AMBULATORY BEST PRACTICES
Preventing Venous Thromboembolism in the Ambulatory Surgical Setting LYNN RAZZANO, MSN, RN, ONCC
V
enous thromboembolism (VTE) is the third most common cardiovascular illness after acute coronary syndrome and stroke.1-3 Although the exact incidence of VTE is unknown, there are approximately one million cases in the United States each year, many of which are recurrent episodes.3 Nearly two-thirds of all VTE events result from hospitalization, and approximately 300,000 of these patients die.3 There are few statistics on VTE in the ambulatory setting; according to an American Academy of Orthopaedic Surgeons report, “Knee arthroscopy is the most commonly performed orthopaedic procedure in The AORN Journal is seeking contributors for the Ambulatory Best Practices column. Interested authors can contact the column coordinator by sending topic ideas to [email protected].
the United States. However, data on the risk of symptomatic venous thromboembolic events (VTEs), including deep vein thrombosis (DVT) and pulmonary embolism (PE), are limited, and most published studies include relatively small numbers.”4 Research-validated incidence data regarding the occurrence of VTE in ambulatory settings are scarce. From June 2004 to December 2008, however, the Pennsylvania Patient Safety Authority received 467 reports related to the preoperative VTE screening or assessment process in ambulatory surgery centers (ASCs), and half of these reports indicated that the patient experienced harm from the lack of assessment or screening or the VTE.5 Ambulatory surgery centers should develop and adhere to thorough preoperative screening and assessment processes to identify VTE risk factors in their patients before surgery.
http://dx.doi.org/10.1016/j.aorn.2015.02.011 ª AORN, Inc, 2015
www.aornjournal.org
AORN Journal j 567
Razzano
VTE RISK FACTORS
Mauck et al6 conducted a case-matched, retrospective review of knee arthroscopies performed at a single institution over a 20-year period, examining the records of 12,595 patients between 1988 and 2008.6 Overall, the authors identified 43 patients with symptomatic VTE, 35 patients with nonsymptomatic VTE, five patients with PE, and three patients with DVT that progressed to PE. The overall incidence of VTE was 0.34%. The authors identified the following as the most common risk factors for VTE:
older than 65 years of age, body mass index (BMI) greater than 30, history of smoking, use of oral contraceptives or hormone replacement, chronic venous insufficiency, and history of previous VTE.6
Other VTE risk factors to consider are gender, history of malignancy, history of lower extremity trauma, or prior knee surgery.7 The type of procedure can affect VTE risk. For example, some procedures commonly performed in ASCs have relatively high risks for VTE. Examples of estimated risks include the following: aesthetic procedures: 8 o abdominoplasty, 2% ; 9 o body contouring, 9.3% ; 10 o face-lift, 0.49% ; and 11 o high-volume liposuction, 1.1% orthopedic procedures: 12 o spine surgery, 1.15% ; 13 o knee arthroscopy, 0.42% ; and 14 o otolaryngology procedures, 1.3%. Joseph Caprini, MD, developed the Caprini Thrombosis Risk Assessment Tool15 to help clinicians assess a patient’s risk of VTE (Table 1). The score depends on the patient’s answers to statements that apply to the past month (eg, surgery, serious infection, bed rest), to women (use of birth control pills or hormone replacement, childbirth within the past month, complicated obstetric history), to their general history (eg, age, history of malignancies, confined to bed for more than 72 hours, planned surgery lasting more than 45 minutes, central lines), and to previous surgery (eg, joint replacement; repair of broken hip, pelvis, or leg; trauma surgery). A total point score of more than eight increases a patient’s risk of DVT to 18.3%.15 Patients with only two to three risk factors have a much smaller risk.15
568 j AORN Journal
May 2015, Volume 101, No. 5
VTE ASSESSMENT AND PROPHYLAXIS Surgery confers a risk of VTE to all patients. Clinicians at ASCs should evaluate all prospective patients to determine their risk.13 General anesthesia has been shown to decrease lower-limb venous return profoundly, and Kiudelis et al16 stated that 50% of anesthetized patients develop some degree of venous stasis intraoperatively because of anesthetic vasodilatation effects similar to those produced by 10 to 14 days of bed rest, which affect the clotting cascade. In addition, sustained intraoperative immobility, tissue trauma, surgical positioning, and postoperative inactivity contribute to VTE development in surgical patients.17 The incidence of VTE in specific ASCs may not be immediately obvious, and determining this may require patient feedback and the