Treatment of DVT's

Speculating · Dec 10, 2003

Originally posted by BarbPick
If it is so easily handled with levanox, how come I get so many patients on heparin drips still? I work occasionally in tele and unit, and it seems like they run sales on heparin drips.Must be where the emboli can launch from...any opinion, please share. These patients seem like they could be out patients.

Because it's hard to teach old dogs new tricks, and $$$ more for heparin protocols. They don't use it for the same reason it's been difficult for some to use the new ACLS cardiac drugs that have been out for the last four years.

southern rn · Dec 10, 2003

our physicians are mainly using the lovenox, not just for dvt but for others that need to be anticoagulated, it also works well in the prophylaxis setting. for dvt treatment the lovenox is weight based usually 1mg/kg of body weight and prophylactically i believe it is a lower dose maybe 40 mg qd? incidentally at one time it seems like we were seeing quite a few pts with retroperitoneal bleeds on lovenox but none lately. has anyone else seen this?

jayne109, RN · Dec 10, 2003

I have only seen one pt have a problem with Lovenox. One of our frequent fliers from a nursing home developed a hematoma in her abdomen that was about the size of a softball. She came in with a small one and through the next 4-5 visits to our hospital till it grew to this size. the docs had stopped the lovenox on the second visit. this pt could not have the surgery to drain it because of COPD and her platelet count was chronically low. I haven't seen any other problems with it since.

Someone said that the dose is 1 mg/kg which I agree with. I have had to give 180 mg! that is 2 shots. This person also had diabetes and SO I had to give 2 shots of insulin as well. They were brave. I don't know that I could do that!

nrsjo · Dec 10, 2003

I also think whether you get admitted and put on heparin depends on the size of the dvt. Mine was groin to ankle, and I spent 4 days on heparin, and am now on coumadin. I got wonderful nursing care, but I wasn't in my own facility.

Our patients don't get sent home on lovenox, because it's horribly expensive without insurance coverage, and they just won't use it. Coumadin ends up being cheaper for them, so we use the "old" system.

ShelleyERgirl, LPN · Dec 11, 2003

Originally posted by Frances LeMay
I've been getting those shots in my belly for over two years now. Every time I'm hospitalized, which is quite often. And the best part is, they don't even hurt.

Fran:)

Don't hurt? Frannie, girl are ya kidding me? I had a DVT last spring and had to have those shots twice a day for about ten days and let me tell ya, those things KILLED me! I don't know if it was the act of injecting myself, the injection itself, or both but let me tell ya.... I was definitely glad I had a little belly on me then because that whole experience pretty much sucked!

New CCU RN · Dec 11, 2003

Originally posted by BarbPick
If it is so easily handled with levanox, how come I get so many patients on heparin drips still? I work occasionally in tele and unit, and it seems like they run sales on heparin drips.Must be where the emboli can launch from...any opinion, please share. These patients seem like they could be out patients.

What is their renal function... w/ an elevated creat/BUN Lovenox can typically be contraindicated. We will go for Heparin over Lovenox if their creat is greater than 2.0.

Another thing seems to be doc preference or the procedure. We have some docs in the cath lab that prefer Heparin during the procedure while others like Lovenox. It does seem we see more getting which ever one dependant on the MD as well.

Another thing is the control issue I think. With Heparin you can monitor their PTT's and know they are therapeutic where as w/ Lovenox you give it and that's it. You don't really know. You assume they are because that is what the pharmaceutic research of it says.. :) However, the catch obviously is the error margin w/ Heparin in that it typically takes some titration to get the therapeutic PTT. Also.... if you run into trouble you can reverse the Heparin and not the Lovenox so that may leave some of the docs a little shaky on the Lovenox.

BarbPick · Dec 11, 2003

There is a lot to say about hands on expereince, much more than looking up a drug and also being able to calculate a drip right.

Thank you

FranEMTnurse, CNA, LPN, EMT-I · Dec 11, 2003

quote:

originally posted by navynurse 29

Frannie, girl are ya kidding me? I had a DVT last spring and had to have those shots twice a day for about ten days and let me tell ya, those things KILLED me! I don't know if it was the act of injecting myself, the injection itself, or both but let me tell ya.... I was definitely glad I had a little belly on me then because that whole experience pretty much sucked!

Well, the only thing I can say about that, is, "I've had so much worse pain than what the Levanox produces, that to me, I actually didn't feel it." and I was also on coumadin for 9 months.

Some of my worst pain came from the emboli that were in my lungs, and the pinched nerve in my groin. Both of which I unfortunately still have, and am still trying to get a medication that will control it. The only thing that doesn't give me pruritis is Demerol, and they won't prescribe that due to its highly addictive effect. I have been able to avoid becoming addicted by taking them PRN. It boggles my mind...

The Dilaudid I've been on since 2001, used to work well, but unfortunately, that too now gives me pruritis. I've tried Fentanyl duragesic which gave me pneumonia, oxycontin, methadone, and morphine all give me pruritis, I also get projectile vomiting with the morphine. I've been to a pain specialist several different times, and they all want me to take pain meds 24/7 to give me the control, which have all given me negative side effects.

I have told them that I take the narcotic analgesics only PRN, but for some reason they don't want to provide them that way. And I don't understand why. I saw my doctor today, and he wants to send me to a medical center two hours away to get help, but that's difficult for me, because I'm in an electric wheelchair.

The most painful tests I ever had were a myelogram, and a sygmoidoscopy.

Fran:confused:

ShelleyERgirl, LPN · Dec 11, 2003

Frannie, my friend, you are right. When you put in the perspective of your med hx, that particular pain is nothing in comparison to what you have been through!

angellavg · Dec 22, 2003

my hospital is in the dark ages:) . we still use hep. drips for ALL DVTs. the only time that i have seen lovenox used is when the patient came from the "big city" hospital and was already using it. sounds a lot easier and less expensive for the patient. i'll have to ask why we still use the heparin drip (probably get yelled at lol). i'm sure this would also make our lab techs happy, not having to come in at all hours of the night to check for theraputic levels:D

OCCHCanada · Dec 22, 2003

Low molecular weight heparin is certainly used extensively now for DVT's, uncomplicated PE's, preventative post hip, knee replacements and ankle fractures/any lower leg immobilties. Often patients are provided one dose and are sent home with a RX to get filled by their pharmacy - it is the pharmacist that does the injecting teaching.

Currently in research and development is an oral form of regular heparin that would eliminate the BID SC injections. It's been bonded with proteins which allow for it's absorption through the gut. But in its liquid form it's unpalatable. Currently it's under trial in a pill form. (It's being trialed on hip replacement patients I believe). The trial is called PROTECT.

Our practise is not to use low molecular heparin with pregnant women in their last trimester due to longer half-life (even 12 hours can be too long). Maternity patients are changed over to regular heparin - this ensure that that the effects of the thinning can be almost immediately reversed in an emergency.

The current data is suggesting that persons with uncomplicated DVT should be on Warfarin for one year. Persons with a second DVT should be treated life long. This includes the use of compression stockings for all - lifelong to prevent post-phelbitis leg syndrome which can be life altering in the long run.

INR monitors can now be purchased for persons on lifelong regiem to control their dosing just like diabetics.

Chaya, ASN, RN · Dec 23, 2003

I've been seeing Lovenox used for DVT's for the past few months. Scary at first but seems to be working fine.