​​Kembara Xtra - Medicine - Deep Vein Thrombophlebitis

​​Kembara Xtra - Medicine - Deep Vein Thrombophlebitis 
The formation of a blood clot inside the deep veins, which is typically followed by inflammation of the vessel wall Major clinical effects include embolization, which typically occurs in the lung, recurrent thrombosis, and postphlebitic syndrome.

Epidemiology (Incidence and Prevalence) 
When taking into account both age and gender, the incidence of venous thromboembolism (VTE) in hospitals is one hundred times higher than it is in the general population. Almost half of all VTEs occur either during a patient's stay in the hospital or shortly after they have been released from the facility following an operation.
Within one month of receiving a diagnosis, death will occur in 10–30% of patients who have been diagnosed with deep venous thrombosis (DVT) and/or pulmonary embolism (PE).
Within the next 10 years, a recurrence of DVT/PE will affect around one-third (about 33%) of persons who have had either condition.
Twenty percent of patients diagnosed with VTE also have PE as a complicating factor. The fatality rate for DVT after 28 days is 5.4%; after 1 year, it is 20%; and after 3 years, it is 29%.

Incidence
The annual incidence of venous thromboembolism in the United States is 50,4 per 100,000 people.
Rising prevalence among people of Caucasian and African American descent, as well as among older people
The lower extremities are the most prevalent site for deep vein thrombosis (DVT), which has an incidence of between 0.5 and 3/1,000 in pregnant women and can complicate 1–5% of central venous catheters.

Prevalence

 Varies, as it is determined by the medical state as well as the procedure.
In patients who have been diagnosed with DVT, as many as forty percent of them also have asymptomatic PE. On the other hand, thirty percent of patients who have been diagnosed with PE do not have a source that can be identified.
11% of patients with acquired brain injuries who are beginning neuro rehabilitation report having this condition.

Causes and effects: etiology and pathophysiology 

The Virchow triad, which consists of venous stasis, endothelial damage, and hypercoagulability, may be one of the contributing factors.
Genetics
Thrombophilia type V Leiden, the most common form of the condition, affects between 10 and 65 percent of all cases of venous thromboembolism (VTE) and raises the risk of VTE by a factor of three to six.
3% of Caucasians have the prothrombin G20210A variant, which is associated with a greater than threefold increased risk of thrombosis.

Acquired risk factors include a history of deep vein thrombosis (DVT), cancer, immobilization, trauma, traumatic brain injury, recent major surgery, medications (oral/transdermal contraceptives, estrogens, tamoxifen, glucocorticoids), obesity, smoking, antiphospholipid syndrome, acute infectious process, thrombocytosis, pregnancy/puerperium, central venous catheters, and inflammatory bowel disease; inherited risk factors include deficiencies


Preventive Measures Low-molecular-weight heparin (LMWH), low-dose unfractionated heparin, or fondaparinux are advised for acutely unwell and critically ill hospitalized patients who are at a higher risk of thrombosis. Mechanical thromboprophylaxis is recommended for patients who have a high risk of bleeding.


History of Present Illness Enhanced clinical suspicion in patients who have risk factors (for more information, see the "Risk Factors" section).
The underlying risk factors are used to categorize deep vein thrombosis (DVT) as either induced or idiopathic.
Before beginning treatment, it is essential to conduct a clinical assessment of the patient's risk of bleeding, which includes taking into account factors such as a history of liver disease, recent surgeries, and gastrointestinal (GI) bleeding in the patient's past.
It is helpful to evaluate the pretest probability of developing a DVT using the modified Wells criteria, which is a clinical prediction rule that has been validated.
- Cancer that is currently active (therapy must be ongoing or have occurred within the past six months). (+1 point)
- Calf enlargement that is greater than 3 centimeters in comparison to the asymptomatic leg (+1 point)
- Collateral superficial veins (nonvaricose) (+1 point)
- Edema with pitting in the leg that is symptomatic (+1 point)
- A history of DVT that has been documented (one point added)
- Swelling throughout the entirety of the leg (one point added)
- Soreness along the deep venous system in specific areas (one point added)
- Paresis, paralysis, or immobilization of the lower extremities by a recent cast (one point added)
- Being recently bedridden for more than three days or having significant surgery within the preceding four weeks (+1 point).
- Another diagnosis that is at least as likely (less than 2 points).
● Interpretation: score of 0, DVT unlikely; score of 1 to 2,
moderate risk; score of ≥3, DVT likely. After the Wells criterion score has been determined, a D-dimer test and/or an ultrasound should be performed.

The Patient's Clinical Examination 
Symptoms could manifest itself as pain, swelling, or discoloration; however, they could also be nonspecific or nonexistent.
The most characteristic symptom is edema, which is brought on by an expansion of the collateral veins.
The Homan sign, which measures resistance to dorsiflexion of the foot, is not dependable and is not specific.
DIFFERENTIAL DIAGNOSIS
Cellulitis, fracture, ruptured synovial cyst (Baker cyst), lymphedema, calf muscle strain/tear/hematoma, Achilles tendon tear, extrinsic compression of vein (e.g., by tumor/enlarged lymph nodes), compartment syndrome, and localized allergic reaction are all possible complications that might arise from a cellulitis infection.

