ORI GI N AL ARTI CLE
Eva lu a t ion of t h e u se of pr oph yla x is for de e p ve n ou s t h r om bosis in a
t e a ch in g h ospit a l
Gu ilh e r m e Be n j a m im Br a n dã o Pit t aI; Ticia n a Le a l e Le it eI I; M a r ia do D e st e r r o Cost a e SilvaI I I; Ca m illa Fe lix Le ã o de M e loI V; Gise lli de Alm e ida Ca lh e ir osI V
IPhysician. Associat e pr ofessor , Depar t m ent of sur ger y, Univer sidade Est adual de Ciências da Saúde de Alagoas ( UNCI SAL) , Maceió, AL, Br azil. Vascular surgeon, Unidade de Em er gência Arm ando Lages, Maceió, AL, Hospit al Escola José Car neir o, Maceió, AL, Br azil.
I IPhysical Therapy St udent , UNCI SAL, Maceió, AL, Br azil. Scholarship holder, Scient ific I nit iat ion Program .
I I IAssociat e professor, Depart m ent of Physical Ther apy, UNCI SAL, Maceió, AL, Br azil. I VPhysical Therapy St udent , UNCI SAL, Maceió, AL, Br azil.
Correspondence
J Vasc Bras. 2007; 6( 4) : 344- 51.
RESUM O
Con t e x t o: A t rom bose venosa pr ofunda ( TVP) é um a doença freqüent e e gr ave. A pr ofilaxia é o m elhor m eio para reduzir a sua incidência, dim inuindo a m or bim or t alidade gerada por suas
com plicações. Na relação cust o x efet ividade, é m elhor m ant er um a rot ina profilát ica do que t rat ar a doença j á inst alada.
Obj e t ivo: Verificar se a pr ofilaxia da TVP est á sendo ut ilizada de m aneir a adequada e r ot ineir a no Hospit al Escola Dout or José Carneiro ( HEJC) , de Maceió ( AL) .
M é t odos:Foi r ealizado um est udo t ransversal descrit ivo no HEJC durant e o per íodo de 6 m eses. A am ost ra foi de 298 pacient es, de diferent es especialidades. Os dados foram colet ados nos
Con clu sã o: Apesar da eficácia da profilaxia para a TVP j á t er sido com pr ovada e difundida, em nosso m eio ainda não at inge os níveis desej ados de ut ilização.
Pa la vr a s- ch a ve : Prevenção e cont r ole, t r om bose venosa, avaliação.
ABSTRACT
Ba ck gr ou n d: Deep venous t hr om bosis ( DVT) is a frequent and severe disease. Pr ophylaxis is t he best m eans t o r educe it s incidence, low er ing m or bidit y and m or t alit y rat es caused by it s
com plicat ions. I n a cost - effect iveness rat io, it is bet t er t o m aint ain a prophylact ic r out ine t han t o t reat an est ablished disease.
Obj e ct ive : To verify w het her DVT pr ophylaxis is being properly and rout inely used at Hospit al Escola Dout or José Carneiro ( HEJC) , in Maceió, Br azil.
M e t h ods: A descr ipt ive, cr oss- sect ional st udy at HEJC w as carried out for a 6- m ont h per iod. The sam ple w as com posed of 298 pat ient s w it hin different specialt ies. Dat a w er e collect ed from m edical records, and divided int o clinical ( 68.5% ) and sur gical ( 31.5% ) . How DVT pr ophylaxis w as
perform ed w as analyzed for each pat ient . Clinical, phar m acological and sur gical fact ors w er e invest igat ed for all pat ient s. Based on t hese dat a, risk st rat ificat ion w as per for m ed in accor dance w it h t he classificat ion r ecom m ended by Sociedade Brasileira de Angiologia e Cir ur gia Vascular. St at ist ical analysis w as perform ed using soft w are SPSS and t he qui- square and bivariat e correct ion t est s, consider ing p value < 0.05.
Re su lt s: Of t he 298 pat ient s analyzed, 204 belonged t o m edical clinic, in w hich 28.9% w er e low risk, 60.3% average risk and 10.8% high risk for DVT; and 94 pat ient s belonged t o sur gical clinic, in w hich 43.6% w er e low r isk, 52.1% aver age risk and 4.3% high r isk. Only 23% of pat ient s in t he clinical gr oup and 2.1% in t he sur gical gr oup w er e given adequat e pr ophylaxis.
Con clu sion : Despit e t he efficiency of pr ophylaxis for DVT having been confirm ed, it does not reach sat isfact ory levels in our count ry.
Ke yw or ds:Prevent ion and cont r ol, venous t hr om bosis, evaluat ion.
