SCDs in Patients with DVT

[gaspasser127]

Got in a discussion with a nurse who was saying that you absolutely cannot put SCDs on a patient with a known lower extremity DVT and when I asked her why she said it's because it can dislodge the DVT (which would make sense) and that "it's the policy." (major eye roll whenever a nurse says that)

Anyway - it got me thinking and I tried to find literature on this. Anyone know if there are known case reports of this happening or any data definitively stating that you can't do this?

I'm open to being wrong about this but my entire point of the conversation with the nurse was for her to not just take a policy at face value and to really critically analyze everything she's doing and to seek out the evidence for it. I guess that's where I went wrong.... you'd think that as a CA-3 I would've learned this lesson by now.

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[vector2]

Got in a discussion with a nurse who was saying that you absolutely cannot put SCDs on a patient with a known lower extremity DVT and when I asked her why she said it's because it can dislodge the DVT (which would make sense) and that "it's the policy." (major eye roll whenever a nurse says that)

Anyway - it got me thinking and I tried to find literature on this. Anyone know if there are known case reports of this happening or any data definitively stating that you can't do this?

I'm open to being wrong about this but my entire point of the conversation with the nurse was for her to not just take a policy at face value and to really critically analyze everything she's doing and to seek out the evidence for it. I guess that's where I went wrong.... you'd think that as a CA-3 I would've learned this lesson by now.

I don't know of any specific literature but SCDs more than double the venous flow velocity of the lower extremity veins . I wouldnt put them on in a known LE DVT.

 

[Katheudontas parateroumen]

Yeah it’s always good to see through dogma or blind policy. It’s kinda similar to people saying don’t do Homan sign for DVT because it might dislodge it as well.

 

[GassYous]

Yeah it’s always good to see through dogma or blind policy. It’s kinda similar to people saying don’t do Homan sign for DVT because it might dislodge it as well.

More like you shouldn't do homans sign because it's useless especially when we have ultrasound

 

[abolt18]

I don't know of any specific literature but SCDs more than double the venous flow velocity of the lower extremity veins . I wouldnt put them on in a known LE DVT.

And how much does walking/flexing the calf increase the flow of the lower extremity veins?

 

[abolt18]

More like you shouldn't do homans sign because it's useless especially when we have ultrasound

Hey, I found a lady's DVT in pre-op clinic with + Homan's sign.

I then sent her for lower extremity duplex which confirmed it.... But hey, not worthless!

 

[Zekchar]

Never get into a "discussion" with a nurse. You are just passing through while they are entrenched and likely to be there long after you are gone. Even if you are correct, all you will elicit is increased nastiness and further undermining. Nurses have limited education and most are unwilling to change their practice or knowledge base even when proven incorrect. They fall back on "well that's the way I do it" or "it's policy" or especially "whatever you say DOCTOR" while harboring extreme ill will. My suggestion is to graduate then do whatever you wish to do within the scope of your influence in the operating room. Anything the nurse wants to do that isn't hurting the patient directly, IDGAF.

Reminds me of this study, every time a nurse tells the patient to uncross their ankles when taking their blood pressure.

The effect of crossing legs on blood pressure - PubMed (nih.gov)

 

[deleted171991]

Got in a discussion with a nurse who was saying that you absolutely cannot put SCDs on a patient with a known lower extremity DVT and when I asked her why she said it's because it can dislodge the DVT (which would make sense) and that "it's the policy." (major eye roll whenever a nurse says that)

Anyway - it got me thinking and I tried to find literature on this. Anyone know if there are known case reports of this happening or any data definitively stating that you can't do this?

I'm open to being wrong about this but my entire point of the conversation with the nurse was for her to not just take a policy at face value and to really critically analyze everything she's doing and to seek out the evidence for it. I guess that's where I went wrong.... you'd think that as a CA-3 I would've learned this lesson by now.

She did critically analyze. She even used her common sense.

Not everything in medicine needs to be "proven". Heck, a lot of things that have been "proven" have poor quality evidence, because it's really hard to do good clinical studies. And a lot of stuff we do (as anesthesiologists or intensivists) and helps has no official "evidence", except that it works. Most (p<0.05) clinical studies are junk anyway (see Ioannidis) or don't really apply to one's particular patient population (e.g. PPV). So you're already not practicing true evidence-based medicine, you just think you do; you're mostly practicing expert opinion-based medicine.

Not following policies blindly is a good thing. However, in this case, one would wonder about your understanding of LE DVT pathophysiology and its consequences. A LE DVT should be considered an asymptomatic undiagnosed PE (in 50+% of patients), and treated with appropriate respect.

