For Student

A 65-year-old woman is reviewed in clinic following recent colonic surgery. Shortly after surgery
the patient developed a hot swollen leg from a deep vein thrombosis (DVT), confirmed on duplex
scanning. She has been started on anticoagulation therapy. She is upset that this developed and
wants you to explain why it occurred and what was done to prevent it.

Tasks:

How would you approach answering this patient?

Student’s name
For examiner

A 65-year-old woman is reviewed in clinic following recent colonic surgery. Shortly after surgery
the patient developed a hot swollen leg from a deep vein thrombosis (DVT), confirmed on duplex
scanning. She has been started on anticoagulation therapy. She is upset that this developed and
wants you to explain why it occurred and what was done to prevent it.
Task 1 (5.0) The essence of this case is to discuss risk reduction and distinguish this from
prevention. Deep vein thrombosis is a well-recognized problem post-surgery. The risk is higher in
people with prothrombotic states such as malignancy or a hypercoagulable syndrome (e.g. factor
V Lieden mutation) and where venous return may be compromised (pelvic surgery, lower limbs
raised intraoperatively, e.g. lithotomy position or with a pneumoperitoneum – laparoscopic
surgery).
Task 2 (5.0) To reduce the risk, the patient is given a low-molecular-weight (LMW) heparin, is
preoperatively well hydrated with intravenous (IV) fluids (especially if they have had preoperative
bowel preparation), will be wearing thromboembolic deterrent stockings and may have been asked
to stop any prothrombotic medication before surgery (e.g. tamoxifen). (LMW heparin works by
activating anti-thrombin III; it inhibits platelet aggregation and decreases the availability of
thrombin. It has a longer half-life than heparin and therefore requires only a single daily
administration. The fact that its response is much easier to predict removes the need for
monitoring.) During surgery the legs are slightly elevated to aid venous return and intermittent calf
compression can be used. Post-surgery, early mobilization is encouraged. Even with these
precautions there is still a risk of a DVT developing. The importance of making the diagnosis and
treating appropriately should be emphasized. If there has been an aberration to the normal
protocols, increasing the patient’s risk, the aberration should be admitted and a reason sought.
There is often a reason that can be explained (e.g. not giving heparin preoperatively if an epidural
is to be inserted). Did the preoperative consent discuss the risk of DVT?

Final score: