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Thrombosis prevention

(Redirected fromThrombosis prophylaxis)
This article is about preventing blood clots. For how blood clots form, seeThrombosis. For information on blood clots in the legs, seeDeep vein thrombosis.

Thrombosis prevention orthromboprophylaxis ismedical treatment to prevent the development ofthrombosis (blood clots insideblood vessels) in those considered at risk for developing thrombosis.[1] Some people are at a higherrisk for the formation of blood clots than others, such as those withcancer undergoing a surgical procedure.[2][3] Prevention measures or interventions are usually begun after surgery as the associated immobility will increase a person's risk.[4]

Thrombosis prevention
A blood clot blocking a blood vessel.
Other namesThrombosis prophylaxis
ICD-10-PCSI80-I82
ICD-9-CM437.6,453,671.5,671.9

Blood thinners are used to prevent clots, these blood thinners have different effectiveness and safety profiles. A 2018 systematic review found 20 studies that included 9771 people with cancer. The evidence did not identify any difference between the effects of different blood thinners on death, developing a clot, orbleeding.[2] A 2021 review found thatlow molecular weight heparin (LMWH) was superior to unfractionatedheparin in the initial treatment ofvenous thromboembolism for people with cancer.[3]

There are medication-basedinterventions and non-medication-based interventions.[4] The risk of developing blood clots can be lowered by lifestyle modifications, the discontinuation oforal contraceptives, andweight loss. In those at high risk, both interventions are often used.[1] The treatments to prevent the formation of blood clots are balanced against the risk of bleeding.[5]

One of the goals of blood clot prevention is to limitvenous stasis as this is a significant risk factor for forming blood clots in thedeep veins of the legs.[6] Venous stasis can occur during the long periods ofnot moving. Thrombosis prevention is also recommended during air travel.[7] Thrombosis prophylaxis is effective in preventing the formation of blood clots, their lodging in the veins, and their developing intothromboemboli that can travel through thecirculatory system to cause blockage and subsequenttissue death in otherorgans.[1]Clarence Crafoord is credited with the first use of thrombosis prophylaxis in the 1930s.

Pathophysiology of blood clot prevention

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The development of blood clots can be interrupted and prevented by the use of medication, changingrisk factors, and other interventions. Some risk factors can be modified. These would be losing weight, increasing exercise, and the cessation oforal contraceptives. Moving during periods of travel is a modifiable behavior. Preventing blood clots includes medications that interrupt the complexclotting cascade and changing the proteins needed for clotting.Antiplatelet drugs also have an effect in preventing the formation of clots.[8]

Medical treatments

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Thrombosis prophylaxis is not only used for the prevention ofdeep vein thrombosis but can be initiated for the prevention of the formation of blood clots in other organs and circumstances unrelated to deep vein thrombosis:[citation needed]

Epidemiology of developing blood clots

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The risk of developing deep vein thrombosis, or pulmonary embolism is different than the total risk of the formation of blood clots. This is due to the observation that not all blood clots form in the lower legs. Most hospitalized medical patients have at least 1 risk factor for thrombosis that progresses to thromboembolism and this risk persists weeks after discharge. Those who remain undiagnosed and not treated prophylactically have a 26% chance of developing a fatal embolism. Another 26% develop another embolism. Between 5% and 10% of all in-hospital deaths are due to pulmonary embolism (as a consequence of thrombosis). Estimates of the incidence of pulmonary embolism in the US is 0.1% persons/year. Hospital admissions in the US for pulmonary embolism are 200,000 to 300,000 yearly.[11] Thrombosis that develops into DVT will affect 900,000 people and kill up to 100,000 in the US. On average 28,726 hospitalized adults aged 18 and older with a VTE blood clot diagnosis die each year.[12] Risk of thrombosis is related to hospitalization.[4] In 2005 the UK the ParliamentaryHealth Select Committee determined the annual rate of death due to thrombosis was 25,000 with at least 50% being hospital-acquired.[13]

