Guideline Quick View: Venous Thromboembolism

Transcription

1 Guideline Quick View: Venous Thromboembolism The AORN Guideline Quick View is a key component of Guideline Essentials, a suite of online implementation tools designed to help the perioperative team translate AORN s evidence- based guidelines into practice. Each Guideline Quick View highlights important elements of the full guideline and includes images, implementation steps, and the rationale for why these steps are important to promote safety and optimal outcomes for patients undergoing operative and other invasive procedures. Access to the full set of Guideline Essentials is included with AORN membership. To access them online, visit Facilities can provide team access to these resources by purchasing a subscription to Guidelines Plus and other products on the AORN Facility Reference Center platform. For more information, visit PREVENTION PROTOCOL Establish and implement a protocol for the prevention of venous thromboembolism (VTE) that: - is evidence-based - is easy to use in clinical practice - includes a standardized assessment of VTE and bleeding risk - provides clinical decision support for evidence-based prophylaxis based on level of risk for VTE and bleeding - includes a start time (eg, upon admission, before surgery, after surgery) for all types of prophylaxis based on the clinical condition of the patient - uses alerts to notify clinicians of a potential lapse in prophylaxis according to the VTE protocol An organization-wide protocol that is developed using evidence-based professional guidelines and that includes clinical decision support for prophylactic choices prompts health care providers to give consistent and effective care for the prevention of VTE. VTE prophylaxis may be pharmaceutical or mechanical. Mechanical prophylaxis includes the use of intermittent pneumatic compression devices, use of graduated compression stockings, early ambulation, and foot and ankle exercises. PREOPERATIVE PATIENT ASSESSMENT Conduct a preoperative patient assessment to determine VTE risk factors, - age greater than 40 years - cancer or cancer treatment - obesity - previous history of VTE or stroke - prolonged bed rest or immobilization longer than 3 days - varicose veins - presence of a central venous catheter - trauma - spinal cord injury - inherited or acquired thrombophilia AORN, Inc, 2018 AORN Journal 281

2 - estrogen therapy - critical care admission - dehydration - comorbidities (eg, heart disease, metabolic/endocrine disease, respiratory disease, acute infectious disease, inflammatory conditions) - pregnancy and the postpartum period - smoking - steroid therapy - ASA physical status classification of 3 or higher - recent surgery - preoperative hospitalization - blood transfusion - known non-o blood type - obstructive sleep apnea - asplenia The causative factors of venous thrombus formation, commonly referred to as Virchow s Triad, include venous stasis, vessel wall injury, and hypercoagulability. The preoperative assessment provides information necessary to determine the individual patient s risk for VTE and identify prophylactic measures recommended by the health care organization s VTE protocol. - any open procedure - emergency procedure - concurrent procedures - transplant surgery - cesarean delivery - major foot and ankle surgery - major hand, wrist, or elbow surgery - procedures involving hardware placement - major plastic surgery All perioperative patients including children may be at risk for VTE because of immobility, vessel injury, and compression of tissue caused by retraction and patient positioning requirements. PROCEDURE- RELATED RISK FACTORS Conduct a preoperative patient assessment for procedure-related risk factors, - duration of surgery (ie, longer than 90 minutes, or longer than 60 minutes for procedures involving a lower limb or the pelvis) - intraoperative patient position (eg, excessive hip flexion, hyperextension of the knee, reverse Trendelenburg) - use of a pneumatic tourniquet - major orthopedic surgery - bariatric surgery - cardiothoracic surgery - vascular surgery - urologic or general surgery involving the abdomen or pelvis - neurosurgery - spine surgery - immobilizing cast of a lower extremity INTERMITTENT PNEUMATIC COMPRESSION DEVICES use of intermittent pneumatic compression devices, - any leg condition that the device may exacerbate (eg, dermatitis, recent skin graft) - known allergy or sensitivity to the sleeve or tubing material - cardiac failure or pulmonary edema from congestive heart failure - any factor that prevents correct fitting of the sleeves (eg, exceeding size limit, severe leg edema, deformity) - preexisting deep vein thrombosis - severe arteriosclerosis or other ischemic vascular disease Notify the prescriber and anesthesia professional of any contraindications to use of the device. 282 AORN Journal

3 Apply the device according to the manufacturer s instructions for use. When applying the sleeves, place the tubing on the external surface of the sleeve facing away from the patient s skin and away from locations that may create a pressure injury. Leave the intermittent pneumatic compression device in place for a minimum of 18 hours daily during the intraoperative and immediate postoperative period. of pneumatic compression devices, - skin injury - hypothermia - numbness, tingling, discomfort, or pain - ischemia Intermittent pneumatic compression reduces VTE risk while also reducing the risk for major bleeding in surgical patients. The addition of intermittent pneumatic compression to pharmacologic prophylaxis reduces the risk for VTE compared to either modality alone. GRADUATED COMPRESSION STOCKINGS use of graduated compression stockings, - any skin conditions that stockings may exacerbate (eg, dermatitis, recent skin graft, leg ulcer) - any vascular conditions that stockings may exacerbate (eg, peripheral vascular disease, peripheral arterial bypass grafting, severe arteriosclerosis) - severe peripheral neuropathy or other sensory impairment - gangrene - known allergy or sensitivity to stocking material - cardiac failure or pulmonary edema from congestive heart failure - any factor that prevents correct fitting of stockings (eg, exceeding the size limit, severe leg edema, deformity) Notify the prescriber and anesthesia professional of any contraindications to use of the stockings. Fit graduated compression stockings to the individual patient. Measure the patient s legs separately and according to the manufacturer s instructions. Apply graduated compression stockings before the administration of regional or general anesthesia. Verify that: - stockings are not rolled up the foot or down the leg - stockings are smooth when fitted - toe holes lie underneath the toes - heel patches are in the correct position - thigh gussets are positioned on the inner thigh Do not use elastic bandages as a replacement for graduated compression stockings. For patients who develop postoperative leg edema, remove the stockings, remeasure the legs, and refit the stockings. of graduaated compression stockings, - skin injury - numbness, tingling, discomfort, or pain - proximal indentation from knee-length graduated compression stockings - ischemia Graduated compression stockings are often used in combination with intermittent pneumatic compression devices and pharmaceutical prophylaxis. Patients may be harmed by wearing graduated compression stockings when the stockings are incorrectly worn or sized. AORN Journal 283

