Deep venous thrombosis (DVT) is a disease of obstruction of venous circulation due to abnormal blood clotting, mainly in the deep veins, femoral veins, and iliac veins. This condition can cause the blood clot to break off and cause a pulmonary embolism, both of which are collectively called venous thromboembolism. Hip fracture is the most serious osteoporotic fracture in the elderly, and its incidence is rapidly increasing in the context of the aging population of Chinese. It is predicted that by 2050, there will be 6.3 million elderly hip fracture patients. Studies have shown that the incidence of DVT in elderly hip fractures is 38.25%~56.83%, often accompanied by limb swelling, pain, skin eczema and pigmentation. Venous leg ulcers tend to recur and cause lifelong damage, with 33% of patients with DVT recurring within 10 years. Therefore, it is particularly important to prevent DVT in patients with hip fractures.
Significance of DVT prevention and management
According to the notice of the national medical quality and safety improvement target, it is clearly proposed to increase the standardized prevention and control of DVT, so as to further enhance the management ability of medical institutions and continuously optimize their service quality and safety management. The incidence of DVT in patients with preoperative hip fracture is as high as 46.59%, which may lead to a series of diseases such as pulmonary embolism and post-thrombotic syndrome, and in more severe cases, it may lead to the death of patients. Therefore, early intervention is essential to reduce the incidence of DVT.
Assess:
1. It is recommended that the patient should be re-evaluated within 24 hours of admission, within 6 hours after surgery, within 6 hours of transfer, before discharge, and if the condition changes.
2. It is recommended to use the Caprini thrombosis risk assessment scale or Wells score to assess the risk of DVT in patients, and at the same time, the risk of all patients with hip fracture is assessed by using the venous thrombosis risk score.
3. Risk factors include advanced age, fractures, surgery, limited mobility, immobilization, malignant tumors, chronic cardiopulmonary diseases, previous history of thrombosis, thrombophilia, obesity, etc.
Diagnosis and screening
DVT in hip fractures is easily masked by pain and swelling caused by fractures and traumatic reactions, so clinically relevant auxiliary tests are the main basis for the diagnosis of DVT. Intravenography is the "gold standard" for diagnosis, but patient acceptance is low because there is a certain risk of iodine allergy to the injection of contrast media, and it is an invasive test and the medical cost is high. D-dimers can present false-positive results due to many other reasons such as liver disease, inflammation, and cancer, which puts them at high risk of misdiagnosis in judgment. Therefore, it is necessary to combine venous ultrasound of the lower extremities to achieve early screening for DVT. The inferior vena cava filter is designed to prevent the detachment of DVT from the lower extremities and cause pulmonary embolism. Evidence suggests that DVT prevention of hip fractures generally does not recommend the placement of an inferior vena cava filter, but may be considered in patients with a high risk of thrombosis and a high risk of bleeding. The expert consensus suggests that patients with high-risk factors for thrombosis are relative indications, and therefore it is recommended that prophylactic filters should be carefully selected.
Diagnosis and Screening:
1. The diagnostic methods of DVT in patients with hip fracture include: color Doppler ultrasound, spiral CT venography, impedance plethysmography, radionuclide vascular scanning, venography and clinical examination.
2. If there is no contraindication to venography if thrombosis is suspected, imaging examinations such as venography should be performed.