I n t r odu ct ion
Developm ent of venous t hr om boem bolism is dependent on alt erat ion in one or m or e fact ors of t he t riad described by Vir chow in 1856, w hich considers changes in venous st asis, hyper coagulable st at e, and vessel w all inj ur y as r esponsible for t he t hr om bot ic pr ocess.1 Aft er 150 years, t hat st at em ent rem ains t rue, but t he know ledge of t he r elat ive role of each of t hese fact ors incr eased t he under st anding of t he t hr om bot ic phenom enon, allow ing t he diagnosis and ident ificat ion of individuals w it h higher r isk of developing t hrom bosis, t hus aiding in t he m or e rat ional m anagem ent of such pat ient s.2
Deep venous t hr om bosis ( DVT) is a frequent disease, especially as a com plicat ion of ot her sur gical and clinical affect ions. How ever , t hey m ay also occur spont aneously in appar ent ly healt hy
individuals.3
it can be r esponsible for several cases of physical disabilit y and huge socioeconom ic expenses, w it h t he developm ent of severe chr onic venous insufficiency, r esult ing in t he so- called post - t hrom bot ic syndrom e.4 , 5 Venous t hr om boem bolism is also descr ibed as t he m ost com m on cause of
prevent able hospit al m or t alit y.6 , 7
DVT pr ophylaxis is essent ial, since t his disease is t he m ain cause of PE,8 w hich in t ur n can be t he
first m anifest at ion of DVT and is usually fat al in 0.2% of hospit alized pat ient s.9
DVT is t he t hird m ost frequent car diovascular disease in t he USA. Ander son et al. est im at ed ar ound 170,000 new cases of DVT or PE a year , and 9,000 r elapses over t he sam e period, result ing in at least 13,000 deat hs ever y year .1 0
I n our count ry, Maffei's st udy report s an est im at e of 0.6 cases per 1,000 inhabit ant s/ year , based on DVT cases confir m ed by phlebogr aphy or duplex scan.1 1 Fow kes et al., in a r eview st udy, using
a m et a- analysis in 2003, est im at ed t hat w orldw ide incidence of DVT is 0.5 cases per 1,000 inhabit ant s/ year.1 2
The European Consensus for pr event ion of t hr om boem bolic disease est im at es annual incidence of 160 DVT cases and 60 cases of fat al PE for each gr oup of 100,000 inhabit ant s in West er n
count ries.1 3
I n general sur ger y, global incidence of DVT assessed by iodine 125- labeled fibrinogen is 25% in pat ient s w it hout pr ophylaxis.1 4
Clinical suspicion of DVT confir m ed by com plem ent ar y phlebogr aphy exam inat ion w as 40% , report ed by Richar ds.1 5 Sandler et al.1 6 found 58% and Rollo et al.1 7 perform ed a phlebogr aphic
st udy in 424 pat ient s w it h suspicion of DVT and found 68.6% of pat ient s w it h confir m ed diagnosis of DVT.
Over t he past 2 decades, DVT pr ophylaxis has been accept ed as a w ell est ablished and efficacious st rat egy. St udies by Am er ican and Eur opean groups defined det ailed r ecom m endat ions, w hich should be used in all classes of hospit alized pat ient s.9 , 1 8 Despit e DVT pr event ion pr ot ocols being available for all healt h professionals, m any do not use t hem rout inely.1 9 , 2 0
Our st udy aim s at ver ifying w het her DVT prophylaxis is being rout inely and adequat ely used at a t eaching hospit al, w orking w it h t he obser vat ional hypot hesis t hat it is not perform ed accor ding t o current guidelines.
M e t h ods
A cr oss- sect ional, prospect ive and descr ipt ive st udy was perform ed, w it h t he aim of evaluat ing DVT prophylaxis at HEJC fr om Januar y t o June 2006.
The sam ple, defined by convenience, included 298 pat ient s fr om differ ent m edical specialt ies hospit alized at HEJC. Dat a collect ion w as per for m ed t hrough analysis of m edical records of
hospit alized pat ient s, w ho w er e divided int o t w o gr oups: clinical and surgical. Sur gical pat ient w as considered t hat w ho had been subm it t ed t o any t ype of surgical pr ocedur e in cur r ent
relevant ) and out pat ient s.
