Deep Vein Thrombosis and Pulmonary Embolism

-Results from thrombophlebitis of larger deep vein (usually of lower legs)

-5% of all surgical patients will develop this complication
-Can results in embolization from the deep veins to the lungs
-Oxygenation: look at 3 things
-Ventilation (pulmonary)
-Perfusion (cardio and vascular)
-Transport (hematologic)

Etiology: Virchow’s Triangle

1. Venous Stasis
2. Damage to Endothelium
3. Hypercoagulabililty of Blood

Etiology: Three Factors

Venous Stasis
- Dyfunctional valves
- Inactive muscles
Endothelial damage
- Trauma, external pressure
- Local, decrease in fibrinolytic properties (clots are not breaking down)
- Anitbiotics, K+, chemo, contrast media
- IV catheters, bone fracture, DM, burns
Hypercoagulability of blood
- Hematologic disorders, polycythemia (too many RBC’s- too thick and viscous,
malignancies (tissue necrosis factors), anemias, systemic infections (endotoxins)
- Smoking, BCP, smoking + BCP = high risk
Risk Factors
• Abdominal/ Pelvic surgery (ext ↑ risk)
• Advanced age • Anemia
• Dehydration
• Antithrombin II
• IV therapy
• A-Fib
• MI
• Cerebrovascular disease
• Neoplasms
• Smoking • Obesity
• CHF • Post-partum
• Drug Abuse • Pregnancy
• Estrogen tx, BCP • Prolonged immobility
• Excessive Vitamin E • Sepsis
• Hx thrombophlebitis • Trauma
• Prostatectomy • Venous catheters

Pathophysiology
• RBC, WBC, platelets, fibrin stick together = THROMBUS
• Enlarges, develops “tail”
• Occludes lumen of vessel
• Can be covered in endothelial cells and lyszed (which is good) OR
• Detach and result in EMBOLI (which is bad)
• From venous circulation to heart, lodges in pulmonary circulation

Manifestations
 Asymptomatic OR
 Unilateral edema
 Pain
 Warm Skin
 Temp › 100.4 F
 Calf tenderness
 SVC: upper extremity, neck, face, and back edema VS
 IVC: lower extremity edema
 Cyanosis
  Pain in calf with dorsiflexion- not reliable indicator (Homan’s sign)

Complications
 Pulmonary Embolism
 Chronic Venous Insufficiency
o Persistent edema, increased pigment, varicosities, ulcers, dependent cyanosis
 Phlegmasia Cerulea Dolens
o Swollen, blue, painful leg
o Sudden massive swelling, intense cyanosis
o Gangrene can occur if arteries are occluded secondary to venous obstruction

Diagnostics
• Doppler Flow studies
– Can be done at bedside
– Determine blood flow thru femoral, popliteal, posterior tibial veins
• Duplex Scan
– Ultrasound and Doppler combined
– Determine location and extent of the clot
• Venogram
– X-ray with contrast
– Determine the location and extent of clot
• D-Dimer: assesses thrombin and plasmin activity in the blood
– Normal: negative, none detectable
– Abnormal: positive
– Suggestive of DVT, PE

Nursing Interventions
• Bed rest (decreases possibility of clot breaking loose-embolization)
• Elevate limb (decreases swelling and increases venous return)
• Compression stocking (extra compression to allow blood flow back)
• Monitor for signs of PE
• Monitor pulses distal to thrombus, edema (getting worse or better?), calf circumference
(mark the spot where it is measured) *make sure they are still getting perfused
• Pain relief (NSAIDS, analgesics)

Drug Therapy
• Anticoagulants
– IV Heparin – Protamine Sulfate (antidote)
– PO (Warfarin) Coumadin - Vit K (antidote)
– LMWH (Lovenox)
• Prevents extension of clot, development of new thrombus, embolization
• Does NOT dissolve clot
• Clot dissolves spontaneously with intrinsic fibrinolytic system

Anticoagulation
o Heparin
 Continuous IV Heparin for up to 7 days
 Antidote is protamine sulfate
 Bedrest until therapeutic levels reached
 Partial thromboplastin time, activated
 Normal: aPTT (30-40 sec), PTT (60-70 sec)
 Therapeutic: 1 ½ to 2 times normal
 If aPTT is 100 sec, need to decrease it, withdraw or hold the drip for a certain
number of hours then restart it. Heparin has fast half-life. So if we decrease it
stop for a period of time, aPTT will drop so quickly. Make sure not to drop it too
much, so patient’s aPTT 4-6 hours after any changes.
 If aPTT is 40 sec, need to increase Heparin and rebolus and start at higher rate
 If aPTT is 60 sec, keep heparin the same
  Bed rest until therapeutic levels reached