Results From the Laboratory Initial Examinations (lab, imaging)
The diagnosis cannot be made based on results from routine laboratory tests such as a complete blood count, metabolic panel, or coagulation investigations.
D-dimer is indicated in patients with a low and moderate pretest probability of DVT or PE but is not indicated in patients with a high pretest probability of either condition; false positives in liver disease, inflammation, malignancy, trauma, pregnancy, and recent surgery.
Patients who have had a previous DVT as well as those who have been diagnosed with cancer have greater risks of VTE, which lowers the NPV of the Wells criterion.
Compression ultrasound, often known as CUS, is the imaging method of choice for diagnosing deep vein thrombosis (DVT) because of its painless and non-invasive nature.
When working with patients who have a possible case of DVT, the process of diagnosis ought to be directed by an evaluation of the pretest probability.
– If the pre-test chance of DVT is low, a high-sensitivity D-dimer assay is adequate to rule out the possibility of the condition. If the test is positive, continue with CUS.
– Pretest likelihood is moderate; a high-sensitivity D-dimer assay is recommended as the initial test; if the result is positive, a CUS should be performed.
- CUS as the initial test; if the results of the CUS test are positive, then treat the patient for DVT. If the test is negative, no additional testing is required; however, if there is continued concern, a CUS test may be repeated after 24 hours. Other imaging modalities, such as CT venography and magnetic resonance venography, are rarely used but may be superior to CUS for demonstrating new from old thrombosis. Contrast venography and impedance plethysmography are no longer commonly used.

Additional Assessments, as well as Other Important Factors
Consider performing thrombophilia testing on young patients, as well as those who raise concerns or who have experienced idiopathic or recurrent VTE (factor V Leiden mutation, prothrombin G20210A genetic assay, ATIII functional assay, protein C functional assay, protein S antigen, and functional assay and free S, phospholipid-dependent tests and anticardiolipin antibodies, lupus anticoagulant [drawn before initiation of heparin]).
The probability of an underlying cancer increases by 3.2 (95% confidence interval [CI]: 2.0–4.8] if you have recurrent VTE. The chances ratio for unprovoked pulmonary embolism is 4.6 times higher compared to the odds ratio for secondary pulmonary embolism. The odds ratio for upper extremity DVT that is not catheter linked is 1.8. The odds ratio for abdominal DVT is 2.2. The odds ratio for bilateral lower extremity DVT is 2.1. 


Medication Used for Management 

When dealing with individuals who have a high pretest likelihood but an acceptable risk of bleeding, you might choose to start treatment before the diagnosis can be confirmed.

Anticoagulation is the primary treatment modality utilized. Long-term therapy of at least three months' duration is suggested for individuals diagnosed with pulmonary embolism or proximal deep vein thrombosis (DVT). The length of treatment after the first three months is determined on an individual basis.
It is possible to consider continuing anticoagulation for an indefinite period of time if there is a low risk of bleeding in the case that the index event is an unprovoked PE and/or if the D-dimer test is positive one month after the patient stopped receiving anticoagulation.
It is suggested that patients with lower extremity DVT or PE who do not have cancer take direct oral anticoagulants such as dabigatran, rivaroxaban, apixaban, or edoxaban during the first three months of treatment rather than vitamin K antagonists.

The patient's medical history, the danger of bleeding, the expense, and the simplicity of complying with the anticoagulant regimen are all factors that should be taken into consideration.

First Line

 Intravenous drip of unfractionated heparin: initial dose of 80 U/kg followed by continuous infusion of 18 U/kg/hr. Target aPTT ratio >1.5 times control. Check the aPTT once every six hours and make necessary adjustments to the infusion rate until two consecutive values fall within the therapeutic range.
LMWH – Enoxaparin (Lovenox): 1 mg/kg/dose intravenous (IV) every 12 hours or 1.5 mg/kg daily – Dalteparin (Fragmin): 200 U/kg intravenous (IV) every 24 hours or 100 U/kg intravenous (IV) every 12 hours
Fondaparinux (Arixtra): 5 mg (body weight 50 kg), 7.5 mg (body weight = 50 to 100 kg), or 10 mg (body weight >100 kg) subcutaneously (SC) once daily Direct and indirect factor Xa inhibitors Fondaparinux (Arixtra):
- Rivaroxaban (Xarelto): 15 milligrams orally (PO) twice daily with food for the first three weeks, then 20 milligrams orally (PO) every day with food after that.
– Apixaban (Eliquis): 10 mg PO twice daily for 1 week followed by 2.5 to 5.0 mg PO twice daily – Edoxaban (Savaysa): Initially provide parenteral anticoagulants for 5 to 10 days and then transition to 60 mg PO daily (>60 kg), 30 mg PO daily (60 kg). Apixaban (Eliquis): 10 mg PO twice daily for 1 week followed by 2.5 to 5.0 mg PO twice daily.
Thrombin inhibitors, such as dabigatran (Pradaxa): At first, provide parenteral anticoagulants for five to ten days, and then switch to 150 mg orally twice daily if the patient's creatinine clearance is higher than thirty milliliters per minute.
Antagonists of vitamin K, such as warfarin (Coumadin): Start with 2 to 5 mg per day. Adjust to a therapeutic INR that is sustained for at least 24 hours, which should be between 2 and 3, and overlap with a parenteral anticoagulant for at least 5 days.
Unfavorable consequences
– Heparin and LMWH can also cause heparin-induced thrombocytopenia (HIT; LMWH has a lesser risk) and discomfort at the injection site. – Warfarin is teratogenic. – All anticoagulants raise the risk of bleeding. – All anticoagulants increase the risk of bleeding. Patients who have a creatinine clearance that is lower than normal may require modifications to their dosage.
Second in Rank
Heparin can be administered via intermittent self-injection into the subcutaneous space.

