DEEP VENOUS THROMBOSIS IN THE NURSING HOME
CLINICAL PRACTICE GUIDELINE

 

DISEASE RECOGNITION

  • Pain, tenderness to deep palpation, with edema in calf or thigh, usually unilateral [may be asymptomatic in LTC population]
  • Pain in leg exacerbated by walking
  • Known risk factors (see below)

 

 CONTEXT/COMMUNICATION

If a DVT is expected as a complication of an underlying condition (ovarian cancer, pelvic mass) and the resident is on comfort care measures, no evaluation or treatment is indicated. The Health Care Agent should be contacted by the MD/NP or facility R.N. if anticoagulation is to be started.

 

ASSOCIATED RISKS 

  • Age > 70 years; previous DVT
  • Recent hospital confinement; residing in a nursing home
  • Recent surgery: orthopedic, abdominal, thoracic, genitourinary
  • Recent fracture: pelvis, vertebral, femur, tibia
  • Neoplasms: pancreas, lung, ovary, testes, breast, stomach, urinary tract
  • Immobilization or recent traumatic injury
  • Hypercoagulable states, myelproliferative disease, dysfibrinogenemia, polycythemia
  • Obesity [>265 pounds]
  • Cardiac: CVA, MI, uncontrolled hypertension, HF
  • COPD or acute respiratory failure
  • Indwelling central venous catheter
  • Drugs: Megace

 

PHYSICAL EXAMINATION

  • Lower extremities for findings consistent with diagnosis
  • Positive Homans sign present only 10% time (low sensitivity)

 

DIAGNOSTIC WORK-UP

  • Venous Doppler (high sensitivity and specificity for DVT in proximal veins)
  • Repeat Venous Doppler in 10-14 days if first result negative and resident  remains symptomatic
  • Document absence of exclusion criteria (see below)
  • Baseline CBC, LFTs, PT, PTT

 

EXCLUSION CRITERIA FOR TREATMENT

If a resident has any of the following conditions discuss anticoagulation with physician colleague: acute PUD or GI bleed, thrombocytopenia, uncontrolled hypertension, history of hemorrhagic CVA, active liver disease, prone to falling.

 

TREATMENT OPTIONS

With baseline labs and exclusion criteria met discontinue Megace and start:

  • Lovenox 1 mg/kg sc Q 12 hours x 5 days and start Coumadin 5 mg po QHS
  • Check INR on 3rd day and then QD until INR 2-3, adjusting as needed
  • Adjust Coumadin dose to maintain INR of 2-3 with INR 2 X week X 2 weeks then weekly*
  • Discontinue Coumadin after 3-6 months (for DVT prophylaxis after surgery continue for 30 days or until walking 100 feet per day or per orthopedist's recommendations)
  • Bed rest or discontinuation of physical therapy is not necessary
  • Elevation of limb is not recommended due to the risk of concurrent arterial disease causing distal limb pain with elevation. Compression stockings can be worn .

 

* DRUGS THAT DECREASE THE EFFECT OF COUMADIN

* DRUGS THAT INCREASE THE EFFECT OF COUMADIN

  • Barbiturates, Tegretol, Cholestyramine, Griseofulvin, Penicillin, Rifampin, Carafate
  • Allopurinol, Amiodarone, Tagamet,  Erythromycin, Diflucan, Lopid, Isoniazid, Flagyl, Nizoral, Prilosec, Dilantin, Feldene, Quinidine, Sulfonylureas, Tamoxifen, Thyroxin, Bactrim, Vitamin E, Tylenol

TREATMENT OF COUMADIN OVERDOSE WITH INR > 3   [half-life 36-42 hours]

INR

Clinical Situation

Action

> 3 < 5

No bleeding & no risk bleeding

Omit 1-2 doses Coumadin; INR QD; restart Coumadin at lower dose at INR of 3 or less

5-9

No bleeding & no risk bleeding

Omit 2-3 doses Coumadin; INR in 2 days; restart Coumadin at lower dose at INR of 3 or less

5-9

Rapid reversal for surgery

Stop Coumadin; give Vitamin K 2 - 4 mg p.o.; repeat does in 24 hours if INR > 5; discuss with physician colleague - may need FFP depending on surgical schedule

5-9

Minor bleeding or increased risk bleeding

Stop Coumadin; give Vitamin K 1-2.5 mg p.o.; repeat INR in 24 hours; discuss with physician colleague before restart

> 9

No bleeding & low risk of bleeding

Stop Coumadin; give Vitamin K 3-5 mg p.o.; repeat INR in 24 hours; then give Vitamin K 3 mg p.o. if INR > 6; repeat INR in 24 hours; discuss with physician colleague before restart

> 9

Bleeding

To ER for treatment

 

Vitamin K dose should be the lowest in a range if Coumadin
is to be continued and bleeding is not present.

 

 References for DVT

  1. Becker, RC, Ansell, J.: Antithrombotic Therapy An Abbreviated Reference for Clinicians, in Arch Intern Med., Vol. 155, Jan 23, 1995, 149-161.
  2. Ewald, GA: Disorders of Hemostasis in The Washington Manual, 28th Edition, 1995, 396-399.
  3. Holman, JR: Peripheral Venous Diseases: Tips on Diagnosis and management in ConsultantVol. 44, No. 4, April 1, 2004, 569-572.
  4. Isselbacher, KJ, Braunwald, E et al: Cardiovascular Diseases in Harrisonís Principles of Internal Medicine, 13th Edition, 1995, 396-397.
  5. Jacobs, LG: The Use of Oral Anticoagulants, AGS Clinical Practice Guidelines in JAGS 48:224-227, 2000.
  6. Jacobs, LG: Thrombosis Management: Long-Term Care Perspective in Supplement to Annals of Long-Term Care, June, 2003.
  7. Korber, KE, Caprini, JA: Deep-Vein Thrombosis New Perspectives On Diagnosis and Therapy in Clinician Reviews, May 1994, 63-86.
  8. Lubetsky, A. et al: Comparison of Oral VS Intravenous Phytonadione (Vitamin K1 ) in Patients With Excessive Anticoagulation in Arch Intern Med, Vol. 163, N0. 10, 2003, 2469-2473.
  9. McPherson, ML, Grace, KA: Anticoagulant Therapy, What to Consider in Practical Management in Advance for Nurse Practitioners, May 1997, 32-39.
  10. Nadeau, C.: The challenges of oral anticoagulation in Patient Care For The Nurse Practitioner, December 2000, 12-26.
  11. Rueben, DB, Grossberg, GT, et al: Anticoagulation Guidelines in Geriatrics at Your Fingertips, 1998/99 Edition, 68.
  12. Turpie, AG, Weart, CW, et al: Anticoagulation: Promises and Pitfalls in Patient Care Nurse Practitioner, April 1998, 44-56.
  13. Wells, PS, Ginsberg, JS: DVT and pulmonary embolism: Choosing the right diagnostic tests for patients at risk in Geriatrics, Vol.50, No.2, February 1995, 29-36.
  14. Wick, JY: Beyond the Basics: Special Issues in Venous Thromboembolism Prevention in Annals of Long-Term care, Vol. 14, No. 1, January 2006, 17-22.

MS/8.99
©EMS
Revised 3.06

 

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