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SMART goal
In post-surgical bariatric patients, how does the implementation of DVT prophylaxis versus the non-use of prophylactic methods decrease the risk of pulmonary embolism during 15 weeks?
Bariatric surgery has been used to better health conditions by reducing excess fats in the body. However, bariatric surgery poses risks of complications and death. One of the major complications associated with bariatric surgery is pulmonary embolism; a blood clot in the artery in the lungs (PE) (El Ansari et al., 2020). PE can be corrected by the use of deep venous thrombosis (DVT) prophylaxis. PE is serious health care because it can cause deaths to occur within 30 days post operation (Chang et al., 2018). The condition is a healthcare concern because to those who get treated it can also pose risks of chronic cardiovascular diseases including heart failure and pulmonary hypertension (El Ansari et al., 2020).
In the United States, about a third of inpatients are at risk of developing PE every year which is estimated to be 600, 000 and the mortality rate is about 100,000 (Chang et al., 2018). PE associated with bariatric surgery develops in around 0.2% to 2.2% of patients, with a fatality rate of 1% within 30 days from surgery (Chang et al., 2018). People with certain characteristics including old age, family history of blood clots, and obesity, in Miami, as well as in other parts, have a 50% chance of developing PE. The purpose of this resear is the benefits of implementing DVT prophylaxis to decrease the risks of PE in patients who had bariatric surgery. The proposed program will address, the health concern, stakeholders and their roles, resources required role of the advanced nurse, and the timeframe for implementation.
Prevention of Pulmonary Embolism Using DVT Prophylaxis post bariatric Surgery
Vulnerable population
Older patients/adults are a vulnerable population to PE. Older adults are described as those aged 60 years and above. Older adults have decreased body functions which render them to stay inactive thus paving way for diseases. Most of them also have chronic conditions which make their immune system weak and an easy target (Zhao et al., 2018). Older adults, should get regular health checks and treat conditions as early as possible.
The increase of age, increases care needs among older adults compared to young adults. Social determinants are factors that promote healthy living among a population and they include economic, environmental and social (Del Brutto et al., 2022). Some social health factors for the older population include access to quality and affordable healthcare, job opportunity or employment, family or support system, and access to affordable transport. The employment has to be stable with a good income to cater to basic needs. Another important factor is food; access to and availability of adequate nutritious food (Del Brutto et al., 2022).
The risk factors that make the elderly population have PE are family history, lifestyle, and certain inherited conditions. Older adults with a family member who had PE increased the risk of the disease or if they inherited a disease related to blood clotting. Most adults stay inactive lifestyles may be due to diseases or lack of body energy, disposing them of diseases (Zhao et al., 2018). Having underlying conditions such as DVT, chronic obstructive pulmonary disease (COPD), malignant tumor, and high blood pressure (Ma et al., 2022).
Literature review
Six articles related to the problem have been reviewed. In Almarshad et al. (2020), the title of the article is "Thromboprophylaxis after bariatric surgery". The study's purpose was to assess the safety and efficacy of thromboprophylaxis in post-bariatric surgery patients for an extended duration. The study included a sample of 374 patients who underwent bariatric surgery. Retrospective study design and quantitative data collection and evaluation methods were used. The study findings indicated that two out of 312 patients who had 3 months follow-ups in the same hospital showed postoperative VTE symptoms, while the rest had no reports of bleeding or deaths related to VTE. The limitations included a small sample size, some of the patients going to another hospital, the use of retrospective design, and a single medical facility.
In Altieri et al. (2018), the title of the article is "Evaluation of VTE prophylaxis and the impact of alternate regimens on post-operative bleeding and thrombotic complications following bariatric procedures”. The authors investigated optimal VTE prophylaxis and the events of bleeding and VTE symptoms after surgery. 11,860 records from more than 500 hospitals were used from the Cerner Health Facts databases. The authors used longitudinal design and mixed methods. The findings indicated that patients with chemoprophylaxis had lower rates of DVT compared to those without. Postoperative prophylaxis reduces the chances of transfusion. Limitations included coding errors, lack of data on hospital visit records, and no clear distinction between cause and effect.
