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DVT & PE: How early can I mobilize a patient ??
11 DVT & PE: How early can I mobilize a patient ?? Hatoun Al-Abdulkarim
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DVT: Formation of a blood clot in a deep veins as complication of immobility that may contribute to Morbidity & mortality
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Signs and symptoms: -Pain -Tenderness -Swelling
-Increased warmth & Redness - Erythema Or Bluish skin discoloration
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Over 50% of DVTs without Signs & symptoms
In Fact, Over 50% of DVTs without Signs & symptoms
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55 US
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Pulmonary embolism (PE):
Blockage of the main artery of the lung or one of its branches by a substance that has travelled from elsewhere in the body through the bloodstream (Usually DVT)
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Signs and symptoms: - Shortness of breath ( suddenly, even at rest)
- Chest pain ( worse with deep breathe, cough, or bend) - Cough Other signs and symptoms may include: - Wheezing - Excessive sweating - Arrhythmia - Weak pulse - Fainting
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-PE are reported as many as one third of patients with DVT
88 -PE are reported as many as one third of patients with DVT -Most pulmonary emboli are multiple, and the lower lobes are involved more commonly than the upper lobes
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99 Lung with PE
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Incidence *Heit J. ASH Abstract 2005. 900,000 PEs/ DVTs in USA in 2002
Incidence 900,000 PEs/ DVTs in USA in 2002 10-40% in medical or general surgery patients 40-60% following major orthopedic surgery 10% hospital deaths attributed to PE *Heit J. ASH Abstract 2005.
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Risk Factors Age (over 40) A past history of DVT A family history
Risk Factors Age (over 40) A past history of DVT A family history Immobility Recent surgery or an injury (especially hips or knees)
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Obesity Pregnancy Cancer and its treatments Contraceptive pill that contains estrogen Hormone replacement therapy (HRT) Circulation or heart problems
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Methods of Prophylaxis
Methods of Prophylaxis Mechanical Pharmacological
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Mechanical Early ambulation Elastic stockings
Mechanical Early ambulation Elastic stockings Intermittent pneumatic compression
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Pharmocologic Methods
Pharmocologic Methods Warfarin. Unfractionated Heparin. Low Molecular Weight Heparin.
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When Can the Patient With DVT Begin to Ambulate?
When Can the Patient With DVT Begin to Ambulate?
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Medical Approach for Mobilizing pts with a DVT has dramatically changed over the past several years
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Partsch and Blattler (2000)
Partsch and Blattler (2000) New PE development was similar in a mobile group with graduated compression stockings and a bed rest group. They also found decreased pain and leg edema in the mobile group.
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Aschwanden et al (2001) New PE occurred in 10 % of mobile subjects while new PE occurred in 14 % of immobile subjects.
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Romero-Villegas (2008) 2 PEs occurrences in a sample of 105 patients on bedrest and 3 PEs in a sample of 114 patients who received early ambulation.
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Compression and walking compared with bed rest in the treatment of proximal DVT during pregnancy
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15 patients with elastic compression bandages and early mobilization
Group A: 15 patients with elastic compression bandages and early mobilization Group B: 17 patients with compression bandages and bed rest. All patients received heparin therapy.
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Objective pain using Lowenberg test.
Subjective Pain was assessed daily with a (VAS) Objective pain using Lowenberg test. Reduction of edema was recorded initially and on day 2, 4 and 7. Ultrasound was repeated after 7 days.
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RESULTS: Resolution of subjective pain was faster in group A
RESULTS: Resolution of subjective pain was faster in group A Objective pain& measurement of leg reduced in group A There was no pulmonary embolism and progression of thrombus diameter.
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A meta-analysis of bed rest vs early ambulation in the management of pulmonary embolism, DVT or both 2009 Sep Department of Cardiology, Cochin Hospital, AP-HP, René Descartes Paris V University, Paris, France
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METHODS - Considered all randomized studies and prospective registries that compared the outcomes of patients with DVT, PE, or both, managed with bed rest versus early ambulation, in addition to anticoagulation. -For each study, data regarding the incidence of new PE, new or progression of DVT, and death from all causes, were used to calculate relative risks (RR) and 95% confidence intervals (CI).
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RESULTS The 5 studies retained in this analysis included a total of 3048 patients. When compared to bed rest, early ambulation was not associated with a higher incidence of a new PE (RR 1.03; 95% ).
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overall mortality (RR 0.79; 95% ).
Furthermore, early ambulation was associated with a trend toward a lower incidence of new PE and new or progression of DVT than bed rest (RR 0.79; 95% ) and overall mortality (RR 0.79; 95% ).
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CONCLUSIONS
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It appears that these studies support that early ambulation and mobilization does not increase the risk of PE compared to bedrest and in some cases may result in actual improvement of other factors like pain and edema.
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Thank you
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