[HSF] DVT in cardiac sugery

[Mitch Lirtzman]

Tea,

We have the same quality indcator forms at our HCA-based hospital. I 
suspect every hospital's CQI person is working on some sort of form like 
the one you describe.

In short, I put SCD's on every post-op heart, on or off pump. I think it is 
just good medicine. No hard facts. Hearts are mobilized the next day. 
Non-cardiac thoracic patients are at higher risk and so they get the whole 
nine yards...compression and Lovenox. They are not as high risk as a THA or 
TKA and do not get Coumadin as the orthopods do. The patient who has had 
lower ext revascularization does not get either. There is a spot on the 
form that allows for that with space for a reason and I always put, "recent 
arterial surgery". It's never been questioned.

If apatient is ambulatory coming out of ICU, we give just a little dose of 
something or other, just to show we've done something. Voodoo? Yes. 
However, we, like many of you, operate on so many obese, diabetic, immobile 
slugs (pardon me) whose gut hangs over their thighs and whose ankles are 
bigger than my thigh, that I feel obligated to go full tilt until they 
reach their fullest ability.

MitchAt 02:57 PM 4/20/2008, you wrote:
>One of the peculiarities of our new heart hospital is that we are 
>partnered which a local hospital system (Baylor). One of the "benefits" of 
>such arrangement is that for reasons that are somewhat mysterious we get 
>some (all?) of the best practice formulations developed by the flagship 
>hospital (medical) staff. At least that is my take on what suddenly 
>appears on my patients chart.
>
>One of these efforts is a 3 page DVT work sheet which we check the boxes 
>and sign an assessment page, a throw away page that explains the graded 
>risks, and a third full page for selection of various prophylaxis options. 
>Interestingly, despite many categories for risk and contra indications no 
>where on this document is there mention of other procedure but no specific 
>mention of cardiac surgery, which is obviously the bulk of what we do at 
>the heart hospital.
>
>As a bias my present practice is not to rountinely prophylax except for 
>the dubious TED hose. Before I start (rather before it becomes noticable) 
>that i am markedly out of step, does anyone have information or comments 
>on these following points?
>
>1) Is there specific data on the risk and benefits of DVT prophylaxis for 
>cardiac patients or any particular subset of rountine CV patients?
>
>2) If there is data, does it break out effects for on and off pump, ASA, 
>plavix, aprotonin, fast track (aggressive mobilization and discharge) and 
>other relevant variables?
>
>3) If there are studies of mechanical compression devices for these 
>patients, are there comparisons of fast track verses immobility (the 
>default nursing solution for all the insulin drips, bladder and invasive 
>lines, etc)? IE does a device that has to be hooked up and taken off 
>repeatedly help or hurt with DVT compared to mobilization?
>
>4) If there is no data how do others stratify their patients at risk? Is 
>just being in the hospital ipso facto a risk, one that favors treatment? 
>Does LOS not really matter?
>
>tea
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