Deep venous thrombosis and pulmonary embolism in psychiatric settings
Venous thromboembolism (VTE) refers to DVT, PE, or both. An association between VTE and air travel was first reported in the early s. Pulmonary embolism (PE) is one of the leading causes of in-patient hospital deaths. As a consequence, the identification of hemostatic. The main concern of most physicians when attending a patient with pulmonary embolism (PE) is the intimate but unpredictable association between thrombosis .
Picture of a used inferior vena cava filter, showing the hook at the top for remove via the jugular vein, the umbrella structure and the leg spikes to fix in place, CC BozMo at English Wikipedia, Pulmonary Embolism Prevention Pulmonary embolism PEalthough serious, can be prevented when correct measures are taken.
The first step to prevent PE is becoming aware of the risk. If at an increased risk, a doctor can recommend medications or graduated compression stockings to help prevent PE from occurring.
Increased risk of PE can also occur when sitting for extended periods of time. This can be mitigated by getting up to walk, wearing loose-fitting clothes while travelling, and exercising the legs while seated. Stretching leg muscles by lifting your heels off the ground and setting them down again Fig. Finally, maintaining a healthy weight and active lifestyle is key to reducing risk of PE.
Complications of Pulmonary Embolism As many as half of post-pulmonary embolism PE patients may suffer from complications.
One of the most severe complications, chronic thromboembolic pulmonary hypertension CTEPHis associated with a high risk of death. It occurs in just under 0. It is also potentially life-ending.
As already discussed, the best clinical outcome comes when the embolism never makes it to the lungs. Further observational studies should ideally include a control group.
Findings on atypical antipsychotic drugs other than clozapine were few and discordant There is only few or no evidence that antidepressants, benzodiazepines or mood stabilizers give an increased risk of VTE5,7,9,10, Physical restraint, catatonia and neuroleptic malignant syndrome predispose to VTE with possibly fatal outcome.
These findings are based on numerous case-reports Table III The common denominator in all three conditions is immobility. The case reports perform an important role in highlighting the risk of immobility in these psychiatric conditions.
Other risk factors for developing VTE were not examined completely. Antipsychotic drugs had often been used in this patients although stopped in catatonia and neuroleptic malignant syndrome. This can be a confounding factor. Observational studies might be difficult to design for severe catatonia and neuroleptic malignant syndrome since they are relatively rare conditions.
There are two important limitations of this literature review: Exclusion of papers published in non-English languages might have limited the total number of cases available for inclusion.
Secondly, pulmonary embolism is often misdiagnosed as sudden cardiac death. Ten of 27 cases of fatal pulmonary embolism were diagnosed in psychiatric patients only at autopsy This makes it possible that some cases of PE are missed and without autopsy are ascribed to other fatal conditions. Underlying biological mechanisms Serveral underlying mechanisms have been proposed to explain the association between antipsychotic drugs and VTE.
Sedation induced by antipsychotic drugs, can increase venous stasis. Hypercaogulability via an enhanced aggregation of platelets with conventional antipsychotics has been suggested in previous studies47,48 or via hyperprolactinemia in an indirect pathway more recently Another hypothesis is the increased levels of lupus anticoagulant and anticaridiolipin antibodies induced by conventional antipsychotic agents and clozapine50, Finally, hyperhomocysteinemia was also suggested as a plausibel underlying mechanism but is probably more related to the psychiatric disorder itself52, Immobilisation is regarded as an important risk factor for surgical and bedridden patients54 but also for healthy persons on long distances air travels55 or in persistent sitting position In conditions like physical restraint, severe catatonia and neuroleptic malignant syndrome immobilisation, causing slowing down of the bloodstream, seems the common risk factor for the development of VTE.
Additional risk factors for VTE inherent to the specific psychiatric conditions are: Three factors can cause delay in medical attention. Firstly, the patient may due to his illness not be able to communicate leg pain from DVT or chest pain or respiratory difficulties from PE Secondly, there is a risk that these physical complaints are ascribed to anxiety or psychosis and are not taken seriously32, Thirdly, PE can occur without warning signs and sometimes patients collapsed when ambulation was restarted which may activate silent cloths The studies on antipsychotic drugs ruled out the influence of immobility by exclusion.
During physical restraint, severe catatonic states or neuroleptic malignant syndrome, antipsychotic drugs are often used before or during the illness. But in catatonia and neuroleptic malignant syndrome antipsychotics are mostly stopped. Prophylactic measures for VTE in medical and surgical settings are physical excercise, placement of elastic stockings, use of pneumatic compression and administration of subcutaneous heparin This review raises the question if patients on antipsychotic agents or during physical restraint, severe catatonic state or neuroleptic malignant syndrome should receive prophylactic measures against VTE.
Although VTE prophylaxis for all patients taking antipsychotic drugs is inappropriate, we have to consider the fact that the risk of VTE increases significantly if several risk factors are present at the same time Screening patients for additional risk factors of DVT and PE seems advisable to identify those patients that would benefit from prophylaxis.
