vol. 74 (2) pp124-128 [online]. Available from Academic Search Premier database. [Accessed 20th June 2011]. TORPY, J.M. (2011). Thrombophlebitis. JAMA, Vol. 305 (13), pp. 1372 [online]. Available from MEDLINE database. [Accessed 18th June, 2011]. TUNKEL, A.R. (2008). Defense against infection. Merck Manuals. [online]. Available from http://www.merckmanuals.com/home/SEC17/ch188/ch188d.html [Accessed 19th June 2011]. VEDANTHAM, S. (2008). Intervention for deep vein thrombosis: Re-emergence of a promising therapy. The American Journal of Medicine, Vol. 121, pp. S28-S39. [online]. Available from doi: 10.1016/j.amjmed.2008.08.007 [Accessed 18th June 2011]. Bibliography AMERICAN THORACIC SOCIETY. (1999). The diagnostic approach to acute venous thromboembolism: Clinical practice guideline. [Online]. Available from www.thoracic.org/statements/resources/respiratory-disease.../venous1-24.pdf [Accessed 22nd June 2011]. BACCARELLI, A., MARTINELLI, I., ZANOBETTI, A., GRILLO, PL, LI-FANG, H., BERTAZZI, P.A., MANNUCCI, P, MANNUCCI, M.D., AND SCHWARTZ, J. (2008). Exposure to Particulate Air Pollution and Risk of Deep Vein Thrombosis Arch Intern Med. 2008, Vol. 168 (9) pp. 920-927. [online]. Available from http://www.genitoriantismog.it/testi_doc/trombosi.pdf [Accessed 22nd June 2011]. FERNANDEZ, M, POLLARD, H., AND MCHARDY, A. (2007). A patient with deep vein thrombosis presenting to a chiropractic clinic: a case report. Journal of Manipulative & Physiological Therapeutics, Vol. 30 (2), pp. 144-51 [online]. Available from CINAHL with full text database. [Accessed 22nd June 2011]. GRANT-FORD, M. AND MIDDLEMAS, D. (2007). Acute Deep-Vein Thrombosis in an Active Male College Student: A Case Report. Athletic Therapy Today Vol. 12 (1). p p26-30. [online]. Available from Academic Search Premier database. [Accessed 22nd June 2011]. GUZZO, J.L., CHANG, K., DEMO J., BLACK, J.H. AND FREISCHLAG, J.A. (2010). Preoperative thrombolysis and venoplasty affords no benefit in patency following first rib resection and scalenectomy for subacute and chronic subclavian vein thrombosis. Journal Of Vascular Surgery: Official Publication, The Society For Vascular Surgery [And] International Society For Cardiovascular Surgery, North American Vol. 52 (3), pp. 658-6. [online]. Available from MEDLINE database. [Accessed 20th June 2011]. SPENCER, F.A., GORE, J.M., LESSARD, D.M., DOUKETIS, J.D., EMERY, C. AND GOLDBERG, R.J. (2008). Patient outcomes after deep vein thrombosis and pulmonary embolism: the Worcester Venous Thromboembolism Study. Archives of internal medicine Vol. 168 (4) [online]. Available from http://works.bepress.com/robert_goldberg/176 WEE-SHIAN, SPENCER, F.A., AND GINSBERG, J.S. (2010). Anatomic distribution of deep vein thrombosis in pregnancy. CMAJ: Canadian Medical Association Journal, Vol. 182 (7), pp. 657-660. [online]. Available from MEDLINE database. [Accesed 20 June 2011]. Appendix What the blood clot looks like in leg Reference: Mayo Clinic http://www.mayoclinic.com/health/medical/IM00928 Duplex Ultrasound for detection of DVT Compression stockings Reference: Vascular Web http://www.vascularweb.org/vascularhealth/Pages/deep-vein-thrombosis-(-dvt-)-.aspx Read More