Here's another interesting question we received:
"Hello. Great blog. We have a patient with an extensive DVT. He is being heparinised. He asked if he should walk on it. Is there a risk of embolization events if you walk on a leg with DVT? If so, what is the time frame in which it becomes safe to do so? On the other hand, is it better or worse to keep the leg up and stay in bed? This would seem counterintuitive to virchow's triad which warns agains immobilisation."
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Back when I was in medical school (try and picture some wheezing and coughing with a raspy voice) we were told that patients with DVT should remain in ABSOLUTE bedrest for the first few days (no bathroom privileges) to prevent embolization od residual unstable clots. Textbooks seemed to favor that suggesting embolic risk was highest in the first 72 hours until th clot started organizing and lysing. Since organization actually starts much faster there is no good data to support that.
Recently on Chest (Trujillo-Santos et al Chest. 2005 May;127(5):1631-6) >2,000 patients with DVT/PE were assigned to early ambulation or bedrest and found no difference in new events (!) so things have really changed since I was in Med school...
Yea, that's back when we "old guys" had to walk 20 miles uphill through daily blizzards both ways at 3 in the morning just to pre-round. Before duty hours and admisison caps...
I agree. I was "taught" initial bedrest, but now we don't restrict patients with DVT and try to get them ambulating. In fact, we try to get them on low molecular weight heparin and out of the hospital; that decision is not based on the "size" of the lower extremity clot, but is based on the "stability" of the patient.
What about at HFH and Beaumont? Do you encourage early ambulation?
Well, I wasn't sure until this post. I think based on that Chest article I will not be so unsure as to whether to ambulate early now....
In other words yes I will ambulate early.
I try to ambulate the patients early based upon the chest article cited above.
However, not all physicians at WBH share in this philosophy.
I suppose it is kind of like prone positioning for ARDS, huh?
Based on my research and readings of the articles the ACCP base their recommondations after...I am skeptical to apply these guidelines to acute care patients. The research is strict as far as which patients were selected to participate.
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