We give these patients therapeutic heparin to decrease the further growth of the clot, while the body does all the fibrinolysis. A piece of clot can detach and embolize anytime, but that doesn't mean that we should help it by manipulating the extremity/vein. A PE is a big deal, because of the inflammatory and vasoactive response, not just the mechanical obstruction; it can be life-threatening. We should tattoo "first do no harm" onto every medical graduate; too few seem to remember it nowadays, especially in their quest for "education".

Don't manipulate the extremity, if it won't change your management. The clot is a loaded gun inside the patient. Just stay away from it. If the patient gets a PE, it won't be on you.

 

[zizzer]

I agree with FFP. You don't need a study for everything and should be very careful that you have critically and skeptically reviewed a study before citing it to support changing your practice. In the absence of convincing evidence to the contrary, I'm going to go with: don't manupulate the extremity with SCDs because common sense says mechanical compression may dislodge the thrombus.

I'm not sure who is more annoying between people who refuse to follow common-sense practices because "there isn't evidence supporting it" and people who cite flawed studies to support dubious practices. In reality, they're often the same people.

 

[gaspasser127]

Lol to be clear I was not advocating that that patient have SCDs placed and yes I’m well aware that evidence comes in a variety of levels.

 

[zizzer]

I wasn't directing anything towards you. Sorry if it seemed like it.

 

[deleted171991]

I'm open to being wrong about this but my entire point of the conversation with the nurse was for her to not just take a policy at face value and to really critically analyze everything she's doing and to seek out the evidence for it. I guess that's where I went wrong.... you'd think that as a CA-3 I would've learned this lesson by now.

I missed this part.

This is absolutely the wrong advice. Nurses lack the knowledge and the critical thinking to question "evidence". They should not "think", they should do what they're told; that's why they need physician orders, policies and protocols, by law.

The first time some under-educated healthcare worker will interfere with a treatment, just because "they have never heard of" whatever you're trying to do, or they "feel uncomfortable", you'll get my point.

 

[zizzer]

Besides, we shouldn't fault nurses for deferring to protocols and algorithms because they exist to help people without the extra decade of training to make certain decisions in every scenario. That's a good thing. Could you imagine trying to manage a cardiac arrest situation and get everybody on board with what needs to be done in an emergency without ACLS algorithms? The only part that becomes annoying is when you explain to them the need to deviate from protocol and they argue with you.

 

[deleted697127]

Got in a discussion with a nurse who was saying that you absolutely cannot put SCDs on a patient with a known lower extremity DVT and when I asked her why she said it's because it can dislodge the DVT (which would make sense) and that "it's the policy." (major eye roll whenever a nurse says that)

Anyway - it got me thinking and I tried to find literature on this. Anyone know if there are known case reports of this happening or any data definitively stating that you can't do this?

I'm open to being wrong about this but my entire point of the conversation with the nurse was for her to not just take a policy at face value and to really critically analyze everything she's doing and to seek out the evidence for it. I guess that's where I went wrong.... you'd think that as a CA-3 I would've learned this lesson by now.

You have to pick your battles. Protocols exist for a reason. It’s embarrassing deviating from protocol or even arguing against their validity particularly when you haven’t fully thought out your stance as it appears to be the case here. Having more education than someone doesn’t inherently make your reactionary off the cuff take on a protocol correct and is toxic.

People like to trash talk protocols yet don’t always appreciate the level of safety they provide. I will gladly step aside and defer to nurses for whatever weekly covid protocols are in place.

You don’t win anything arguing over nonsense.

 

[Neopolymath]

Even if you are right this is a case of "play stupid games and win stupid prizes" on all fronts. The nurse won't like you and the patient could get a symptomatic PE. Bad gamble IMO

 

[Hork Bajir]

Pulmonary Embolism as a Consequence of Applying Sequential Compression Device on Legs in a Patient Asymptomatic of Deep Vein Thrombosis

INTRAOPERATIVE pulmonary embolism (PE) is an uncommon complication of emergency intraabdominal surgery. Best practice recommendations for longer surgi-cal cases include the fitting of antithrombotic leg de-vices such as stockings and pneumatic compressiondevices. 1,2Although these devices...

pubs.asahq.org

On a related note, there is some evidence that the mechanism of action for sequential compression devices wasn’t necessarily mechanical per se, but has more to do with elaboration of various vasoactive substances, regulation of fibrinolysis, etc (the implication being that you could put the SCDs on the arm, and they work just as well for lower extremity DVT).

