The Relationship Between Surgical Procedures and Blood Clots

Wake-up time. If you're going to have surgery in the near or distant future, please read this post. As common, a little history first.  

Blood clot

Blood clots are a solemn reminder of just how fragile the human body is. Blood clots usually appear in your legs and are called deep vein thrombosis (DVT), the most common type of blood clot after surgery. They typically remain in the legs, but can break free and begin to move through the blood stream, like to the lungs or brain, known as an embolism. I had two blood clot experiences as a stroke survivor, and with both, the hospital kept me for a week each time. You might think that doctors and nurses are obsessed by blood clots, but this event is serious business. And the obsession is valid.

Blood clots can lead to a stroke, another name for an embolism that travels to the brain. Strokes can result in long-term disabilities including slurred speech, an inability to speak, one-sided weakness, and facial drooping, for example. 

Pulmonary embolism

A pulmonary embolism means one clot landed up in your lungs, causing possible pain and severe shortness of breath, resulting in death for 30%.   

Clots are often associated with surgery. The reason is, the person is lying still during the procedure and potentially for many hours post-surgery. (Blood clots, as mentioned in my blog, can also form when an person is motionless for long periods of time, such as during airplane ride a long car trip. http://stroketales.blogspot.com/search?updated-min=2013-07-01T00:00:00-04:00&updated-max=2013-08-01T00:00:00-04:00&max-results=2)

The type of surgery you are having can also increase the risk of having blood clots after the procedure. If your surgery requires your arteries, veins, or tendons to be cut or repaired, the risk of a blood clot is higher because your body works to stop bleeding by forming clots. 

The risk factors for blood clots both during and after surgery may include:

• History of Blood Clots: If you have had a blood clot in the past, your are more likely to have one in the future.  
• Genetics: If your family is prone to clots, you may be, too. 
• Atrial Fibrillation: Patients with an irregular heart beat have an increased risk of forming blood clots.
• Pregnancy: The chance of blood clots increase as the body makes blood clot faster in preparation for child birth.
• Cancer: Some types of cancer make blood clot more easily.
• Hormone Replacement Therapy (HRT): One known side effect of HRT is the increased risk of forming blood clots.
• Obesity
• Smoking
• Prolonged Immobility which include the time during anesthesia and recovering
• Heart Valve Issues people with replacement heart valves or heart valve problems have a higher risk of forming clots that can then travel to the lungs or brain.

After surgery, if you are able, get up and move during your recovery, one of the ways to prevent blood clots. Staying well hydrated by drinking ample amounts of water can also reduce your risk of forming clots, too.  


One treatment for blood clots post surgery is heparin, a medication that is given by injection or by IV to prevent the formation of clots, to reduce the clots that already formed, or to keep the blood clots from getting larger. Another is Coumadin, or the generic Warfarin, given to help the body remove a clot from the bloodstream.

In cases where there is a high risk of the clot moving to the lungs or brain, especially after surgery, a device called an inferior vena cava filter (or Greenfield Filter) may be placed, which acts like a tiny porous vessel, catching clots before they can damage the lungs or brain. A small incision in the groin or neck is how the filter is put into place in the inferior vena cava. But the blood clots can break off and go to your lungs or brain anyway. That is how I had a pulmonary embolism. The filter can catch all, but sometimes not everything.

So you really have to hope for the best because the cold truth is, you never know what's gonna bite you in the ass next.

Walmart--A Convenient Place to Shop, Unless You're a Shoplifter

As a stroke survivor, I always feel vulnerable. I can't escape  from danger because I can't run away--from a fire, a mugging, or even a bee attack, for instance. As a result, I evoke unsolicited drama wherever I go. So it's time to tell you the story of when we went to Walmart.

Walmart, especially the super-sized ones, is the place you go when you need a variety of things, a consolidation of the trips you would have taken to the grocery store, the hardware emporium, and the plant shop, for example.

A couple of days ago, I (in my wheelchair because sometimes the scooters are wet from I-don't-know-what but I can take a guess) and my friend went to Walmart wearing casual clothing--the two of us in jeans and hoodies (my hoodie comes into play later on)--to shop for a bag of romaine, light bulbs, and a plant not requiring much of anything, like water and sunlight. But every time I go there, I get what's on the list and a slew of more items. Every time. Good marketing, I imagine.