results of postoperative follow-up. An ASC that has no defined tracking system or way to identify trends may have a difficult time assessing the true incidence of VTE in the patient population. If no defined policy or procedure exists for screening patients, then the opportunity to prevent VTE is lost and staff members may assume that the procedures performed in the center are short enough and patients are not of high enough acuity to warrant screening. As noted by the Caprini rating scale, however, the risk of DVT is associated with cumulative risk factors, regardless of the procedure, and a defined process to ensure maximum VTE prevention is needed. In addition, without a VTE policy and awareness of patient risk factors, pertinent questions may not be asked in postoperative follow-up interviews. Personnel in ASCs should be able to assess patients, identify those at risk, and institute prophylaxis measures using appropriate resources and DVT protocol tools specific to the patient population for whom care is provided. In 2013, the Accreditation Association for Ambulatory Health Care (AAAHC) Institute for Quality Improvement produced the Patient Safety Toolkit: Ambulatory Surgery and VTE (Venous Thromboembolism)14 to help ASC personnel determine a patient’s VTE risk. Michota18 recommends that ASC personnel do the following: complete a VTE risk factor assessment on patients and identify those who are at high risk, use guidelines for measuring and applying mechanical prophylaxis before the induction of anesthesia, ensure that sufficient sequential compression devices (eg, leg sleeves) or venous foot pumps and ImPadsTM (ie, under-cast, hard-soled compression devices that are applied to the sole of the patient’s foot to compress the plantar plexus) of different sizes and their accompanying pumps are fully charged and ready for use,
www.aornjournal.org
May 2015, Volume 101, No. 5
Preventing Venous Thromboembolism
Table 1. Assessment of Venous Thromboembolism Risk Using Caprini Scoring System Criteria
1
Criteria occurring within the past month or that are present now (one point for each that applies)
Criteria that apply to women (one point each)
Current use of birth control pills or hormone replacement Pregnancy or birth within the past month History of complicated pregnancy (eg, stillborn infant, spontaneous abortion [more than three], premature birth, toxemia, low-birth-weight infant)
Criteria that apply (two points each)
Criteria that apply (three points each)
Older than 75 years of age History of blood clots, deep vein thrombosis, pulmonary embolism Familial or personal history of increased risk of blood clotting
Criteria that apply now or within the past month (five points each)
Elective hip or knee joint replacement Broken hip, pelvis, or leg Serious trauma (eg, multiple fractures) Spinal cord injury resulting in paralysis Stroke
Additional criteria, not validated by research, that appear to affect risk of deep vein thrombosis (one point each)
Airline flight of five hours or more Body mass index of 40 or more Smoking Type 1 diabetes mellitus Chemotherapy History of transfusion Surgery more than two hours in duration
4-60 years of age Minor surgery less than 45 minutes in duration Major surgery more than 45 minutes in duration Visible varicose veins Inflammatory bowel disease Swollen legs Congestive heart failure Serious infection Lung disease Bed rest or restricted mobility < 72 hours
61-74 years of age Current or past malignancy Planned surgery more than 45 minutes in duration Cast that prevents leg movement in the past month Placement of a central venous line within the past month Bed rest for 72 hours
Reference 1. Caprini JA. Risk assessment as a guide for the prevention of the many faces of venous thromboembolism. Am J Surg. 2010;199(1):S3-S10. http://www.americanjournalofsurgery.com/article/S0002-9610(09)00638-2/abstract. Accessed December 16, 2014.
verify that patients at risk for VTE have mechanical prophylaxis applied and that the devices are functional, confirm the length of time for postoperative mechanical prophylaxis and have a defined criteria for discontinuation, provide VTE/DVT education to all staff members, and verify staff member competencies.18
CONCLUSION To improve VTE assessment and prevention in the ambulatory setting, staff must acknowledge that VTE is an
www.aornjournal.org
important issue. Leaders should identify staff members who are committed to the VTE assessment and prevention process to act as champions to encourage buy-in from appropriate stakeholders. A defined process helps perioperative personnel identify patients at risk for and prevent harm from VTE, wherever an operative or invasive procedure takes place.
Editor’s note: Impad is a trademark of Novamedix Distribution Limited, Nicosia, Cyprus.
