DRG Category: 253
Mean LOS: 5.4 days
Description: Surgical: Other Vascular Procedures With Complication or Comorbidity
DRG Category: 299
Mean LOS: 5.1 days
Description: Medical: Peripheral Vascular Disorders With Major Complication or Comorbidity
Thrombophlebitis, inflammation of a vein with an associated blood clot (thrombus), typically occurs in the veins of the lower extremities when fibrin and platelets accumulate at areas of stasis or turbulence near venous valves. Deep vein thrombophlebitis (deep vein thrombosis [DVT]) occurs more than 90% of the time in small veins, such as the lesser saphenous, or in large veins, such as the femoral and popliteal. DVT and its possible consequence, pulmonary embolism, are the leading causes of preventable mortality in hospitalized patients in the United States. DVT occurs in approximately 1 in every 20 individuals over their lifetime, but in hospitalized patients, the incidence of DVT ranges from 20% to 70%.
DVT is potentially more serious than superficial vein thrombosis (SVT) because the deep veins carry approximately 90% of the blood flow as it leaves the lower extremities. Once a thrombus begins to move, it becomes an embolus (a detached intravascular mass carried by the blood). If it reaches the lungs, a pulmonary embolus, it is potentially fatal. Another complication is postphlebitic syndrome, which leads to lasting and disabling pain, swelling, and heaviness in the affected leg.
Venous stasis, hypercoagulability, and vascular injury are major causes of thrombophlebitis. Venous stasis results from prolonged immobility, pregnancy, obesity, chronic heart disease such as congestive heart failure or myocardial infarction, recovery from major surgery (surgical procedures lasting more than 30 minutes), cerebrovascular accidents, and advanced age. Hypercoagulability is associated with pregnancy, cigarette smoking, dehydration, deficiencies of substances involved in clot breakdown, tamoxifen use, long airplane flights, disseminated intravascular coagulation, estrogen supplements and oral contraceptives, malignancy, and sepsis. Vascular injury can occur with lower extremity fractures, surgery, burns, multiple trauma, childbirth, infections, irritating IV solutions, venipuncture, and venulitis. Other diseases that may lead to thrombus formation are cancer of the lung, gastrointestinal tract, and genitourinary tract and also atrial fibrillation; individuals older than 55 years are also particularly susceptible to thrombophlebitis.
Coagulopathies such as factor V Leiden, a thrombophilia that predisposes to thrombophlebitis, is due to a very poor response to activated protein C. This is caused by mutations in factor V (F5) that render it resistant to cleavage. Factor V Leiden increases clot formation in heterozygote carriers, but homozygotes are most severely affected. Testing for factor V Leiden should be considered when a person has a thrombophlebitis meeting any of the following criteria: onset before age 50 years, idiopathic venous thromboembolism at any age, recurrent thromboembolism, and venous thrombosis at unusual sites (e.g., cerebral, mesenteric, portal, and hepatic veins). Testing has also been recommended when thrombophlebitis occurs during pregnancy, in the postpartum period, or in association with oral contraceptive use or hormone replacement therapy. Anyone with a strong family history should also be tested for factor V Leiden. The prothrombin 20210G-A variant also increases the risk of thrombophilia, especially in combination with the factor V Leiden mutation.
Young women and older adults are more likely to develop thrombophlebitis than adult men because young adult women may have many risk factors (pregnancy, oral contraceptives, smoking, obesity). Women over age 30 years who smoke and use oral contraceptives are at particular risk. The older person's increased tendency for immobility, platelet aggregation, and elevated fibrinogen levels increases their risk.
Ethnicity, race, and sexual/gender minority status have no known effect on the risk for thrombophlebitis.
Global incidence is likely similar to that of the United States and Western Europe. Little is known about the incidence in developing countries, and definitive diagnosis is often difficult or even impossible in low-resourced areas.
PLANNING AND IMPLEMENTATION
Collaborative
To prevent thrombus formation, most physicians prescribe compression of the legs by graduated compression stockings to reduce venous stasis in low-risk general surgical patients. In higher-risk patients, intermittent pneumatic compression boots prevent venous stasis and increase the normal breakdown of fibrin in the body with increased fibrinolytic activity.
The location of the thrombus dictates the treatment. If a DVT is suspected, anticoagulation is used to prevent pulmonary emboli. For patients with SVT, low molecular weight heparin (LMWH) is the treatment of choice. Most patients who develop thrombophlebitis are placed on bedrest with extremity elevation to avoid dislodging the thrombus. Local heat with warm soaks may also be used to reduce venospasm and decrease inflammation, but data are not clear whether or not this therapy improves outcomes. Generally, the patient is given analgesics for pain control along with the anticoagulant therapy to prevent further clot formation. From 1 to 3 days later, warfarin therapy is started. LMWH is usually discontinued 48 hours after the patient's PT reaches a therapeutic value. (Box 1).
