The Efficacy of Venous Thromboembolism Prophylaxis on Patient Post Lower Extremity Amputations - Term Paper Example

NURSING Student’s name Course & code Professor’s name University City Date The efficacy of venous thromboembolism prophylaxis on patient post lower extremity amputations: a literature review. Introduction As the world population increases so is the increase of incidences of diseases like diabetes mellitus, trauma, tumor or other limb deficiencies and infections. These has in turn increased the level of lower extremity amputations cases from the ancient to current world. Lower limb amputation (LLA) is a high risk surgical procedure done in patients majorly diabetic patients with end stage vascular disease (Dillingham et al., 2008) with the aim of eliminating dead tissues, where it varies from the partial removal of the toe to the entire removal of the leg even up to the pelvis girdle. It has also been observed that the incidences of lower limb are greater than the upper limb and it comes with more challenges (Ziegler et al., 2008). It has also been reported that among 100000 people, 18-20% patients in Netherlands undergo amputation, 66 in France and America having a high record of 500 patients amputated. (Ziegler et al., 2008) adds on that 1.7 million people in have undergone a limb loss. LLA may seem as a solution of the disease but after it the patient stands a high risk of getting a life threatening disorder known as Venous thromboembolism (VTE) the third most common vascular disease, heart attack and stroke (Bell et al., 2014).  It is a blood clot that starts in vein, having two categories that is; deep vein thrombosis (DVT) and pulmonary embolism (PE). DVT is known to be when the clot is in deep veins of the leg or the arms or other vein but when it breaks the vein wall and travels to the lungs where it can block some or all the blood flow it is known as PE. Venous thromboembolism causes significant morbidity in the lower limb and may result in death in the manner of massive pulmonary embolism. An estimate of 25% of patients submitted to general surgery is susceptible to DVT due to uncertainties in its occurrence. However, appropriate risk assessment and prophylaxis can minimize the risk of developing deep vein thrombosis (DVT) and pulmonary embolism (PE). In my clinical practice, all patients are on VTE prophylaxis and most of them are on pharmacological prophylaxis. In vascular unit, only few patient on mechanical prophylaxis. Guided by Clinical practice guideline for the prevention of venous thromboembolism in patient admitted to Australia hospitals (NHMRC 2009), doctors and nurses work together to ensure patient are prevented. There is lack of significant data on the effectiveness and safety of thromboprophylaxis in patients with major trauma, those with spinal cord injuries and those with hip or knee surgery as well. Method The research was conducted by the application of electronic search using Cumulative Index Nursing and Allied Health (CINAHL), Cochrane, PubMed and ProQuest databases. A Boolean search was conducted using the search terms; prophylaxis surgery, surgery and hospital, adult inpatients. Recommended search criteria and strategies for inclusion was applied, the articles were considered if were published between 2014 and 2017, written in English language and were peer reviewed with full text. The articles of literature reviewed covered different setting that include surgical, Intensive care units, medical and community. However, they all discuss the importance VTE risk assessment and the use of prophylaxis on adult inpatients and outpatients. Selected articles were based on adult patients. Discussion Lower limb amputations. An increase in lower limb amputation cases has been recorded since there has been an improved medical facilities that can handle diabetes mellitus and peripheral vascular disease. However, a study done by the Malta government (2011) recorded a decrease in patients who had undergone amputation by 33% between 2003 and 2010. Lower limb amputation has also been associated with age where it is generalized that the elderly are the most affected by the diseases that are the main cause LLA. A study done by NSH Scotland (2009) in UK shows that almost half of the individuals referred to prosthetic centers are elderly people with an average age of 65years, whereas another study shows that people with 60 years undergo amputations because of trauma and cancer while says that in the western world 80-90% undergo amputation caused by vascular disease. This implies that the elderly people are most associated with amputation simply because they are more susceptible to impairment of cognitive functioning. Cognitive impairment in elderly people is found to be higher due to increased risk of dementia, a clinical syndrome featured by progressive deterioration in brain functioning. This is supported by Rafnsson et al (2009) who found that between 5-10% of people with age 65years and more are normally affected by dementia which is higher up to 30% of persons with 80years. Cognitive impairment has also been associated with diabetes mellitus and peripheral vascular disease which are the main causes of lower limb amputation