Case 1: Brenda: Reducing her risk of DVT

Brenda

A picture of Brenda Brenda is 66 years old and is married with three young grandchildren. She was previously well except for having high blood pressure, being overweight and being an ex-smoker.

Yesterday she was admitted to the medical assessment ward at 9pm with a left hemisphere stroke causing aphasia and right side weakness – she presented too late to benefit from thrombolysis. On admission she was unable to walk or talk and unable to answer even simple questions. The CT scan excluded intracerebral haemorrhage.

She was transferred up to the stroke unit in the morning of the following day (in line with Scottish Stroke Care Standards 2016)

She was transferred up to the stroke unit in the morning of the following day (in line with  Scottish Stroke care standards (2016) and Local Delivery Plans (LDP) Рsee the Clinical standards topic loop below for further information). She received 300mg of aspirin orally after she passed her swallow screen in the assessment unit and has been prescribed heparin and anti-embolism stockings (e.g. TED) by the doctors in the assessment ward but these have not yet been started.

You are the nurse in charge of the stroke unit. What will you do with respect of these prescriptions?


Topic Loop:

Give heparin as prescribed and apply the stockings

No, this is incorrect, Brenda should not be given heparin or have stockings applied.

Why Brenda should not be given heparin:

Guideline Description
NICE NICE guidelines [.pdf] do not recommend routine anticoagulation for patients with stroke: ‘Anticoagulation treatment should not be used routinely for the treatment of acute stroke’
Cochrane review Cochrane review : A systematic review of all relevant trials indicates that whilst heparin will reduce the risk of DVT (mostly asymptomatic DVTs picked up only on scans) it will also increase the risk of serious bleeding. Patients treated with heparin do not have better overall outcomes than those without i.e. they have similar mortality and functional outcomes.

Highly selected patients who are judged to be at low risk of bleeding but much higher than average risk of DVT may be treated based on a clinician’s individual judgment.

For Brenda the issue is whether the heparin was written up following such an assessment or simply because the junior doctor was applying the protocol for non stroke patients to her – in error!

Why Brenda should not have stockings applied:

Guideline Description
SIGN 118 SIGN 118 guideline states:
‘Above-knee graduated elastic compression stockings to reduce the risk of deep vein thrombosis after acute stroke are not recommended” Grade A, Level 1++’
NICE NICE guideline [.pdf] on prevention of venous thromboembolism (Jan 2010) states:
“Do not offer anti-embolism stockings for VTE prophylaxis to patients who are admitted for stroke.”

Don’t give either but sign for both on the medication chart

Incorrect, this would represent a medication error and would lead to an investigation of your practice.


Give heparin but not stockings

Incorrect, Brenda should not be given heparin.

Why Brenda should not be given heparin:

Guideline Description
SIGN 118 SIGN 118 Guideline does not recommend anticoagulation: ‘Anticoagulant therapy in the first two weeks after ischaemic stroke can cause haemorrhagic stroke or haemorrhagic transformation of the ischaemic stroke and has no net benefit 1++”
NICE NICE guidelines [.pdf] do not recommend routine anticoagulation for patients with stroke: ‘Anticoagulation treatment should not be used routinely for the treatment of acute stroke’
Cochrane review Cochrane review : A systematic review of all relevant trials indicates that whilst heparin will reduce the risk of DVT (mostly asymptomatic DVTs picked up only on scans) it will also increase the risk of serious bleeding. Patients treated with heparin do not have better overall outcomes than those without i.e. they have similar mortality and functional outcomes.

Highly selected patients who are judged to be at low risk of bleeding but much higher than average risk of DVT may be treated based on a clinician’s individual judgment.

For Brenda the issue is whether the heparin was written up following such an assessment or simply because the junior doctor was applying the protocol for non stroke patients to her – in error!


Apply stockings but don’t give heparin

Incorrect, Brenda should not have stockings applied.

Why Brenda should not have stockings applied:

Guideline Description
SIGN 118 The SIGN 118 guideline states: ‘Above-knee graduated elastic compression stockings to reduce the risk of deep vein thrombosis after acute stroke are not recommended” Grade A, Level 1++’
NICE NICE guideline [.pdf] on prevention of venous thromboembolism (Jan 2010) states:“Do not offer anti-embolism stockings for VTE prophylaxis to patients who are admitted for stroke.”

However, you are right that Brenda should not be given heparin.

Why Brenda should not be given heparin:

Guideline Description
SIGN 118 SIGN 118 guideline does not recommend anticoagulation: ‘Anticoagulant therapy in the first two weeks after ischaemic stroke can cause haemorrhagic stroke or haemorrhagic transformation of the ischaemic stroke and has no net benefit 1++”
NICE NICE guidelines [.pdf] do not recommend routine anticoagulation for patients with stroke: ‘Anticoagulation treatment should not be used routinely for the treatment of acute stroke’
Cochrane review Cochrane review : A systematic review of all relevant trials indicates that whilst heparin will reduce the risk of DVT (mostly asymptomatic DVTs picked up only on scans) it will also increase the risk of serious bleeding. Patients treated with heparin do not have better overall outcomes than those without i.e. they have similar mortality and functional outcomes.

Highly selected patients who are judged to be at low risk of bleeding but much higher than average risk of DVT may be treated based on a clinician’s individual judgment.

For Brenda the issue is whether the heparin was written up following such an assessment or simply because the junior doctor was applying the protocol for non stroke patients to her – in error!


Query the appropriateness of the prescription

This is correct as neither prescribing heparin or applying stockings are correct courses of action.

Page last reviewed: 16 Sep 2020