Anyway, I also picked up an avocado and a box of tomatoes that an AARP article nudged me to do, a sun hat (which I didn't at all need), flip-flops for the future even though I still have an AFO, an extra extra jar of Musselman's  applesauce, just-in-case, that I use for taking my pills, a can of Pledge, two dust cloths (that are related to the Pledge), and two plants in case one of them dropped dead on the ride home. I also picked up batteries for my MP3 player that I use for exercising. My friend picked up a plastic container of Hershey's syrup that her son loved for chocolate milk.

The ride through the store was a hard one, going down every aisle in case I missed something, especially the sale items which Walmart calls "rollbacks." After a while, I couldn't carry the things on my lap anymore, after dropping the Hershey's syrup and Pledge three times. So my friend put the dropped items in my hood and we went to the cashier to check out. I got the receipt and attempted to exit the store.

However, I was in a high-anxiety state when extraordinarily loud alarm bells and buzzers started going off simultaneously. Soon, two beefy security men appeared. My friend (soon to be not) forgot to take out the Hershey's syrup and Pledge from my hood unknowingly. Really. Unknowingly! Evidently, Walmart has cameras, or security people watching from above.

Could it just prove my theory: You never know what will bite you in the ass next? I closed my eyes, expecting the worse, thinking to myself in the wheelchair, "Where am I exactly going? Could I run away? NO way!" My friend was standing alongside me.

"You have something in your hood," one of the guards said to me. It wasn't the time for jokes, but actually I had two things in my hood.

"Oh? I didn't know," I replied with all the self-righteousness I could muster. And I didn't know. She and I forgot about the allegedly stolen items. Because that's what they were. Allegedly stolen. Good thing the guards stopped us inside the store. I don't want to even think about what could've happened if we were outside the store.

I offered to pay for them and the two guards were looking at us skeptically with we-don't-give-away-free-stuff-at-Walmart expressions. Not a word from the guards any more. Without looking back, we just turned around, went to a cashier, and paid--me for the Pledge and her for the Hershey's. 

We didn't say a word during the long drive home. I was proud of myself for not saying, "She did it. It was her fault." And she was probably saying to herself, "Why do I even work for this woman." 

I found this article the next day on the computer:

Fort Lee, FL--A security guard at a Fort Myers Walmart was caught on video tackling a suspected shoplifter and holding her down. That employee has since been fired for how he handled the situation.

That worker told investigators he tried to stop them and they took off running. That's when he tackled them.

If that's the way Walmart's security guards were trained, were we lucky in retrospect? Absolutely!

Falls and Stroke Survivors: 5 Studies in 5 Continents, and 5 of My Tips for Preventing Falls

I'm out of the hospital. The reason I was in there at all for two weeks is because of blood clots--in my leg (DVT) and lung (pulmonary embolism, PE as an acronym). 

No matter what you call it, I feel like a ticking time bomb, never knowing if the time will come where another clot ultimately goes to my brain, and it's lights out--permanently. The docs assured me that wouldn't happen, but who knows? It's just the docs' educated guesses, one after another. I have an educated guess, too. I may be fucked.

A stroke survivor

So to take my mind off death, for the moment, I started to research falls as related to stroke survivors. Between 40 to 70% of stroke survivors worldwide have serious falls within a year of their stroke. I had many falls, most my own fault out of chancy stupidity and a few not. Here's some of my favorite findings, from 5 of the 7 continents. South America has an excuse. (And is anybody even living in Antarctica?) All continents used international and certifiable scales as related to stroke survivors and the falls they encountered.



NORTH AMERICA
 
Focus: Improving walking and reducing falls post-stroke

Background: California researchers understood that better comprehension of falls was imperative, as broken bones, hips the most common, and head trauma might be the result. 

So ambulatory stroke survivors were enrolled in Locomotor Experience Applied Post Stroke (LEAPS) and were assessed 2 months post-stroke. Falls were assessed for 12 months post-stroke and participants were characterized as: multiple or injurious (M/I); single, non-injurious (S/NI); or non-fallers. 