Prophylaxis proposed by some authors to prevent VTE in patients during prolonged restraint or with severe catatonia, range from a higher awarness of VTE, conducting frequent physical examinations, physical excercise, until anticoagulation34, Some authors suggest anticoagulation therapy during immobility due to neuroleptic malignant syndrome for al such patients42, There is one report on a prophylaxis scheme in a mental hospital in the Czech Republic but this is not based on scientific evidence Until there is more evidence from prospective observational and randomized controlled studies recommendations based on prophylactic measures taken in medical and surgical settings58 seems appropriate.
If a psychiatric patient is identified as having an increased risk for VTE the following prophylactic measures should be considered. Firstly, avoidance of strict bedrest or immobility and an increased amount of exercise is for most patients sufficient but often ignored. Also sufficient hydration is of importance. Secondly, complaints such as swelling, pain or discolouring of the leg, chest pain or dyspnoea merit special attention.
Conducting physical examinations focusing on this complaints is essential. Further technical investigations as Doppler ultrasound of the lower extremity to diagnose DVT or ventilation-perfusion scan or spiral CT of the chest to diagnose for PE is necessary.
Pulmonary Embolism – DVT to PE
Thirdly, the implementation of other deep venous thrombosis prophylactic measures i. We consider patients taking antipsychotics combined with multiple other risk factors, physical restraint for long periods, persistent immobility due to severe catatonia and neuroleptic malignant syndrome at high risk for VTE.
Conclusion Psychiatric patients taking conventional antipsychotic drugs or clozapine, under physical restraint or suffering from severe catatonia or neuroleptic malignant syndrome seem to have an increased risk to develop deep venous thrombosis and pulmonary embolism which are potentially life-threatening events. A double blind study in the psychiatric population is needed in order to refine the subgroups of our patients who would benefit from DVT prophylaxis.
Lancet Apr 24; Pathophysiol Haemost Thromb ; Acute massive pulmonary thromboembolism associated with risperidone and conventional phenothiazines. Circ J ; Massive pulmonary thromboembolism demonstrated at necropsy in Japanese psychiatric patients treated with neuroleptics including atypical antipsychotics. Antipsychotic and antidepressant drug use in the elderly and the risk of venous thromboembolism.
Thromb Haemost Aug; 88 2: Venous thromboembolism among elderly patients treated with atypical and conventional antipsychotic agents.
Pulmonary Embolism (PE) - DVT to PE, Symptoms, Treatment & Causes
Arch Inter Med ; Zornberg G, Jick H. Antipsychotic drug use and risk of first-time idiopathic venous thromboembolism: Antipsychotic medication and venous thrombosis. Br J Psychiatry ; Psychotropic drugs and fatal pulmonary embolism. Pharmacoepidemiol Drug Saf ; Association between antipsychotic drugs, antidepressant drugs and venous thromboembolism: Fundam Clin Pharmacol Dec; 21 6: Mortality in current and former users of clozapine.
Association of venous thromboembolism and clozapine. Clardy J, Gale RH. Mortality risk and clozapine. Am J Psychiatry Apr; 4: Lacika S, Cooper JP. Pulmonary embolus possibly associated with clozapine treatment. Can J Psychiatry May; 44 4: Coodin S, Ballegeer T. The weight of the baby pressing on veins in the pelvis can slow blood return from the legs. Clots are more likely to form when blood slows or pools.
Complications Pulmonary embolism can be life-threatening. About one-third of people with undiagnosed and untreated pulmonary embolism don't survive. When the condition is diagnosed and treated promptly, however, that number drops dramatically. Pulmonary embolism can also lead to pulmonary hypertension, a condition in which the blood pressure in your lungs and in the right side of the heart is too high.
When you have obstructions in the arteries inside your lungs, your heart must work harder to push blood through those vessels.
This increases the blood pressure within these vessels and the right side of the heart, which can weaken your heart. In rare cases, small emboli occur frequently and develop over time, resulting in chronic pulmonary hypertension, also known as chronic thromboembolic pulmonary hypertension. Prevention Preventing clots in the deep veins in your legs deep vein thrombosis will help prevent pulmonary embolism.
For this reason, most hospitals are aggressive about taking measures to prevent blood clots, including: These medications are often given to people at risk of clots before and after an operation — as well as to people admitted to the hospital with a heart attack, stroke or complications of cancer.
Compression stockings steadily squeeze your legs, helping your veins and leg muscles move blood more efficiently. They offer a safe, simple and inexpensive way to keep blood from stagnating during and after general surgery. Elevating your legs when possible and during the night also can be very effective. Raise the bottom of your bed 4 to 6 inches with blocks or books.
Moving as soon as possible after surgery can help prevent pulmonary embolism and hasten recovery overall.