Deep venous thrombosis and pulmonary embolism following physical restraint

OBJECTIVE: We describe a case of deep venous thrombosis (DVT) and pulmonary embolism (PE) following the use of physical restraint in a patient with a diagnosis of acute delusional psychotic disorder. METHOD: A new case report of DVT and PE associated with prolonged physical restraint is presented. The literature on physical restraint, DVT, and PE was reviewed using a search of Medline and Psychinfo from 1966 to the present. RESULTS: Four other reported cases of DVT and PE were found in association with physically restrained patients. CONCLUSION: Risk of DVT and PE in association with immobilization during physical restraint may occur in spite of no pre-existing risk factors. Medical guidelines for the prevention of thrombosis following physical restraint are presented. Despite the absence of controlled trials of treatment effectiveness, the catastrophic outcome of DVT and PE warrants early and vigorous intervention in patients undergoing physical restraint.     

Flow-simulated thrombin generation profiles as a predictor of thrombotic risk among pre-menopausal women

A large number of individuals are at risk for deep venous thrombosis (DVT) due to alterations in multiple coagulation factors and inhibitors secondary to malignancy, drug interactions, or other general medical conditions. Traditional metrics of haemostasis such as prothrombin time, partial thromboplastin time, and bleeding time, generally estimate anticoagulation status and bleeding risk rather than thrombosis risk. The objective of this study was to correlate a novel, systems-based metric of clotting potential to risk of DVT from a database derived from the Leiden Thrombophilia Study (LETS). We utilised a computational model of blood coagulation, which addresses the interplay between biochemical factors, blood flow, and physiologic surface initiation of coagulation, to calculate an individualised, systems-based metric of clotting potential, termed the flow-simulated thrombin generation (FSTG), for 210 pre-menopausal women in LETS. Both DVT and oral contraceptive (OC) use were associated with higher values of FSTG. We demonstrated a nearly three-fold increased risk of DVT for each standard deviation increase above the mean in FSTG determined under venous flow conditions, which remained highly predictive after adjustment for age and OC status (adjusted odds ratio 2.66; 95% confidence interval 1.69-4.19; p<0.0001). In conclusion, a systems-based screening approach that integrates biochemical factors and flow haemodynamics identifies small subgroups of patients at risk of thrombosis that may benefit from oral anticoagulants.     

精神科住院病人10年猝死情况分析

目的了解精神科住院病人猝死特点，以便降低住院精神病人猝死发生率。方法回顾性调查住院期间猝死病人的病史，并进行均数及发生率统计分析。结果10年间猝死病人共有52例，猝死率为0．7％，男性和新入院者较多，秋冬季、4：00～8：00时间段为猝死高峰期，猝死者中96．15％伴有躯体疾病，服用氯氮平、氯丙嗪、奋乃静者在猝死病人中占较高比例，且合用药物者较多。结论精神科猝死病人中伴有躯体疾病者较多，对此类患者使用精神药物时应格外小心。     

Prevention of venous thromboembolism in internal medicine with unfractionated or low-molecular-weight heparins: a meta-analysis of randomised clinical trials

BACKGROUND: The prevention of venous thromboembolic disease is less studied in medical patients than in surgery. METHODS: We performed a meta-analysis of randomised trials studying prophylactic unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) in internal medicine, excluding acute myocardial infarction or ischaemic stroke. Deep-vein thrombosis (DVT) systematically detected at the end of the treatment period, clinical pulmonary embolism (PE), death and major bleeding were recorded. RESULTS: Seven trials comparing a prophylactic heparin treatment to a control (15,095 patients) were selected. A significant decrease in DVT and in clinical PE were observed with heparins as compared to control (risk reductions = 56% and 58% respectively, p <0.001 in both cases), without significant difference in the incidence of major bleedings or deaths. Nine trials comparing LMWH to UFH (4,669 patients) were also included. No significant effect was observed on either DVT, clinical PE or mortality. However LMWH reduced by 52% the risk of major haemorrhage (p = 0.049). CONCLUSIONS: This meta-analysis, based on the pooling of data available for several heparins, shows that heparins are beneficial in the prevention of venous thromboembolism in internal medicine.     