Results: The results were alarming. Among the 408 participants, 36%  were M/I, 21% S/NI, and 43% non-fallers. A majority of falls occurred at home in the first 3 months. Although multiple fallers are not at higher risk for injury for any given fall, cumulative injury risk increases with each fall. Thus, falls prediction and management for individuals post-stroke should focus on multiple falls.

A primary goal of stroke rehabilitation is to improve individuals’ mobility in the presence of motor, balance, and visual-spatial deficits. Yet, increasing mobility and physical activity increases exposure to fall risks. A review of exercise in older people strongly implies that strength and balance exercises reduce falls, whereas walking training alone may increase them.

Participants were assigned to one of three groups:
* a locomotor training program (LTP) that included use of the treadmill followed by walking practice 2 months post-stroke
* a progressive strength and balance exercise program provided by a physical therapist in the home started 2 months post-stroke.  
* late LTP, 6-months post-stroke

Each program was provided for 36 sessions over 16 weeks and was monitored between 2 and 12 months post-stroke. The researchers defined a fall as, “A person has a fall if they end up on the ground or floor when they did not expect to. Most often a fall starts while a person is on their feet, but a fall could also start from a chair or bed. If a person ends up on the ground, either on their knees, their belly, their side, their bottom, or their back, they have had a fall."

Of individuals who fell, 74% had at least one fall from which they could not get up independently. Fall rate per person year was 1.76 overall, 1.33 for moderately impaired walkers, and 2.13 for severely impaired walkers. But here's the thing: Of the three groups, there was no difference in overall fall incidence between 2 and 12 months post-stroke. And between 2 and 6-months post-stroke, both groups receiving early intervention had a higher fall rate than individuals in the late-LTP group. Over-confidence, the researchers theorized.

AUSTRALIA
 

Focus: Falls in older adults with strokes

Background: This Australian study aimed at two things: probe the  differences in the incidence of falls between chronic stroke subjects and matched non-stroke subjects who were 65 years or older and community dwellers, and establishing factors associated with falling with chronic stroke survivors.

Results: More stroke survivors reported falling in the previous twelve months after the stroke than non-stroke subjects (36% vs 24%). When comparing stroke survivors who fell to stroke survivors without any falls, the first group were more likely to report to have difficulty in stooping or kneeling, getting up in the night to urinate more than once, and having a greater problem with activities that involved hygiene, that is, bathing or showering.

 

 

ASIA

 

Focus: Risk factors and management in stroke survivors who have fallen

 

Background: Israeli researchers found that falls are common events among hospital inpatients and constitute a major health problem in rehabilitation. Many risk factors for stroke falls such as muscle weakness, hypotension, and medication side effects have been identified.

Results: In a 5-year study of 56 falls in 41 stroke patients hospitalized for rehabilitation, 30 patients fell once, 9 patients twice and 2 patients four times, obtained from the medical and nursing records.
 

Most falls occurred among male patients who had reduced muscular tone (70%), paralysis (54%) and/or hemiparesis (one-sided body weakness). In addition, 48% percent of the falls occurring during the first month, 70% during the morning or the afternoon, and 62% occurred close to the patient's bed.
 

Also, 89% of stroke survivors' falls were attributed to medication side effects, 29% to communication disorders, 21% to blindness, and 18% visual sensory disorders.


EUROPE

Focus: Patient Falls in Stroke Rehabilitation

Background: Falling is a major complication in stroke rehabilitation. This study intends to investigate the incidence, characteristics, and consequences of falls in an in-patient stroke rehabilitation setting.

Precisely 161 patients were admitted to a geriatric stroke rehabilitation unit. Falls that occurred during their stay were registered and analyzed. The study was performed at the stroke rehabilitation unit of the geriatric clinic at Umeå University Hospital, Sweden. This unit is a 24-bed ward that specializes in stroke care and rehabilitation; patients are usually admitted from acute-care clinics 2 to 4 weeks after their strokes.

