Before deciding to pursue an advanced degree as a nurse practitioner, I worked for seven years as an orthopedic nurse. I’ve seen many detrimental and near fatal complications following orthopedic surgery, but venous thromboembolisms (VTEs) comprise the majority of these complications. Many potentially fatal VTEs are the consequence of patient non-compliance, lack of education and failure to follow the recommended guidelines for prophylaxis.

Many patients remove deep venous thrombosis (DVT) prophylactic boots and compression stockings for prolonged periods of time, because they do not like the way they feel. Many times healthcare providers witness these actions and do not reinforce the interventions or provide essential patient education.

DVT prophylactic pharmacologic intervention with subcutaneous enoxaparin injections (Lovenox, Sanofi-Aventis) administered to the abdomen are also unpopular, because many patients and their family members are afraid of needles. Non-compliance results in patient failure during the essential outpatient DVT prophylactic period, leading to unnecessary complications and increased risk for fatal VTEs.

Decades of research support simple, successful and cost-effective prophylactic measures, yet such options remain persistently underused — 40% to 60% of patients receive no or inadequate prophylaxis.1 Because only a fraction of time and resources are currently allocated to VTE prevention, efforts to promote essential post-operative nursing care guidelines could help improve these numbers.

VTE is the most common preventable cause of hospital death, resulting in more than 300,000 deaths every year in the United States.1 Patients undergoing orthopedic surgical procedures are at greatest risk for a VTE-related life-threatening complication, particularly those receiving total joint arthroplasty of the hip or knee. DVT prevalence for total hip arthroplasty, total knee arthroplasty and hip fracture surgery ranges from 50% to 60% in the seven to 14 day post-operative period.2

Improving these statistics will require that all members of the health care team be educated regarding evidence-based DVT prophylaxis, which should begin in primary care with the initial patient assessment, continue throughout the hospital stay with perioperative nurses and be maintained after hospital discharge in rehabilitation or with home health nurses during the recovery period.

Adjunctive treatment modalities

The ideal thromboprophylactic regimen is cost-effective, easy to administer and requires no laboratory monitoring. Successful prophylaxis with pharmacologic agents and adjunctive treatment modalities depends on both consistency and accuracy.

Ensuring that stockings are fitted and worn correctly is the first step. Be sure to document patient’s leg measurements and stocking size to serve as a baseline for future assessments. The Sigel profile recommends pressures of approximately 18 mmHg at the ankle, 14 mmHg at mid-calf and 8 mmHg at upper thigh, and evidence shows that thigh-length stockings are superior to knee-length stockings.3

Calf compression devices should compress the calf muscles to a pressure of 35 mmHg to 40 mmHg for 10 seconds every minute to stimulate fibrinolysis.3 Some investigators report that unilateral application also results in benefit to both extremities, as this triggers systematic fibrinolytic activity.2 Compression pumps should be used preoperatively in patients confined to bed, intraoperatively and continued until the patient is ambulatory. 

Because venous stasis is a contributing factor to VTE, limb immobility after orthopedic surgery increases DVT risk 10-fold.3 Early mobilization should begin immediately after surgery, with ambulation initiated as soon as the patient’s condition permits. Once ambulation has begun, the patient should avoid prolonged standing and sitting without leg elevation. Walking and other types of permitted weight-bearing physical activity should also be encouraged on a habitual basis.

Pharmacological agents

Pharmacological agents should only be initiated adjunctively with pneumatic compression devices, compression stockings and early mobilization. Agents commonly used in DVT prophylaxis include low molecular weight heparin, warfarin and unfractionated heparin. Other pharmacological agents have been proposed, but to-date there is controversy as to which, if any, therapies are superior. 

For the last several years, all of the orthopedic surgeons on my wing have used enoxaparin injections for DVT prophylaxis postoperatively at the recommended prophylactic dose of 40 mg daily for 7 to 10 days. But excessive bleeding, heparin-induced thrombocytopenia (HIT) and patient fear related to self-administering or receiving the injection contribute to noncompliance.

Recently, our orthopedic surgeons have switched to prescribing rivaroxaban (Xarelto, Janssen), an oral oxazolidinone-based anticoagulant, which received FDA approval for VTE prophylaxis in adult patients after total hip replacement (10 mg administered orally, once daily for five weeks post surgery) or total knee replacement (10 mg administered orally surgery once daily for two weeks post surgery).

Like enoxaparin injections, rivaroxaban has a long half-life that permits once-daily dosing, but offers the advantage of oral administration. Rivaroxaban has predictable and consistent anticoagulant effects and a wide therapeutic window, so it does not require the routine coagulation monitoring necessary with warfarin.

Since we’ve switched from enoxaparin injections to rivaroxaban, there has been an increase in compliance, patient satisfaction and favorable outcomes.  Anecdotally, patients report that they prefer the daily oral agent to the injection, and patients who have had a previous knee or hip are generally happy that they do not have to go home on injections again.

Optimizing clinical outcomes and averting declines in the overall level of function is the goal of DVT prophylaxis in orthopedic patients. We can accomplished this if we remain open and willing to adapt our care to reflect evidence-based practices.     

Matthew Lucostic is a DNP candidate at Carlow University’s Family Nurse Practitioner School in Pittsburgh. He expects to graduate in 2012, and has accepted a position with Sheba Orthopedic Surgeons in Uniontown, Penn.

References

  1. Findlay J, Keogh M, Cooper L. “Venous thromboembolism prophylaxis: the role of the nurse. British Journal of Nursing. 2010; 19(16):1028-1032. 
  2. Rice KL, Walsh ME. “Minimizing Venous Thromboembolic Complications in the Orthopaedic Patient.” Orthopaedic Nursing. 2001; 20(60):,21-27.
  3. Rogers BA, Little NJ. “Thromboprophylaxis in orthopaedic surgery: a clinical review.” Journal of Perioperative Practice. 2010; 20(10): 358-362.