3. Initial screening for possible DVT based on clinical risk stratification and D-dimer assessment.
4. Doppler ultrasonography is not recommended for asymptomatic patients before discharge.
Precautions for DVT
Stratified prophylaxis is a key measure for the prevention and management of DVT in patients with hip fractures. Studies have shown that DVT in hip fracture patients mainly occurs 3 days after injury and on the first day after surgery. Therefore, active prevention after admission is an effective approach to the management of DVT. Physical prevention mainly includes intermittent inflatable compression devices and gradient compression stockings, which are non-invasive for patients and easy to use and operate. Based on this, experts have given suggestions based on clinical experience and literature, but in clinical practice, a reasonable prevention plan should be formulated according to the patient's tolerance. Evidence suggests that the duration of anticoagulant therapy should be extended to 28~35 days after surgery. At the same time, after the anesthesia subsides, a multidisciplinary team was formed to formulate early rehabilitation functional training, including isometric contraction of lower limb muscles, active flexion and extension of knee and ankle joints, ankle pump exercises, etc., which were gradual and throughout the entire rehabilitation process. In clinical practice, it is recommended that departments formulate DVT nursing plans to systematize and standardize DVT prevention and promote the improvement of nursing quality.
Intervention strategies (choice of prevention):
1. Elderly patients with hip fracture are all at high risk of thrombosis, and it is recommended to prevent DVT from admission.
2. A combination of physical and pharmacological prophylaxis is recommended.
3. For patients with bleeding or a high risk of bleeding complications, physical prophylaxis is recommended until the patient reaches normal mobility or is discharged.
4. For physical prophylaxis that cannot or is not suitable for the limb, it can be implemented on the limb. Contraindications should be routinely screened prior to use.
5. Inferior vena cava filters are not recommended for the prevention of pulmonary embolism in patients with a high risk of bleeding or contraindications to pharmacological and physical prophylaxis.
Intervention Strategies (Basic Prevention):
1. The surgical operation should be as gentle and delicate as possible to avoid venous intimal damage.
2. Standardize the use of tourniquets during surgery.
3. Appropriate fluid rehydration in the perioperative period, with a water intake of 1500~2500mL/d to avoid dehydration.
4. Carry out functional exercises early, elevate the lower limbs by 15°~30°, and encourage effective coughing and breathing guidance.
Intervention Strategies (Physical Prevention):
1. It is recommended to routinely screen patients for dyspnea, pain, swelling and other symptoms before physical prevention, inform patients and their families in writing, and obtain their informed consent.
2. It is recommended to choose grade I GCS, and the leg length is better than the knee length; GCS should be selected based on the diameter of the lower extremity, worn as soon as possible after admission, for as long as possible, and the patient and GCS should be assessed daily during hospitalization.
3. Intraoperatively, IPC is recommended as the first choice, followed by GCS.
4. Choose the appropriate length of IPC according to the patient's height and leg length, at least 18h/d, and evaluate the patient's condition and equipment during use.
Intervention strategies (pharmacological prophylaxis):
1. It is recommended to take drug prophylaxis for at least 10~14 days, and it is recommended to extend it to 28~35 days after surgery.
2. It is recommended to evaluate whether the patient has the risk of bleeding and drug contraindications before medication, and evaluate the patient for bleeding and other adverse reactions after administration.
3. If there is bleeding, thrombocytopenia, and the circumference of the affected limb is increasing, follow the doctor's instructions to give accurate treatment.
4. Always wear a medical bracelet, necklace or similar warning label containing the name of the anticoagulant when taking anticoagulants.
5. LMWH, fondaparinux sodium, and low-dose unfractionated heparin are recommended for DVT prophylaxis. Subcutaneous injection of LMWH heparin is recommended.
6. Low molecular weight heparin was started ≥ 12 hours before surgery or ≥ 12 hours after surgery, and subcutaneous injection.
7. Patients who refuse to inject should take rivaroxaban orally directly after 6~10 hours after surgery.
8. For patients who undergo surgery 12 hours after hip fracture, it is recommended to give the conventional dose of LMWH subcutaneously 12 hours after surgery (4 hours after epidural catheter removal). 6~24h postoperatively, sulfamidone hepardiffine sodium 2.5mg was injected subcutaneously. Dose is monitored with a vitamin K antagonist (warfarin) 20 hours before surgery or overnight after surgery.
