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Guideline for prevention of venous thromboembolism
Guideline for prevention of venous thromboembolism Carina Stanton, Contributing Writer
A
ORN’s updated “Guideline for prevention of venous thromboembolism” will provide guidance to perioperative team members for developing and implementing a protocol for prevention of venous thromboembolism (VTE), including prevention of deep vein thrombosis (DVT) by mechanical and pharmacologic prophylaxis and prevention of pulmonary embolism as a complication of DVT.1 Patient injuries incurred as a result of VTE can include death; VTE recurrence; and long-term complications such as swelling, pain, discoloration, and scaling in the affected limb as part of post-thrombotic syndrome, as well as chronic thromboembolic pulmonary hypertension.2,3
Originally published in 2011 as the “Recommended practices for prevention of deep vein thrombosis,” this first update offers new and revised recommendations on evidence-based practices for the prevention of all VTE events, including preoperative patient assessment to determine VTE risk factors and implementing interventions for patients receiving VTE prophylaxis. “We know [that] as many as 70 percent of hospital-associated VTE cases can be prevented, yet fewer than half of hospitalized patients receive VTE preventive measures. Perioperative nurses should take these facts seriously and understand current evidence-based practices for VTE prevention,” said Amber Wood, MSN, RN, CNOR, CIC, FAPIC, AORN senior perioperative practice specialist and lead author of the updated guideline. Wood said that the RN’s role in VTE risk assessment can vary, but she stressed the important role every perioperative nurse plays in verifying that a patient’s VTE risk is assessed.
Preoperative VTE risk assessment The updated guideline provides a more extensive review of patient-specific and procedure-specific VTE risks. A preoperative assessment provides
information necessary to determine the patient’s risk for VTE and to identify prophylaxis measures recommended by the health care organization’s VTE protocol.1 The perioperative RN should assess the patient preoperatively for risk factors that contribute to venous stasis, vessel wall injury, or hypercoagulability (e.g., age, previous history of VTE or stroke, obesity, presence of a central venous catheter). For a complete list of VTE risk factors, please read the guideline.1 The perioperative RN also should assess the patient’s procedure-related risk factors for VTE (e.g., length of surgery, position of patient, type of surgery, use of a tourniquet).1 “The collective evidence outlines very specific procedure-related VTE risks that the perioperative RN should consider with patient-specific VTE risks to assess overall risk—certain risks may outweigh others,” Wood said. For example, a patient with a history of VTE undergoing an outpatient eye surgery will be at high risk for VTE, even though the procedural risk is low. A patient who is obese and undergoing bariatric surgery is at a much higher risk for VTE because the patient has a high individual and procedural risk for VTE. Procedure-specific risks that occur during surgery, such as a prolonged procedure (i.e., surgery and general anesthesia time longer than 90 minutes, or longer than 60 minutes for procedures involving the lower limb or pelvis) or excessive bleeding, can alter a patient’s overall risk for developing VTE. Therefore, the perioperative RN has a professional responsibility to advocate for the patient during the entire perioperative period by consulting and collaborating with other professional colleagues regarding patient care.1
Mechanical VTE prophylaxis The updated guideline recommends that the perioperative RN implement interventions for safe and effective mechanical VTE prophylaxis. Mechanical prophylaxis includes early ambulation,
http://dx.doi.org/10.1016/S0001-2092(17)30730-5
© AORN, Inc, 2017
September 2017 Vol 106 No 3 • Periop Briefing | P7
PERIOP BRIEFING
GUIDELINE FIRST LOOK
PERIOP BRIEFING
GUIDELINE FIRST LOOK
foot and ankle exercises, and the use of graduated compression stockings and intermittent pneumatic compression devices. Mechanical prophylaxis often is recommended in addition to pharmacologic prophylaxis, or as a single therapy if pharmacologic methods are contraindicated because of bleeding risk or if the patient is at low risk for VTE.4 When prescribed, intermittent pneumatic compression devices or graduated compression stockings should be applied on admission and initiated before the administration of regional or general anesthesia, which dilates the calf veins as a result of the loss of leg muscle tone.5 Risks associated with the use of mechanical VTE prophylaxis should be considered (e.g., increased risk of pressure injury, hypothermia, falling during ambulation). However, intermittent pneumatic compression devices are preferred to graduated compression stockings that can pose a risk for skin complications. For example, high-risk patients undergoing gynecological pelvic surgery have significantly reduced VTE rates when using a combination of intermittent pneumatic compression devices and graduated compression stockings compared with use of graduated compression stockings alone.6 The updated guideline also addresses new evidencebased safety considerations for managing pneumatic compression devices in the intraoperative setting. For example, the device sleeves must be sterile or sterilized according to the manufacturer’s instructions when used on the sterile field. Also, when managing pneumatic compression devices in a hybrid OR setting, devices should be used that are designed for safe use with magnetic resonance imaging equipment. The guideline also cautions against the use of elastic bandage wraps that are sometimes substituted in procedures such as bariatric surgeries when a standard pneumatic compression device or graduated compression stocking will not fit. “Specialized mechanical VTE prophylaxis devices are available and perioperative RNs play an important role in requesting such devices if they are not currently available for various patient populations and specific procedures as needed,” Wood said.