The type of surgery performed prior to the formation of blood clots influences the risk.Without prophylactic interventions, the calculated incidence of clot formation in the lower leg veins after surgery is:

As the population of the US ages, the development of blood clots is becoming more common.[15]

General risks and indications for blood clot prevention

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Some risk factors for developing blood clots are considered higher than others. One scoring system analyzes the probability of clot formation by assigning a point value system to significant risk factors.[16] The benefit of treating those who are at low risk of developing blood clots may not outweigh the higher risks of significant bleeding.[17]

Risk factors for developing blood clots that are assessed before treatments
Risk factorNotesReferences
Previous episodes ofthrombosisalso a risk factor for embolism formation[18][19][20]
Family History of Deep Vein Thrombosis[21][15]
Gender, andracenot firmly established
increased prevalence in women during childbearing years		[15]
Smokingmodifiable, difficult[20][22]
Diabetes[19]
Arteriosclerosis[19]
Renal disease"hypercoagulable state"[19][19]
Vasoconstriction[23]
Myocardial infarction and other types of heart diseaseHeart attack, UnstableanginaDysrhythmias Heart failure[24][21][23][19]
Slow or turbulent blood flowmodifiable with exercise[23][24][25]
Strokeheparins contraindicated[25][19][25]
Sedentary lifestylemodifiable with exercise[23][20][15]
Plaster casttransient[19]
Dehydrationmodifiable
also related to athletic activities and sports		[23][21]
Acute respiratory failure[19]
Dysrhythmias[23][24]
Shock[23]
Obesitymodifiable[16][26][1][23][19][24][20]
Pregnancy and the post-partum period"hypercoagulable state"[19][16][1][23][21][15]
Varicose veins[19]
Surgerylength of the surgical procedure
type of operation
hip or knee surgery[15]
related to subsequent state of hypercoagulability[14]		[16][1][26][20][21][22]
Lung disease[21]
Traumarelated to immobility[16][1][19][24][15]
Estrogen-basedoral contraceptivediscontinuation reduces risk
related to progestogen and ethinylestradiol[27]		[16][1][23][21][27][15][22]
Hormone replacement therapydiscontinuation reduces risk[16]
Ovarian hyper-stimulation therapy to treat infertility[16]
Compression of a vein orartery by abnormality,tumor,hematoma[16]
Pacing wires[1]
Local vein damage, incompetent valves[1][23]
Central venous catheters[1][24]
Dialysiscatheters[1][24]
Repetitive motion injury[1]
Immobilityassociated with air travel, long travel times, and
post-surgical – modifiable risk		[1][19][24][20][15][22][14]
Spinal cord injury[1]
Age[1][16][23][19]
Cancers

[1][21][15]

Sepsis[1]
Polycythemiaheparins contraindicated[25][1]
Genetic deficiencies orautoimmune disorders,Protein C and/orS deficiencycongenital; associated withwarfarin necrosis, heparins contraindicated[25][1][28][22]
Antiphospholipid antibody syndromealtered coagulation; heparins contraindicated[25][1]
Factor V Leiden defectaltered coagulation[1]
Prothrombin G20210A defectaltered coagulation; heparins contraindicated[25][1]
Hyperhomocysteinimiaaltered coagulation; heparins contraindicated[25][1]
Elevatedfactors II,VIII,IX,XIaltered coagulation; heparins contraindicated[25][1][15]
Antithrobin III deficiencyaltered coagulation; heparins contraindicated[25][1][15]
Falls andhip fracturerelated to immobility[1][20]
Selective estrogen-receptor modulators[16]
Erythropoiesis-stimulating agents[16]
Acute medical illness[16][15]
Inflammatory bowel disease[16]
Nephrotic syndrome[16]
Myeloproliferative disorders[16]
Paroxysmal nocturnal hemoglobinnuria[16]
Thrombophiliasheparins contraindicated[25][16][15]
Post-menopausal hormone replacement therapydiscontinuation reduces risk[16]
Right heart failure[23]
Venousinflammation/phlebitiswhen a thrombus forms, it isthrombophlebitis[23]
Sickle cell disease
Artificial heart valves[25]
Probability and risk estimation for developing blood clots
Major risk (=1 point)Minor risk (=2 points)
CancerFamily history of
deep vein thrombosis
ImmobilityHospitalization within
the past 6 months
Calf swellingsuperficial vein dilation
Recent major surgeryredness of area
Edema or swelling of only legRecent trauma
to leg
Tenderness in
the calf and/or thigh
Scoring of the risks associated with the formation of blood clots
Probability determination and scoring
High probability scoring (12–7 points
3 major points OR
2 major points AND >2 minor points
Low probability scoring (3–5 points)
0 major points AND > 2 minor points
1 major point AND >2 minor points
0 major points and >3 minor point
1 major point and more than one minor point
Moderate probability scoring (varies)
all other risk combinations

