Lovenox and a bleed? grrr

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I had a patient yesturday that had a stroke, a hip fracture and a small bleed behind her eye. The doctor had come by and written orders for no anticoagulants so I clarified a few other things with the order and said so we are holding the lovenox for now. And she said no, no we don't want to do that because she has a hip fracture and the risk of a DVT is high so lets give it to her and I said even though she has the bleed and the doctor said it was a very, very small bleed and the risk of a DVT was higher... ok so I did what the doctor ordered. And nights said I never would have done now because I would have been afraid to get sued. Now I feel just wonderful... I guess I should have asked another nurse or doctor before giving the shot.

Specializes in Community Health, Med-Surg, Home Health.

Based on what is being presented by the OP, I would have also administered it, documented who I consulted with, their response and moved on. I can understand your questioning, though.

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Specializes in ICU,ANTICOAG,ACUTE STROKE,EDU,RESEARCH.

OK, unless someone could provide me with robust evidence for the use of LMWH in this situation, then I would sue the a... off the hospital.

LMWH at a treatment dose would be appropriate for a stroke patient that needed treatment for a DVT/PE.

However, the evidence that I am aware of showed that giving prophylactic doses (which I assume this was) to stroke patients to prevent DVT increased the risk of haeamorrhagic transformation (bleeding into the brain infarct caused by the blockage in the artery). Additionally this patient already had a bleed behind her eye.:down:

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Specializes in Cardiac Telemetry, ED.
OK, unless someone could provide me with robust evidence for the use of LMWH in this situation, then I would sue the a... off the hospital.

LMWH at a treatment dose would be appropriate for a stroke patient that needed treatment for a DVT/PE.

However, the evidence that I am aware of showed that giving prophylactic doses (which I assume this was) to stroke patients to prevent DVT increased the risk of haeamorrhagic transformation (bleeding into the brain infarct caused by the blockage in the artery). Additionally this patient already had a bleed behind her eye.:down:

There are risks to every single medication we administer as nurses, and it's the MD's job to weigh the risks vs. the benefits.

Just because a study suggests an increased risk does not mean we stop giving the med. Lovenox is contraindicated in major active bleeding. A small bleed behind the eye does not qualify.

As nurses, we absolutely should question orders that seem to conflict with established standards of care, but this MD's rationale seemed pretty solid to me, and I would have given the med.

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Specializes in Acute Care Cardiac, Education, Prof Practice.

Did the patient have SCD's and TED hose? That would have been a great start for DVT prophylaxsis.

I think you covered your bases with the doc. I would have charted my butt off after that.

Tait

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Specializes in ICU,ANTICOAG,ACUTE STROKE,EDU,RESEARCH.
There are risks to every single medication we administer as nurses, and it's the MD's job to weigh the risks vs. the benefits.

Just because a study suggests an increased risk does not mean we stop giving the med. Lovenox is contraindicated in major active bleeding. A small bleed behind the eye does not qualify.

As nurses, we absolutely should question orders that seem to conflict with established standards of care, but this MD's rationale seemed pretty solid to me, and I would have given the med.

Yes, I agree that there are risks to every single medication, but there is also evidence based practice that should govern the care we give our patients.This eveidence doesn't come from single studies, but from systematic reviews by agencies like the ASA and Cochrane database in the UK.

I am sure most nurses with little stroke experience would have given the med, however if you look at the profile of Lovenox it should be used with caution in patients with acute ischaemic stroke and the bleeding side effects include intracerebral haemorrhage.This patient has a lesion in her head that is very susceptable to haeamorrhagic transformation even without anticoagulation.

There is no evidence for the use of LMWH over combined antiplatelet agents for prevention of further events or DVT prophylaxis in stroke patients.

If this patient had the stroke without the #NOF would they have been prescibed LMWH?

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Specializes in ICU,ANTICOAG,ACUTE STROKE,EDU,RESEARCH.
The pt had a hip fx, and a stroke (embolic I presume?). She/he fell, due to the stroke, fx the hip, and suffered a small bleed behind the eye, correct...? Definately as a new nurse question the doc about the rationale, you do need to understand. But as long as the stroke was embolic vs. hemmorhagic, lovenox dosing therapeutically is appropriate (was it therapeutic dosing or prophylactic?) This pt needs anticoagulation, they could get a DVT due to hip fx, or perhaps already has one and that is why they stroked in the first place.

As one of the prior posts stated sometimes the docs have to pick the lesser of 2 evils when determining care. Just chart appropriately to CYA, and move on.

Venous thrombosis would not lead to a Stroke.

Therapeutic anticoagulation in this patient wouldn't be appropriate as they don't have a condition that warants it.

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Specializes in Cardiac Telemetry, ED.
Yes, I agree that there are risks to every single medication, but there is also evidence based practice that should govern the care we give our patients.This eveidence doesn't come from single studies, but from systematic reviews by agencies like the ASA and Cochrane database in the UK.

I am sure most nurses with little stroke experience would have given the med, however if you look at the profile of Lovenox it should be used with caution in patients with acute ischaemic stroke and the bleeding side effects include intracerebral haemorrhage.This patient has a lesion in her head that is very susceptable to haeamorrhagic transformation even without anticoagulation.

There is no evidence for the use of LMWH over combined antiplatelet agents for prevention of further events or DVT prophylaxis in stroke patients.

If this patient had the stroke without the #NOF would they have been prescibed LMWH?

Used with caution, yes. Do not use? Not necessarily.

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Specializes in ICU,ANTICOAG,ACUTE STROKE,EDU,RESEARCH.
Used with caution, yes. Do not use? Not necessarily.

I am going round in circles here with you guys. Would you like to point me in the direction of guidelines that say that LMWH should be used for DVT prophylaxis in stroke patients?

Lovenox has never been trialed specifically in stroke patients, just sick medical patients as a group.

Maybe it is the drug of choice for #NOF, however this patient has had a recent active bleed AND has an infarct in her head.

I asked if Lovenox was prescribed routinely for stroke patients, or just this one because she had a #NOF?

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Specializes in Cardiac Telemetry, ED.
I had a patient yesturday that had a stroke, a hip fracture and a small bleed behind her eye. The doctor had come by and written orders for no anticoagulants so I clarified a few other things with the order and said so we are holding the lovenox for now. And she said no, no we don't want to do that because she has a hip fracture and the risk of a DVT is high so lets give it to her and I said even though she has the bleed and the doctor said it was a very, very small bleed and the risk of a DVT was higher... ok so I did what the doctor ordered. And nights said I never would have done now because I would have been afraid to get sued. Now I feel just wonderful... I guess I should have asked another nurse or doctor before giving the shot.
As per the original post, the patient was prescribed this medication because the risk of DVT was determined by the physician to be greater than the risk of hemorrhage.
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