Pharmacologic VTE prophylaxis The revised guideline includes updated
P8 | Periop Briefing
evidence specific to interventions for safe and effective pharmacologic VTE prophylaxis. These interventions should address contraindications and adverse effects related to pharmacologic prophylaxis, which consists of anticoagulant medications that inhibit blood clotting. The RN should assess the patient for contraindications related to the use of pharmacologic VTE prophylaxis (e.g., active or previous major bleeding, severe hepatic or renal failure, acute stroke). A comprehensive list of contraindications can be found in the guideline. The perioperative RN should discuss potential contraindications with the prescriber and any identified adverse effects with the prescriber and anesthesia professional.1
Education and quality improvement The guideline reinforces the important role that the perioperative RN should take in educating the patient and his or her designated caregiver(s) with instructions regarding prevention of VTE and prescribed prophylactic measures.1 “Collaborating to ensure VTE risk assessment and subsequent VTE prophylaxis is provided, clearly explained, and reinforced throughout a patient’s continuum of care is critical,” Wood said. She also said this emphasis on education surrounding VTE prevention is equally important among perioperative professionals, and that it should start at the leadership level to ensure every perioperative team member is aware of the most current evidence regarding VTE prevention practices. Furthermore, these practices must also be reflected in a facility’s policies, procedures, and regular in-service education and competency reviews as required by regulatory and accreditation standards. A systematic review with meta-analysis found that educational interventions significantly improved the quality of VTE prophylaxis, especially when they are combined with other interventions as part of a multifaceted systems approach.7
Conclusion Perioperative team members must follow evidence-based practices for assessing VTE risks and implementing prophylactic VTE interventions to minimize a patient’s risk of developing VTE. Current data suggests 10 to 15 percent of patients who develop VTE following a surgical procedure
do not survive.8 Perioperative RNs can ensure comprehensive VTE assessments take place and specific prophylactic devices and protocols are provided to reduce the risks of VTE. References 1. Guideline for prevention of venous thromboembolism. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2018. In press. 2. Venous thromboembolism (blood clots): facts. Centers for Disease Control and Prevention. https://www.cdc.gov/ncbddd/dvt/facts.html. Reviewed June 26, 2017. Updated July 7, 2017. Accessed July 27, 2017. 3. Maynard G. Preventing Hospital-Associated Venous Thromboembolism: A Guide for Effective Quality Improvement. 2nd ed. Rockville, MD: Agency for Healthcare Research and Quality; August 2016. AHRQ Publication No. 16-0001-EF. 4. Farge D, Debourdeau P, Beckers M, et al. International clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer. J
© AORN, Inc, 2017
Thromb Haemost. 2013;11(1):56-70. 5. Venous Thromboembolism: Reducing the Risk for Patients in Hospital. National Institute for Health and Care Excellence. https://www.nice.org.uk/ guidance/cg92. Published January 27, 2010. Updated June 2015. Accessed July 27, 2017. 6. Gao J, Zhang ZY, Li Z, et al. Two mechanical methods for thromboembolism prophylaxis after gynaecological pelvic surgery: a prospective, randomised study. Chin Med J (Engl). 2012;125(23):4259-4263. 7. Kahn SR, Morrison DR, Cohen JM, et al. Interventions for implementation of thromboprophylaxis in hospitalized medical and surgical patients at risk for venous thromboembolism. Cochrane Database Syst Rev. 2013;(7):CD008201. 8. Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 suppl):e227S-e277S.