Assessment of risk of venous thromboembolism and its possible prevention in psychiatric patients

Aims:  The aim of the present study was to compile a specific algorithm of prevention of venous thromboembolism in hospitalized psychiatric patients because this specific issue has not been addressed sufficiently in the literature.
Methods:  The computer database MEDLINE was searched using key words (schizophrenia OR depression OR bipolar) AND (antipsychotic OR antidepressant) AND (venous thromboembolism OR pulmonary embolism) AND (prevention OR prophylaxis) in 2006.
Results:  Based on the literature regarding non-surgical and surgical patients with respect to specificities in mental disorders (obesity induced with psychotropic drugs, possible catatonia, physical restraint, potential dehydration, antipsychotic treatment), a scoring system and a synoptic algorithm of prevention of venous thromboembolism modified for hospitalized psychiatric patients, were suggested.
Conclusions:  According to the authors' knowledge this is the first attempt to establish such guidelines exclusively in psychiatry. Individual preventative clinical measures are suggested, ranging from regular physical exercise of lower extremities to repeated parenteral application of high doses of heparin tailored to every patient's risk for venous thromboembolism. Economic data support implementation of a proposed decision procedure into psychiatric clinical practice. Prospective discussion of its international applicability would be beneficial from both the clinical and the scientific points of view.     

Prophylactic use of heparin for deep vein thrombosis in restrained psychiatric patients: a chart review

ObjectivePhysical restraint sometimes causes deep vein thrombosis (DVT) and pulmonary embolism. Although unfractionated heparin (UFH) is used for the prophylaxis of DVT, its effectiveness remained unknown for restrained patients.MethodWe conducted a chart review of restrained inpatients at Sakuragaoka Memorial Hospital in Japan. Restrained patients received subcutaneous injection of UFH 5000 IU bid from December 2008 to September 2010 [heparin (+) period] while UFH was not used from December 2010 to September 2012 [heparin (−) period]. A Doppler ultrasound scanning was performed to examine the presence of DVT. The incidence of DVT was compared between the two periods by chi-square test. A multiple logistic regression model was used to examine effects of demographic and clinical characteristics on the incidence of DVT.ResultsNo significant difference was found in the incidence of DVT between the heparin (+) and (−) periods [11.8% (11/93) vs. 11.1% (13/117)]. Sedation [odds ratio (OR)=3.78], physical comorbidities (OR=6.29) and a longer duration of restraint (OR=1.22) were associated with the incidence of DVT.ConclusionThe use of UFH was not associated with any reduction in the incidence of DVT in restrained psychiatric patients.     

全髋关节置换后早期并发深静脉血栓的多因素Logistic回归分析

背景：随着对全髋关节置换后并发深静脉血栓的认识加深,减少和避免其发生已成为临床面临的重要课题。以往对影响深静脉血栓形成的相关因素报道虽多,但着眼点片面、样本量过少、统计学意义差、基础试验与临床研究的结果相混淆、研究方法及设计缺乏科学性,造成报道不一致,各抒己见。 目的：探讨全髋关节置换术早期并发深静脉血栓的原因及其相关因素,并提出预防与处理对策,从而降低发生率。 方法：回顾分析1 780例首次全髋关节置换术病例,选择性别、年龄、体质量、病种、合并症、患髋既往手术、麻醉、手术时间、假体固定方式、输血、术后患肢训练、防血栓药物、并发症指标进行统计,采用SPSS建立标准化数据库,行Logistic多因素回归分析。 结果与结论：1 780例全髋关节置换患者中有深静脉血栓136例。年龄、合并症、麻醉、假体固定方式、输血、患肢术后主被动训练、防血栓药物因素与深静脉血栓有相关性(P < 0.05)。高龄、高血压或糖尿病、全麻、骨水泥固定、输全血是全髋关节置换术早期并发深静脉血栓的危险因素,患肢术后主被动训练、防血栓药物应用是保护因素。认真做好围手术期处理,积极控制慢性合并症、术前做好评估、术中操作精细、术后积极预防治疗及护理可以降低深静脉血栓的发生。     

A clinical trial for developing PICU management scale, a tool reviewing the frequency and use of seclusion and restraint in psychiatric acute care]

