Continuing medical education article—patient safety: The need for venous thromboembolism (VTE) prophylaxis in plastic surgery

Abstract

The reader is presumed to have a broad understanding of plastic surgical procedures and concepts. After studying this article, the participant should be able to: Physicians may earn 1 AMA PRA Category 1 credit credit by successfully completing the examination based on material covered in this article. The examination begins on page 176. ASAPS members can also complete this CME examination online by logging onto the ASAPS Members-Only Web site (http://www.surgery.org/members) and clicking on "Clinical Education" in the menu bar. Little has been published about venous thromboembolism (VTE) complications in plastic surgery. The authors investigated the recent literature, particularly literature reviews and meta-analyses of clinical studies, in order to outline strategies for prevention of deep vein thrombosis (DVT) and pulmonary embolism (PE) applicable to plastic surgery patients. Major risk factors for VTE include trauma, a prior history of VTE, older age, use of oral contraceptives or hormone replacement therapy, and prolonged travel. Although the frequency of VTE among plastic surgery patients is estimated to be from less than 1% to 2% of cases, in fact many of our patients are at moderate to high risk of VTE. Moreover, the actual frequency of VTE among plastic surgery patients is probably higher than we know, because up to two thirds of cases are asymptomatic. Mechanical methods of VTE prophylaxis include graduated compression stockings (GCSs), intermittent pneumatic compression (IPC) devices, and venous foot pumps (VFPs). They are recommended primarily for patients with a high risk of bleeding or as an adjunct to chemoprophylaxis. Intermittent pneumatic compression devices were found to be more effective than passive compression using GCSs. For plastic surgery patients, IPC devices or VFPs are recommended for any procedure that lasts more than 1 hour, and for all patients receiving general anesthesia. Use should begin 30 to 60 minutes before surgery. Low-molecular-weight heparin (LMWH) is the most widely used form of DVT/PE prophylaxis. Other forms of chemoprophylaxis are coming onto the market or under development. In particular, fondaparinux, an indirect FXa inhibitor, was approved in 2004 for VTE prophylaxis in orthopedic surgery. Studies have indicated that it is significantly more effective than LMWH after joint replacement, hip fracture surgery, and in cancer patients. Other drugs in development include idraparinux, another indirect FXa inhibitor, direct FXa inhibitors, and several direct thrombin inhibitors. Plastic surgeons have generally been reluctant to use antithrombotic agents because of the increased risk of bruising or hematoma and the possible need for blood transfusion. However, numerous studies have found little or no increase in the frequency of clinically important bleeding associated with their use. Some plastic surgeons now routinely use chemoprophylaxis in patients undergoing abdominoplasty, combined procedures, or procedures lasting more than 4 hours. The authors also recommend postoperative chemoprophylaxis in circumferential body contouring, thighplasty, surgery requiring open space dissection, transverse rectus abdominus muscle (TRAM) procedures, and surgical procedures likely to contribute to venous stasis or compression. It is impractical and expensive to screen every patient for asymptomatic DVT. A patient history focusing specifically on VTE risk factors should be performed within a few weeks of surgery. Patient education should include information about the symptoms of DVT and PE (including the fact that most patients with VTE are asymptomatic) and a full explanation of the risks and benefits of anticoagulant prophylaxis.