September 2017 Vol 106 No 3 • Periop Briefing | P9
PERIOP BRIEFING
GUIDELINE FIRST LOOK
A
ORN’s updated “Guideline for prevention of venous thromboembolism” will provide guidance to perioperative team members for developing and implementing a protocol for prevention of venous thromboembolism (VTE), including prevention of deep vein thrombosis (DVT) by mechanical and pharmacologic prophylaxis and prevention of pulmonary embolism as a complication of DVT.1 Patient injuries incurred as a result of VTE can include death; VTE recurrence; and long-term complications such as swelling, pain, discoloration, and scaling in the affected limb as part of post-thrombotic syndrome, as well as chronic thromboembolic pulmonary hypertension.2,3
Originally published in 2011 as the “Recommended practices for prevention of deep vein thrombosis,” this first update offers new and revised recommendations on evidence-based practices for the prevention of all VTE events, including preoperative patient assessment to determine VTE risk factors and implementing interventions for patients receiving VTE prophylaxis. “We know [that] as many as 70 percent of hospital-associated VTE cases can be prevented, yet fewer than half of hospitalized patients receive VTE preventive measures. Perioperative nurses should take these facts seriously and understand current evidence-based practices for VTE prevention,” said Amber Wood, MSN, RN, CNOR, CIC, FAPIC, AORN senior perioperative practice specialist and lead author of the updated guideline. Wood said that the RN’s role in VTE risk assessment can vary, but she stressed the important role every perioperative nurse plays in verifying that a patient’s VTE risk is assessed.
Preoperative VTE risk assessment The updated guideline provides a more extensive review of patient-specific and procedure-specific VTE risks. A preoperative assessment provides
information necessary to determine the patient’s risk for VTE and to identify prophylaxis measures recommended by the health care organization’s VTE protocol.1 The perioperative RN should assess the patient preoperatively for risk factors that contribute to venous stasis, vessel wall injury, or hypercoagulability (e.g., age, previous history of VTE or stroke, obesity, presence of a central venous catheter). For a complete list of VTE risk factors, please read the guideline.1 The perioperative RN also should assess the patient’s procedure-related risk factors for VTE (e.g., length of surgery, position of patient, type of surgery, use of a tourniquet).1 “The collective evidence outlines very specific procedure-related VTE risks that the perioperative RN should consider with patient-specific VTE risks to assess overall risk—certain risks may outweigh others,” Wood said. For example, a patient with a history of VTE undergoing an outpatient eye surgery will be at high risk for VTE, even though the procedural risk is low. A patient who is obese and undergoing bariatric surgery is at a much higher risk for VTE because the patient has a high individual and procedural risk for VTE. Procedure-specific risks that occur during surgery, such as a prolonged procedure (i.e., surgery and general anesthesia time longer than 90 minutes, or longer than 60 minutes for procedures involving the lower limb or pelvis) or excessive bleeding, can alter a patient’s overall risk for developing VTE. Therefore, the perioperative RN has a professional responsibility to advocate for the patient during the entire perioperative period by consulting and collaborating with other professional colleagues regarding patient care.1
Mechanical VTE prophylaxis The updated guideline recommends that the perioperative RN implement interventions for safe and effective mechanical VTE prophylaxis. Mechanical prophylaxis includes early ambulation,
http://dx.doi.org/10.1016/S0001-2092(17)30730-5
© AORN, Inc, 2017
September 2017 Vol 106 No 3 • Periop Briefing | P7
PERIOP BRIEFING
GUIDELINE FIRST LOOK
PERIOP BRIEFING
GUIDELINE FIRST LOOK
foot and ankle exercises, and the use of graduated compression stockings and intermittent pneumatic compression devices. Mechanical prophylaxis often is recommended in addition to pharmacologic prophylaxis, or as a single therapy if pharmacologic methods are contraindicated because of bleeding risk or if the patient is at low risk for VTE.4 When prescribed, intermittent pneumatic compression devices or graduated compression stockings should be applied on admission and initiated before the administration of regional or general anesthesia, which dilates the calf veins as a result of the loss of leg muscle tone.5 Risks associated with the use of mechanical VTE prophylaxis should be considered (e.g., increased risk of pressure injury, hypothermia, falling during ambulation). However, intermittent pneumatic compression devices are preferred to graduated compression stockings that can pose a risk for skin complications. For example, high-risk patients undergoing gynecological pelvic surgery have significantly reduced VTE rates when using a combination of intermittent pneumatic compression devices and graduated compression stockings compared with use of graduated compression stockings alone.6 The updated guideline also addresses new evidencebased safety considerations for managing pneumatic compression devices in the intraoperative setting. For example, the device sleeves must be sterile or sterilized according to the manufacturer’s instructions when used on the sterile field. Also, when managing pneumatic compression devices in a hybrid OR setting, devices should be used that are designed for safe use with magnetic resonance imaging equipment. The guideline also cautions against the use of elastic bandage wraps that are sometimes substituted in procedures such as bariatric surgeries when a standard pneumatic compression device or graduated compression stocking will not fit. “Specialized mechanical VTE prophylaxis devices are available and perioperative RNs play an important role in requesting such devices if they are not currently available for various patient populations and specific procedures as needed,” Wood said.