OBJECTIVE AND METHODS: Medical management in psychiatric acute care involving seclusion and restraint is an intervention of which reasonable use is often required. Regarding such measures, guidelines for seclusion and restraint are important, and also, psychiatric treatment facilities should engage in a continuous quality improvement process that seeks to minimize the use of seclusion and restraint. To review and monitor the existing use of seclusion and restraint, the authors developed a tool, the "PICU management scale", and investigated its usefulness in two functionally different psychiatric wards, a psychiatric emergency care unit (emergency ward) and a psychiatric acute care unit (acute ward) in the Japanese payment system. The PICU management scale is a tool which classifies the status of psychiatric intensive care into six categories by four factors; "S: seclusion", "R: restraint", "N: forced nutrition" and "Ph: physical care", and we evaluated its usefulness by occurrence of variance. In terms of minimizing or optimizing the use of seclusion and restraint, we also analyzed characteristics and risk factors of 1) recurrent application of seclusion and restraint, 2) high PICU management ranking, and 3) prolongation. RESULTS: During the five months of investigation, medical management involving seclusion and restraint was applied in 98 cases at the emergency ward and 50 at the acute ward. The total number of management days was 894 and 950, respectively. The mean management duration per case was 9.1 and 19.0 days, respectively. The variance was 2.5 % and 4.5 %, respectively, and our tool covered most of the statuses and conditions observed in psychiatric emergency and acute care. Analysis of the variance suggested the existence of a trend which is considered to be typical of the status of medical management. Most cases that required recurrent application of seclusion and restraint were diagnosed as F0 or F2 in ICD -10, and hebephrenic cases with a high grade of disability, refractory-paranoid schizophrenic, or drug-resistant cases in F2 were remarkable in this category. In the high PICU management ranking, most cases were related to consciousness disturbance, and the mean duration of intervention was short. Reversal of the therapeutic stage was considered to be a risk factor of prolongation. CONCLUSION: The "PICU management scale" is considered to be a useful tool for minimizing the use of seclusion and restraint, in addition to the guidelines for the use of seclusion and restraint. Contributions to team strategy and consensus by the addition of objectivity or symbolizing are also expected. To verify these findings and make further progress, more clinical trials using this tool in various institutions are required.     

Soigner sans contention physique,quels enjeux psychiques ? De la contention à la contenance

AimsVia a brief history of mechanical restraint and its current use in psychiatry, we discuss its implications, its negative impact and the scope for and the consequences of non-restraint in clinical practice.MethodsWe conducted a literature review to analyze mechanical restraint use in Europe and also made use of clinical experience in a psychiatric hospital in Marseille, France.ResultsThe use of mechanical restraint is controversial and its therapeutic benefits remain unsubstantiated. Research suggests that the most efficient strategies to avoid physical restraint include a better working environment, better staff training, improved staff-to-patient ratio, and implementation of an open-door policy.DiscussionDespite a gradual reduction in the use of mechanical restraint in psychiatry in the 1960s, as reforms progressed in Europe and particularly in France, psychiatric departments today have to cope with new security issues. In this context, coercive physical measures and isolation strategies have increased. There are even “recommendations” about limiting the use of restraint, so as to avoid aggravating situations. This is a paradoxical situation, since it supports a practice whose deleterious effects are recognized.ConclusionsThe increasing use of physical restraint in the management of psychiatric patients is not attributable solely to security and legal considerations. The phenomenon can also be interpreted as an evolution of psychiatry from a practice based on a relationship and talking therapy to a more objective practice, where subjectivity and the spoken word seem to be ignored.     

Deep venous thrombosis and multiple regression analyses of the influence from various clinical factors on the fibrinogen half-life in surgical patients,using 125I-fibrinogen

The biological half-life (T_B) of ¹²⁵I-fibrinogen and detection of deep venous thrombosis (DVT) have been studied simultaneously in 153 patients after major surgery. Multiple regression analyses of the influence from various clinical factors on the shortened T_B indicated operation time as the most important factor. Malignancy not removed at operation, postoperative infections and DVT were also significant, but less important. The frequency of DVT was significantly increased in the postoperative patients receiving blood transfusions.It is concluded that the T_B of ¹²⁵I-fibrinogen is not useful in the diagnosis of DVT in the postoperative period, when other clinical factors with significant influence on the T_B are present. The possibility of using the T_B for early diagnosis of disseminated intravascular coagulation (DIC) is discussed.     

In vitro comparison of the effect of fondaparinux and enoxaparin on whole blood tissue factor-triggered thromboelastography profile

