UPPER EXTREMITY DEEP VEIN THROMBOSIS (UEDVT)

Although lower extremity deep vein thrombosis has been studied in depth and prevention and treatment algorithms are common, much less is known about upper extremity DVT. The UE DVT is now recognized as a serious condition that results in considerable morbidity, including symptomatic or asymptomatic pulmonary embolism, chronic venous insufficiency, or post thrombotic syndrome. UE DVT accounts for 1% to 10% of all cases of DVT, according to the reviews, which note that its incidence seems to be increasing with more frequent use of central venous catheters in patients requiring chemotherapy, parenteral nutrition, or haemodialysis.

Pathogenesis
Universally accepted definition is lacking, the term UE DVT most often refers to thrombosis of the subclavin vein, axillary vein or both; the internal jugular and brachial veins are less common sites. It is

classified as primary or secondary on the basis of pathogenesis. Primary Thrombosis Primary UEDVT accounts for 20% to 30% of all cases that is either idiopathic or associated with strenuous physical activity i.e. also known as effort induced thrombosis or Paget-Schroetter Syndrome. Its common in young men usually healthy with symptoms of pain, swelling and bruising after strenuous work like rowing, wrestling, weight lifting, or baseball pitching .These patients develop spontaneous UEDVT, usually in their dominant arm. The heavy exertion causes microtrauma to the vessel intima and leads to activation of the coagulation cascade. Significant thrombosis may occur with repeated insults to the vein wall, especially if mechanical compression of the vessel is also present. Patients with idiopathic UEDVT have no known trigger or obvious underlying disease. Idiopathic UEDVT may, however, be associated with occult cancer. In one study, one fourth of patients presenting with idiopathic UEDVT were diagnosed with cancer most commonly lung cancer or lymphomas within 1 year of follow-up. Most of these cancers were discovered during the first week of hospital admission for the venous thrombosis.

Secondary Thrombosis Secondary UEDVT is often a result of an identifiable risk factor, often associated with disruptions to coagulability or blood vessels or flow. Such factors include use of invasive lines such as central venous catheters, pacemakers, non malignancy related coagulopathies, infections, previous surgeries, cancer and history of lower extremities DVT. Nearly all patients have at least one risk factor for DVT (according to the current clinical practice guidelines from American college of Chest Physicians) Catheter related UEDVT accounts for as many as 72% of all secondary cases. One study revealed found that use of central venous catheter increased the risk of developing UEDVT by seven fold. Catheter size and type and duration of use, are thought to be important variables. The infusion Nurses society recommends using the smallest size and length catheter as possible. The nature of infusate may also play a role, many chemotherapy drugs and contrast media are known to be caustic, and any drug known to be a chemical irritant has the potential to damage the vein. Signs And Symptoms: Pain Swelling Bruising and discolouration of the area of or proximal to the thrombosis Decreased range of motion or vague shoulder or neck pain Mild cyanosis of the extremity Pruritis Vein tenderness Asymptomatic Physical examination: Palpable cord Mild cyanosis in affected arm Edema Distension of jugular vein

Differential Diagnosis: Hematomas Muscle Tears Contusions Superficial phlebitis of the arm cellulitis venous compression lymphedema

Diagnostic Findings: o Color Doppler o Ultra sonography (preferred as non invasive) o Contrast Venography o Magnetic resonance angiography (promising) Treatment: Treatment of upper extremity DVT remains controversial. There are widely divergent recommendations in the literature. They are surgical embolectomy, thrombolysis and heparin therapy to symptomatic treatment, controlled trials of such interventions have not been performed. Therefore standards for treatment of upper extremity are still being developed and current regime are based on the cause and on the prognosis of the individual patient One review stated that low dose warfarin or low molecular weight heparin in high risk patients : those with cancer who receive chemotherapy or parenteral nutrition through a central venous catheter :showed reduced thrombus formation but the ACCP, noting that in other trials these drugs failed to show any such benefit and increased the risk of major bleeding ONE HOSPITALS PREVENTIVE EFFORT: A quality improvement project was conducted with patients who underwent UE ultra sonography during 2008, focusing on UEDVT In March 2008 a nurse led multidisciplinary team was formed reviewed patients with secondary UEDVT till December 2008. These patients had a thrombus of different sizes and had undergone ultrasonography between Jan and April 2008 Patients charts were audited for IV assessments , flushes , site changes , drugs administered IV and pts complains during peripheral IV care . Results :Of the 26 nosocomial cases of secondary upper extremity DVT that occurred in 2008 , 15 were at antecubital peripheral IV line sites, five were peripherally inserted central catheter sites, one was associated with implanted central venous catheter . The remaining five cases were associated with harsh medications given through peripheral IV lines that were inserted below the antecubital fossa.