Risk for subsequent blood clots

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Developing blood clots is more probable after the first episode. Risk assessment and intervention for those with one or more episodes of deep vein thrombosis or blood clots in the veins utilize the Well's test. It has been inconsistently modified by several publishers with the results listed below:[29]

Well's and modified Well's risk scoring

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Well's and modified Well's scoring
Findingpointsreferences
D-dimer abonormal one month after stopping anticoagulants2[29]
Age > or = to 501[29]
male1[29]
use of hormone at DVT onset1[29]

Adapted for the emergency department

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modified Well's scoring
Findingpointsreferences
Malignancy1[30]
Age > or = to 501[30]
cast on lower leg/Paralysis/paresis/1[30]
Recent surgery or immobility1[30]
tenderness over deep vein1[30]
entire leg swollen1[30]
difference of 3 cm between legs1[30]
pitting edema of the affected leg1[30]
Collateral superficial veins1[30]
another diagnosis more probable than DVT−2[30]

Scoring:

  • less than 2 points – low risk (3%)
  • 2–6 points moderate risk (17%)
  • > 6 points high risk (75%)[30]

General interventions

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TheCenters for Disease Control and Prevention have issued general guidelines describing the interventions that can be taken to reduce the risk of the formation of blood clots:

The Centers for Disease Control and Prevention recommend the following:

  • Move around as soon as possible after being confined to bed, such as after surgery, illness, or injury.
  • If you're at risk for DVT, talk to your doctor about:
    • Graduated compression stockings (sometimes called "medical compression stockings")
    • Medication (anticoagulants) to prevent DVT.
  • When sitting for long periods, such as when traveling for more than four hours:
    • Get up and walk around every 2 to 3 hours.
    • Exercise your legs while you're sitting by:
      • Raising and lowering your heels while keeping your toes on the floor
      • Raising and lowering your toes while keeping your heels on the floor
      • Tightening and releasing your leg muscles
    • Wear loose-fitting clothes.
  • You can reduce your risk by maintaining a healthy weight, avoiding a sedentary lifestyle, and following your doctor's recommendations based on your individual risk factors.[7]
 
A lower leg vein with good flow. Statis of blood would occur if this vein was compressed and blood flow decreased or was stopped.

Interventions during travel

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Seat-edge pressure from the seat on an airplane on thepopliteal area may contribute to vessel wall damage as well asvenous stasis.Coagulation activation may result from an interaction between cabin conditions (such ashypobarichypoxia) and individual risk factors for the formation of blood clots. Studies of thepathophysiologic mechanisms for the increased risk ofvenous thromboembolism or VTE after long-distance travel have not produced consistent results, but venous stasis appears to play a major role; other factors specific to air travel may increase coagulation activation, particularly in passengers with individual risk factors for VTE.[31]

