ASSIGNMENT

ON
PREVENTION OF DEEP VEIN THROMBOSIS

SUBMITTED TO SUBMITTED BY

SUBMITTED ON
INTRODUCTION

Venous thromboembolism (VTE) A condition in which a blood clot (thrombus) forms in a vein,
which in some cases then breaks free and enters the circulation as an embolus, finally lodging in and
completely obstructing a blood vessel, e.g., in lungs causing a PE (PULMONARY EMBOLISM).
The most common type of venous thromboembolism is DEEP VEIN THROMBOSIS, which occurs
in veins deep within the muscles of the leg, arm and pelvis. A superficial venous thrombosis (also
called phlebitis or superficial thrombophlebitis) is a blood clot that develops in a vein close to the
surface of the skin. These types of blood clots do not usually travel to the lungs unless they move
from the superficial system into the deep venous system first.

DEFINITION

Deep vein thrombosis is the formation of a blood clot in one of the deep veins of the body,
usually in the leg

CAUSES

Veins are blood vessels that carry blood from the tissues of the body back to the heart. Veins that lie
just beneath the skin surface are referred to as “superficial veins” while veins found deep inside the
muscles are referred to as “deep veins”. Other veins connect the superficial and deep veins, allowing
blood to flow between them.

When a blood clot occurs in a vein it is referred to as a venous thrombosis. A DVT is a blood clot that
occurs in the deep veins. DVTs can occur in any of the deep veins but most commonly occur in the
leg veins. The clot will either partially or completely block the flow of blood through the affected
vein.

A DVT is usually more serious than a blood clot in one of the superficial veins, as there is a much
greater risk with a DVT that part of the clot may dislodge and circulate through the body.
RISK FACTORS

DVT can occur in anyone, but some factors can increase the risk. Having more than one risk factor
further increases the risk. Events or conditions that increase the risk of DVT include the following:

 Surgery
 Trauma
 Long periods of not moving (bed rest, sitting, long car or airplane trips)
 Cancer and cancer therapy
 Past history of DVT
 Increasing age
 Pregnancy and the 4–6 weeks after giving birth
 Use of birth control methods that contain estrogen or hormone therapy for menopause
symptoms
 Certain illnesses, including heart failure, inflammatory bowel disease, and some kidney
disorders
 Obesity
 Smoking
 Varicose veins
 Having a tube in a main vein (sometimes needed to give medications over a period of time)

 Having a thrombophilia, one of several diseases in which the blood does not clot correctly
PATHOPHYSIOLOGY

Although the exact cause of deep vein thrombosis remains unclear, there are mechanisms believed to
play a significant role in its development.

 Reduced blood flow. Venous stasis occurs when blood flow is reduced, when veins are
dilated, and when skeletal muscle contraction is reduced.
 Damage. Damage to the intimal lining of blood vessels creates a site for clot formation.
 Phlebitis. Formation of a thrombus frequently accompanies phlebitis, which is an
inflammation of the vein walls.
  Platelet aggregates. Venous thrombi are aggregates of platelets attached to the vein wall that
have a tail-like appendage containing fibrin, white blood cells, and many red blood cells.
 Tail. The “tail” can grow or can propagate in the direction of the blood flow as successive
layers of the thrombus form.
 Fragmentation. Fragmentation of the thrombus can occur spontaneously as it dissolves
naturally, or it can occur with an elevated venous pressure.
 Recanalization. After an acute episode of DVT, recanalization or reestablishment of the

lumen of the vessel typically occurs.

SIGNS AND SYMPTOMS

A DVT does not always cause symptoms. If symptoms do occur, the first symptom is usually a
cramp-like aching pain in the affected muscle. This pain might worsen when exercising but does not
subside with rest. Symptoms of a DVT in the calf muscle may include:

 Swelling of the lower leg

 Tenderness of the calf muscle
 Localized redness and warmth
 A mild fever
 Lower leg veins may become more prominent (darker and raised) and sometimes the skin
becomes darker.
A DVT can also occur in the upper leg, arms or neck and cause similar symptoms in those areas of
the body.

If a pulmonary embolism occurs as a result of a DVT it may produce barely noticeable symptoms
such as chest discomfort and mild breathlessness, or more noticeable symptoms such as sharp chest
pain, a rapid heart rate, breathlessness, and coughing-up blood.
DIAGNOSTIC EVALUATION

 Duplex ultrasonography is an imaging test that uses sound waves to look at the flow of
blood in the veins. It can detect blockages or blood clots in the deep veins.  It is the standard
imaging test to diagnose DVT.
 A D-dimer blood test measures a substance in the blood that is released when a clot breaks
up. If the D-dimer test is negative, it means that the patient probably does not have a blood
clot.
 Contrast venography is a special type of X-ray where contrast material (dye) is injected into
a large vein in the foot or ankle so that the doctor can see the deep veins in the leg and hip.  It
is the most accurate test for diagnosing blood clots but it is an invasive procedure, which
means it is a medical test that requires doctors to use instruments to enter the body.  Therefore
this test has been largely replaced by duplex ultrasonography, and it is used only in certain
patients.
 Magnetic resonance imaging (MRI)—a test that uses radio waves and a magnetic field to
provide images of the body—and computed tomography (CT) scan—a special x-ray test—are
imaging tests that help doctors diagnose and treat a variety of medical conditions.  These tests
can provide images of veins and clots, but they are not generally used to diagnose DVT.