AORN Journal j 569
Razzano
References 1. Anderson FA Jr, Wheeler HB, Goldberg RJ, et al. A populationbased perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT Study. Arch Intern Med. 1991;151(5):933-938. 2. Heit JA, O’Fallon WM, Petterson TM, et al. Relative impact of risk factors for deep vein thrombosis and pulmonary embolism: a population-based study. Arch Intern Med. 2002;162(11): 1245-1248. 3. Ozaki A, Bartholomew JR. Venous Thromboembolism (Deep Venous Thrombosis & Pulmonary Embolism). The Cleveland Clinic. http:// www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/ cardiology/venous-thromboembolism/#s0025. Accessed December 16, 2014. 4. Pollack P. Knee arthroscopy and VTE: what are the risks? American Academy of Orthopaedic Surgeons (AAOS). http://www.aaos .org/news/aaosnow/aug11/clinical1.asp. Accessed December 17, 2014. 5. Patient screening and assessment in ambulatory surgical facilities. Pa Patient Safe Adv. 2009;6(1):3-9. Pennsylvania Patient Authority. http://patientsafetyauthority.org/ADVISORIES/Advisory Library/2009/mar6%281%29/Pages/03.aspx. Accessed December 18, 2014. 6. Mauck KF, Froehling DA, Daniels PR, et al. Incidence of venous thromboembolism after elective knee arthroscopic surgery: a historical cohort study. J Thromb Haemost. 2013;11(7): 1279-1286. 7. Andersen FA Jr, Spencer FJ. Risk factors for venous thromboembolism [Review]. Circulation. 2003;107(23 Suppl):19-16. 8. Most D, Kozlow J, Heller J, Shermak M. Thromboembolism in plastic surgery. Plast Reconstr Surg. 2005;115(2):20e-30e. 9. Clavijo-Alvarez JA, Pannucci CJ, Oppenheimer AJ, Wilkins EG, Rubin JP. Prevention of venous thromboembolism in body contouring surgery: a national survey of 596 ASPS surgeons. Ann Plast Surg. 2011;66(3):228-232. 10. Reinisch JF, Bresnick SD, Walker JW, Rosso RF. Deep venous thrombosis and pulmonary embolus after face lift. A study of incidence and prophylaxis. Plast Reconstr Surg. 2001;107(6): 1570-1575. 11. Hsu P, Basu CB, Venturi M, Davison S. Venous thromboembolism prophylaxis. Semin Plast Surg. 2006;20(4):225-232.
570 j AORN Journal
May 2015, Volume 101, No. 5 12. Sansone JM, del Rio AM, Anderson PA. The prevalence of and specific risk factors for venous thromboembolic disease following elective spine surgery. J Bone Joint Surg Am. 2010;92(2): 304-313. 13. Maletis GB, Inacio MC, Reynolds S, Funahashi TT. Incidence of symptomatic venous thromboembolism after elective knee arthroscopy. J Bone Joint Surg Am. 2012;94(8):714-720. 14. Patient Safety Toolkit: Ambulatory Surgery and VTE (Venous Thromboembolism). AAAHC Institute for Quality Improvement. http://www.aaahc.org/Global/pdfs/AAAHC%20Institute%20content/ Patient%20Safety%20Toolkits/PST_VTE_FINAL.pdf. Accessed December 16, 2014. 15. Caprini JA. Risk assessment as a guide for the prevention of the many faces of venous thromboembolism. Am J Surg. 2010; 199(1):S3-S10. http://www.americanjournalofsurgery.com/article/ S0002-9610(09)00638-2/abstract. Accessed December 16, 2014. 16. Kiudelis M, Endzinas Z, Mickevicius A, Pundzius J. Venous stasis and deep vein thrombosis prophylaxis during laparoscopic fundoplication [German]. Zentralbl Chir. 2002;127(11):944-949. 17. Guidelines for the prevention of deep vein thrombosis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015: 469-478. 18. Michota FA. Prevention of venous thromboembolism after surgery. Cleve Clin J Med. 2009;76(Suppl 4):S45-S52. http://www.ccjm .org/content/76/Suppl_4/S45.full?related-urls¼yes&legid¼ccjm; 76/Suppl_4/S45. Accessed December 16, 2014.
