Download Early Ambulation After Acute Deep Vein Thrombosis

Early Ambulation After Acute Deep Vein
Thrombosis: Is It Safe?
Marilyn Slavin Blumenstein, MSN, RN
The number of thrombotic events in children,
although significantly less than that in adults, is
increasing as a result of therapeutic advances in primary illnesses that were previously fatal. When a
patient, adult or pediatric, develops a deep vein
thrombosis and anticoagulation therapy is initiated,
many health professionals ask, “When should this
patient have physical therapy and/or ambulate?”
Fear of causing a pulmonary embolism with
increased activity drives this question. Often, an
order for bed rest is prescribed based more on tradition than on evidence-based medicine. A review of the
literature has provided an evidence-based answer to
the question, and although the studies are all of adult
populations, the results have been extrapolated for
use with comparable pediatric populations. The
majority of studies agree that early ambulation does
not increase an anticoagulated patient’s risk for pulmonary embolism. Moreover, most studies report that
early ambulation carries benefits such as decreased
pain and swelling and fewer postthrombotic syndrome symptoms.
Key words: deep vein thrombosis, ambulation, physical therapy, pulmonary embolism, children
vein thrombosis (DVT). Her staff had 4 questions:
(1) Is it correct to hold ambulation/out-of-bed orders
if there is a suspected DVT or if an ultrasound result
is pending? (2) Once a DVT is diagnosed and the
patient is placed on anticoagulant therapy using
enoxaparin (Lovenox®), how long until the patient is
out of bed and/or ambulating? (3) With DVTs, are
bed exercises on the unaffected limbs allowed? (4)
Who is the point person for questions related to
ambulation and physical therapy for patients with
DVTs? Questions like these are also asked by other
health care providers who are responsible for the dayto-day supervision and coordination of patient activities. One-size-fits-all answers to these questions are
unhelpful and potentially dangerous. The attending
physician responsible for the patient, sometimes in
collaboration with a hematologist, is in the best position to direct the patient’s care. Our pediatric physical
therapy manager was advised to continue to collaborate with the patient’s attending physician. In addition, I conducted a literature search and evaluated the
evidence-based clinical research concerning ambulation in the setting of acute DVT. Those results were
used to inform our practice and are offered here so
that other pediatric nursing and physical therapy
groups can inform their practices too.
R
ecently, a pediatric physical therapy manager
asked me for practice recommendations for her
staff when they are working with children with deep
© 2007 by Association of Pediatric Hematology/Oncology Nurses
DOI: 10.1177/1043454207308896
Marilyn Slavin Blumenstein, MSN, RN, is a thrombosis program nurse
coordinator at the Children’s Hospital of Philadelphia. Address for correspondence: Marilyn Slavin Blumenstein, MSN, RN, 34th and Civic
Center Boulevard, Hematology, Philadelphia, PA 19101; e-mail:
[email protected].
Journal of Pediatric Oncology Nursing, Vol 24, No 6 (November-December), 2007; pp 309-313
309
Blumenstein
Table 1.
List of Treatment Options for DVT
Observation with serial imaging and without anticoagulation
Thrombolysis with or without balloon angioplasty or Angiojet
Inferior vena cava filter placement (temporary or permanent) with or without anticoagulation
Anticoagulation
Unfractionated heparin
Low molecular weight heparin (eg, enoxaparin/Lovenox®)
Vitamin K antagonist (eg, warfarin/Coumadin®)
Direct thrombin inhibitors (eg, hirudin, argatroban)
Gradient compression therapy
Table 2.
Inherited/Congenital Risks for Thrombosis Organized Using Virchow’s Triad
Alterations in Flow
May-Thurner syndrome
Thoracic outlet syndrome
Vascular Endothelial Injury
Hypercoagulability
Hyperhomocysteinemia (?)