Things to Think About When Expecting
A teratogen is a substance that can cause birth defects. It should not be used during pregnancy because of the potential risks, however it is safe to use during breastfeeding.
When treating acute DVT and PE in pregnant patients, LMWH is suggested over unfractionated heparin as the treatment of choice.
Enoxaparin, dalteparin, fondaparinux, and apixaban are all considered to be pregnancy Category B medications. Dabigatran, rivaroxaban, and edoxaban are considered to be pregnancy Category C medications.

Surgical Methods and Operations 
It is possible to consider catheter-directed thrombolysis or open thrombectomy in certain individuals who have proximal DVT (acute iliofemoral DVT lasting less than 14 days, good functional level, and a life expectancy of more than one year).
After a proximal (iliofemoral or femoral) DVT, the risk of a postthrombotic syndrome (PTS) can be reduced by one third by the use of thrombolysis, which can be either systemic or catheter-directed.
Patients who are suffering from limb-threatening ischemia as a result of iliofemoral venous outflow blockage are candidates for thrombectomy.
The insertion of an IVC filter is not something that is done frequently in patients who have acute DVT. However, it is something that should be taken into consideration for individuals who have DVT or PE with an absolute contraindication to anticoagulation, or who have repeated embolisms despite appropriate anticoagulation. Patients who are permanently unable to move, such as those who have suffered a spinal cord damage, may be eligible for additional considerations.

Admission 

If a patient with acute PE meets all of the conditions listed below, then it is not essential for them to be admitted to the hospital. Patients who are admitted despite meeting these requirements have the potential to be discharged early (after less than five days of inpatient therapy) (2):
Clinically, the patient is doing well and has a healthy amount of cardiopulmonary reserve.
- No active bleeding, significant renal or hepatic illness, or thrombocytopenia with a count below 70,000
– The patient reports that they are feeling well enough to receive treatment at home. – Compliance with the treatment plan is anticipated.
Admission because of respiratory distress, high cardiac biomarkers, right ventricular dysfunction, candidate for thrombolysis, active bleeding, renal failure, phlegmasia alba dolens, phlegmasia cerulea dolens, and a history of HIT.
An overlap of anticoagulation and warfarin monitoring is something that can be done as an outpatient procedure in people who are medically stable and who are appropriately anticoagulated.
Symptomatic alleviation can be achieved with the use of limb elevation and progressive compression stockings.


Compression stockings are not usually advised for the prevention of PTS after acute DVT (2)[B], although they can be utilized for patients who already present with symptoms of PTS. Follow Up Resumption of normal activity with avoidance of prolonged immobility Compression stockings are not typically suggested for the prevention of PTS after acute DVT (2)[B].
Patient Monitoring Keep track of platelet counts when using heparin, LMWH, and fondaparinux for HIT. An anti-Xa activity level can be helpful in determining how much LMWH therapy should be increased or decreased.

Investigate any severe bleeding (such as hematuria or gastrointestinal hemorrhage), as anticoagulant medication has the potential to reveal a previously undetected condition (such as malignancy, peptic ulcer disease, or arteriovenous [AV] malformation).
PATIENT EDUCATION When starting treatment with warfarin, the patient should be educated about the importance of monitoring their consumption of foods rich in vitamin K and their dietary patterns should be discussed.

A prognosis less than twenty percent of untreated proximal (iliofemoral, femoral, or popliteal) lower extremity DVTs proceed to PE, and ten to twenty percent of those who progress to PE die from their condition. Anticoagulant therapy, on the other hand, has been shown to reduce mortality by a factor of five to ten.
venous thromboembolism (DVT) that is restricted to the infrapopliteal veins carries a low risk of embolization but has the potential to spread proximally. Up to 75% of individuals who have symptomatic DVT manifest with PTS after 5 to 10 years.

Complications pulmonary embolism (which is fatal in 10–20%), arterial embolism (paradoxical embolization) with AV shunting, chronic venous insufficiency, post-thrombotic syndrome (PTS), treatment-induced hemorrhage, soft tissue ischemia associated with massive clot and high venous pressures; phlegmasia cerulea dolens (which is rare but a surgical emergency).

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