Each pat ient w as assessed and st r at ified accor ding t o DVT r isk. Clinical, sur gical and
phar m acological fact ors w er e analyzed, follow ing a previously defined prot ocol. Table 1 has t he dat a t hat w er e part of t he st udy pr ot ocol, w hich w er e searched in hospit al records. Once t he prot ocol w as filled in, pat ient s w er e gr ouped in low , m oder at e and high r isk, accor ding t o t he Nor m s of Clinical Guidance of t he Sociedade Brasileira de Cir ur gia e Angiologia Vascular ( SBACV)2 1
Correct use of pr ophylaxis for DVT w as evaluat ed according t o SBACV r ecom m endat ions.2 1 For
low-risk pat ient s r ecom m endat ion is m ovem ent in bed and m ot or t herapy ( physical t herapy) ; for t hese pat ient s, phar m acological pr ophylaxis is not r ecom m ended. For pat ient s at m oderat e risk for DVT, use of unfract ionat ed hepar in ( UFH) subcut aneously ( SC) at a dose of 5,000 I U t w ice a day is indicat ed; anot her opt ion w ould be adm inist rat ion of low m olecular w eight heparin ( LMWH) , SC, at t he low est pr ophylact ic dose r ecom m ended by t he m anufact ur er , once a day. For pat ient s at high risk for DVT, use of UFH, SC at a dose of 5,000 I U, t hree t im es a day is suggest ed; an alt er nat ive w ould be LMWH, SC, at t he highest pr ophylact ic dose r ecom m ended by t he m anufact urer. For all groups adequat e m ot or t herapy should be com bined at each risk, and reassessm ent s should be perform ed daily as t o pr esence of venous t hr om bosis.2 1
Physical prophylact ic m et hods consist of kinesiot her apy for t he low er lim bs;2 2 gr aded com pr ession elast ic st ockings;2 3 int erm it t ent pneum at ic com pr ession;2 4 and w alking. Toget her , t hose
t echniques w or k t o r educe pr obabilit y of DVT incidence. Mot or physical t herapy is r ecom m ended for all DVT risks, w orking as adj uvant t o t he phar m acological t her apy or in cases of cont raindicat ion for use of ant icoagulat ing agent s.
The st at ist ical st udy w as perform ed using t he soft w ar e SPSS version 12.0, in w hich chi- square and bivariat e correct ion t est s w er e used, consider ing p value < 0.05.
Re su lt s
Most pat ient s w er e clinical ( 204- 68.5% ) ; of t hese, only 47 pat ient s ( 23% ) w er e given pr ophylaxis for DVT and, of t hese, only 14 pat ient s ( 29.7% ) w er e given adequat e pr ophylaxis. I t w as m or e frequent ly used in pat ient s at m oder at e r isk. I n pat ient s of t he sur gical group ( 94- 31.5% ) , only t w o ( 2.1% ) w er e given adequat e pr ophylaxis for DVT, one at m oder at e risk and anot her at high risk ( Table 5) .
Of 198 clinical and sur gical pat ient s w ho had indicat ion of phar m acological and physical
prophylaxis, cases of m oder at e and high risk, only 48 ( 24.2% ) w er e given com bined t her apy. Of t hese, 36 ( 18.1% ) w er e m oder at e risk and 12 ( 6% ) w er e high risk.
Correlat ion r isk and adequat e pr ophylaxis in t he clinical gr oup w as 57% ( r = 0.57; p < 0.01) ; how ever , in t he sur gical group t here w as no significant correlat ion, possibly due t o t he fact t hat t here w er e only t w o cases of adequat e pr ophylaxis.
D iscu ssion
DVT pr ophylaxis is needed and cr ucial t o pr event com plicat ions, such as pulm onar y
t hr om boem bolism , and sequelae, such as post t hr om bot ic syndrom e. Mainly due t o DVT silent nat ure, PE is oft en it s first m anifest at ion.2 5 - 2 7
I n t he 1960's, t he nat ur al hist or y of venous t hr om boem bolism w as w ell est ablished aft er t he cont ribut ions by Kakkar et al.2 8 Their st udies dem onst r at ed t hat clinical exam inat ion of DVT alone
has low reliabilit y, since t hey det ect ed t hat 50% or m or e of DVT cases had no clinical signs. Based on t hat discovery, prophylaxis for DVT and
PE gained a new perspect ive, allow ing cr eat ion of consensus and r ecom m endat ions for each risk group for t hat ent it y.2 9 How ever , venous t hr om boem bolism is st ill t he m ain cause of sudden deat h
in hospit al beds.1 8
Prophylaxis is descr ibed as beneficial and, since gr oups of pat ient s at low , m oder at e and high risk for t he developm ent of DVT can be ident ified, it is reasonable and desir able t o consider pr event ion form s, w hich is m uch bet t er t han t reat m ent .9 Alt hough accessible, pr ophylaxis for DVT is st ill
underused, ev en in developed count ries, as dem onst r at ed in t he st udy published by Goldhaber & Tapson, in w hich out of 2,726 pat ient s diagnosed w it h DVT during t heir hospit al st ay, only 1,147 ( 42% ) had been given pr ophylaxis over a 30- day per iod befor e diagnosis.3 0
This st udy show s an even w or se sit uat ion, since out of 198 pat ient s indicat ed t o receive
phar m acological and/ or physical pr ophylaxis, only 6% of high- risk pat ient s and 18% of m oder at e-risk pat ient s w er e given pr ophylaxis. Lack of pr ophylaxis prescript ion for pat ient s indicat ed t o receive it w as higher in t he gr oup of sur gical pat ient s, in w hich 97.9% of pat ient s w er e not given adequat e prophylaxis considering t heir risk. I n t he clinical gr oup, 77% of pat ient s w it h indicat ion w er e not given pr ophylaxis. Ot her st udies per for m ed in differ ent t ypes of hospit al in our count r y also show ed underuse of DVT pr ophylaxis: Gar cia et al.1 verified t hat only 24% of pat ient s w er e
given phar m acological prophylaxis for DVT; Caiafa & Bast os4 found t hat 59% of pat ient s w er e
subm it t ed t o adequat e pr ophylaxis; Engelhorn et al.2 0 dem onst r at ed t hat in 12.7% of cases
adequat e prophylaxis; and Franco et al.,3 1 in an evaluat ion of a t eaching hospit al, obser ved t hat 26.4% of pat ient s w er e given pr ophylaxis.