4 PHARMACOLOGIC VTE PROPHYLAXIS use of pharmacologic VTE prophylaxis, - active bleeding - previous major bleeding - known, untreated bleeding disorder - severe renal or hepatic failure - thrombocytopenia - acute stroke - uncontrolled systemic hypertension - lumbar puncture or epidural or spinal anesthesia within the previous 4 hours or subsequent 12 hours - concomitant use of anticoagulants, antiplatelet therapy, or thrombolytic drugs - procedures in which bleeding complications may have especially severe consequences (eg, craniotomy, spinal surgery, spinal trauma, reconstructive procedures involving a free flap) - bacterial endocarditis - allergy to medication - pregnancy - ophthalmic surgery - prosthetic heart valve Notify the prescriber of any identified contraindica tions. of pharmacologic VTE prophylaxis, - bleeding - hematoma - thrombocytopenia - osteoporosis and osteopenia - skin necrosis - calciphylaxis - atheroembolism - injection site irritation, pain, bruising, bleeding, or itching - Notify the prescriber and anesthesia professional of any identified adverse effects. Pharmacologic prophylaxis consists of administering anticoagulant mediations that inhibit blood clotting. The pharmacologic regimen may include medications such as low molecular weight heparin, low-dose unfractionated heparin, warfarin, factor Xa inhibitors, dabigatran, vitamin K antagonists, or aspirin. POSTOPERATIVE MOBILITY Help the patient to ambulate as soon as possible after surgery. Collaborate with the perioperative team to minimize barriers to postoperative ambulation, - inadequate pain control - pain management techniques that reduce patient mobility (eg, regional anesthesia) - an indwelling catheter - IV infusion - lack of patient motivation (sedation) Implement measures to prevent falls during postoperative ambulation. Instruct the patient to perform postoperative foot and ankle exercises. Ambulation decreases venous stasis by creating natural compression of the venous system through muscle contraction and compression. Foot and ankle exercises decrease venous stasis by creating natural compression of the venous system through muscle contraction. 284 AORN Journal

5 PREOPERATIVE AND POSTOPERATIVE INSTRUCTIONS Provide the patient and his or her designated caregiver(s) with written and verbal instructions on prevention of VTE, including information about: - the common signs and symptoms of deep vein thrombosis or pulmonary embolism (eg, leg pain, swelling, unexplained shortness of breath, wheezing, chest pain, palpitations, anxiety, sweating, coughing up blood) - the importance of mobilization, including ambulation and foot and ankle exercises - maintaining adequate hydration - preventive measures to use when traveling long distances after surgery (eg, frequent ambulation; calf muscle exercise; wearing fitted, knee-length graduated compression stockings) - elevating the legs - avoiding clothing that constricts the lower extremities - avoiding sitting with knees bent or legs crossed for long periods of time - avoiding sitting or standing for long periods of time Provide the patient receiving mechanical prophylaxis with preoperative and postoperative instructions, - the benefits of mechanical prophylaxis - the importance of compliance - instruction on removal and reapplication of graduated compression stockings and intermittent compression devices - the importance of postoperative ambulation - the potential for skin injury (eg, marking, blistering), ischemia, numbness, tingling, discomfort, or pain - who to contact if the patient has problems using the prescribed prophylaxis Provide the patient receiving pharmacologic VTE prophylaxis with preoperative and postoperative instructions, - the importance of following through with medicationrelated laboratory tests - the importance of continuing medication post discharge as prescribed - who to contact if there are any problems self- administering the prescribed pharmacologic prophylaxis - the importance of not stopping medication or not starting new medication, including over-the-counter medications (eg, aspirin, ibuprofen), without consulting the physician - potential adverse effects and when to seek medical attention - interactions with herbal and other over-the-counter preparations (eg, ginger, ginkgo biloba) - reporting signs of bleeding - carrying or wearing medication identification to let health care providers know that the patient is on anticoagulation therapy Education related to VTE prevention may reduce the patient s risk for developing VTE by increasing the patient s awareness and, potentially, compliance with prophylaxis. DOCUMENTATION Document activities for prevention of VTE, - pharmacologic prophylaxis administration (eg, medication, dose, time, route) - contraindications to mechanical or pharmacologic prophylaxis and actions taken - adverse effects from mechanical or pharmacologic prophylaxis and actions taken - patient education provided - the reason for any variance from the VTE protocol - the type and size of the intermittent pneumatic compression sleeve and graduated compression stockings applied - results of a fall risk assessment and measures taken to prevent patient falls during postoperative ambulation - application and removal times for all mechanical prophylactic measures - intermittent pneumatic compression device identification (eg, serial or biomedical number) and settings - results of a patient skin assessment for mechanical prophylactic measures Documentation in the patient s medical record provides a description of the perioperative care administered, status of patient outcomes upon transfer, and information to support continuity of care. Documentation provides data for identifying trends and demonstrating compliance with regulatory requirements and accreditation standards. AORN Journal 285