From this study several risk factors for upper extremity DVT in the patients were the use of the antecubital veins for peripheral IV lines, the administration of IV promethazine and other harsh medications and certain PICC flushing and care practices. These factors were looked into and initiatives were implemented . CHANGES IMPLEMENTED : Using the large veins at the antecubital fossa for peripheral IV access was found to increase the risk of upper-extremity DVT. This risk increased with the duration of use: movement of the elbow joint over time caused the catheter to migrate along the vein, leading to injury of the intimal lining of the blood vessel and triggering clot formation.To address this, the peripheral IV insertion and care policy was updated to emphasize the importance of immobilizing the site, and soft splints for such use were made available. Because immobilization is itself a risk factor for DVT, staff were reminded to practice appropriate management, including regular assessment of circulation to the extremity. Harsh medications administered through a peripheral IV, even when given through a large vein, can cause intimal damage. For example, patients undergoing radiologic tests often require such administration of contrast media, which are known to be caustic. The staff were encouraged to remove the catheters as soon as testing is complete, in order to prevent phlebitis and subsequent thrombus formation at the site. And we updated the peripheral IV insertion and care policy so that it specifies which tests require antecubital sites; these include computed tomographic (CT) scans for pulmonary embolism, aortic dissection, and abdominal aortic aneurysm and angiography. All other radiologic tests, including routine chest CT scans, can be performed using peripheral IVs in other locations. Among the patients tracked, intravenous administration of promethazine, a highly caustic antiemetic, was found to be associated with UE DVT. Several patients developed upperextremity thrombi that extended beyond the site of administration. This occurred despite our practices of administering promethazine through a running IV line at the port farthest from the patient's vein and diluting the drug in 10 ml normal saline, as recommended by the manufacturer. promethazine is diluted in 25 to 50 ml normal saline and administer it through a secondary IV set to prevent intimal damage and subsequent upper-extremity DVT. Catheter flushing remains controversial because "research has not yet demonstrated the optimal flushing solution or frequency." The Infusion Nursing Standards of Practice recommends flushing vascular access devices "at established intervals" with either preservative-free 0.9% sodium chloride or with heparin, and states that when heparin is used, the concentration should be low enough to avoid systemic anticoagulation. In all patients with lines requiring either saline or heparin flushes, our standard policy now is to perform flushes every 24 hours.

Staff education. A curriculum of beginner and advanced courses for all staff responsible for invasive line care was developed by the clinical educator. All staff whose jobs involved starting peripheral IVs, and all new hires, were required to take the beginner course and demonstrate competency; those caring for patients with central venous access devices were also required to take the advanced course. In August 2008 the staff were educated specifically on the revised peripheral IV policy. Nursing implications. Any patient with a history of DVT, a genetic predisposition to clot formation, or any other risk factors for upper-extremity DVT should be monitored closely, especially when invasive lines are being used. Because cancer patients with invasive lines are known to be at particularly high risk, nurses caring for these patients should remain alert and immediately report any signs and symptoms of venous occlusion or thrombosis to the patient's physician. Patients at high risk for upper-extremity DVT should be taught to recognize the signs and symptoms and instructed to report them without delay. Result : At the end of the study the incidence of secondary upper-extremity DVT continued to decline, despite sharp increases in the number of patients cared for and in case complexity. When this complication does occur, it was detected earlier. We believe these improvements are largely the result of enhanced policies and staff