Abstract
BackgroundVenous thromboembolism is a common postoperative complication following orthopedic surgeries, with morbid and potentially fatal consequences. Perioperative low-molecular-weight heparin (LMWH) therapy can reduce the incidence of venous thromboembolism, but may also increase the risk of bleeding complications. Current literature reflects the need to balance the improved efficacy of early initiating prophylaxis with increased risk of perioperative bleeding. The purpose of this study was to compare the effectiveness and hemorrhage related safety of preoperative versus postoperative LMWH therapy for prevention of deep venous thrombosis (DVT) and pulmonary embolism (PE) in hip fracture patients.MethodsWe retrospectively evaluated 222 patients who underwent surgical treatment at Peking University People's Hospital between January 2009 and December 2010. Patients were allocated to two groups, receiving either preoperative or postoperative initiation of LMWH therapy for venous thromboembolism prophylaxis. Preoperative anticoagulation therapy was initiated 1–12 days prior to surgery (133 patients), and postoperative anticoagulation therapy was initiated 12 h after completion of surgery (89 patients). The preoperative group was further subdivided into four subgroups according to the time of initiation of therapy: 1–3 days before surgery (group A, 54 patients), 4–6 days before surgery (group B, 57 patients), 7–9 days before surgery (group C, 15 patients), and 10–12 days before surgery (group D, 7 patients). Occurrences of DVT, PE, adverse drug effects, intraoperative and postoperative bleeding were recorded, along with concentrations of preoperative and postoperative hemoglobin and length of hospital stay. The above parameters were compared between groups.ResultsAmong recipients of preoperative anticoagulation therapy, two patients developed postoperative PE (1.5 %), one patient developed DVT (0.75 %). In the group receiving postoperative initiation of anticoagulation therapy, one patient each developed PE and DVT (1.1 %, 1.1 %). There was no difference in the occurrence of PE and DVT between the two groups (P>0.05, Chi-square tests). We identified the incidences of major bleeding, minor bleeding, and intraspinal hematoma after spinal anesthesia, which were 0 %/0 %, 3.76 %/3.37 %, and 0 %/0 %, respectively in preoperative and postoperative anticoagulation groups. There was no significant difference in the incidence of bleeding complications between patients receiving preoperatively initiated LMWH with patients receiving postoperatively initiated LMWH. Spinal anesthesia was administered to 168 patients, with no cases of postoperative intraspinal hematoma.ConclusionsPreoperative anticoagulation therapy with LMWH may not increase intraoperative or postoperative blood loss, or the rate of intraspinal hematoma after spinal anesthesia, but also does not significantly reduce the risk of postoperative DVT or PE, compared to postoperative initiation.
Highlights
Venous thromboembolism is a common postoperative complication following orthopedic surgeries, with morbid and potentially fatal consequences
There was no difference in the occurrence of pulmonary embolism (PE) and deep venous thrombosis (DVT) between the two groups (P>0.05, Chi-square tests)
We identified the incidences of major bleeding, minor bleeding, and intraspinal hematoma after spinal anesthesia, which were 0 %/0 %, 3.76 %/3.37 %, and 0 %/0 %, respectively in preoperative and postoperative anticoagulation groups
Summary
Venous thromboembolism is a common postoperative complication following orthopedic surgeries, with morbid and potentially fatal consequences. Regardless of the drug used, benefits (prevention of VTE) and risks (bleeding and intraspinal hematoma) should be taken into account while deciding whether to administer anticoagulation therapy [13] Such decision making depends on many parameters such as type of drug, drug dosage, timing of drug administration, surgical procedure, medical history, condition of the patient etc. The timing of initiation of anticoagulation therapy varies widely across geographical region [5, 14] This retrospective study analyzed outcomes of perioperative anticoagulation therapy in 222 patients who underwent surgery for treatment of femoral neck or intertrochanteric fractures, between January 2009 and December 2010 at Peking University People’s hospital, to evaluate the effectiveness and safety of pre- and postoperative initiation of anticoagulation therapy for DVT prophylaxis. As the optimal regimen is uncertain because direct comparisons among different regimens with sufficient large sample sizes are not available, our study may provide a reference in choosing the appropriate methods to prevent the perioperative venous thromboembolism
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