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The Economy Class Syndrome

The Economy Class Syndrome

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Published by Taufik Abidin

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Published by: Taufik Abidin on Jan 25, 2010
Copyright:Attribution Non-commercial


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Air travel is associated with a risk of deep vein thrombosis and pulmonary embolism,which may be fatal. The exact incidence of thromboembolism in relation to air travel isuncertain, though it has been estimated that at least 5% of all cases of deep venousthrombosis may be linked to air travel. The term “economy class syndrome” has beencoined to describe the phenomenon, and this also emphasizes the role of impairment of venous circulation due to prolonged immobility in a cramped position, in the pathogenesis of the thrombosis.
The mechanism for thrombosis in travelers is probably due to a combination of immobilization,dehydrationand underlying factors. Patients with disease that predisposes them for thrombosis, such asantiphospholipid syndromeor cancer , are  probably at a much greater risk. The highest risk groups include the elderly, pregnantwomen, those suffering serious medical conditions such as cancer and those with recentorthopedic surgery (legs or knees).Prevention consists of adequate hydration (drinking, abstaining fromalcoholic  beveragesandcaffeine), moving around and calf muscle exercises. In patients with a known predisposition for thrombosis,aspirinis often prescribed, as this acts as a mildanticoagulant. Severe risk for thrombosis can prompt a physician to prescribe injectionswithlow molecular weight heparin(LMWH), a form of prophylaxis already in commonuse in hospital patients.There is clinical evidence to suggest that wearingcompression sockswhilsttravelling also reduces the incidence of thrombosis in people on long haul flights. Arandomised study in 2001 compared two sets of long haul airline passengers, one setwore MediUK mediven travel compression hosiery the others did not. The passengerswere all scanned and blood tested to check for the incidence of DVT. The results showedthat asymptomatic DVT occurred in 10% of the passengers who did not wear compression socks. The group wearing compression had no DVTs. The authorsconcluded that wearing elastic compression hosiery reduces the incidence of DVT in longhaul airline passengers.
CHAPTER 1Economy Class Syndrome1.1DefinitionThe economy class syndrome
is the occurrence of deep vein thrombosisin air travelers.The term was first coined in the late 1980s when it turned out that people who hadtraveled long distances byairplanewere at an increased risk for thrombosis, especially deep venous thrombosisand its main complication, pulmonary embolism. Although all these diseases had been recognized for a long time, the possibility of litigationagainstairline companies brought them into the limelight when this "syndrome" was reported.
1.2Deep Venous Thrombosis (DVT)
Deep Vein Thrombosis (DVT) is a thrombus formation in a deep vein of the body. Theycommonly inhabit the femoral vein. Patients presenting with symptoms of a DVT areconsidered high-risk patients because of the sequelae that may follow.
Venous clots most often occur in the deep veins of the leg which is called deepvein thrombosis (DVT), or deep vein clot. Venous thrombosis in the lower limbs can beconfined to the superficial leg veins, or may extend to involve the deep veins of the calf,or the more proximal veins such as the superficial femoral, common femoral, or even theiliac veins. Thrombosis is significantly more common in the left leg, probably due to thefact that the femoral artery on that side passes anterior to the vein and may compress it.Thrombosis in the superficial veins of the legs often occurs in varicosities, but is usuallyself-limiting. By contrast, the risk of pulmonary embolism is much higher when proximalveins are involved.
Three predisposing factors are always present in the development of DVT, knownas Virchow’s Triad: vessel wall injury, blood stasis, and hypercoagulability.Damaged endothelium may be caused by direct trauma, infections of surroundingsoft tissue, intravenous catheters or prolonged use of them. The trauma revealssubendothelial tissue which releases platelet activating factors, initiating coagulationcascade, results in platelet adhesion to the wall and the beginning of thrombus formation.2
Blood stasis in the veins interferes with nutrition to the endothelial lining,rendering the wall susceptible to minute thrombus formation. Causes of venous stasis areimmobilization or inactivity, typically following a stay in hospital, long plane flight,application of a cast, illness, or caused by poor deep venous muscle pump fromapropulsive gait. Stasis may also be caused by sluggish or impaired venous return to theheart following CVA, congestive heart failure, myocardial infarct, and valvular incompetence.Hypercoagulability of blood may be caused by haematological conditions such asanaemia and polycythemia vera, through infectious disease such as typhoid and pneumonia, as a secondary complication to nephrotic disease, or hypercoagulable drugsand oral contraceptives.
Fig 1: Deep Vein Thrombosis (DVT of the Leg3

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