Limb Ischaemia (Acute) 2.0 FINAL. Guideline adopted from the Bedside Clinical Guideline Partnership

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Hugh Sherman Nicholson
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1 Appendix FINAL Guideline adopted from the Bedside Clinical Guideline Partnership EQUALITY IMPACT The Trust strives to ensure equality of opportunity for all both as a major employer and as a provider of health care. This policy has therefore been equality impact assessed by the authorising body to ensure fairness and consistency for all those covered by it regardless of their individual differences, and the results are shown in Appendix 1. Version: 2.0 Final Authorised by: Surgery DMT Date authorised: April 2013 Next review date: April 2013 Document author: Mr C Pratap

2 VERSION CONTROL SCHEDULE Version :2.0 Final Version Number Issue Date Revisions from previous issue 1.0 (final) May Final April 2013 Amendment to flow chart

3 INDEX/ TABLE OF CONTENTS EQUALITY IMPACT... 1 INTRODUCTION... 4 PURPOSE... 4 SCOPE... 4 DEFINITIONS... 4 DUTIES... 4 GUIDELINE STATEMENT... 5 GUIDELINE DEVELOPMENT AND REVIEW... 7 IMPLEMENTATION... 5 MONITORING... 5 REVIEW... 5 REFERENCES AND BIBLIOGRAPHY... 6 THE GUIDELINE... 6 EQUALITY IMPACT ASSESSMENT TOOL... 11

4 INTRODUCTION This clinical guidance document produced by the Bedside Clinical Guidance Partnership has been amended and adopted for local use by Tameside Hospital NHS Foundation Trust. PURPOSE This clinical guideline is a systematically developed statement designed to assist practitioners in deciding appropriate health care for specific clinical circumstances. The guideline is intended to provide guidance for staff in the diagnosis and management of a particular condition, and provides indication of the best choices for the clinical management of the patient. SCOPE This guideline is to be used by staff or professional groups involved in the diagnosis management of the condition to which to the document relates in all areas within Tameside Hospital NHS Trust. DEFINITIONS The definitions of key words, terms and concepts used in the policy document will be clearly defined within the body of the guideline where necessary. DUTIES Chief Executive The Chief Executive is responsible and accountable for ensuring that clinical guidelines are in place and that implementation of the guidelines is undertaken and monitored. Medical Director The Medical Director is responsible for overseeing that minated Divisional Leads implement guidelines according to the Bedside Clinical Guideline Policy and for ensuring that specifics of this guideline are implemented and monitored as appropriate. minated Divisional Leads for Clinical Guidelines Will ensure that guidelines adopted by their specialty or Division are appropriately scrutinised and amended where applicable and that they are subject to adoption and ratification by the Division at the Divisonal DMT meeting or other appropriate Committee as specified in the Trusts Controlled Documents Policy. Clinical Risk Officer for General CNST and Elective Services Is responsible for facilitating the implementation of clinical guidelines by liaison with minated Divisonal Leads. The Clinical Risk Offcier is also responsible for the review of the overarching Bedside Clinical Guidelines policy and guideline template and for producing monitoring reports for the Medical Director on

5 progress of the implementation, review and monitoring of clinical guidelines adopted from the Bedside Partnership. These monitoring reports will be on an annual basis. Local Implementation Author The person submitting the ratified guideline for publishing on the Intranet is considered the local implementation author and will be responsible for any subsequent review process and for ensuring that guidelines are implemented and monitored where appropriate, e.g. through their inclusion in the annual Clinical Audit Plan for the Division. All staff All staff have a duty to follow this guideline unless there are sound clinical reasons for not doing so which can be supported by evidence. Junior Staff should discuss any proposed deviation with their senior colleagues, and gain their approval prior to implementation. Junior doctors should document the discussion with the Consultant and reasons for deviation in the Health records. Where consultants choose to deviate from agreed practice stated in the guideline this should also be documented. GUIDELINE STATEMENT The guideline is presented using set headings in the body of the guideline which provide structure to the guideline and a methodical order The guideline subheadings will differ dependening on the topic of the guideline but will given structured guidance to staff on treatment and management of the specific clinical condition or procedure. GUIDELINE DEVELOPMENT & CONSULTATION This guideline has been developed by the Bedside Guidelines Partnership and has been amended to reflect local implementation processes by a consultative process within the division responsible for delivering care. Where appropriate consultation with other stakeholders within the Trust was appropriate this has taken place before final ratification at the Divisional DMT or other approved Committee or Group stated on the cover page table. IMPLEMENTATION This guideline has been distributed to main stakeholders and members of the ratifying Committee for dissemination and uploaded to the Trust s intranet in the clinical guidelines section MONITORING Responsibility for monitoring of this guideline is with the Division of surgery REVIEW This guideline will be formally reviewed at a minimum of every 2 years. The date of review is stated on the title page. The guideline may be reviewed earlier

6 depending on the results of monitoring, recommendations from recognised bodies or as a result of incident complaint or claim review REFERENCES AND BIBLIOGRAPHY Extensive reference material and evidence base is provided by the Bedside Clinical Guidelines Partnership for each individual guideline and is accessible on the TIS site, under the section Policies and Procedures entitled Bedside Clinical Guidelines Reference section.