“Beyond simply overcoming stasis, some forms of mechanical VTE prophylaxis also appear to offer fibrinolytic properties to combat the hypercoagulable component of Virchow’s triad. The increased venous velocity through vessels caused by pneumatic compression devices also triggers endogenous fibrinolytic activity. Studies have revealed a reduction in plasminogen activator inhibitor-1 (PAI-1) and a net increase in tissue plasminogen activator (tPA) activity in participants wearing these devices [7].”

source:

Mechanical Prophylaxis for Post-Traumatic VTE: Stockings and Pumps - Current Trauma Reports

Trauma patients pose unique challenges when it comes to the decision for optimal thromboprophylaxis. Risk reduction of venous thromboembolic (VTE) events is paramount in the modern management of trauma patients. The choice of pharmacologic prophylaxis is standard for most hospitalized patients...

link.springer.com

 

[abolt18]

Pulmonary Embolism as a Consequence of Applying Sequential Compression Device on Legs in a Patient Asymptomatic of Deep Vein Thrombosis

INTRAOPERATIVE pulmonary embolism (PE) is an uncommon complication of emergency intraabdominal surgery. Best practice recommendations for longer surgi-cal cases include the fitting of antithrombotic leg de-vices such as stockings and pneumatic compressiondevices. 1,2Although these devices...

pubs.asahq.org

On a related note, there is some evidence that the mechanism of action for sequential compression devices wasn’t necessarily mechanical per se, but has more to do with elaboration of various vasoactive substances, regulation of fibrinolysis, etc (the implication being that you could put the SCDs on the arm, and they work just as well for lower extremity DVT).

“Beyond simply overcoming stasis, some forms of mechanical VTE prophylaxis also appear to offer fibrinolytic properties to combat the hypercoagulable component of Virchow’s triad. The increased venous velocity through vessels caused by pneumatic compression devices also triggers endogenous fibrinolytic activity. Studies have revealed a reduction in plasminogen activator inhibitor-1 (PAI-1) and a net increase in tissue plasminogen activator (tPA) activity in participants wearing these devices [7].”

source:

Mechanical Prophylaxis for Post-Traumatic VTE: Stockings and Pumps - Current Trauma Reports

Trauma patients pose unique challenges when it comes to the decision for optimal thromboprophylaxis. Risk reduction of venous thromboembolic (VTE) events is paramount in the modern management of trauma patients. The choice of pharmacologic prophylaxis is standard for most hospitalized patients...

link.springer.com

Yes, I feel like I remember them taking about this on ACCRAC before and said putting it on an arm showed equal benefit.

 

[teacher2md]

My question is why is the patient getting SCDs to begin with? They’ve already declared themselves as high-risk for VTE— they need pharmacological prophylaxis.

 

[abolt18]

My question is why is the patient getting SCDs to begin with? They’ve already declared themselves as high-risk for VTE— they need pharmacological prophylaxis.

Why not both?

 

[coffeebythelake]

Pulmonary Embolism as a Consequence of Applying Sequential Compression Device on Legs in a Patient Asymptomatic of Deep Vein Thrombosis

INTRAOPERATIVE pulmonary embolism (PE) is an uncommon complication of emergency intraabdominal surgery. Best practice recommendations for longer surgi-cal cases include the fitting of antithrombotic leg de-vices such as stockings and pneumatic compressiondevices. 1,2Although these devices...

pubs.asahq.org

On a related note, there is some evidence that the mechanism of action for sequential compression devices wasn’t necessarily mechanical per se, but has more to do with elaboration of various vasoactive substances, regulation of fibrinolysis, etc (the implication being that you could put the SCDs on the arm, and they work just as well for lower extremity DVT).

“Beyond simply overcoming stasis, some forms of mechanical VTE prophylaxis also appear to offer fibrinolytic properties to combat the hypercoagulable component of Virchow’s triad. The increased venous velocity through vessels caused by pneumatic compression devices also triggers endogenous fibrinolytic activity. Studies have revealed a reduction in plasminogen activator inhibitor-1 (PAI-1) and a net increase in tissue plasminogen activator (tPA) activity in participants wearing these devices [7].”

source:

Mechanical Prophylaxis for Post-Traumatic VTE: Stockings and Pumps - Current Trauma Reports

Trauma patients pose unique challenges when it comes to the decision for optimal thromboprophylaxis. Risk reduction of venous thromboembolic (VTE) events is paramount in the modern management of trauma patients. The choice of pharmacologic prophylaxis is standard for most hospitalized patients...

link.springer.com

Yep I was taught this back in med school. That was 10 plus years ago! 😳