In Rodriguez et al. (2020), the title of the article is "Prophylaxis with rivaroxaban after laparoscopic sleeve gastrectomy could reduce the frequency of portomesenteric venous thrombosis”. The purpose of the study was to assess the influence of rivaroxaban on the frequency of mesenteric and portal venous thrombosis and its safety record following a laparoscopic sleeve gastrectomy. 516 patients were identified but only 421 were reviewed. The authors used a retrospective design and quantitative data methods. The use of thromboprophylaxis with rivaroxaban, compared to the use of intrahospital thromboprophylaxis only prevents mesenteric and portal venous thrombosis. The limitations of the study included the study design used and small sample size.
In Ahmad et al. (2021), the title of the article is “incidence of silent deep venous thrombosis after laparoscopic bariatric surgery in patients who received combined mechanical and chemical thromboprophylaxis compared to patients who received mechanical thromboprophylaxis only”. 150 morbidly obese patients were recruited. The study was to identify DVT cases in lower limbs after bariatric surgery and assess the safety and efficacy of prophylaxis to prevent DVT. A prospective randomized controlled study and quantitative data methods were used. The authors found that combined mechanical and mechanical thromboprophylaxis, compared to mechanical thromboprophylaxis only, is safe and effective for DVT after bariatric surgery. The limitations of the study included short-term follow-up and small sample size.
In Bouteloup et al. (2022), the title of the article is “fondaparinux to prevent venous thromboembolism after bariatric surgery: an observational clinical trial”. The researchers evaluated the effectiveness of fondaparinux after Laparoscopic Sleeve Gastrectomy (LSG) to prevent VTE. I54 participants were included. Observational study with qualitative methods were applied. The study found that Fondaparinux appeared to be effective and safe when used for postoperative thromboprophylaxis after bariatric surgery, without adverse reaction. The limitations included the lack of a control group and lack of systemic technology for detection of VTE.
In Bayat et al. (2022), the title of the article is “the influence of enoxaparin or rivaroxaban for venous thromboembolism in morbidly obese patients undergoing bariatric surgery". The aim was to assess the usefulness of thromboprophylaxis including Rivaroxaban and Enoxaparin in postoperative laparoscopic sleeve gastrectomy patients. The sample size was 1,000 patients. A retrospective design and quantitative methods were used. The study found that thromboprophylaxis therapy was effective to prevent LSG without bleeding risks. The limitations included the use of a single study center and the inclusion of a single ethnicity group.
All the researchers analyzed included essential research elements with proper study designs for the desired outcomes and the purposes of the study. The research was compared to previous studies done which agreed with what the current studies were about. Also, the studies used data analysis methods that were valid and reliable. They all recommended future research on similar topics. The weakness shown is that the studies incorporated smaller sample sizes which made their results hard to be replicated in a wider population. The researchers used single centers where they did not compare or use studies with other centers.
Proposal
To address the issue of the development of PE after bariatric surgery, it is important to make an evidence-based proposal. The proposal to deal with the problem is the use of DVT prophylaxis in the postoperative period to avoid PE. This proposal is hospital-based and the care facility where the patients underwent their surgery will be involved actively in the follow-up program. The rates of PE after bariatric surgery are expected to drop by about 50 to 60%. According to Altieri et al., (2018), prophylaxis is safe for patients who had a bariatric operation as it does not cause any more blood loss and has no adverse side effects. The intervention will be coordinated between the care workers and patients who will sign the recruitment form (with their consent). Only patients above 18 years will be included in this intervention.
Resources
The resources required are plenty of medication for all the patients (estimated 770), assessment equipment, and data recording resources. These resources are important as they will help keep data before, during, and after the intervention period. The data will also be used for evaluation purposes. Importantly human resources are needed including nurses from the surgical ward who will be recording the patients.
Professionals involved
General nurses to help with the follow-up program. Surgeon/s who performed the procedures. Pharmacists for medication recording and allocation. A nutritionist will also be used to guide on the proper diet for these patients.