Fondaparinux and enoxaparin are both effective and safe in preventing post-operative venous thromboembolism. However, neither of them significantly influence the conventional clotting tests.We compared the influence of clinically relevant concentrations of fondaparinux and enoxaparin on normal whole blood (WB) thromboelastographic profiles after triggering TF-pathway with minimal amount of thromboplastin. Diluted thromboplastin was added to WB samples supplemented with buffer (control), fondaparinux (0.25; 0.5; 1 microg/ml), or enoxaparin (0.1; 0.5; 1 anti-Xa IU/ml). Four parameters were analyzed, R: clotting time, K: time required to reach an amplitude of 20 mm, alpha angle: measurement reflecting clot development kinetics and MA: maximal amplitude. At concentrations used in prophylaxis, both enoxaparin (0.1 anti-Xa IU/ml) and fondaparinux (0.25 microg/ml which correspond to 0.27 anti-Xa IU/ml) significantly prolonged the R and K times, but did not significantly modify the alpha angle as compared to the control. At concentrations observed after administration of curative doses for the treatment of DVT (> or = 0.5 anti-Xa IU/ml for enoxaparin and > or = 0.5 microg/ml for fondaparinux) both drugs induced a significant increase of R and K times, and a significant decrease of the alpha angle (p < 0.05). In contrast to fondaparinux, enoxaparin at concentrations equal to or higher than 0.5 anti-Xa IU/ml significantly reduced MA. The present study provides evidence that the whole blood TF-triggered TEG assay is sensitive to the presence of clinically relevant concentrations of enoxaparin or fondaparinux. Moreover, the angle may be used in order to distinguish the effect of prophylactic and therapeutic concentrations, since it was significantly reduced by the later ones. Further studies are needed to evaluate the clinical usefulness of whole blood TF-triggered TEG assay for the monitoring of treatment with enoxaparin or fondaparinux.     

Coercion within Danish psychiatry compared with 10 other European countries

Background: In 2008, the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) criticized the use of mechanical restraint in Denmark and referred to it as ill-treatment. What do other European countries do better? To answer this question, we compared the use of coercive measures regarding psychiatric inpatients in Denmark and comparable European countries. Aims: Comparing coercive measures from Denmark, Sweden, Norway, Finland, Iceland, Belgium, The Netherlands, United Kingdom, Ireland, France and Italy. Methods: Review of international literature and a cross-sectional study performed as a questionnaire survey. Results: Denmark used more mechanical restraint and holding than Finland and Norway; however Sweden used twice as much as Denmark. Finland used more seclusion than did the other countries. Norway was the country that used the smallest amount of physical coercion. Only Norway, Finland, Sweden and Denmark had comparable representative data on coercion. Conclusions: Norway used less physical restraint than Denmark. We could not find any obvious reasons for the differences in the use of physical restraint. Clinical implications: Comparing the factors surrounding coercion between countries may serve as a basis for minimizing coercion and carrying it out in the most acceptable manner for the patients, thereby providing better psychiatric treatment in Europe.     

Enjeux de la contention mécanique dans les services d’urgence

IntroductionIn France, a new law now requires very strict supervision of seclusion and mechanical restraint measures for patients submitted to compulsory, unconsented psychiatric care. Many professionals perceive this law, along with other recent laws and rules, as reflecting defiance towards psychiatry professionals, and, above all, as utterly inapplicable except at the cost of medical and administrative chaos. This law has put in place a strict (overly strict?) framework for the use of seclusion and mechanical restraint in unconsented psychiatric care. No such legal framework is in place, however, for psychiatric or non-psychiatric emergency units. Yet, psychiatric emergency teams look after patients in crisis, agitated and potentially dangerous for others or for themselves. For them, alternative, non-coercive measures are not always appropriate or effective. More coercive measures, may, with demonstrated clinical evidence, be required.Objectives and methodsThe work presented here reviews the medical, legal and ethical considerations which need to be taken into consideration in light of the lack of a framework defined by the law. This work is based on interviews with different experts, and it also considers legal data. It was conducted before the recent law was passed, a law that does not cover medical practice prior to hospitalization in any event.ResultsIt appears that the practice of physical restraint in emergency departments is sometimes necessary. A study of the latest decisions in French case law shows that emergency services must, in certain situations, take necessary measures for patients “such as restraint, chemical treatment or [intensive] surveillance”. If not, they run the risk of being found legally at fault. Case law also teaches us that physical restraint in emergency services must be carried out in accordance with non specific recommendations of good practice. This legal framework is not well-known to all practitioners working in emergency units. It ought to circulate more, thanks perhaps to the release of a scientific article that can synthetize this information. In addition, in the absence of specific good practice recommendations for the implementation of physical restraint in emergency services, more work is needed, on standardization, on protocols for the implementation of physical restraint, and on monitoring trackers. Finally, this works endorses monitoring the use of such coercive measures, in order to plot out its extent, to analyze its evolution over time and ultimately to reduce recourse to it. This work submits a proposal to that end.ConclusionIronically, in emergency departments there may ultimately be less forensic risk in physically containing than in not containing - provided that it is done with appropriate supervision. Of course in emergency departments even more than elsewhere such measures are temporary and do not always result in admission to compulsory psychiatric care. Such measures must be proportionate with the perceived risk or danger. In our opinion, the present legal void, which permits all the flexibility that emergency care requires, must not be followed by the legal inflexibility currently applicable to coerced hospitalization. But it is necessary that every medical decision be justifiable, solidly argued and traced.     

