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CLINICAL REVIEW: William E Cayley, Jr Preventing deep vein thrombosis in hospital inpatients BMJ 2007; 335: 147-151 [Full text]

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Venousthromboembolism and tamoxifen

Paul Abram   (21 July 2007)

Can graded stocking prevent DVT and in help treating it ?

Bibi Leila R parahoo   (23 July 2007)

Preventing deep vein thrombosis in hospital inpatients

Alan W Fowler   (23 July 2007)

Enhancing mobility with improved IV anchoring

Phillip J Colquitt   (24 July 2007)

Venousthromboembolism and tamoxifen 21 July 2007
Paul Abram, Consultant Clinical Oncologist NI Cancer Centre BELFAST BT97AB Send response to journal: Re: Venousthromboembolism and tamoxifen	The anti-oestrogen tamoxifen is used in the management of both pre and postmenopausal women with oestrogen receptor positive early or advanced breast carcinoma.The association between VTE and tamoxifen is well documented, most of the excess deaths in the tamoxifen arm of the IBIS chemoprevention trial were in postoperative patients taking tamoxifen. Given the frequency of breast carcinoma it is vital that patients taking tamoxifen are identified and advised to stop this drug for 5 days prior to surgery and to remain of it until fully mobilised. Competing interests: None declared
Can graded stocking prevent DVT and in help treating it ? 23 July 2007
Bibi Leila R parahoo, doctor/carer fairmount nursing home BD18 4EJ Send response to journal: Re: Can graded stocking prevent DVT and in help treating it ?	With the research done all over the world, it has been shown that there is little evidence to show that these stockings help. However when compared to people who are not using anything at all during immobility period, those with the stockings seem to have less chance of developing DVT. However the stockings do not seem to help in the case when a clot has already been formed. On the contrary it seems to agravate the situation by increasing the swelling in the dependant area. Hence medication is crucial in this situation. But what do we do if our patient has got a hemorrhagic stroke and a DVT at the same time? Competing interests: None declared
Preventing deep vein thrombosis in hospital inpatients 23 July 2007
Alan W Fowler, Retired orhtopaedic surgeon Home CF31 1QJ Send response to journal: Re: Preventing deep vein thrombosis in hospital inpatients	Dear Sir, Preventing deep vein thrombosis in hospital inpatients I am surprised that no mention is made of the importance of posture and exercise in Dr. Cayley’s clinical review of the prevention of DVT.¹ Venous stasis is a common factor in all hospital inpatients and there are four simple measures that help to reduce stasis. 1. All hospital beds should have an obligatory upward tilt of the lower limbs Selective tilt of the lower limbs is easy to achieve in modern profiling beds and nurses need to be taught the importance of this simple measure. 2. All patients should be taught to do foot and ankle exercises, (active ‘foot pumps’) every hour or so. 3. All patients should be taught to do deep breathing exercises. Hyperventilation is avoided by holding each breath in maximal inspiration for a few seconds. Even higher negative thoracic pressure can be achieved if the patient can be taught to expand the chest while keeping the glottis closed (‘Expand your chest but don’t let the air in’). 4. No patient who is unable to walk should be asked to sit in a chair for more than a short time. For sick people, chair sitting is a grossly over- rated past-time because it impedes venous return from the legs. Profiling beds provide a sitting option together with leg elevation and without the disadvantage of hospital chairs which have horizontal seats which allow the sitter to slump forwards. All of the above measures are additional to those outlined in the clinical review. Alan W Fowler 1. Cayley WE. Preventing deep vein thrombosis in hospital inpatients. BMJ 2007; 335:147-51 (21 July). Competing interests: None declared
Enhancing mobility with improved IV anchoring 24 July 2007
Phillip J Colquitt, Technician/RN Independent Comment Send response to journal: Re: Enhancing mobility with improved IV anchoring	I take heart from statements of Alan W Fowler, in response to Cayley[1]. He says …….”No patient who is unable to walk should be asked to sit in a chair for more than a short time. For sick people, chair sitting is a grossly over-rated past-time because it impedes venous return from the legs”……. I imagine Bliss[2] would agree. With particular regard to mobility of post operative patients, much benefit is lost to anxiety when one observes the precarious anchoring of IV therapy sites attached to the various analgesic infusions which are intended to make mobility more humane. The tradition of limited IV anchoring harks back to a time when the patient was expected to lie still and be quiet, and when patients with an IV thought of themselves as an endangered species.[ "I was on a drip!!!" ] Tension forces which an IV line is subjected to when patients are mobilized, are considerable. Many IV sites are replaced and/or occlude unnecessarily, as a kink occurs where the fine plastic cannula emerges from the vein and meets the coloured female hub of the cannula, due to poor fixing and subsequent loosening. Generally, I find that when all hair is removed[clipped not shaved] from the elbow down to the fingers, larger[4”x6”] transparent dressings[eg. OPSITE] placed over IV sites adhere well. Additional OPSITE can be placed over that section of IV line leading in a straight line from the cannula to the three way tap. This ensures that the tension is taken on the IV line, NOT on the cannula. The patient can now be mobilized with more confidence, and the entire IV site can be visualized for any complications. [1] Cayley, WE Jr . Preventing deep vein thrombosis in hospital inpatients BMJ 2007; 335: 147-151. [2]Bliss MR. The rationale for sitting elderly patients in hospital out of bed for long periods is medically unsubstantiated and detrimental to their recovery. Med Hypotheses. 2004;62(4):471-8. Competing interests: None declared