where peripheral vascular disease was found to cause 82% of all amputations performed in the US yearly as NLLIC (2008) reports, but diabetes mellitus was found to cause almost half of all cases of lower extremity amputation (Fosse 2009) due to high incidence of dementia and high level of cognitive functioning impairment (Verdelhoet 2009). Studies shows that trauma was the major cause of amputation in the developing countries (Kohler et al., 2009) and also that there are a lot of amputation cases in non-industrialized countries due to wars and accidents, however, it has been found that females are less affected by trauma than men. Venous Thromboembolism There is a high risk of VTE in patients who have undergone surgery, trauma as well as in pregnant and puerperal women ranging from 28-50% one month post lower limb amputation (Matielo et al., 2008). VTE incidences have been said to be more in patients in hospital than those who are at home. DVT in such patients may be symptomatic where it causes swelling and pain or asymptomatic and if this case is not well handled it can result to morbidity, recurrent thrombosis and death (Jameson et al., 2010). Referring to the million women study in UK, the results indicated that VTE significantly increased in the first 12 weeks after surgery although it is stated that the risk can increase even in a day after surgery depending on the type of surgery but highest level of risk were noted in lower extremity amputation and cancer surgery. Thus, prophylaxis of VTE is a necessary process in hospitalized patients although its rationale is more dependent on its efficacy, and its fatal impacts (Jameson et al., 2010). An evidence that continuous prophylaxis reduces morbidity and incidences of death exist but there is no significance number of reduced mortality after amputation as indicated in the recent data (Jameson et al., 2010). However, there is a contrary result showing that screening and treatment for DVT is not effective in terms of cost relative to routine prophylaxis in patients who are at risk of VTE (Jameson et al., 2010). Other than the mortality threat that exist if VTE is not treated, there is also a risk that comes with the treatment which is hemorrhage. Therefore, a proper diagnosis is a vital process in all patients not to forget that improper use of antithrombotic may not only increase the risk of hemorrhage but also the risk of recurrent thrombosis. VTE prophylaxis Pharmacological prophylaxis and mechanical prophylaxis are the two types of thromboprophylaxis and they are administered to patients depending on the level of amputation. They can be given one at a time or combined to complement one another (UK National Clinical Guidelines 2010). They all reduce the level of VTE or DVT and PE but pharmacological prophylaxis is linked with bleeding and reduced platelet level in the patients’ body. Mechanical prophylaxis has no sufficient evidence to cause bleeding but it is not recommendable for people with double lower extremity amputation, peripheral arterial disease. Geerts et al (2008) shows an evidence that pharmacological prophylaxis has been found to reduce the risk of VTE in patients who undergo lower limb amputation where they are supported by NICE Clinical Guideline (2010) who still supports the significance of pharmacological prophylaxis that it reduces the risk of pulmonary embolism. However some studies shows that heparin and antiplatelet drugs increase the rate of bleeding in patients at risk. Unfractioned heparin (UFH) prevents the formation of blood clots thus it acts as an anticoagulant. In 2010, UK national Clinical Guidelines states that UFH can be given subcutaneously or intravenously by injection since it has a short half-life thus a continuous and a frequent infusion is necessary. It has been reported that Lower Molecular Weight Heparin (LMWH) has a 4-5 hours half-life thus a once daily dose is enough. In another study it is stated that neither LMWH nor UF was superior over each other and there was no bleeding incidence when their effectiveness was compared 8 days after amputation. Another study results concerning PE showed that no matter the level of amputation, heparin was not superior over placebo. Adding pharmacological prophylaxis to compression was found to decrease the incidence of symptomatic PE in high risk patients as compared to compression alone. The reduction was form 2.7 to 1.1 for PE and from 4.0 to 1.6 for DVT. Adding compression to pharmacological prophylaxis was also found to be effective than using only pharmacological prophylaxis. Several studies shows that LMWH is effective in reducing the risk of both symptomatic and asymptomatic DVT by approximately 60% relative to placebo and also LMWH has been found to be more effective that UFH even more effective that warfarin in reducing the risk of DVT after LLA. Cohen et al (2007) argues that starting a dose of LMWH within first 8 hours after surgery was as well effective in lowering the bleeding complications as giving the dose 1 hour prior to surgery. In 2008 (Geerts et al) suggests that the supply of vitamin K antagonists is effective, unfortunately they are not widely used independently as a method of prophylaxis in Europe because