7 THE GUIDELINE ACUTE LIMB ISCHAEMIA DEFINITION Acute limb ischaemia results from sudden interruption of limb blood supply by thrombus (often in an artery containing atherosclerotic plaque/stenosis), embolus, trauma or external compression. It carries a high morbidity, including loss of limb. There are two major categories Acute limb ischaemia Most commonly caused by emboli from the heart that lodges, often at bifurcations, in otherwise normal arteries most commonly femoral, followed by brachial and aortic (saddle embolus). An embolus carries a higher morbidity than a thrombus because the extremity has not had time to develop collateral circulation Acute-on-chronic limb ischaemia Existing atherosclerosis in patient with a history of peripheral vascular disease (PVD), acutely compounded by thrombus this must be regarded as a vascular emergency Risk factors Smoking Diabetes Hypertension Hypercholesterolaemia Pre-existing PVD AAA/popliteal aneurysm Atrial fibrillation Previous myocardial infarction Hypercoagulable states CLINICAL FEATURES Symptoms and signs Limb becomes: pale (later mottled and cyanosed) painful pulseless perishing cold paraesthetic/anaesthetic paralysed Acute total ischaemia with an acute 'white leg' indicates threat of muscle necrosis within 6 12 hr Assessment Ask about: claudication

8 night pain previous tissue necrosis (e.g. ulcers) Determine site of occlusion: check presence of all peripheral pulses, including abdominal aortic pulse assess quality and regularity of pulse, noting AF in particular auscultate for bruits (e.g. subclavian, axillary, femoral) Assess likely nature of occlusion THROMBUS SUGGESTED BY: pre-existing claudication with sudden deterioration no obvious source for emboli reduced or absent pulses in contralateral limb evidence of widespread vascular disease (e.g. myocardial infarction, stroke, TIA, previous vascular surgery) Embolus suggested by: sudden onset of painful leg (<24 hr) no history of claudication clinically obvious source of embolus (e.g. atrial fibrillation, recent myocardial infarction) no evidence of peripheral vascular disease (normal pulses in contralateral limb) evidence of proximal aneurysm (e.g. abdominal or popliteal) Assess neurosensory deficit and blood flow, clinically and using bedside Doppler scanner Grade I Variable Painful, tender calf/painful plantar flexion neurosensory deficit Audible Doppler signal Grade II Threatened Reduced sensation in foot audible Doppler signal Grade III Irreversible Cold extremity with tense muscles Complete neurological deficit audible Doppler signal INVESTIGATIONS Bloods: FBC, U&E INR, APTT, platelet count, group & save creatine kinase ECG Chest X-ray Ankle Brachial Pressure Index (ABPI) performed by vascular team If aneurysm suspected: abdominal USS duplex Doppler scan of popliteal arteries IMMEDIATE TREATMENT General ASSESS AIRWAY, BREATHING AND CIRCULATION, AND RESUSCITATE AS REQUIRED Give oxygen see Oxygen therapy in acutely hypoxaemic surgical patients (or those with suspected poor regional perfusion) guideline Give adequate analgesia

9 morphine, give 5 mg IV (2.5 mg if very frail). If required, give further aliquots of 1 2 mg at 5 min intervals up to total of 15 mg see Opioids guideline, with prochlorperazine 12.5 mg IM 6 hrly (6.25 mg if aged 60 yr) up to 4 doses as anti-emetic if nausea/vomiting not suppressed by prochlorperazine, add ondansetron 4 mg by slow IV 6 hrly Give IV fluids as increased viscosity can easily lead to dehydration see Maintenance fluid therapy guideline Nil-by-mouth until opinion of vascular team obtained Catheterize and monitor input/output Specific see flowchart Seek opinion from vascular team as soon as possible. Include in discussion: Angiography (if evidence of renal impairment, consider cover with acetylcysteine 600 mg IV 12 hrly on day of procedure and, if possible, on day before procedure. See Prevention of contrast induced nephrotoxicity guideline Length of history if history 1 week, discuss giving pain relief until next working day as ischaemia likely to be irreversible if history <1 week, discuss immediate operation If not for surgery within 4 hr, start IV heparin infusion to prevent propagation of thrombus see IV unfractionated heparin guideline If signs of infection, seek advice of consultant microbiologist (4666) Monitor vital signs and condition of leg regularly

10 Acute leg ischaemia Vascular surgical opinion S Neurosensory deficit yes IV heparin Criteria for embolus? (see Clinical features Assessment) Yes Angiography either MR or DSA (next day, if out-of-hours) Probable embolus Consider duplex Doppler and/or angiography SUBSEQUENT MANAGEMENT Monitor condition of leg closely post-operatively/post-thrombolysis to detect early re-occlusion Continue IV heparin infusion for at least a further 48 hr Vascular surgeon to decide regarding subsequent anticoagulation If anticoagulation recommended, ensure APPT/INR within target range and checked regularly Treat AF as required see Atrial fibrillation in Medical guidelines Encourage early mobilization Identify risk factors Give patient appropriate advice regarding lifestyle change: smoking cessation exercise diet Treat hypertension and/or raised cholesterol appropriately Ensure appropriate out-patient follow-up with vascular team

11 EQUALITY IMPACT ASSESSMENT TOOL. Yes/ Comments 1. Does the policy/guidance affect one group less or more favourably than another on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Age Disability - learning disabilities, physical disability, sensory impairment and mental health problems 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? 4. Is the impact of the policy/guidance likely to be negative? 5. If so can the impact be avoided? n/a 6. What alternatives are there to achieving the policy/guidance without the impact? 7. Can we reduce the impact by taking different action? n/a n/.a

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