9. For patients with hip fracture whose surgery is delayed until the second day after admission, the last dose of low molecular weight heparin or the last dose of hepatitis E sodium should be given ≥ 12 hours before operation or 24 hours before surgery.
10. It is recommended to use a combination of traditional Chinese medicine and Western medicine to prevent and treat DVT in elderly patients with hip fracture.
Intervention Strategies (Rehabilitation Care):
1. It is suggested that postoperative rehabilitation should be carried out by a multidisciplinary team of orthopedic surgeons, geriatricians, rehabilitation specialists and nursing staff to develop an individualized rehabilitation training program.
2. Quadriceps isometric contraction exercises. Quadriceps isometric contraction exercises. After waking up from anesthesia, take a supine position, stretch the lower limbs, straighten the knee joint, press down the heel to the maximum tolerance, and maintain it for 5~10s; Back foot dorsiflexion to maximum tolerance, hold for 5~10s, 10~15 times/set, at least 3 times/d.
3. Ankle pump exercise. 1~3 days after the operation, take a sitting or lying position, hook the toes as much as possible, make the toes force on the body, and maintain the toes at the maximum extent for 2~10s, then slowly press the toes down as much as possible, and then maintain the maximum amount for 2~10s and then relax, 2~4min/time. Hip flexion and knee flexion training on the unaffected side, 10~15s each time, 30 times/group, every 2h/group; Horizontal movement training, 10~20 times/d.
4. Hip joint movement angle training. 4~7 days after surgery, hip flexion movement: the heel slides to the hip joint, and the hip flexion must be <70°; Hip abduction exercise: supine position, slight abduction of the hip joint on the affected side 20°~30° to ensure that the hip joint does not rotate, each time for 5~15min; Hip extension training, keep the body upright, prevent internal rotation, 3~4 times/d.
5. Sit-to-stand training. 1~2 weeks after surgery, hold the armrests and back chair, sit down slowly, move one side first, limbs in front, hip flexion < 90°, 2~3 times/time; Standing leg lift training, the patient slowly lifts the legs, and the knee joint is always kept below the waist, 2~3 times/time.
6. Walking training. During walking training, walk on tiptoe for 50~100m/time, and gradually transition from double crutches to single crutches.
7. 3~4 weeks after surgery, adhere to crutches walking training, daily living ability training, and avoid weight-bearing time for too long.
Health education
Various forms of guidance for elderly hip patients with different cultural levels can effectively improve patient compliance. Health education is to explain the process of disease, surgery and care to patients so that they can fully understand the disease and improve their awareness of the disease. Nurses are regarded as the promoters and implementers of DVT prevention knowledge, so nurses should take the initiative to educate patients about the causes, symptoms, treatment and prevention strategies of DVT.
Health Education:
1. Provide health education to patients and caregivers in a variety of ways, including the risks and possible consequences of DVT, the importance of prevention, and possible side effects.
2. Patients should be instructed to improve their lifestyle, eat more fiber-rich and low-fat foods, and keep their stools smooth.
3. It is recommended to inform patients and their families of the necessity, application methods and precautions of taking drugs on time after discharge, physical prevention, and avoiding bumps.
4. It is recommended that patients and their families be provided with the importance of DVT prevention and basic prevention methods at the time of discharge, and that they be reviewed regularly, through verbal education and written information guidance again.
It is suggested that multidisciplinary cooperation should scientifically use evidence to carry out individualized and precise prevention and management of elderly patients with hip fracture, and medical staff should standardize the prevention and treatment of DVT, so as to narrow the gap between clinical practice and evidence-based guidelines and reduce the occurrence of DVT in patients.
bibliography
Ren Xin, Zhang Jiayu, Zhang Meixia. Best evidence study on perioperative prevention and management of deep vein thrombosis in elderly patients with hip fracture[J/OL].Journal of Air Force Military Medical University, 1-12[2024-03-15]. http://kns.cnki.net/kcms/detail/61.1526.R.20240311.1448.005.html.
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