Results: 62 of the patients (39%) suffered falls. The total number of falls was 153, which corresponds to an incidence rate of 159 falls per 10,000 patient days. Most falls occurred during transfers or from sitting in a wheelchair or on some other kind of furniture. 17 falls (11%) were classified as the result of extrinsic mechanisms, 49 (32%) were intrinsic falls, 39 (25%) occurred in a sitting or lying position, and 48 falls (31%) remained unclassified. No injury was observed in 109 of 153 incidents (71%), whereas 6 falls (4%) involved fractures or other serious injury.
 
(Per the above: For falls with an extrinsic precipitating cause, the most significant risk factors were: age, diabetes mellitus, a history of falling, and treatment with neuroleptics or oral bronchodilators. For falls with an intrinsic precipitating cause, the independent risk factors were: age, diabetes, dementia, alterations of gait and balance, previous falls, and treatment with digitalins, neuroleptics or antidepressants).
 
AFRICA

Focus: Gait and balance performance of stroke survivors in South Western Nigeria

Background: Stroke survivors are often left with neurological and functional deficits, which impair their ability to walk and affect their balance. This study assessed gait parameters and balance performance among stroke survivors.

Results: Seventy stroke survivors (65% males) who were 6 months or more post stroke participated in this study. The gait of participants was assessed by gait speed and cadence (rhythmic flow). Balance performance was assessed using the Activities-specific Balance Confidence scale for balance self-efficacy and Functional Reach Test for standing balance.

Participants were 43 to 65 years in age. Forty five (64%) stroke survivors had hemorrhagic strokes while 25 (36%) had ischemic stroke. There were significant relationships between gait speed and balance self-efficacy and between cadence and functional reach distance.

The study concluded that stroke survivors with higher cadences had higher functional reach distances, and those with higher gait speeds had better balance.

About 35% of survivors with initial paralysis of the leg do not regain useful walking function, and 25% of all survivors are unable to walk without full physical assistance. They also demonstrate postural control problems such as loss of anticipatory activation during voluntary movements, increased sway during quiet standing, especially on the affected side, and decreased area of stability during weight shifting while standing.

Postural balance is closely related to gait ability. A strong relationship has been reported between gait velocity and dynamic balance in the acute rehabilitation period among patients with first time stroke. 

"We did not find significant differences in the gait speed and cadence between fallers and non-fallers, though the non-fallers had higher gait speed and cadence values. The reason for this result may be because all our participants could ambulate independently and therefore had similar gait speeds and balance performance," say the researchers.

Stroke survivors with higher cadences had higher functional reach distances, and those with higher gait speeds had better balance. This implies that gait speed and cadence are factors related to balance performance and should be considered during balance and gait retraining.

SOUTH AMERICA

There should have been 6 continents in my review about falls and stroke survivors, but The American Heart Association says the following about South America:

"Current knowledge of stroke risk factors and epidemiology is

based mostly on North American or European studies; so scarce data have been published from developing countries. Stroke will be a public health problem in South America during the next decades because of an increase in life expectancy and changes in the lifestyle of the population. Because epidemiological and clinical characteristics of stroke vary according to environmental, racial, and socio-cultural factors, we need to be aware of the peculiarities of stroke on 
this continent to reduce the impact burden of this epidemic."

Preventing Falls 

These are my new ways to go about preventing falls. I tried all of them and I haven't had any falls in a year since I began implementing these tips:

• Use nightlights in bedrooms, bathrooms and hallways. If the light bothers your eyes, wear a mask. I don't. I deal with it. But either way.
• Sit on a bench or stool with a handle in the shower and use a hand-held showerhead.
• Secure area rugs with double-sided tape.
• Review medications with your doctor as some may cause dizziness and balance problems.
• Slow down and take all the time you need when walking. There is no need to hurry, and it may be safer to go more slowly. By the way, since most of my falls were in the kitchen, bending over to pick up something that landed me on the floor, I bought a used wheelchair, got a new cushion, and always use it when I've dropped something on the floor. I sit, retrieve, and stand. So much easier!

Granted, all strokes suck, but falling compounds strokes, like broken hips or bleeding heads. Keep that in mind.