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Adult Guideline: Diagnosis Deep Vein Thrombosis (DVT) and Superficial Venous Thrombobis (SVT)

Discharge Protocol Emergency Department(ED) to Outpatient Management

Reprinted with the permission of Jennie Edmundson Memorial Hospital, Council Bluffs, IA

POTENTIAL BARRIERS TO OUTPATIENT TREATMENT REGIMEN / AVAILABLE RESOURCES
Issues with financial resources:
Insurance, Medicare, Medicaid Reimbursement
Self-pay
Inability or non-willingness to learn administration of injections
Lack of support system
History/potential lack of adherence / Hospital Social Services
Clinical Pharmacist
Charitable Foundation
Industry Patient Assistance Programs
Home Health Care
CLINICAL MANAGEMENT / EMERGENCY DEPARTMENT
Refer to Chest Guidelines for Management of VTE
Dosing with LMWH, UFH, Fondoparinux (see attached ACCP 8thed. guidelines)
Refer to Chest Guidelines for Management of VTE
Dosing with vitamin K agonist (warfarin)
Stop Oral Contraceptives/Estrogen
(alternate form of birth control)
Smoking cessation
Knee high compression stockings (30-40mmHg at the ankle) as often as possible during day—recommended 2 years duration.
Activity: as tolerated in the home, no contact sports, individualized to employment situation
Elevate extremity and apply local heat for comfort and to decrease swelling
Dietary considerations of anticoagulation / First dose in the ED
Prescription for 5 days LMWH
First dose in the ED
Prescription for 5 days warfarin
Teaching on LMWH/ warfarin administration while in ED
Patient discharge instructions
  • Deep Venous Thrombosis
  • Phlebitis, thrombophlebitis
  • Anticoagulation
  • Compression Stockings
Reinforce signs and symptoms of complications:
  • Chest pain
  • Shortness of Breath
  • Bleeding

FOLLOW-UP POST DISCHARGE
Provider-to-provider communication while patient in ED, establishing primary care / INR arranged in accordance with primary provider in 2 days, office or Coumadin Clinic-patient to call clinic and schedule

Clinical Recommendations for INITIALtreatment of Lower Extremity DVT and SVT

Summary Recommendations American College of Chest Physician Guidelines (8th Edition)

Kearon, C., Kahn, S.R., Agnelli, G., Goldhaber, S., Raskob, G.E., & Comerota, A.J. (2008)

Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians evidence-based practice guidelines (8th ed.) Chest, 133, 454S-545S.

Initial Treatment DVT of the Leg / Recommendation / Level of Evidence
Objectively confirmed DVT of the leg initial anticoagulation / Short-term treatment (rather than no treatment) with
  • SC LMWH
  • IV UFH
  • Monitored SC UFH
  • Fixed-dose SC UFH
  • SC fondaparinux
/ Grade 1A
Grade 1A
Grade 1A
Grade 1A
Grade 1A
High Clinical Suspicion of DVT / Treatment with anticoagulants while awaiting the outcome of diagnostic tests / Grade 1C
Acute DVT /
  • Initial treatment with LMWH, UFH, or fondaparinux, and
  • Initiation of VKA (warfarin 5 to 10mg) on the first treatment day and for at least 5 days and until the INR is≥ 2 for 24 hours
/ Grade 1C
Activity / Early ambulation in preference to initial bed rest when this is feasible / Grade 1A
Elastic Stockings and Compression Bandages to Prevent Post Thrombotic Syndrome / Elastic compression stocking with an ankle pressure gradient of 30 to 40mm Hg if feasible after starting anticoagulant / Grade 1A
Note: Feasibility refers to ability of patients and their caregivers to apply and remove stockings
Refer to ACCP Guidelines 8th Ed. for recommendations regarding catheter-directed thrombolysis, systemic thrombolytic therapy, percutaneous venous thrombectomy, operative venous thrombectomy, and vena caval filters
SC LMWH / Recommendation / Level of Evidence
Acute DVT / Rather than treatment with IV UFH:
  • Initial treatment with SC LMWH once or twice daily as an outpatient if possible
  • Inpatient if necessary
Against routine monitoring with anti-factor Xa level measurements
Patients with severe renal failure, suggest UFH over LMWH / Grade 1C
Grade 1A
Grade 1A
Grade 2C
SC UFH / Recommendation / Level of Evidence
Acute DVT / Monitored SC UFH
Rather than starting with a smaller initial dose:
  • Initial dose of 17,500units, or a weight-adjusted dose of about 250units/kg twice per day
  • Dose adjustment to achieve and maintain an aPTT prolongation that corresponds to plasma heparin levels of 0.3 to 0.7 international units/ml anti-Xa activity when measured 6hours after injection
/ Grade 1C
Acute DVT / Fixed dose unmonitored SC UFH
Rather than non-weight-based dosing:
  • Initial dose of 333units/kg
  • Followed by 250units/kg twice per day
/ Grace 1C
Initial Treatment of SVT of Leg / Recommendations / Level of Evidence
Spontaneous SVT of Leg /
  • Prophylactic or intermediate doses of LMWH for at least 4 weeks or
  • Intermediate doses of UFH for at least 4 weeks duration
  • Alternative to 4 weeks of LMWH or UFH, VKA (target INR, 2.5; range, 2 to 3 can be overlapped with 5 days of UFH and LMWH and continued for 4 weeks)
  • Oral nonsteroidal anti-inflammatory drugs should not be used in addition to anticoagulation
/ Grade 2B
Grade 2B
Grade 2C
Grade 2B
Remark: It is likely that less extensive superficial vein thrombosis (i.e., where the affected venous segment is short in length or further from the saphenofemoral junction) does not require treatment with anticoagulants. It is reasonable to use oral or topical nonsteroidal anti-inflammatory drugs for symptom control in such cases
Legend for Abbreviations
DVT / Deep Venous Thrombosis
ED / Emergency Department
SC / Subcutaneous
LMWH / Low Molecular Weight Heparin
IV / Intravenous
UFH / Unfractionated Heparin
INR / International Normalized Ratio
mmHg / Millimeters of Mercury
ACCP / American College of Chest Physicians
aPTT / activated Partial Thromboplastin Time
SVT / Superficial Venous Thrombosis
VKA / Vitamin K agonist
Grades of Recommendation for Antithrombotic Agents
Grade 1 / Recommendations are strong and indicate that the benefits do or do not outweigh risks, burden and costs, can be applied uniformly to most patients
Grade 2 / Recommendation weaker, less certain of the magnitude of the benefits and risks, burden, and costs, and thus their relative impact. Suggests that individual patient values and preferences may lead to different choices
Quality / Randomized controlled trials, quality based on precision, consistency of results, directness , likelihood of reporting bias
A / High quality
B / Moderate quality
C / Low quality