A possible explanat ion for not using pr ophylaxis for DVT in sur gical pat ient s is concern by healt h professionals as t o risk of bleeding dur ing t he surgery t hat m ay be caused by use of ant icoagulant agent s.2 0 Anot her j ust ificat ion for not using pr ophylaxis is it s financial cost . How ever , Ber gqvist et
al.3 2 show ed t hat use of pr ophylaxis, w hen correct ly indicat ed, has a posit ive cost- benefit r at io.
Anot her possibilit y t o explain underuse of prophylaxis are doubt s regarding classificat ion of risk groups and adequat e indicat ion for each gr oup, since t her e are m any published classificat ions of risk, som e m or e suit able for clinical pat ent s and ot her s bet t er for sur gical pat ient s, such as t he score by Nicolaides et al.9
As t o pr ophylaxis adequacy, it can be seen t hat , even having m any t echnically adequat e
prophylact ic schem es available, bot h phar m acological and physiot her apeut ic, t hey are not alw ays follow ed.2 7
Educat ional pr ogr am s about adequat e prophylaxis of DVT for healt h professionals ar e ext r em ely im port ant . Anderson et al. r epor t ed an increase in use of pr ophylaxis from 29 t o 52% in
hospit alized pat ient s w it h m aj or r isk for developm ent of DVT, aft er int r oduct ion of educat ional st rat egies w it h t he aim of w ar ning professionals for t he im port ance of t hr om boem bolism prevalence. Pr ophylaxis w as higher in hospit als in w hich healt h professionals oft en at t ended educat ional program s. Know ledge of st at ist ical dat a about t hrom boem bolic disease in t he hospit al t hey w or ked w as an im por t ant fact or t hat m ot ivat ed t hem t o use prophylaxis.3 3
Con clu sion
Based on dat a analysis, it can be concluded t hat pr ophylaxis for DVT is being underused, bot h in clinical and sur gical pat ient s, despit e it s efficacy having been confir m ed in several st udies.
I n our st udy, prophylaxis for DVT w as not used in m ost pat ient s, clinical or surgical, and in t hose in w hich it w as used, m ost w as not perform ed adequat ely. This brief st udy dem onst r at ed t he need of cont inuous educat ion for healt h professionals and inst it ut ional educat ive cam paigns for fur t her change in t his sit uat ion, gener at ing unquest ionable benefit s for pat ient s and hospit als.
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Cor r e spon de n ce :
Ticiana Leal e Leite
Rua Louren€o Moreira da Silva, 267/701, Ponta Verde CEP 57035-360 – Macei‚, AL, Brazil
This st udy was present ed as a post er at t he 58ª Reunião Anual da Sociedade Brasileira par a o Progresso da Ciência ( SBPC) , held in 2006.
Support m odalit y: Scholarship Pr ogr am for Scient ific I nit iat ion ( PROBI C) , gr ant ed by Fundação de Am par o à Pesquisa do Est ado de Alagoas ( FAPEAL) .
This st udy was appr oved by t he research et hics com m it t ee at Univer sidade Est adual de Ciências da Saúde de Alagoas ( UNCI SAL) , pr ocess no. 511/ 2005, w it h per m ission by t he HEJC m anagem ent , and was conduct ed accor ding t o r esolut ion 196/ 96 of Conselho Nacional de Saúde.
