Reducing thromboembolic risk
Diagnose catatonia early. Treating symptoms of catatonia early with benzodiazepines (and, in refractory cases, with electroconvulsive therapy) prevents immobility, thereby decreasing the risk of thromboembolic events.3,11 It may be useful to minimize antipsychotic use.
Monitor activity levels. Fatal thromboembolic events may appear early in the course of catatonia before risk factors associated with thromboembolic events are evident.4 However, these events may be more common when the patient resumes movement.3 Monitor patients’ activity status and encourage ambulation throughout treatment.
Monitor vital signs for signs of pulmonary embolism, including hypoxia, tachycardia, tachypnea, and fever. Take serial pulse oximetry and, if indicated, arterial blood gas measurements to monitor hemoglobin oxygen saturation. Be vigilant for other signs and symptoms of pulmonary embolism and DVT (Table).
Consider prophylactic treatment. Some studies recommend prophylaxis against thromboembolic events in catatonic patients.3-6,10,15 These measures include:
- intravenous fluids
- nasogastric tube feeding
- physical examinations to assess for signs of DVT
- support stockings
- sequential/pneumatic compression devices
- physical therapy or range-of-motion exercises
- complete anticoagulation during immobility, although there are no data that support using anticoagulation medications in catatonic patients who have not yet experienced a thromboembolic event.
Consider prophylactic antithrombotic treatment in catatonic patients and other immobile inpatients who have risk factors for thromboembolic events.9,16 Although it has not been rigorously tested, the Algorithm suggested by Malý et al15 can serve as a guideline for determining the need for prophylaxis against venous thromboembolism in psychiatric inpatient settings.
Table
Signs and symptoms of deep vein thrombosis and pulmonary embolism
| Deep vein thrombosis |
| Swelling of the leg or along a vein in the leg |
| Pain or tenderness in the leg, which may be felt only when standing or walking |
| Increased warmth in the area of the leg that is swollen or in pain |
| Red or discolored skin on the leg |
| Pulmonary embolism |
| Unexplained shortness of breath or pain with deep breathing |
| Chest pain |
| Coughing or coughing up blood |
| Arrhythmia |
| Source: National Heart, Lung, and Blood Institute. What are the signs and symptoms of deep vein thrombosis? Available at: www.nhlbi.nih.gov/health/dci/Diseases/Dvt/DVT_ SignsAndSymptoms.html. Accessed November 8, 2010 |
Algorithm
Does my patient need venous thromboembolism prophylaxis?
| Step 1. Assess risk factors for venous thromboembolism and determine risk level score | |
|---|---|
| Risk factor | Score |
| Consensus-based | |
| Immobilization | 1 |
| Hormone therapy | 1 |
| Obesity (BMI ≥30 kg/m2) | 1 |
| Age 60 to 74 | 1 |
| Varicose veins/venous insufficiency | 1 |
| Dehydration | 1 |
| Thrombophilia | 1 |
| Expert opinion | |
| Treatment with antipsychotics | 1 |
| Evidence-based | |
| History of deep vein thrombosis or pulmonary embolism | 2 |
| Cancer (active/treated) | 2 |
| Age ≥75 | 2 |
| Acute infection/respiratory disease | 2 |
| TOTAL | |
| BMI: body mass index | |
| Step 2. Determine recommended prophylaxis based on risk level score | |
| Risk level score | Recommended prophylaxis |
| All risk levels | Regular physical exercise of lower extremities, sufficient hydration, graduated compression stockings |
| Medium risk (4 to 7 points) and/or physical restraint ≥8 hours | Heparin, 5,000 units every 12 hours, or low molecular weight heparin equivalent until patient is fully mobilized |
| High risk (≥8 points) | Heparin, 5,000 units every 8 hours, or low molecular weight heparin equivalent until patient is fully mobilized |
| Source: Adapted from reference 15 | |
OUTCOME: Stable and speaking
In the hospital, Mr. M remains immobile and mute for several days. The hospital’s psychiatric consult team recommends lorazepam, 3 mg/d, to address his catatonia. Mr. M improves and begins speaking and eating after starting lorazepam, but becomes agitated, banging his head against walls and threatening to jump out the window. Because this puts him at risk for trauma, Mr. M is not a good candidate for warfarin therapy, and an inferior vena cava filter is placed on an emergency basis. Later, a Dobhoff tube is placed for feeding and administering oral medications.
Mr. M’s catatonic state gradually improves and he begins to respond to the staff with short phrases, eats all of his food, and accepts oral medications. He is transferred back to our inpatient psychiatric facility with haloperidol, 10 mg/d, lorazepam, 3 mg/d, and benztro-pine, 2 mg/d, in addition to sulfacetamide eye drops for bilateral conjunctivitis. At our facility, we start him on warfarin, 5 mg/d, and closely monitor his international normalized ratio levels, with a plan to remove the inferior vena cava filter after 6 months of anticoagulation therapy. Mr. M remains at our facility for 3 weeks to stabilize his medications and is discharged to his apartment.
Six months after being discharged from our facility, Mr. M is stable at an intensive outpatient mental health program.
Related Resources
- Fink M, Taylor MA. Catatonia: a clinician’s guide to diagnosis and treatment. Cambridge, United Kingdom: Cambridge University Press; 2003.
- Snow V, Qaseem A, Barry P, et al, and American College of Physicians; American Academy of Family Physicians Panel on Deep Venous Thrombosis/Pulmonary Embolism. Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2007;146(3):204-210.