| BackgroundsVenous thromboembolism,including deep venous thrombosis and pulmonary embolism,is a condition in which blood clots form(most often)in the deep veins of the leg.The ninth edition guideline of the venous thromboembolism prophylaxis published by American College of Chest Physicians and “Expert consensus on prevention of perioperative venous thromboembolism in Chinese orthopedic trauma patients ” published by Chinese Orthopedic Association in 2012 are clearly pointed out that people with lower extremity fractures are at high risk of VTE.if not take preventive measures,the incidence of deep vein thrombosis is as high as 8%-80 %,PE up to 1%-10%.The occurrence of VTE seriously delays patient’s rehabilitation process and quality of rehabilitation,and fatal PE has become the third leading cause of death in patients with fractures.Even many guidelines and consensuses have published at aboard and home;no VTE prophylaxis strategy can be applied in clinic.Enhanced Recovery after surgery has been widely used in surgical patients in recent years.A series of studies at home and abroad show that the application of ERAS can effectively reduce the incidence of VTE in surgical patients,such as hysterectomy,hip and knee replacement surgery,and accelerate the rehabilitation of patients.We conduct the study of construction of VTE prophylaxis strategy in lower limb fracture patients based on related guidelines and consensus.ObjectivesBased on evidence-based medicine,through literature review,clinical experience and Delphi method to build scientific VTE prophylaxis strategy based on ERAS suitable to patients with lower limb fracture,apply the strategy to clinical to verify its safety and effectiveness,and form a perioperative VTE prophylaxis strategy which is scientific and standardized,safe and effective,with clinical operability for patients with lower limb fracture,in order to provide lower limb fracture patients safe and effective VTE prophylaxis measures in line with the concept of ERAS,to minimize the incidence of VTE,and improve patient’s satisfaction with nursing and accelerate patient’s rehabilitation.Methods1.Literature review and evidence-based research: reviewing literature related to VTE in recent years,especially the relevant clinical practice guidelines,expert consensus and high-quality clinical randomized controlled trials,and selecting high-quality evidence-based evidence to construct the draft of VTE prophylaxis strategy.2.Delphi: experts consulting through convening experts in nursing,trauma orthopedic medicine experts,anesthesiology experts,management experts,VTE experts and other multidisciplinary experts to discuss and revise the draft and eventually form the VTE prophylaxis strategy suitable to patients with lower limb fracture.3.Clinical trails: Convenience sampling,prospective randomized parallel controlled trail,according to the inclusion criteria and exclusion criteria,80 patients,who were admitted to orthopedics of the major hospital in Shanghai due to lower limb single site fracture between 2016.06 and 2016.12,were randomized to experimental group and control group.There were no significant differences in the incidence of chronic diseases such as age,sex ratio,BMI,educational level,smoking,alcohol consumption and hypertension in the two groups of(P>0.05).Experimental group was treated with perioperative nursing care strategy in line with ERAS,The control group received routine nursing care,and then compare the differences of VTE incidence,D-dimer,TEG coagulation parameters,color Doppler ultrasonography,anxiety and depression scores,pain scores at different times,satisfaction with nursing work,length of hospital stay were compared between the two groups.The quantitative data of normal distribution were analyzed with t test,the comparison of rate were analyzed with chi-square test,the quantitative data which were not normally distributed and constitute ratio data which did not meet the requirements of chi-square test were analyzed with nonparametric test-Wilcoxon rank sum test.Results1.Literature review shows that people with lower limb fracture are at high risk of VTE,Even many guidelines and consensuses have published at aboard and home;no VTE prophylaxis strategy can be applied in clinic.2.We form the draft of vte prophylaxis strategy through literature review.And then we verify the strategy through holding Delphi consult.Eventually,VTE prophylaxis strategy.3.Effectiveness analysis of experimental and control group(1)There is no statistically significant difference between the two groups in age,sex ratio,BMI,education,smoking,alcohol consumption,hypertension,diabetes mellitus,varicose veins,stroke history,surgical history,fracture type,fracture site,anesthesia rating,and operation time(P >0.05).The two groups were comparable.(2)Main indicator-VTE incidence: the venous blood flow of the lower limbs in the experimental group was better than that in the control group(P <0.05).No DVT and PE occurred in ERAS group,but there were 2 cases of venous blood stasis,1 case of popliteal vein blood stasis,1 case of femoral vein blood stasis,the remaining blood flow smoothly;No PE occurred in control group,there were 2 cases of Calf muscle vein thrombosis,1 case for each side,6 cases of blood stasis,4 cases of popliteal vein blood stasis,2 cases of femoral vein blood stasis.(3)Secondary indicators-coagulation indexes3.1 There was no significant difference in the D-dimer level between the two groups after 24 hours of admission.The D-dimer level in the experimental group was lower than that in the control group at postoperative day 3,differences were statistically significant(P <0.05).3.2 There were no significant differences in R value,K value,Angel,MA,CI,EPL and LY30 levels between the two groups at 24 hours after admission.Of the 80 patients,52(65%)patients had normal coagulation function.(27.5%)patients were in hypercoagulable state,6(7.5%)patients were in hypoechoic state;The R value of the control group was lower than that of the experimental group at postoperative day 3;The values of Angel,MA and CI in the control group were higher than those in the experimental group,the difference was statistically significant(P <0.05),However,there was no significant difference between the two groups in K value,EPL and LY30(P> 0.05);In experimental group,12 patients returned to normal coagulation function at postoperative day 3,but only 1 patient in the control group,the other patients remain hypercoagulable state,the control group coagulation was significantly higher than the control group.3.3 The number of patients with Homans syndrome and Neuhof sign in experimental group was significantly lower than that in control group after surgery(P <0.05).(4)Other indicators-comfortable and economic idexes4.1 The satisfaction of the experimental group was higher than that of the control group.The satisfaction analysis showed that the scores of the experimental group were significant in the three dimensions of service and technology,care and love,environment and guidance and overall satisfaction Higher than the control group(P <0.05).4.2 There was no significant difference in the pain score between the two groups at admission.The pain scores of the patients in the experimental group were significantly lower than those in the control group at preoperative day 1,postoperative hour 24,48 and discharge day(P <0.05).4.3 There was no significant difference in the scores of anxiety and depression between the two groups when admitted.The scores of anxiety and depression were significantly lower in the experimental group than those in the control group when discharge.4.4 The compliance with physical exercise of patients in experimental group is significantly better than that in the control group(P <0.05).Conclusion1.Based on VTE prophylaxis strategy,the perioperative care can effectively improve deep venous blood flow and coagulation abnormalities of patients with traumatic lower extremity fractures,reduce the incidence of venous thromboembolism.2.Based on VTE prophylaxis strategy,the perioperative care can effectively improve patients’ satisfaction with nursing,relieve the perioperative pain,improve depression,anxiety and other adverse psychological mood,and improve patient compliance with nursing care. |
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