Lynn Razzano, MSN, RN, ONCC is a clinical nurse consultant for Physician Patient Alliance for Health and Safety (PPAHS), Westboro, MA. Ms Razzano has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
www.aornjournal.org
Preventing Venous Thromboembolism in the Ambulatory Surgical Setting LYNN RAZZANO, MSN, RN, ONCC
V
enous thromboembolism (VTE) is the third most common cardiovascular illness after acute coronary syndrome and stroke.1-3 Although the exact incidence of VTE is unknown, there are approximately one million cases in the United States each year, many of which are recurrent episodes.3 Nearly two-thirds of all VTE events result from hospitalization, and approximately 300,000 of these patients die.3 There are few statistics on VTE in the ambulatory setting; according to an American Academy of Orthopaedic Surgeons report, “Knee arthroscopy is the most commonly performed orthopaedic procedure in The AORN Journal is seeking contributors for the Ambulatory Best Practices column. Interested authors can contact the column coordinator by sending topic ideas to [email protected].
the United States. However, data on the risk of symptomatic venous thromboembolic events (VTEs), including deep vein thrombosis (DVT) and pulmonary embolism (PE), are limited, and most published studies include relatively small numbers.”4 Research-validated incidence data regarding the occurrence of VTE in ambulatory settings are scarce. From June 2004 to December 2008, however, the Pennsylvania Patient Safety Authority received 467 reports related to the preoperative VTE screening or assessment process in ambulatory surgery centers (ASCs), and half of these reports indicated that the patient experienced harm from the lack of assessment or screening or the VTE.5 Ambulatory surgery centers should develop and adhere to thorough preoperative screening and assessment processes to identify VTE risk factors in their patients before surgery.
http://dx.doi.org/10.1016/j.aorn.2015.02.011 ª AORN, Inc, 2015
www.aornjournal.org
AORN Journal j 567
Razzano
VTE RISK FACTORS
Mauck et al6 conducted a case-matched, retrospective review of knee arthroscopies performed at a single institution over a 20-year period, examining the records of 12,595 patients between 1988 and 2008.6 Overall, the authors identified 43 patients with symptomatic VTE, 35 patients with nonsymptomatic VTE, five patients with PE, and three patients with DVT that progressed to PE. The overall incidence of VTE was 0.34%. The authors identified the following as the most common risk factors for VTE:
older than 65 years of age, body mass index (BMI) greater than 30, history of smoking, use of oral contraceptives or hormone replacement, chronic venous insufficiency, and history of previous VTE.6
Other VTE risk factors to consider are gender, history of malignancy, history of lower extremity trauma, or prior knee surgery.7 The type of procedure can affect VTE risk. For example, some procedures commonly performed in ASCs have relatively high risks for VTE. Examples of estimated risks include the following: aesthetic procedures: 8 o abdominoplasty, 2% ; 9 o body contouring, 9.3% ; 10 o face-lift, 0.49% ; and 11 o high-volume liposuction, 1.1% orthopedic procedures: 12 o spine surgery, 1.15% ; 13 o knee arthroscopy, 0.42% ; and 14 o otolaryngology procedures, 1.3%. Joseph Caprini, MD, developed the Caprini Thrombosis Risk Assessment Tool15 to help clinicians assess a patient’s risk of VTE (Table 1). The score depends on the patient’s answers to statements that apply to the past month (eg, surgery, serious infection, bed rest), to women (use of birth control pills or hormone replacement, childbirth within the past month, complicated obstetric history), to their general history (eg, age, history of malignancies, confined to bed for more than 72 hours, planned surgery lasting more than 45 minutes, central lines), and to previous surgery (eg, joint replacement; repair of broken hip, pelvis, or leg; trauma surgery). A total point score of more than eight increases a patient’s risk of DVT to 18.3%.15 Patients with only two to three risk factors have a much smaller risk.15
568 j AORN Journal
May 2015, Volume 101, No. 5
