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LETTER TO EDITOR
Year : 2012  |  Volume : 56  |  Issue : 6  |  Page : 593-595  

Identification of occult deep vein thrombosis before the placement of sequential compression devices


1 Department of Anaesthesia and Critical Care, JPNA Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
2 Department of Anaesthesia and Critical Care, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication14-Dec-2012

Correspondence Address:
Manpreet Kaur
426 Masjid Moth Resident Doctor's Hostel, AIIMS, New Delhi- 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5049.104593

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How to cite this article:
Kaur M, Sinha C, Singh P M, Gupta B. Identification of occult deep vein thrombosis before the placement of sequential compression devices. Indian J Anaesth 2012;56:593-5

How to cite this URL:
Kaur M, Sinha C, Singh P M, Gupta B. Identification of occult deep vein thrombosis before the placement of sequential compression devices. Indian J Anaesth [serial online] 2012 [cited 2019 Sep 17];56:593-5. Available from: http://www.ijaweb.org/text.asp?2012/56/6/593/104593

Sir,

Trauma patients with multisystem injuries and a high injury severity score (ISS) have an increased risk of thromboembolic events. Safe and effective thromboprophylaxis is highly desirable to prevent deep vein thrombosis (DVT). Unfractionated heparin, low-molecular-weight heparin (LMWH), sequential compression devices (SCDs), and vena cava filters are used as prophylaxis in trauma patients. [1] We encountered a case wherein occult DVT was already present and SCD was applied as part of the protocol. Routine use of compression ultrasound (USG) to assess for lower extremity thrombus is justified to prevent such incidents as in our patient.

A 40- year-old male with moderate head injury, central cord syndrome and faciomaxillary injury was being managed conservatively in the ward for two weeks. He was admitted to the trauma intensive care unit (ICU) in view of tachypnoea and decreasing saturation. He had sequential organ failure assessment (SOFA) score of 11, pulse rate 130 per min, invasive blood pressure 80/60 mm Hg and SpO 2 of 82%. He was not receiving LMWH for DVT prophylaxis and was given thromboprophylaxis only by mechanical compression device in view of head injury. On admission to the ICU as there was no evidence of DVT on clinical examination as a part of protocol, the staff nurse applied SCD on both the limbs. Routine USG colour Doppler of the lower limbs [Figure 1] was done which revealed left partial thrombus in the left common femoral vein extending into the profunda femoris and popliteal vein; right complete thrombus extending to the right common femoral vein, superficial femoral and popliteal vein. Computed tomography (CT) pulmonary angiography was done which revealed that right pulmonary artery had a filling defect at the junction of ascending and descending trunk and left descending trunk showed a large filling defect extending into segmental branches.
Figure 1: Ultrasound of left lower limb showing partial thrombus in the left common femoral vein

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SCDs are safe alternatives to LMWH when anticoagulation with LMWH is contraindicated, as in patients with head injury. SCDs are well tolerated as a method of DVT prophylaxis, with no bleeding complications. SCDs target stasis and the fibrinolytic pathway which exacerbates the complications associated with DVT in trauma patients. [2]

Routine use of compression USG to assess for lower extremity thrombus is easily justifiable after the occurrence of such mishaps as in our patient. Despite even prophylactic methods with low-dose heparin (LDH) or SCD the incidence of DVT remains up to 21% [3] as demonstrated by Burns et al., with biweekly ultrasound scans. Bedside USG has achieved the contemporary role as a diagnostic tool for the assessment of DVT. All the patients should be screened for the presence of lower-extremity DVT before graded SCDs are placed on the legs as there is a risk of embolization of DVT from the legs on which SCDs have been placed.

Various studies have demonstrated that 10-100% of DVTs diagnosed by USG were not found on clinical examination or were asymptomatic. [4],[5] There is an upcoming role of USG as a diagnostic modality for DVT. The American College of Chest Physicians (ACCP) Evidence-based clinical practice guidelines (2012) favour the combined use of pretest clinical probability assessment, D-dimer and USG to aid the diagnosis of DVT. [6] But ACCP (2012) guidelines do not recommend periodic surveillance with venous compression USG for major trauma patients (Grade 2C which is not a strong level of evidence). [7] However, ACCP guidelines (2008) do recommend USG screening in patients who are at high risk for venous thromboembolism (e.g., in the presence of a spinal cord injury, lower extremity or pelvic fracture, or major head injury), and who have received suboptimal thromboprophylaxis or no thromboprophylaxis (Grade 1C) as was our case. [1] Besides, the latest study by Azaretal has also recommended Duplex USG DVT screening of all critically ill trauma patients. [5]

We recommend screening of patients by compression ultrasound routinely to identify significant occult DVT (unrecognized thrombus capable of producing pulmonary embolism) before the placement of SCDs since clinical examination is not reliable. Search for more effective methods of thromboprophylaxis in patients in whom pharmacological thromboprophylaxis is contraindicated should continue as the current methods offer limited efficacy against DVT.

 
   References Top

1.Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8 th Edition). Chest 2008;133:381S-453S.  Back to cited text no. 1
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2.Burns GA, Cohn SM, Frumento RJ, Degutis LC, Hammers L. Prospective ultrasound evaluation of venous thrombosis in high-risk trauma patients. J Trauma 1993;35:405-8.  Back to cited text no. 2
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3.Kelsey LJ, Fry DM, VanderKolk WE. Thrombosis risk in the trauma patient. Prevention and treatment. HematolOncolClin North Am 2000;14:417-30.  Back to cited text no. 3
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4.Mosely JC. Hypercoagulable states. In: Kollef MH, Bedient TJ, Isakow W, et al. editors. The Washington Manual of Critical Care. 9 th ed. Philadelphia: Lippincott William and Wilkins; 2011. p. 433.  Back to cited text no. 4
    
5.Azarbal A, Rowell S, Lewis J, Urankar R, Moseley S, Landry G, et al. Duplex ultrasound screening detects high rates of deep vein thromboses in critically ill trauma patients. J VascSurg 2011;54:743-7; discussion 747-8.  Back to cited text no. 5
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6.Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9 th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141:7S-47S.  Back to cited text no. 6
    
7.Bates SM, Jaeschke R, Stevens SM, Goodacre S, Wells PS, Stevenson MD, et al. Diagnosis of DVT: Antithrombotic Therapy and Prevention of Thrombosis, 9 th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141:e351S-418S.  Back to cited text no. 7
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