How to prevent deep vein thrombosis of the lower extremities?

Patients with a low risk of deep venous thrombosis (eg who underwent a minor surgical intervention but who have no clinical risk factors for deep venous thrombosis, as well as those who need to be temporarily restricted in movements for a long period, such as during an air flight) must walk or periodically perform various moves with your feet. Apparently, it's enough to bend your legs 10 times an hour. There is no need for treatment.

Patients with a higher risk of deep venous thrombosis (for example, who underwent insignificant surgical intervention but who have clinical risk factors for deep venous thrombosis, who underwent extensive surgical intervention, especially orthopedic surgery, even without risk factors, bed-sickness) need additional prevention. Such patients need to be identified and treated before the blood clot forms. After surgical intervention, lifting of the legs and refusal to sit on the chairs (which prevents the venous outflow due to the forced position of the legs) are effective. Additional treatment may include low doses of UFH, LMWH, warfarin, newer anticoagulants, compression devices or stockings, and a combination of these depending on the level of risk, type of surgery, anticipated duration of prophylaxis, contraindications, adverse effects, relative cost, ease in application and local practice.

UFH in a low dose (5 thousand units) is administered subcutaneously 2 hours prior to surgery and every 8-12 hours after it for 7-10 days or until the patient is discharged to an outpatient schedule. Bedridden patients who did not tolerate surgical intervention are given 5,000 U of SC subcutaneously every 12 hours for an indefinite period (or until the risk factors completely disappear).

LMWH are more effective than low-dose UFH, to prevent deep venous thrombosis and pulmonary embolism, but widespread use is limited in cost. Enoxaparin sodium 30 mg subcutaneously after 12 h, sodium dalteparin 2,5 thousand units once a day and tinzaparin 3,5 thousand units once a day are equally effective.

Warfarin 2-5 mg once a day or in a dose adjusted under the control of MHO (at the level of 1.5-2) is usually prescribed, but efficacy and safety are not proven.

Newer anticoagulants (eg, hirudin, ximelagatran, danaparoid, fondaparinox) are effective in preventing deep venous thrombosis and pulmonary embolism, but their cost-effectiveness and safety compared with sodium heparin and warfarin requires further study. The efficacy of acetylsalicylic acid is higher than placebo, but lower than all other available drugs that serve to prevent deep venous thrombosis and pulmonary embolism.

Intermittent pneumatic compression (PKI) involves the use of a pump for the cyclical filling and emptying of hollow plastic gaits, which provides external compression of the shins and sometimes the hips. PKI can be used in place of or together with anticoagulants prior to and during surgery. PKI is more effective in preventing deep venous thrombosis of the lower legs than proximal deep venous thrombosis, and therefore it is considered ineffective after surgical intervention on the thigh or knee. PKI is usually contraindicated in obese patients and can theoretically cause pulmonary embolism in immobilized patients who develop a "mute" deep venous thrombosis without prevention.

The effectiveness of compression stockings with distributed pressure is questionable, except for patients with low surgical risk. However, combining the use of stockings with other preventive measures can be more effective than any measure separately.

In cases of surgical interventions or diseases with a high incidence of venous thromboembolism (eg, orthopedic, some neurosurgical operations, spinal cord injuries, multiple traumas), neither low doses of UFH nor acetylsalicylic acid have the desired effect. Orthopedic operations on the hip and lower limb are recommended LMWH or warfarin in an individually selected dose. When prosthetic knee joint LMWH and PKI have a comparable efficacy, and should be assigned to their combination in clinical risk factors. In orthopedic operations, prevention begins before the intervention and continues for at least 7 days after it. For neurosurgical patients, it is suggested to use physical measures (PKI, compression knitwear), because there is a risk of intracerebral hemorrhage; However, LMWH is likely to be an acceptable alternative. The combination of PKI and LMWH in some cases is more effective than any of these effects alone, in patients at risk. A limited number of studies support the combination of PKI, compression stockings and LMWH in patients with spinal cord injury or multiple trauma.

For patients who have a very high risk of venous thromboembolism, bleeding and taking anticoagulants, the installation of FNPV becomes a means of choice.

Preventive treatment of deep vein thrombosis of the lower limbs is also prescribed for patients who underwent acute myocardial infarction or ischemic stroke. Low doses of UFH are effective in patients who are no longer receiving intravenous heparin drugs or thrombolytic agents. You can use PKI, compression knitwear or a combination of them, when there are contraindications to the appointment of anticoagulants. After a stroke, low doses of UFH or LMWH are used; IPC, elastic stockings or a combination thereof can also be useful. Other recommendations include low doses of UFH for patients with heart failure, warfarin in an individually selected dose (MHO 1.3-1.9) for patients with metastatic breast cancer, warfarin at a dose of 1 mg 1 time per day for cancer patients with a central venous catheter.

Primary prophylaxis of venous insufficiency and post-phlebitis syndrome is the wearing of knee compression stockings that provide a pressure of 30-40 mm Hg. Art.

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