THROMBOPHLEBITIS AND DEEP VEIN THROMBOSIS

INTRODUCTION: Thrombophlebitis is an inflammation of the walls of the veins, often accompanied by the formation of a clot. When a clot develops initially in the veins as a result of stasis or hypercoagulability, but without inflammation, the process is referred to as phlebothrombosis. Venous thrombosis can occur in any vein but is most frequent in the veins of the lower extremities than the upper extremities. Both superficial and deep veins of the legs may be affected. Damage to the lining of blood vessels creates a site for clot formation, and increased blood coagulability occurs in patients who abruptly stop taking anticoagulant medications and also occurs with oral contraceptive use and several blood dyscrasias. The danger associated with venous thrombosis is that parts of a clot can become detached and produce an embolic occlusion of the pulmonary blood vessels.

RISK FACTORS: History of varicose veins, hypercoagulation, neoplastic disease, cardiovascular disease, or recent major surgery or injury. Obesity, Advanced age, Oral contraceptive use.

CLINICAL MANIFESTATIONS: Signs and symptoms are nonspecific. Edema and swelling of the extremity resulting from obstruction of the deep veins of the leg; bilateral swelling may be difficult to detect because of lack of size difference. Skin over the affected leg may become warmer; superficial veins may become more prominent showing cordlike venous segment. Tenderness occurs later and is detected by gently palpating the leg. In some cases, signs of a pulmonary embolus are the first indication of DVT. Pulmonary embolism

Thrombus of superficial veins produces pain or tenderness, redness, and warmth in the involved area. In massive iliofemoral venous thrombosis, the entire extremity becomes massively swollen, tense, painful, and cool to touch.

ASSESSMENT AND DIAGNOSTIC METHODS: History revealing risk factors such as varicose veins or neoplastic disease. Doppler ultrasonography, duplex ultrasonography, air plethysmography, contrast phlebography (venography).

PREVENTION: Prevention is dependent on identifying risk factors for thrombus and on educating the patient about appropriate interventions.

MEDICAL MANAGEMENT: Objectives of management are to prevent the thrombus from growing and fragmenting, resolve the current thrombus, and prevent recurrence.

PHARMACOLOGIC THERAPY: Unfractionated heparin is administered for 5 days by intermittent or continuous intravenous (IV) infusion.

Dosage: Regulated by monitoring the activated partial thromboplastin time (APTT), the international normalized ratio (INR), and the platelet count. Low-molecular-weight heparin (LMWH) is given in one or two injections daily; it is more expensive than unfractionated heparin but safer. Oral anticoagulants such as, warfarin [Coumadin]) are given with heparin therapy. Thrombolytic (fibrinolytic) therapy such as, alteplase, is given within the first 3 days after acute thrombosis. Throughout therapy, PTT, prothrombin time (PT), hemoglobin and hematocrit levels, platelet count, and fibrinogen level are monitored frequently. Drug therapy is discontinued if bleeding occurs and cannot be stopped.

ENDOVASCULAR MANAGEMENT: Endovascular management is necessary for DVT when anticoagulant or thrombolytic therapy is contraindicated, the danger of pulmonary embolism is extreme, or venous drainage is so severely compromised that permanent damage to the extremity is likely. A thrombectomy may be necessary.

RELATED;

1. ARTERIOSCLEROSIS

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