Interventions for those hospitalized

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Compression devices

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Mechanical compression devices are used to prevent thrombosis and are beneficial enough to be used by patients at low to moderate risk.[4] The use of fittedintermittent pneumatic compression devices before, during, and after procedures is used in inpatient settings. It consists of an air pump and inflatable auxiliary compartments that sequentially inflate and deflate to provide an external 'pump' that returns venous blood toward the heart.[32] The use of intermittent pneumatic compression is common.[32][20][5] These devices are also placed on a surgical patient in the operating room (the intra-surgical period) and remain on the person while recovering from the surgery.[33]

The application ofantiembolism stockings can be used to prevent thrombosis.[4] The correct use and properly fitted graded compression stockings can reduce the rate of thrombosis by 50%.[16][20]: 745–46  Contraindications for the use of antiembolism stockings include the presence of advanced peripheral and obstructive arterial disease, septic phlebitis, heart failure, open wounds, dermatitis and peripheral neuropathy.[34] Differences between the use of thigh-high compression stockings and shorter types to prevent blood clots exist, but remain inconsistent.[4][5]

Assessment

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There has been some success in preventing blood clots through an early risk assessment upon hospital admission, a strategy recognized by the Centers for Disease Control and Prevention. Hospitals that have participated in this effort to reduce the incidence of thrombosis found that rates of DVT decreased in some instances.[35] Some hospitals developed a mandatory assessment quantifying the risk of developing blood clots and a plan of care developed from the results. The person's risk for developing blood clots is entered into their record, 'following' them through their treatment regime. If the hospital stay exceeds three days, the person will be reassessed for risk. Clinicians can then apply protocols for prevention based on best clinical practices.[36][37]

Interventions to treat immobility

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The poplitial vein can be one site of venous stasis in the lower leg. Obstruction of this vein during travel contributes to stasis.

Immobility is a significant risk factor in the development of thrombosis.[38][39][23][26] Immediate post-surgical interventions, such as out of bed orders (OOB), are typically ordered by the physician to prevent thrombosis. These orders, typically delegated to a nurse, but may include the participation of a physical therapist and others trained to perform the intervention, are to perform range of motion (ROM) activities that include: muscle contractions of the lower legs for those who are very weak, moving the feet, wiggling the toes, bending the knees, raise and lower the legs. In addition, changes in positioning prevent immobility and shift areas of venous stasis. If the person is too weak to perform these preventative activities, hospital personnel will perform these movements independently. Exercise of the lower extremities is a post-operative method of prophylaxis. Nursing personnel will often perform a range of motion exercises and encourage frequent moving of the legs, feet, and ankles. Frequent positioning changes and adequate fluid intake. After a surgical procedure, ambulation as soon as possible is prophylactic in preventing the formation of blood clots.[39][23][26]

Early ambulation also prevents venous stasis and physicians order OOB activities on the same day of surgery. This is accomplished in increments. The progression of increasing mobility proceeds by: raising the head of the bed, sitting up in bed, moving to the edge of the bed, dangling the legs off the bed, and then ambulating to a closed chair.[20][26]

Patient education and compliance reduce the risk of developing blood clots. These exercises and the use of equipment and follow-up by clinicians reduce the risk of developing blood clots.[26]

If a blood clot has already formed in the deep veins of the leg, early movement out of bed is usually prescribed, except in some severe cases of deep vein thrombosis or in people who havephlegmasia cerulea dolens. The treatment to prevent blood with physical intervention (e.g., sequential compression device) iscontraindicated.[citation needed]

Medication

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Anticoagulants and antiplatelets