Pharmacologic VTE prophylaxis The revised guideline includes updated
P8 | Periop Briefing
evidence specific to interventions for safe and effective pharmacologic VTE prophylaxis. These interventions should address contraindications and adverse effects related to pharmacologic prophylaxis, which consists of anticoagulant medications that inhibit blood clotting. The RN should assess the patient for contraindications related to the use of pharmacologic VTE prophylaxis (e.g., active or previous major bleeding, severe hepatic or renal failure, acute stroke). A comprehensive list of contraindications can be found in the guideline. The perioperative RN should discuss potential contraindications with the prescriber and any identified adverse effects with the prescriber and anesthesia professional.1
Education and quality improvement The guideline reinforces the important role that the perioperative RN should take in educating the patient and his or her designated caregiver(s) with instructions regarding prevention of VTE and prescribed prophylactic measures.1 “Collaborating to ensure VTE risk assessment and subsequent VTE prophylaxis is provided, clearly explained, and reinforced throughout a patient’s continuum of care is critical,” Wood said. She also said this emphasis on education surrounding VTE prevention is equally important among perioperative professionals, and that it should start at the leadership level to ensure every perioperative team member is aware of the most current evidence regarding VTE prevention practices. Furthermore, these practices must also be reflected in a facility’s policies, procedures, and regular in-service education and competency reviews as required by regulatory and accreditation standards. A systematic review with meta-analysis found that educational interventions significantly improved the quality of VTE prophylaxis, especially when they are combined with other interventions as part of a multifaceted systems approach.7
Conclusion Perioperative team members must follow evidence-based practices for assessing VTE risks and implementing prophylactic VTE interventions to minimize a patient’s risk of developing VTE. Current data suggests 10 to 15 percent of patients who develop VTE following a surgical procedure
do not survive.8 Perioperative RNs can ensure comprehensive VTE assessments take place and specific prophylactic devices and protocols are provided to reduce the risks of VTE. References 1. Guideline for prevention of venous thromboembolism. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2018. In press. 2. Venous thromboembolism (blood clots): facts. Centers for Disease Control and Prevention. https://www.cdc.gov/ncbddd/dvt/facts.html. Reviewed June 26, 2017. Updated July 7, 2017. Accessed July 27, 2017. 3. Maynard G. Preventing Hospital-Associated Venous Thromboembolism: A Guide for Effective Quality Improvement. 2nd ed. Rockville, MD: Agency for Healthcare Research and Quality; August 2016. AHRQ Publication No. 16-0001-EF. 4. Farge D, Debourdeau P, Beckers M, et al. International clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer. J
© AORN, Inc, 2017
Thromb Haemost. 2013;11(1):56-70. 5. Venous Thromboembolism: Reducing the Risk for Patients in Hospital. National Institute for Health and Care Excellence. https://www.nice.org.uk/ guidance/cg92. Published January 27, 2010. Updated June 2015. Accessed July 27, 2017. 6. Gao J, Zhang ZY, Li Z, et al. Two mechanical methods for thromboembolism prophylaxis after gynaecological pelvic surgery: a prospective, randomised study. Chin Med J (Engl). 2012;125(23):4259-4263. 7. Kahn SR, Morrison DR, Cohen JM, et al. Interventions for implementation of thromboprophylaxis in hospitalized medical and surgical patients at risk for venous thromboembolism. Cochrane Database Syst Rev. 2013;(7):CD008201. 8. Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 suppl):e227S-e277S.
September 2017 Vol 106 No 3 • Periop Briefing | P9
PERIOP BRIEFING
GUIDELINE FIRST LOOK