Feasibility
For a nurse in an advanced role, the feasibility includes being there for patients both in the clinical setting and at home. The patients can be monitored either from home or from the hospital (depending on their choice), and a nurse will be required for the job. Also, the nurse is subordinate to physicians, so they should help where the physician needs them. Also, they should not act outside their licensure.
Time
The timeframe for implementation of the intervention is 15 weeks. This is enough time to access all the patients and draw a conclusion on the effectiveness of DVT prophylaxis.
References
Ahmad, K. S., Zayed, M. E., Faheem, M. H., & Essa, M. S. (2021). Incidence of silent deep venous thrombosis after laparoscopic bariatric surgery in patients who received combined mechanical and chemical thromboprophylaxis compared to patients who received mechanical thromboprophylaxis only. Surgical innovation, 28(1), 144–150.
Almarshad, F. M., Almegren, M., Alshuaibi, T., Alobaodi, N., Almutawa, A., Basunbl, H., AlGahtani, F., & Al Rawahi, B. (2020). Thromboprophylaxis after bariatric surgery. Blood research, 55(1), 44–48. https://doi.org/10.5045/br.2020.55.1.44
Altieri, M. S., Yang, J., Hajagos, J., Spaniolas, K., Park, J., Gasparis, A. P., Bates, A. T., Docimo, S., Talamini, M., Shroyer, A. L., & Pryor, A. D. (2018). Evaluation of VTE prophylaxis and the impact of alternate regimens on post-operative bleeding and thrombotic complications following bariatric procedures. Surgical endoscopy, 32(12), 4805–4812.
Bayat, B., Obney, J. R., Goudarzi, H., Hemmatizadeh, M., & Anbara, T. (2022). The influence of enoxaparin or rivaroxaban for venous thromboembolism in morbidly obese patients undergoing bariatric surgery. Medicina Clínica Práctica, 5(4), 100334.
Bouteloup, G., Ghedira, A., Chaouch, A, M., Faul, A., Ferretti, C., Usai, S., Farah, Z., Cesari1, C., Beaussier, M., Boutron, M., Ruaultand & Pourcher, G. Fondaparinux to Prevent Venous Thromboembolism after Bariatric Surgery: An Observational Clinical Trial. World J Surg Surgical Res; 5 (1377).
Chang, S. H., Freeman, N., Lee, J. A., Stoll, C., Calhoun, A. J., Eagon, J. C., & Colditz, G. A. (2018). Early major complications after bariatric surgery in the USA, 2003-2014: a systematic review and meta-analysis. Obesity reviews: an official journal of the International Association for the Study of Obesity, 19(4), 529–537.
Del Brutto, O. H., Rumbea, D. A., Mera, R. M., Recalde, B. Y., & Sedler, M. J. (2022). Social Determinants of Health (Social Risk) and Nutritional Status Among Community-Dwelling Older Adults Living in a Rural Setting: The Atahualpa Project. Journal of primary care & community health, 13, 21501319221087866.
El Ansari, W., Sathian, B., & El-Menyar, A. (2020). Venous thromboembolic events after bariatric surgery: Protocol for a systematic review and meta-analysis. International Journal of Surgery Protocols, 22, 10-14.
Ma, Y., Liu, Y., Zhi, Y., Wang, H., Yang, M., Niu, J., Zhao, L., & Wang, P. (2022). Risk factors of pulmonary embolism in the elderly patients: a retrospective study. Aging clinical and experimental research, 34(5), 1133–1137. https://doi.org/10.1007/s40520-021-02031-6
Rodríguez, J. I., Kobus, V., Téllez, I., & Pérez, G. (2020). Prophylaxis with rivaroxaban after laparoscopic sleeve gastrectomy could reduce the frequency of portomesenteric venous thrombosis. Annals of the Royal College of Surgeons of England, 102(9), 712–716.
Zhao, C., Wong, L., Zhu, Q., & Yang, H. (2018). Prevalence and correlates of chronic diseases in an elderly population: A community-based survey in Haikou. PloS one, 13(6), e0199006.