Factor V Leiden mutation
Prothrombin gene mutation
Antithrombin deficiency
Protein C deficiency
Protein S deficiency
Elevated lipoprotein (a)
Hyperhomocysteinemia
Dysfibrinogenemia
Case 1
Joann is a 16-year-old female who has a body mass
index in the 90th percentile, is using estrogencontaining oral contraception pills, and has just returned
to the United States from a school-sponsored trip to
Australia. She presented to the emergency department
with a red, hot, swollen, and painful left leg. Doppler
ultrasound demonstrated an occlusive DVT in her left
superficial femoral and external iliac veins; the inferior vena cava was open. Oral contraception pills
were stopped and anticoagulation with enoxaparin
was initiated. Joann wants to get out of bed and walk
around. Is it safe?
Case 2
Dillan, an 11-month-old infant born at 30 weeks
gestation, was noted to have significant swelling
in his right leg at his wellness check by his primary
care provider. Imaging studies revealed an occlusive
thrombosis of his infrarenal inferior vena cava and
right iliac vein. His parents reported noticing a slight
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difference in leg size recently and attributed it to his
new skill of standing and cruising while holding onto
furniture. Dillan’s medical history included an umbilical cord line placed during his neonatal intensive
care unit stay. Anticoagulation with enoxaparin was
started. Results of Dillan’s thrombophilia workup
were normal except for factor V Leiden. He is heterozygous for the mutation. Dillan wants to crawl and
cruise! Is it safe?
To help you answer this safety question, the following sections provide a definition for DVT, a list of
treatment options (Table 1), a list of risk factors associated with the development of DVTs (Tables 2 and
3), an introduction to postthrombotic syndrome
(PTS), and results of a literature review focused on
finding practice recommendations regarding early
ambulation after acute DVT.
Deep Vein Thrombosis
A DVT is a blood clot in any vessel of the body’s
deep venous system. DVTs can be partially or completely occlusive, can be fixed or embolic, and can
Journal of Pediatric Oncology Nursing 24(6); 2007
Early Ambulation After Deep Vein Thrombosis
Table 3.
Common Acquired Risks for Thrombosis Organized Using Virchow’s Triad
Alterations in Flow
Central lines
Immobilization
Trauma
Surgery/anesthesia
Cancer
Dehydration
Cardiac disease
Prosthetic valves
Thrombocytosis
Polycythemia vera
Vascular Endothelial Injury
Hypercoagulability
Central lines
Increasing age
Systemic lupus
Crohn’s disease
Ulcerative colitis
Diabetes mellitus
Infection
Trauma
Surgery
Cancer
Obesity
Smoking
L-asparaginase
Heparin-induced thrombocytopenia
Estrogen/pregnancy
Antiphospholipid antibodies
Renal disease
Cancer
develop suddenly or gradually. Patients with DVTs
often have inherited/congenital and/or acquired risk
factors that contribute to their development. More
than 140 years ago, Rudolf Virchow described thrombosis as the result of alterations in blood flow, vascular endothelial injury, or alterations in the constitution
of the blood (hypercoagulability) (Ennis, 2005).
When blood flow is sluggish in any of the body’s
vessels for many hours, as happens when patients are
confined to bed rest or are under general anesthesia
for long operating room procedures, the first part of
this triad, alterations in blood flow, occurs. Stasis
allows blood coagulation to be completed at the initial site of thrombus formation (Hoffbrand, Moss, &
Pettit, 2006). When intravascular clotting starts, it
often grows, mainly in the direction of the slowly
moving venous blood. Untreated, about 1 clot in 10
(in adults) breaks loose and travels through the right
side of the heart into pulmonary arteries, causing a
pulmonary embolism (PE) (Guyton & Hall, 2006).
The practice of prescribing bed rest after acute DVT
stems from fear that patients will develop PEs.