VTE ASSESSMENT AND PROPHYLAXIS Surgery confers a risk of VTE to all patients. Clinicians at ASCs should evaluate all prospective patients to determine their risk.13 General anesthesia has been shown to decrease lower-limb venous return profoundly, and Kiudelis et al16 stated that 50% of anesthetized patients develop some degree of venous stasis intraoperatively because of anesthetic vasodilatation effects similar to those produced by 10 to 14 days of bed rest, which affect the clotting cascade. In addition, sustained intraoperative immobility, tissue trauma, surgical positioning, and postoperative inactivity contribute to VTE development in surgical patients.17 The incidence of VTE in specific ASCs may not be immediately obvious, and determining this may require patient feedback and the results of postoperative follow-up. An ASC that has no defined tracking system or way to identify trends may have a difficult time assessing the true incidence of VTE in the patient population. If no defined policy or procedure exists for screening patients, then the opportunity to prevent VTE is lost and staff members may assume that the procedures performed in the center are short enough and patients are not of high enough acuity to warrant screening. As noted by the Caprini rating scale, however, the risk of DVT is associated with cumulative risk factors, regardless of the procedure, and a defined process to ensure maximum VTE prevention is needed. In addition, without a VTE policy and awareness of patient risk factors, pertinent questions may not be asked in postoperative follow-up interviews. Personnel in ASCs should be able to assess patients, identify those at risk, and institute prophylaxis measures using appropriate resources and DVT protocol tools specific to the patient population for whom care is provided. In 2013, the Accreditation Association for Ambulatory Health Care (AAAHC) Institute for Quality Improvement produced the Patient Safety Toolkit: Ambulatory Surgery and VTE (Venous Thromboembolism)14 to help ASC personnel determine a patient’s VTE risk. Michota18 recommends that ASC personnel do the following: complete a VTE risk factor assessment on patients and identify those who are at high risk, use guidelines for measuring and applying mechanical prophylaxis before the induction of anesthesia, ensure that sufficient sequential compression devices (eg, leg sleeves) or venous foot pumps and ImPadsTM (ie, under-cast, hard-soled compression devices that are applied to the sole of the patient’s foot to compress the plantar plexus) of different sizes and their accompanying pumps are fully charged and ready for use,
www.aornjournal.org
May 2015, Volume 101, No. 5
Preventing Venous Thromboembolism
Table 1. Assessment of Venous Thromboembolism Risk Using Caprini Scoring System Criteria
1
Criteria occurring within the past month or that are present now (one point for each that applies)
Criteria that apply to women (one point each)
Current use of birth control pills or hormone replacement Pregnancy or birth within the past month History of complicated pregnancy (eg, stillborn infant, spontaneous abortion [more than three], premature birth, toxemia, low-birth-weight infant)
Criteria that apply (two points each)
Criteria that apply (three points each)
Older than 75 years of age History of blood clots, deep vein thrombosis, pulmonary embolism Familial or personal history of increased risk of blood clotting
Criteria that apply now or within the past month (five points each)
Elective hip or knee joint replacement Broken hip, pelvis, or leg Serious trauma (eg, multiple fractures) Spinal cord injury resulting in paralysis Stroke
Additional criteria, not validated by research, that appear to affect risk of deep vein thrombosis (one point each)
Airline flight of five hours or more Body mass index of 40 or more Smoking Type 1 diabetes mellitus Chemotherapy History of transfusion Surgery more than two hours in duration
4-60 years of age Minor surgery less than 45 minutes in duration Major surgery more than 45 minutes in duration Visible varicose veins Inflammatory bowel disease Swollen legs Congestive heart failure Serious infection Lung disease Bed rest or restricted mobility < 72 hours
61-74 years of age Current or past malignancy Planned surgery more than 45 minutes in duration Cast that prevents leg movement in the past month Placement of a central venous line within the past month Bed rest for 72 hours
Reference 1. Caprini JA. Risk assessment as a guide for the prevention of the many faces of venous thromboembolism. Am J Surg. 2010;199(1):S3-S10. http://www.americanjournalofsurgery.com/article/S0002-9610(09)00638-2/abstract. Accessed December 16, 2014.
verify that patients at risk for VTE have mechanical prophylaxis applied and that the devices are functional, confirm the length of time for postoperative mechanical prophylaxis and have a defined criteria for discontinuation, provide VTE/DVT education to all staff members, and verify staff member competencies.18
CONCLUSION To improve VTE assessment and prevention in the ambulatory setting, staff must acknowledge that VTE is an
www.aornjournal.org
important issue. Leaders should identify staff members who are committed to the VTE assessment and prevention process to act as champions to encourage buy-in from appropriate stakeholders. A defined process helps perioperative personnel identify patients at risk for and prevent harm from VTE, wherever an operative or invasive procedure takes place.
Editor’s note: Impad is a trademark of Novamedix Distribution Limited, Nicosia, Cyprus.
