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J R Soc Med. 2006 September; 99(9): 436–437.
PMCID: PMC1557877

Controversies in thromboprophylaxis for immobile patients secondary to neurological impairment

As venous thromboembolism (VTE) kills 25 000 people in the UK each year, it is not surprising to hear several voices warning about that menace and to find many guidelines suggesting strategies to reduce the risk.1 However, it is hard to find guidance when you are dealing with neurologically impaired, immobile patients who constitute 7% of all VTE patients.2

One of the main points of controversy is the duration of thromboprophylaxis. Medical and surgical patients receive thromboprophylaxis for 1-2 weeks as they usually regain independent mobility by that time. Many of the neurologically impaired immobile patients take a long time to achieve independent mobility, and some of them will never do. So when should one discontinue thromboprophylaxis?

The only clear guidelines deal with acute spinal cord injury for which there is a more than 80% risk of suffering VTE in its acute stage.3 That risk drops and becomes comparable to the normal population in 3-4 months. The reason is not completely understood, but femoral artery atrophy and reductions of venous distensibility are well documented.4 Development of spasticity can also improve calf muscle pump.3 These vascular changes are common to any patient with long-term immobility, so theoretically we should expect most immobile patients to behave similarly to spinal injury patients showing significant reduction of risk of VTE 4 months after the onset. To confirm or refute this hypothesis prospective studies will be needed.

Notes

Competing interests None declared.

References

1. Perrin K, Robinson P, Beasley R. Venous thromboembolism in medical patients—the silent epidemic of neglect. J R Soc Med 2005;98: 484-5 [PMC free article] [PubMed]
2. Heit JA, O'Fallon WM, Patterson TM, et al. Relative impact of risk factors for deep venous thrombosis and pulmonary embolism. Arch Intern Med 2002;162: 1245-8 [PubMed]
3. Consensus conference on deep venous thrombosis in spinal cord injury: summary and recommendations. Chest 1992;102(suppl): 633-5s
4. Gaber TA. Significant reduction of the risk of venous thromboembolism in all long term immobile patients a few months after onset of immobility. Med Hypoth 2005;64: 1173-6 [PubMed]

Articles from Journal of the Royal Society of Medicine are provided here courtesy of Royal Society of Medicine Press