|Year : 2019 | Volume
| Issue : 3 | Page : 114
Commentary on the screening for occult lower extremity deep vein thrombosis upon admission to the acute inpatient rehabilitation
Manisha Bawa1, Manuel F Mas2
1 University of Texas Health Science Center at Houston TX USA, McGovern Medical School, Physical Medicine and Rehabilitation, Clinical Assistant Professor, Medical Director Rehabilitation at Memorial Hermann South West, TIRR Memorial Hermann Greater Heights, San Juan, Puerto Rico, USA
2 HIMA San Pablo, San Juan, Puerto Rico, USA
|Date of Submission||12-Jan-2019|
|Date of Decision||08-Apr-2019|
|Date of Acceptance||12-Apr-2019|
|Date of Web Publication||25-Oct-2019|
Prof. Manisha Bawa
6431 Fannin St MSB G 550 A Houston TX 77030
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Bawa M, Mas MF. Commentary on the screening for occult lower extremity deep vein thrombosis upon admission to the acute inpatient rehabilitation. J Int Soc Phys Rehabil Med 2019;2:114
|How to cite this URL:|
Bawa M, Mas MF. Commentary on the screening for occult lower extremity deep vein thrombosis upon admission to the acute inpatient rehabilitation. J Int Soc Phys Rehabil Med [serial online] 2019 [cited 2020 Jan 19];2:114. Available from: http://www.jisprm.org/text.asp?2019/2/3/114/269959
Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism (PE), is a life-threatening complication for patients who experienced traumatic brain injury, traumatic and nontraumatic spinal cord injury, ischemic and hemorrhagic strokes, polytrauma, and immobility, among others. The vast majority of patients in rehabilitation settings fit into one of these categories. VTE is the leading cause of preventable death among hospital inpatients in the United States, and patients in rehabilitation are at a particular high risk.
The early detection of deep venous thrombosis (DVT) and treatment with systemic anticoagulation to prevent further complications is essential in the management of these patients. However, improvements in prophylactic measures have significantly decreased the occurrence of DVT in these patients. The implementation of evidence-based, specialty-specific, risk stratification tool, and VTE prophylaxis order set results in increase in compliance with the American College of Chest Physicians (ACCP) VTE prophylaxis guidelines and reduction in the symptomatic VTE.
Schwarcz et al. concluded that postoperative inpatient surveillance duplex scans for DVT provide very minimal benefit and that a routine screening program is not clinically useful for patients managed with effective DVT prophylaxis.
The ACCP Evidence-Based Clinical Practice Guidelines in 2012 recommended against screening venous duplex ultrasound (VDU). VDU in asymptomatic patients after major orthopedic surgery because it did not result in fewer symptomatic postdischarge VTE. However, screening for asymptomatic DVT appeared to cause harm by leading to unnecessary anticoagulation for several months, which resulted in a higher risk of major bleeding in this population.
Lennox et al. concluded that application of a clinical diagnostic model had the potential for saving a large proportion of unnecessary duplex scans with the associated time and costs. VDU is costly and may have limited sensitivity for asymptomatic DVT. There is no consensus regarding appropriate screening, prophylaxis, or treatment during acute rehabilitation.
Screening of all patients with TBI on admission to rehabilitation using VDU consumes significant valuable resources unnecessarily. Most of these patients will screen negative on VDU. Thus, a stratified screening program based on an individual patient's risk has merit. The ACCP recommends that the choice of the diagnostic test should be based on pretest probability rather than performing the same diagnostic test in all patients. Screening all patients with VDU of the lower extremities on admission to rehabilitation has not been proven to lower risk of PE during rehabilitation.
Adherence to an evidence-based VTE prophylaxis protocol is more important than surveillance duplex scanning in preventing VTE in trauma patients. For example, screening patients who have been immobile and have signs of VTE in an extremity or those who were not receiving proper prophylaxis based on available evidence. This approach could be similar in terms of preventing complications of VTE while proving to be more cost-effective. It is our duty as physicians to not only effectively diagnose and treat our patients but also to do so efficiently, consuming the least amount of resources for the benefit of our patients.
| References|| |
Cipolle MD, Wojcik R, Seislove E, Wasser TE, Pasquale MD. The role of surveillance duplex scanning in preventing venous thromboembolism in trauma patients. J Trauma 2002;52:453-62.
Greenwald BD, Park MJ, Levine JM, Watanabe TK. The utility of routine screening for deep vein thrombosis upon admission to an inpatient brain injury rehabilitation unit. PM R 2013;5:340-7.