In pediatrics, the second component in Virchow’s
triad, endothelial damage, is most often incurred when
a central venous catheter is placed. These lines are
thrombogenic because they damage vessel walls and
disrupt blood flow. Although central lines are essential
for the medical management of pediatric patients, they
are associated with significant morbidity (>90% of
DVTs in neonates and 60% of DVTs in children are
associated with central lines) and, occasionally, mortality (Andrew, Monagle, & Brooker, 2000).
Journal of Pediatric Oncology Nursing 24(6); 2007
The third part of Virchow’s triad consists of alterations in the constitution of the blood, causing hypercoagulability. Several congenital abnormalities in
hemostasis have been identified, and strategies for
prevention and treatment of DVT in both adults and
children vary. Andrew et al. (2000) reported that
without an additional acquired risk for thrombosis, it
is rare for a child who inherits a single gene defect for
thrombophilia to develop a DVT. However, children
who are homozygous for a defect or are double heterozygous often present with symptoms of DVT in
the newborn period or as children (Andrew et al.,
2000). Tables 2 and 3, organized using Virchow’s
triad, list the more common inherited/congenital and
acquired risks for thrombosis, respectively.
Literature Review
Fear of causing serious or fatal PE and a belief that
pain and swelling would be improved faster by
immobilization drive the traditional recommendation
of bed rest in combination with anticoagulation
(Partsch, 2005). In 1944, William Dock, writing in
the Journal of the American Medical Association,
warned physicians about the hazards of complete bed
rest. His article, “The Evil Sequelae of Complete Bed
Rest,” alerts readers to the dangers of this “highly
unphysiologic and definitely hazardous form of therapy” (p. 1084). Fear of dislodging thrombi, especially
in the lower extremities, has prompted many physicians
to disregard Dock’s advice, ignore their knowledge
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Blumenstein
that immobility promotes stasis, and order lengthy
bed rest for patients with acute DVTs. This practice is
without evidence-based studies demonstrating that
bed rest with anticoagulation is superior in reducing
the risk of PE for patients. “Bed rest has obviously
more risks concerning thrombus propagation and lifethreatening complications, especially in old patients,
and does not prevent pulmonary embolism” (Partsch,
2001, p. 202).
Buller and colleagues (2004), reporting at the 7th
American College of Chest Physicians Conference,
strongly recommended that patients with DVTs
ambulate as soon as possible and as much as tolerated. A prospective, observational study of 2650
patients with acute, symptomatic DVTs or pulmonary
embolism, all of whom were treated with low molecular weight heparin, was reported (Trujillo-Santos
et al., 2005). Bed rest was prescribed for 54% of the
patients, whereas the others had early ambulation.
Patients in the bed rest group tended to be sicker at
baseline than the ambulation group, which is a limitation of this study. Over a 15-day period, 9 patients
treated with bed rest and 6 of those ambulating developed clinically evident and radiographically confirmed PEs. The authors concluded that there was no
apparent association between early ambulation and
new, symptomatic PEs (Trujillo-Santos et al., 2005).
Partsch (2001) reported on 1289 consecutive
patients admitted for acute DVT, all treated with low
molecular weight heparin, early ambulation, and gradient compression therapy. The study, which identified 5 endpoints, concluded that the low incidence of
recurrent and fatal PE in this series affirms the value
of early ambulation with leg compression therapy.
Reporting on the findings of several adult studies,
Partsch (2001) concluded that bed rest is potentially
harmful. Starting therapeutic doses of anticoagulation
and encouraging patients to walk as soon and as
much as possible with good compression therapy for
lower extremity DVT are associated with better outcomes (decreased pain, decreased swelling, and
decreased occurrence/severity of postthrombotic
syndrome) (Partsch, 2001).
Although postthrombotic syndrome (PTS) is not a
focus of this article, I want to provide some information about it because several studies cited in this article identified a reduction in PTS incidence and/or
severity as an important study outcome or end point.