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Thromboprophylaxis, such asanticoagulants or perioperative heparin, is effective for hospitalized patients at risk for VTE.[2][40] Additional risk factors such as obesity, disease, malignancies, long surgeries, and immobility may influence the prescribed dosage. Anticoagulant medications may prevent the formation of blood clots in people who are at high risk for their development.[4] Treating blood clots that have already formed is managed by the use of anti-hemolytic ("clot busters"). Despite its effectiveness, the use of thromboprophylaxis remains under-utilized, though alerts (computer or human) in hospitals are associated with increased prescription and reductions in symptomatic VTE.[40] The list below describes some of the more common medications used to prevent blood clots.[25] Note that generally since blood clotting is inhibited, a side effect typically is increased bleeding, though it can be reversed by administering a medication that stops the bleeding or by discontinuation of the medication itself. Anti-coagulant administration is often given before the start of the operation.[26] Medications that inhibit blood clot formation include:

Medications used to prevent blood clots
Name of medicationTherapeutic/pharmacologic classActionRouteOther usesNotesSide effectsReferences
aspirinantiplateletrisks for GI tract bleeding and hemorrhagic stroke[41][42][33][43][44]
dipyridamoleplatelet aggregation inhibitororal or intravenousAbdominal orstomach cramps,diarrhea, dizziness or lightheadedness[45][46][47][42]
clopidogrelantiplatelet[46][42]
ticlid
enoxaparinanticoagulantactivation of antiprothrombin, prevents fibrin formationslow IVplatelet count is monitored[46][42]
dalteparinanticoagulantactivation of antiprothrombin, prevents fibrin formationIV[42]
fondaparinuxanticoagulantinhibits thrombin productioninjectionaspirin not recommended with this medication[42][25][2]
dabigatraninhibits prothrombin[42]
bivalirudininhibits prothrombinoften given with aspirin[42]
argatrobananticoagulantinhibits prothrombinIValternative to heparin in those developing heparin-induced thrombocytopenia[42][25]
desirudinanticoagulantinhibits prothombininjectionused with hip replacement[42][25]
Eptifibatideantiplatelet[42]
tirofibanantiplatelet[42]
ticlopidineantiplatelet[42]
pentoxifyllineantiplatelet[42]
cilostazolantiplatelet[42]
rivaroxabaninhibits factor Xause with antiplatelets cautionedGI bleeding[42]
warfarinanticoagulantThrombin inhibitor;IV[25]
lipirudinanticoagulantinhibits prothrombinIVtreatment may extend to 10 days[25]
dextran[4]

Heparins

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Adding heparin to the use of compression stockings may prevent thrombosis for those at higher risk.[4][48]

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Heparin Prophylaxis
nameactionstructurereferences
Low-molecular weight heparin
(example:Reviparin)		[1][49][50][51][52]

The discontinuation of contraceptives also prevents blood clots.[16]

Herbal interactions

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The therapeutic effects of warfarin may be decreased byvalerian.Chamomile can affect the action of anticoagulants.Dong quai, garlic,ginger,Ginkgo biloba,bilberry, andfeverfew can increase bleeding time. These sameherbal supplements taken with warfarin increasedprothrombin time.[25]

Dietary interactions

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By containing significant content ofvitamin K, some foods act asantagonists to antiplatelet and anticoagulant medications; these include green leafy vegetables, likespinach,legumes, andbroccoli.[25]

Contraindications

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Preventing blood clots with medication is not considered safe in the following circumstances:

Research

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An international registry and risk assessment calculator is being used to centralize data on post-surgical venous thrombosis and its prevention.[53] Hospitals are implementing amultidisciplinary approach to prevent of blood clots. This includes adequate assessment of the risks, follow-up on missed doses of medication, and instituting a 'patient-centered' approach endorsed by theJoint Commission.[35] Recommendations regarding the prevention of blood clots vary widely between clinicians and treatment facilities. Research continues to clarify these discrepancies.[5] The metabolic state of hypercoagulability (the tendency to form blood clots) tests are being developed. These include the evaluation of thethrombin–antithrombin complexes (TAT), low levels of the anticoagulants ATIII and protein C, but these tests are not yet widely available.[14]

References

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 Using Wikipedia for Research

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