Deep Vein Thrombosis (DVT) Prophylaxis After Orthopedic Surgery: A Case of Life-threatening Gastrointestinal (GI) Bleed

Abstract

DVT prophylaxis after orthopedic surgery is controversial; agents and doses vary by individual practitioners. We present a case of recurrent life-threatening GI bleeding after hip arthroplasty followed by a discussion of guidelines and evidence for DVT prophylaxis after orthopedic surgery. Case: An 88 year-old female with COPD, coronary artery disease, chronic kidney disease stage III and diverticulosis was admitted for hematemesis, melena and bright red blood per rectum (BRBPR). 10 days prior, she had undergone bipolar hemiarthroplasty for a left femoral neck fracture and discharged on aspirin 325mg BID for 4 weeks of post-operative DVT prophylaxis (previously on aspirin 81mg daily). On admission, she was hemodynamically stable with a hemoglobin (hgb) of 7.9 g/dL (normal 12-15.5 g/dL) compared to her baseline hgb of 13 g/dL. She received 2 units of RBCs and IV pantoprazole. Esophagogastroduodenoscopy (EGD) showed non-bleeding duodenal ulcers, the largest measured 17mm. Aspirin was stopped. She was discharged the following day on pantoprazole 40mg BID with hgb stable at 7.2 g/dL. 30 hours later, she was readmitted to the intensive care unit for BRBPR with hgb of 5.4 g/dL and respiratory distress. 5 units of RBCs were administered over the next 24 hours to maintain hgb >7 g/dL. EGD, colonoscopy and mesenteric angiography did not show active bleeding. 4 days later, she was discharged with no further bleeding and hgb stable at 11.6 g/dL with a presumptive diagnosis of occult small bowel bleed. Discussion: After orthopedic surgery, American College of Chest Physicians recommend low-molecular weight heparin, novel oral anticoagulants, heparin, vitamin K antagonists, aspirin or pneumatic compression devices depending on risk of bleeding for a minimum of 10-14 days and suggest extending for up to 35 days. Aspirin at varying doses (200mg to 3.5g a day) has been compared with anticoagulation and may be associated with higher risk of DVT, although overall bleeding rates are lower. Minimum effective dose of aspirin is unclear. Data on the risk of GI bleed specifically are lacking. Aspirin 81mg after GI bleed is favored for a more significant reduction in cardiovascular risk relative to re-bleed risk. The risk and benefit of higher aspirin doses are unclear. Therefore, lack of clear, evidenced-based guidelines on the type and dose of DVT prophylaxis and risk stratification of patients undergoing orthopedic surgery exposes some patients to life-threatening GI bleed.Figure 1