Venous macrothromboembolism in an unselected autopsy material and its relation to antiplasmin activity in the vessel wall

Deep venous thrombosis (DVT) and pulmonary embolism (PE) were studied in an unselected prospective series of 75 autopsies. DVT occurred in 76 % and macroscopic PE in 59 % 'of patients who had been confined to bed for longer than 24 h immediately before death. DVT was most common in the posterior tibial veins, the soleal and gastrocnemius veins and in the great saphenous vein. In 6 % of the bed ridden patients PE alone caused the death, in 12 % it was a contributory cause of death and in 41 % it did not seem to have contributed to death.

Patients with thromboembolism showed higher plasmin inhibition activity in the wall of their great saphenous veins than patients without thromboembolism.     

精神科住院患者17例猝死死因分析

目的研究精神科住院患者猝死的可能原因,为猝死的预防提供依据。方法检索2014年1月至2019年4月在广州医科大学附属脑科医院精神科病房住院的29702例患者病历资料,对符合猝死标准的病例进行回顾性研究,分析其一般人口学资料、临床资料和辅助检查结果。结果29702例精神科住院患者中17例猝死,猝死率为0.57‰,死亡的主要原因为心源性猝死(6例)和异物吸入性窒息(3例)。结论应对精神科住院患者的心脏功能和吞咽功能进行定期监测,动态评估猝死风险。     

Thrombosis associated with physical restraints

OBJECTIVE: Physical restraint is controversial, but still frequently used in psychiatric units. We describe two cases of thromboembolic phenomena, one with a fatal outcome, in association with physical restraint. METHOD: The world literature on physical restraint and thrombosis was reviewed by undertaking a search of electronic databases. RESULTS: To our knowledge, we are the first to report thrombosis associated with physical restraint. CONCLUSION: Immobilization and trauma to the legs while restraining a patient are adequate explanations for the occurrence of thrombosis. Special attention should be paid to thrombosis when employing restraints in psychiatric wards. Further systematic research into physical restraints in psychiatry is clearly needed.     

Dying in the psychiatric ward

General hospital staff is experienced in dealing with the death of a patient. However, aside from cases of sudden death among psychiatric inpatients, psychiatric medical staff faces such situations considerably less frequently. Many chronic psychiatric patients do not have a family or home, a situation which may become even more painful if the patient is dying of a physical illness. Coping with a terminally-ill oncology patient is a difficult task for the multidisciplinary staff and for fellow patients in chronic care psychiatric departments. The authors describe the slow deterioration of two psychiatric inpatients who were also diagnosed with advanced cancer, and present the dilemmas involved with continued treatment of terminal oncology patients in a psychiatric ward when the psychiatric status no longer warranted inpatient psychiatric care.     

创伤性深静脉血栓模型大鼠组织蛋白酶B，C基因对血管内皮细胞的作用☆

背景：骨科手术后易出现深静脉血栓形成，但目前临床上对此尚缺乏有效预测诊断手段，组织蛋白酶可能是血栓形成的有效生物标记物。 目的：观察大鼠深静脉血栓形成前后组织蛋白酶B和组织蛋白酶 C在血细胞中的表达变化情况，探讨二者作为深静脉血栓形成早期诊断候选分子标志物的可行性。 方法：将100只SD大鼠随机分为正常对照组和模型组，模型组采用血管钳夹股静脉+双后肢固定制动的方式建立大鼠创伤性深静脉血栓模型，根据观察时间点和血栓形成情 况分为血栓形成前组、血栓形成高峰期组和血栓不形成组，提取各组血液RNA并反转录为cDNA，应用实时荧光定量PCR检测组织蛋白酶 B和组织蛋白酶 C在血细胞中的表达变化情况。 结果与结论：血栓形成高峰期组大鼠血细胞中组织蛋白酶B，C 表达明显，血栓形成前组和血栓不形成组大鼠血细胞中组织蛋白酶B，C表达于正常对照组大鼠为无明显差异。提示组织蛋白酶B和组织蛋白酶C与深静脉血栓形成密切相关，可作为深静脉血栓形成早期诊断的候选分子标志物。