TREATMENT

Anticoagulants

 Anticoagulants (commonly referred to as “blood thinners”) are the medications most

commonly used to treat DVT or PE. Although called blood thinners, these medications do not
actually thin the blood. They reduce the ability of the blood to clot, preventing the clot from
becoming larger while the body slowly reabsorbs it, and reducing the risk of further clots
developing.
 The most frequently used injectable anticoagulants are
o Unfractionated heparin (injected into a vein),
o Low molecular weight heparin (LMWH) (injected under the skin), and
o Fondaparinux (injected under the skin).
  Anticoagulants that are taken orally (swallowed) include
o Warfarin,
o Dabigatran,
o Rivaroxaban,
o Apixaban, and
o Edoxaban.
 All of the anticoagulants can cause bleeding, so people taking them have to be monitored to
prevent unusual bleeding.

Thrombolytics

 Thrombolytics (commonly referred to as “clot busters”) work by dissolving the clot. They
have a higher risk of causing bleeding compared to the anticoagulants, so they are reserved for
severe cases.

Inferior vena cava filter

 When anticoagulants cannot be used or don’t work well enough, a filter can be inserted inside
the inferior vena cava (a large vein that brings blood back to the heart) to capture or trap an
embolus (a clot that is moving through the vein) before it reaches the lungs.

Thrombectomy/Embolectomy
In rare cases, a surgical procedure to remove the clot may be necessary.  Thrombectomy involves
removal of the clot in a patient with DVT.   Embolectomy involves removal of the blockage in the
lungs caused by the clot in a patient with PE.
PREVENTION

Methods for Preventing DVT and PE

I. LIFESTYLE MODIFICATIONS
A. Avoid obesity and inactivity    
i. Nutrition without excess calories        
ii. Exercise        
1. Daily aerobic such as walking            
2. Anaerobic activity useful for muscle
toning            
a. Heavy weightlifting may traumatize
muscles                
b. Anaerobic does not substitute for
aerobic                
B. Avoid dehydration    
i. Drink water        
ii. Minimize alcohol consumption        
C. Avoid cigarette smoking    
I . Quit smoking        
1. Willpower is best            
2. Nicotine patch, gum, nasal spray            
3. Bupropion (Wellbutrin
[GlaxoSmithKline])            
D. Maintain normal blood pressure    
i. Note some guidelines define normal as <120/80 mm Hg rather than <140/90 mm Hg
ii. If lifestyle changes do not reduce blood pressure, use medication        
II. MECHANICAL MEASURES
A. Vascular compression stockings    
i. 10 to 18 mm Hg if immobilized or in bed; otherwise, use higher compression
levels        
ii. 20 to 30 mm Hg below-knee stockings if no varicose veins, swelling, or skin pigmentation
changes        
iii. 30 to 40 mm Hg below-knee stockings if leg exam has evidence of prior venous
disease        
B. Intermittent pneumatic compression boots    
i. Ideal for immobilized patients, either in hospital, skilled nursing facility, or at
home        
ii. Device is better tolerated when combined with 10- to 18-mm Hg vascular compression
stockings        
iii. Some devices have “cooling buttons” to enhance comfort        
III. PHARMACOLOGICAL MEASURES
A. Injectable medications    
i. Low-molecular-weight heparin
1. Enoxaparin 40 mg daily
2. Dalteparin 5000 Units daily
ii. Unfractionated heparin 5000 Units every 8 hours        
iii. Fondaparinux 2.5 mg daily        
B. Oral medication    
i. Warfarin        
C. Baby aspirin 81 mg daily    
i. Provides more protection against heart attack and stroke than against DVT
ii. DVT prevention effect is weak
IV. COMBINED MECHANICAL AND PHARMACOLOGICAL MEASURES

BEFORE AND AFTER SURGERY TO PREVENT DVT

Doctor may prescribe medications to prevent blood clots from forming before or after surgery. Also
may be told to stop taking certain medications before surgery. At the hospital, wear special elastic
stockings or inflatable boots. These devices squeeze the muscles to help keep blood flowing. Urged to
get up and walk around soon after the procedure. Foot end of the bed will be elevated.

PREVENTED DURING PREGNANCY

During pregnant, medication or other treatments may be prescribed to prevent DVT have certain risk
factors:

 Strong family history of DVT

 An inherited thrombophilia
 Need for bed rest
 Likely to have a cesarean birth
  If medication is prescribed for you, your health care provider will make sure you know how to
take the medication and what you should avoid while taking it.

PREVENTED DURING TRAVEL

When planning a long trip, the following preventive steps are recommended, especially are pregnant
or have other risk factors for DVT:

 Drink lots of fluids.

 Wear loose-fitting clothing.
 Walk and stretch at regular intervals (for example, when traveling by car, make frequent stops to
allow you to get out and stretch your legs).
 Special stockings that compress the legs below the knee may help prevent blood clots from forming.
However, talk to your health care provider first before you try these stockings because some people
should not wear them (for example, those with diabetes or problems with blood circulation).
REFERENCES

 Douketis, J.D. (2018). Deep vein thrombosis (DVT) [Web Page]. MSD Manual Consumer
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 Liao, S. et al. (2014). Incidence of venous thromboembolism in different ethnic groups: a
regional direct comparison study. J Thromb Haemost 2014;12:214-9.
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 O’Toole, M.T. (Ed.) (2017). Deep vein thrombosis (DVT). Mosby’s Dictionary of Medicine,
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 Tran, H.A., et al. (2019).New guidelines from the Thrombosis and Haemostasis Society of
Australia and New Zealand for the diagnosis and management of venous thromboembolism.
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