The clinical features of PTS are pain, swelling, visible
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collateral vein formation, and skin abnormalities that
range from hyperpigmentation and induration to stasis ulcers (Manco-Johnson, 2006). Citing 4 studies in
her article “How I Treat Venous Thrombosis in
Children,” Dr Manco-Johnson reported a PTS occurrence rate in children of 10% to 60% following DVT
(2006). The pathophysiology of PTS begins with
venous hypertension caused by blood flow obstruction (by the thrombus) and/or refluxed blood flow
attributable to incompetent venous valves damaged
by the clot or mechanical therapies directed at breaking
up the clot (eg, Angiojet system, Possis, Minneapolis,
MN) (Manco-Johnson, 2006). Therapies that reduce
the incidence and severity of PTS, such as anticoagulation with early ambulation and gradient compression
therapy, have important implications for long-term
morbidity, especially for children with DVT because
they might expect to have 5 to 8 decades of life after
DVT (unlike most adults with DVT).
The literature review can be summarized as follows: study populations were adults, often elderly,
with no infants or children studied. All studies recommended the initiation of anticoagulation before
ambulation or physical therapy. Some studies recommended immediate ambulation as tolerated, whereas
others suggested a 48- to 72-hour waiting period
before ambulating regularly. Most studies involved
DVT of the lower extremities and also recommended
gradient compression therapy with ambulation
(Aschwanden, Labs, & Engel, 2001; Ciccone, 2002;
Partsch, 2000; Schellong et al., 1999). All studies
reviewed for this article concluded that early ambulation with anticoagulation does not increase risk for
patients for pulmonary embolism. Most studies
reported improved outcomes on pain, swelling, and
incidence of PTS with early ambulation.
Conclusions and Implications
for Nursing Practice
Early ambulation and physical therapy are of particular importance to pediatric patients at risk for loss
of range of motion, skin breakdown, or joint contracture if physical therapy or ambulation orders are held
as a consequence of the development of a DVT. There
are no published studies evaluating the safety and
benefits of early ambulation and physical therapy in
pediatric patients with acute DVTs. Clearly, this is an
Journal of Pediatric Oncology Nursing 24(6); 2007
Early Ambulation After Deep Vein Thrombosis
issue nurses should study in children. In the interim,
pediatric nurses and other health care providers are
encouraged to consider the findings from the adult literature on this topic to matched pediatric patients.
Early ambulation and physical therapy, as tolerated,
should be encouraged once anticoagulation is instituted. In addition, there were no reports that physical
therapy, such as active or passive range of motion
exercises, performed with the unaffected limbs caused
any morbidity or mortality in patients with acute
DVT on anticoagulation therapy. Furthermore, the
addition of gradient compression therapy for patients
with lower extremity DVTs seems to further improve
patient outcomes (Partsch, 2001). Early ambulation is
not associated with an increased risk for pulmonary
embolism in anticoagulated patients with acute deep
vein thromboses.
References
Andrew, M., Monagle, P. T., & Brooker, L. (2000).
Thromboembolic complications during infancy and childhood. Hamilton, ON: B.C. Decker.
Aschwanden, M., Labs, K. H., & Engel, H. (2001). Acute deep
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Haemostasis, 85, 42-46.
Buller, H. R., Agnelli, G., Hull, R. D., Hyers, T. M., Prins, M. H.,
& Raskob, G. E. (2004). Antithrombotic therapy for venous
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Ciccone, C. D. (2002). Does ambulation immediately following
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of American Medical Association, 125, 1083-1085.
Ennis, R. S. (2005). Deep venous thrombosis prophylaxis in
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Schellong, S., Schwarz, T., Kropp, J., Prescher, Y., BeutheinBaumann, B., & Daniel, W. (1999). Bed rest in deep vein
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Trujillo-Santos, J., Perea-Milla, E., Jimenez-Puente, A., SanchezCantalejo, E., del Toro, J., Grau, E., et al. (2005). Bed rest or
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