o Warfarin

Warfarin orally for 3-6 months
Antidote is Vitamin K

 Must reach therapeutic level before discontinuing Heparin(48-72 hrs)
 PT: Prothrombin time
 Normal PT: 11-12.5 sec
 Therapeutic: 1 1/2 to 2 times
 INR: 2-3.5 (Measurement)
 Both Heparin and Warfarin are anticoagulant. Warfarin doesn’t work in the same
manner with Heparin. Heparin works with the clotting cascade. Warfarin works
on Vit K related factors. There is a therapeutic level assoc with Warfarin. Pt
stays with Heparin drip and start be started on PO Warfarin and be on it for few
days at the same time. Warfarin has to be at a therapeutic level before we
discontinue (D/C) the Heparin. So they are always anti-coagulated.
 If INR is 6, heart palpation, sweat, = patient is over anticoagulated = bleeding!!!
Give patient Vit K
 If INR 1.5, Not therapeutic. Increase dose.
 If INR is 2.5, need to discontinue (D/C) heparin
o LMWH (Lovenox)
 Use for prophylaxis and for treatment (Pt can self administer it at home)
 Prevention of thrombus
 Prevention of extension or recurrence
 Predictable dose response.
 Longer half-life
• Pt don’t need f/u for PTT because LMVH has predictable dose
response and longer half life.
 No monitoring of blood levels required
 Given SQ, daily or BID
o Thrombolytic agents (break up clots)
 Tissue plasminogen activator (tPA)
 Streptokinase, alteplase
 Used with new, large clots
 High risk for hemorrhage

Direct Thrombin Inhibitors

• Heparin-Induced Thrombocytopenia with Thrombosis or HITT
– Complication occurring in 1% of pts receiving Heparin
– Maybe immune-mediated response r/t antibodies develop
– Platelet count drops below 100,000/microliter or 40% below baseline. NOTE: Pt at more
risk for worst clots.
• Parenteral Alternatives to Heparin
– Argatroban
• Metabolized by liver, LFTs
• Weight-based, monitor PTT
• Hirudins
– Lepirudin:specific for HITT (Heparin-Induced Thrombocytopenia with Thrombosis)
• Rapid onset, short half life
• PTT
• No antidotes

Surgical Intervention
 Prevent PE
 Vena Cava Interruption Device
-Greenfield filter
-Filter clots without disturbing blood flow

Educative Interventions
 Pt with taken home Warfarin/Coumadin
for 3-6 months, need to be dose suggested.
Pt has to come back to test blood and dose
adjusted, 1 a week until stabilize then 2-3
weeks.
 Action and SE of anticoagulants
 Assess for bleeding – gums, stools, urine,
nose, emesis
 Prevention of bleeding – no crossed legs,
use electrical razor, soft toothbrushes,
wear shoes
 Positioning - frequent position changes
 Hydration cause viscosity of the blood
 S/S of PE
 Use/wear of compression stockings
 Skin changes
 F/U care (monitoring PT/INR)
 Ambulation after surgery
 Avoid prolonged standing sitting
 Quit smoking
 Anticoagulant Therapy
 Patient Teaching Guide p. 917

Evaluation
• Ongoing
• Decrease in signs and symptoms
• No side effects from anticoagulant therapy
• Adequate circulation

Pulmonary Embolism
◊ Most common pulmonary complication in hospitalized patients (↑ mortality rate)
◊ From thrombi in deep veins of the legs
◊ R side of the heart r/t A-Fib
◊ Emboli are mobile, continue until they lodge in narrowed part of circulation
◊ Lower lobes of lungs most affected
◊ Other causes: fat emboli from fractured long bones, air emboli, tumors

Manifestations
• Depend on the size of the emboli and the size and number of vessels occluded
• Most common: sudden onset of unexplained dyspnea, tachypnea, tachycardia
• Also: cough, chest pain, hemoptysis, crackles, fever, hypoxemia with mental status changes
Complications
• Pulmonary Infarction (death to lung tissue)
o -Occlusion of large or medium sized vessels
o -Insufficient collateral blood flow
o -Pre-existing lung disease (COPD, smoking)
o -May see effusion or abscess
• Pulmonary Hypertension
o -Elevated pulmonary pressure
o -60-70% reduction in pulmonary vascular bed (r/t obstruction of blood flow)

Diagnostics
• Ventilation-Perfusion Scan(V-Q Scan)
– Perfusion: IV injection of radioisotopes, detects adequacy of pulmonary circulation
– Ventilation: inhalation of radioactive gas (xenon), detects distribution of gas through the
lungs
 – Look for “mismatch”
• D-Dimer: suggestive, not conclusive
• Spiral CT Scan of Lungs
– Continuous slices of the lungs
– Reconstruct the slices for 3-D picture
• Pulmonary Angiography
– Invasive, catheter to pulmonary artery, contrast medium injected
– Allows visualization of pulmonary vasculature
• ABGs:
– paO2: below normal-inadequate oxygenation
– paCO2: below normal-tachypnea, hyperventilation
– pH: normal unless underlying cardiac/pulmonary disease, or lactic acidosis-shock

Treatment
• O2 based on ABG, intubation and mechanical ventilation
• Turn, cough, and deep breath
• Heparin/Warfarin
• Thrombolytic agents (t-PA- will lyse clot)
• Intracaval filter device (Greenfield filter)

Educative Interventions
• Same as DVT
• Pt with taken home Warfarin/Coumadin for 3-6 months, need to be dose suggested. Pt has to come
back to test blood and dose adjusted, 1 a week until stabilize then 2-3 weeks.
• Action and SE of anticoagulants
• Assess for bleeding – gums, stools, urine, nose, emesis
• Prevention of bleeding – no crossed legs, use electrical razor, soft toothbrushes, wear shoes
• Positioning - frequent position changes
• Hydration cause viscosity of the blood
• S/S of PE
• Use/wear of compression stockings
• Skin changes
• F/U care (monitoring PT/INR)
• Ambulation after surgery
• Avoid prolonged standing sitting
• Quit smoking
• Anticoagulant Therapy
• Patient Teaching Guide p. 917