Box 1 Caring for the Patient on Anticoagulants
Assessment- Monitor coagulation profile (PT, partial thromboplastin time, INR) daily and report values below and above the therapeutic range to the physician.
- Monitor for overt bleeding such as bruising, tarry stools, coffee ground or bloody vomitus, oozing gums, hematuria, vaginal bleeding, and heavy menstruation.
- Monitor for occult bleeding demonstrated by flank pain or abdominal pain and for changes in mental status.
Management Considerations- Have the antidote for heparin (protamine sulfate) and warfarin (vitamin K) available for emergency use in case of hemorrhage.
- Avoid administering aspirin to patients on anticoagulants because the synergistic effect may induce bleeding.
- Avoid the following procedures if possible because of the risk of increased bleeding: intramuscular injections, central line insertions, arterial cannulation, lumbar puncture, and surgical procedures.
- Note that the following conditions are relative contraindications to anticoagulant therapy: active bleeding, cerebrovascular accident, severe hypertension, pericarditis and endocarditis, pregnancy (particularly warfarin therapy), and chronic alcoholism.
Note that the following medications may interact with warfarin:
- Increased activity: Allopurinol, cimetidine, indomethacin, metronidazole, oral hypoglycemic agents, phenothiazines, quinidine, tricyclic antidepressants
- Decreased activity: Barbiturates, oral contraceptives, rifampin. Apply pressure on all punctures for 5 minutes or as long as needed to stop bleeding.
Some patients may continue heparin subcutaneously for several weeks before changing to warfarin. Because prothrombin assays are performed in various ways, PT results are now also reported as an INR. The target INR for oral anticoagulation is at least 2; current recommendations are to stop heparin therapy after 5 to 7 days of joint therapy when the INR is 2 to 3 with the patient off heparin. For patients with massive DVT in proximal veins, thrombolytic therapy may be considered. Before initiating therapy, the risk that the clot presents to the patient is compared with the risk of bleeding from thrombolytic agents.
Surgical.
Other treatments that may be used for severe, obstructive DVT are thrombectomy (surgical clot removal) and surgical prophylaxis against pulmonary embolism with implantation of an umbrella filter in the inferior vena cava.
| Medication or Drug Class | Dosage | Description | Rationale |
|---|
| Fibrinolytic agents | Varies with drug | Reteplase (r-PA, Retavase), Alteplase (t-PA, Activase) | Breakdown of the blood clot for extensive DVT but usually not SVT |
| Anticoagulants | Varies with drug and patient weight | LMWH: Enoxaparin (Lovenox), dalteparin (Fragmin), and tinzaparin (Innohep); warfarin | Standard treatment is to initiate IV heparin to reduce further formation of clots; leads to early discharge for some patients |
| NSAIDs | Varies with drug | Ibuprofen, naproxen | Resolve symptoms and prevent extension of thromboembolism |
Other Drugs: Analgesics; antibiotics if infection is suspected
Independent
The most important nursing interventions focus on prevention. Decrease the risk of venous stasis in a bedridden patient by performing early ambulation and active or passive range-of-motion exercises several times a day. Avoid using the knee bed adjustment because of the risk of popliteal pressure and venous stasis with the knees bent; encourage patients not to cross their legs, especially when sitting. If pillows are needed to elevate extremities, position them along the entire length of the extremity to prevent additional pressure on veins and to allow for adequate venous drainage. If the patient is immobile and not on fluid restriction, encourage the patient to drink at least 3 L of fluid a day to prevent dehydration and venous stasis.
To prevent injury to vessel walls, monitor IV cannulas to prevent infiltration. If IV medications are irritating to the vein, IV cannulas should be changed and rotated to new sites more often than the standard procedure.
Discuss activity restrictions with the patient and family. The patient usually feels confined and may become resentful because of the need for absolute bedrest. To increase mobility in bed, install an orthoframe and trapeze system to the bed. A sheepskin, air mattress, foam pad, foot cradle, or heel pads can reduce the risk of skin breakdown while the person is on bedrest. Provide diversional activities to reduce anxiety.
Evidence-Based Practice and Health Policy
Marone, E., Bonalumi, G., Curci, R., Arzini, A., Chierico, S., Marazzi, G., Diaco, D., Rossini, R., Boschini, S., & Rinaldi, L. (2020). Characteristics of venous thromboembolism in COVID-19 patients: A multicenter experience from Northern Italy. Annals of Vascular Surgery, 68, 83–87.
- The authors aimed to determine the characteristics of DVT and pulmonary embolism in COVID-19 patients based on four high-volume hospitals in Italy. They reviewed all cases of patients undergoing duplex ultrasound for clinically suspected DVT
- Of 101 ultrasounds performed, 42 were positive for DVT, 7 for SVT, and 24 for pulmonary emboli. Most patients had moderate (44%) or mild (17%) pneumonia. Diagnosis of thrombophlebitis and pulmonary embolism was generally during the first 2 weeks of hospitalization. Two-thirds of the pulmonary emboli occurred in the absence of a recognizable DVT.