they are less effective than LMWH and are associated with increased risk of bleeding as supported by (AAOS; 2007). On the other hand aspirin was found to reduce the risk of DVT by 25-30% relative to placebo but it was less effective than LMWH, warfin and fondaparinux in the few direct comparisons that have been done. However, Watson and Chee in 2008 suggested that aspirin should be continually supplied in the preoperative process to reduce the risk of DVT. The evidence that support the use of aspirin alone in thromboprophylaxis in not sufficient however patients who use it for other reasons have noted a small reduction in the risk of VTE. Similarity in efficacy is reported by Gomes et al (2011) between branded enoxaparin and generic enoxaparin in 170 patient who underwent abdominal surgery and he is supported by Lage et al (2007). The use of fondaparinux has been seen to be more effective than enoxaparin in reducing asymptomatic DVT but not symptomatic DVT (Ivanovic et al., 2007). However, a higher incidence of bleeding event has been noted as compared to LMWH. Unlike LMWH and UFH, fondaparinux does not inhibit thrombin but it inhibits coagulation. It is required that it be administered once daily by subcutaneous injection since it has a longer half-life hours (UK National Clinical Guidelines 2010). It is realized that the use of fondaparinux does not risk the patient to HIT because there is no interaction between it and the platelets. However, it is costly than heparin thus it is not widely used. In Europe and Canada, rivaroxaban has been found to prevent DVT in people who have undergone lower limb amputation (NICE 2009) but it has been associated with heavy bleeding as compared to LMWH. Mechanical performance A recent review by Cochrane found that use of Antiembolism stockings (AES) alone without combining them with other prophylaxis methods of reducing DVT is effective in all patients. Although Sachdeva et al (2010) found the main challenge to be the complicance of the patient given that the devices have to be used continuously while the patients is on a rest bed in the postoperative period so as to be effective. In a multicenter observational study of elective hip replacement, it was found that the combination of AES and pharmacological prophylaxis was more effective in reducing asymptomatic DVT that pharmacological prophylaxis alone. No evidence exist that the devices are able to reduce symptomatic DVT or PE. Period of prophylaxis Post-operative VTE is an essential process that comes after hospital discharge even when prophylaxis has been employed while the patient is in hospital Sweetland et al (2009) states that the benefit of post discharge prophylaxis with LMWH is greater in TRH than TKR patients. RCT results showed that patients given LMWH after hospital discharge had a reduction in the incidence of DVT from 2.7% to 1.1% as compared to those who only received it while in hospital. Sweetland et al (2009) also recommended that fondaparinux is effective after a hip surgery and that its use should be continued for 28 days without interruption. Bleeding risk There is a risk of increased bleeding that is linked with all forms of pharmacological prophylaxis although there is no evidence of a published comparison (Lassen et al., 2010). An RCT found that the overall risk of 'clinically significant' bleeding was 5% with LMWH while in another study it was found that the risk of 'major bleeding' (stroke or life threatening GI hemorrhage) was lowest for aspirin (Johansson et al., 2009). The use of pharmacological thromboprophylaxis post LLA reduces concerns about vertebral canal hematoma linked to central neuraxial regional anesthesia techniques which are widely practiced in lower limb orthopedic surgery. Conclusion Lower limb amputation is a life threatening procedure across the globe. It has had a successfully increase over many years due to increased number of patients. It may be caused by trauma, tumor, diabetes mellitus, uncontrollable infection as stated by Frutch et al (2009) and vascular disease with or without diabetes as well as landmine as argued by Surrency et al; (2009). It may involve partial or whole removal of leg. It has been more associated with the aged people with an average mean of 70 years in the U.S. VTE prophylaxis is essential in preoperative and post-operative process to facilitate the survival of the patient. Therefore proper diagnosis need to be done to all patients as a form of managing risk associated with DVT and PE. Both pharmacological and mechanical prophylaxis can be used as individual or combined in accordance to the clinical guidelines and prescriptions. References American Academy of Orthopaedic Surgeons. Clinical guideline on prevention of symptomatic pulmonary embolism in patients undergoing total hip or knee arthroplasty. Rosemont (IL): American Academy of Orthopaedic Surgeons (AAOS); 2007. [Cited Available from http://www.aaos.org/research/guidelines/PE_guideline.pdf Australian Government National Health and Medical Research Council (NHMRC) 2009, Clinical Practice Guideline for the prevention of venous thromboembolism in patients| admitted to Australian Hospitals. 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