AORN Journal j 569
Razzano
References 1. Anderson FA Jr, Wheeler HB, Goldberg RJ, et al. A populationbased perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT Study. Arch Intern Med. 1991;151(5):933-938. 2. Heit JA, O’Fallon WM, Petterson TM, et al. Relative impact of risk factors for deep vein thrombosis and pulmonary embolism: a population-based study. Arch Intern Med. 2002;162(11): 1245-1248. 3. Ozaki A, Bartholomew JR. Venous Thromboembolism (Deep Venous Thrombosis & Pulmonary Embolism). The Cleveland Clinic. http:// www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/ cardiology/venous-thromboembolism/#s0025. Accessed December 16, 2014. 4. Pollack P. Knee arthroscopy and VTE: what are the risks? American Academy of Orthopaedic Surgeons (AAOS). http://www.aaos .org/news/aaosnow/aug11/clinical1.asp. Accessed December 17, 2014. 5. Patient screening and assessment in ambulatory surgical facilities. Pa Patient Safe Adv. 2009;6(1):3-9. Pennsylvania Patient Authority. http://patientsafetyauthority.org/ADVISORIES/Advisory Library/2009/mar6%281%29/Pages/03.aspx. Accessed December 18, 2014. 6. Mauck KF, Froehling DA, Daniels PR, et al. Incidence of venous thromboembolism after elective knee arthroscopic surgery: a historical cohort study. J Thromb Haemost. 2013;11(7): 1279-1286. 7. Andersen FA Jr, Spencer FJ. Risk factors for venous thromboembolism [Review]. Circulation. 2003;107(23 Suppl):19-16. 8. Most D, Kozlow J, Heller J, Shermak M. Thromboembolism in plastic surgery. Plast Reconstr Surg. 2005;115(2):20e-30e. 9. Clavijo-Alvarez JA, Pannucci CJ, Oppenheimer AJ, Wilkins EG, Rubin JP. Prevention of venous thromboembolism in body contouring surgery: a national survey of 596 ASPS surgeons. Ann Plast Surg. 2011;66(3):228-232. 10. Reinisch JF, Bresnick SD, Walker JW, Rosso RF. Deep venous thrombosis and pulmonary embolus after face lift. A study of incidence and prophylaxis. Plast Reconstr Surg. 2001;107(6): 1570-1575. 11. Hsu P, Basu CB, Venturi M, Davison S. Venous thromboembolism prophylaxis. Semin Plast Surg. 2006;20(4):225-232.
570 j AORN Journal
May 2015, Volume 101, No. 5 12. Sansone JM, del Rio AM, Anderson PA. The prevalence of and specific risk factors for venous thromboembolic disease following elective spine surgery. J Bone Joint Surg Am. 2010;92(2): 304-313. 13. Maletis GB, Inacio MC, Reynolds S, Funahashi TT. Incidence of symptomatic venous thromboembolism after elective knee arthroscopy. J Bone Joint Surg Am. 2012;94(8):714-720. 14. Patient Safety Toolkit: Ambulatory Surgery and VTE (Venous Thromboembolism). AAAHC Institute for Quality Improvement. http://www.aaahc.org/Global/pdfs/AAAHC%20Institute%20content/ Patient%20Safety%20Toolkits/PST_VTE_FINAL.pdf. Accessed December 16, 2014. 15. Caprini JA. Risk assessment as a guide for the prevention of the many faces of venous thromboembolism. Am J Surg. 2010; 199(1):S3-S10. http://www.americanjournalofsurgery.com/article/ S0002-9610(09)00638-2/abstract. Accessed December 16, 2014. 16. Kiudelis M, Endzinas Z, Mickevicius A, Pundzius J. Venous stasis and deep vein thrombosis prophylaxis during laparoscopic fundoplication [German]. Zentralbl Chir. 2002;127(11):944-949. 17. Guidelines for the prevention of deep vein thrombosis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015: 469-478. 18. Michota FA. Prevention of venous thromboembolism after surgery. Cleve Clin J Med. 2009;76(Suppl 4):S45-S52. http://www.ccjm .org/content/76/Suppl_4/S45.full?related-urls¼yes&legid¼ccjm; 76/Suppl_4/S45. Accessed December 16, 2014.
Lynn Razzano, MSN, RN, ONCC is a clinical nurse consultant for Physician Patient Alliance for Health and Safety (PPAHS), Westboro, MA. Ms Razzano has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
www.aornjournal.org
