Administration Of Venous Thromboembolism Prophylaxis Research Articles

Implementation of a Venous Thromboembolism Prophylaxis Protocol Using the Caprini Risk Assessment Model in Patients Undergoing Mastectomy.

Guidelines for venous thromboembolism (VTE) prophylaxis are not well-established for breast surgery patients. An individualized VTE prophylaxis protocol using the Caprini score was adopted at our institution for patients undergoing mastectomy ± implant-based reconstruction. In this study, we report our experience during the first year of implementation. In August 2016, we adopted a VTE prophylaxis protocol for patients undergoing mastectomy ± implant-based reconstruction. We used the Caprini score, a validated risk assessment tool for VTE, to determine each patient's perioperative prophylaxis regimen. Detailed chart review was performed to record patient and treatment details, the Caprini score, pharmacologic VTE prophylaxis administration, and 30-day incidence of VTE and bleeding complications. We performed univariate analysis to identify factors associated with protocol compliance. Overall, 522 patients met the inclusion criteria. Median age was 51years, 486 (93.1%) patients had malignancy, 234 (44.8%) underwent bilateral mastectomy, and 350 (67.0%) underwent reconstruction. Caprini scores ranged from 2 to 11, with 431 (82.6%) patients having a score from 5 to 7. Overall protocol compliance was 60.5%, and was associated with bilateral mastectomy (p = 0.02), reconstruction (p = 0.03), and longer procedures (p < 0.001). The rate of VTE was 0.2% (95% confidence interval [CI] 0.03-1.1%), rate of reoperation for hematoma was 2.7% (95% CI 1.6-4.5%), and rate of blood transfusion was 0.4% (95% CI 0.1-1.4%). The implementation of an individualized VTE prophylaxis protocol for patients undergoing mastectomy ± implant-based reconstruction is safe and feasible. Despite a high-risk cohort, the incidence of VTE was very low and bleeding complications were consistent with reported rates for breast surgery. Continued evaluation of this strategy is warranted.

Improving Venous Thromboembolism Prophylaxis Administration in an Acute Surgical Unit.

Venous thromboembolism (VTE) prophylaxis regimes frequently have a wide variation in application. Nepean acute surgical unit was established in 2006 as a novel model for emergency surgical care. As part of the model's rollout, there were several areas of clinical management targeted for improvement, one being VTE prophylaxis compliance. It was decided all patients older than 18 years treated for a variety of acute surgical conditions within the acute surgical unit should be administered routine VTE prophylaxis with heparin and compression stockings. A novel multifaceted intervention was implemented at the time to achieve this goal. The primary aim of this study was to determine VTE prophylaxis administration rates before and after this intervention. A before-after study conducted as a retrospective review of medical records of all patients 18 years or older, having an appendicectomy in 3 periods: Before acute surgical unit (ASU) (November 2004 to October 2006), Early ASU (November 2006 to October 2008), and Established ASU (January 2012 to December 2013). Outcomes were mechanical and pharmacological VTE prophylaxis administration rates for each group. There were 1149 patients included in the study: Before ASU, 167; Early ASU, 375; and Established ASU, 607. There was a significant stepwise increase in parmacological VTE prophylaxis administration: Before ASU, 54.5%; Early ASU, 74.7%; and Established ASU, 96.9% (Before versus Early: odds ratio [OR], 2.46; 95% confidence interval [CI], 1.68-3.61; P < 0.001; Early versus Established: OR, 10.500; 95% CI, 6.29-17.53; P < 0.001). Mechanical VTE prophylaxis was significantly increased in the established group (Before versus Established: OR, 47.18; 95% CI, 25.61-86.91; P < 0.001). There was a significant increase in VTE prophylaxis administration after the implementation of our multifaceted intervention. Allocating a responsible provider dedicated to VTE prophylaxis prescription and compliance checking was a key component to this intervention.

Sepsis in emergency surgical patients: Is management optimal?

Sepsis in emergency surgical patients: Is management optimal?

Early pharmacological venous thromboembolism prophylaxis is safe after operative fixation of traumatic spine fractures.

Retrospective cohort study. To examine the impact of early (<48 hr) versus late (≥48 hr) initiation of pharmacological venous thromboembolism (VTE) prophylaxis on outcomes and complications among trauma patients undergoing operative fixation of spine fractures. VTE complications are associated with poor outcomes after trauma. Although pharmacological prophylaxis decreases the risk of VTE after trauma, concerns regarding bleeding-related complications among certain patient subgroups persist. At present, there are limited data regarding the safety of early VTE prophylaxis in trauma patients undergoing operative fixation of spine fractures. We performed a 5-year retrospective analysis of our level 1 trauma center registry to identify consecutive patients undergoing operative fixation of spine fractures. Demographics, injury patterns and severity, details of operative procedures, timing of administration of VTE prophylaxis, and outcomes were analyzed. Patients receiving early VTE prophylaxis were compared with patients receiving late VTE prophylaxis. Multivariate analysis was performed to identify independent predictors of VTE. Of 1432 patients with spine fractures, 206 patients (14.4%) underwent operative fixation. Forty-eight (23.3%) received early VTE prophylaxis and 158 (76.7%) received late VTE prophylaxis. No patient developed an epidural hematoma or postoperative bleeding necessitating intervention in either group. Thirteen patients (6.2%) developed VTE, of which 12 occurred in the late VTE prophylaxis group. Age 45 years or more (odds ratio = 5.12, 95% confidence interval = 1.01-25.94, P = 0.048) and traumatic brain injury (odds ratio = 6.94, 95% confidence interval = 1.19-40.35, P = 0.031) were independently associated with an increased risk for VTE. Pharmacological VTE prophylaxis initiated within 48 hours of operative fixation of traumatic spine fractures seems to be safe and is not associated with an increased risk of bleeding or neurological complications. Large, multicenter prospective studies are required to further define the efficacy and safety of an early pharmacological VTE prophylaxis strategy in this at-risk patient population. 3.

Thromboembolism incidence and prophylaxis during vaginal delivery hospitalizations

Although major international guidelines recommend venous thromboembolism (VTE) prophylaxis during vaginal delivery hospitalization for women with additional risk factors, US guidelines recommend prophylaxis for a very small number of women who are at particularly high risk for an event. The purpose of this study was to characterize practice patterns of VTE prophylaxis in the United States during vaginal delivery hospitalizations and to determine VTE incidence in this population. A population-level database was used to analyze VTE incidence and use of VTE prophylaxis during vaginal delivery hospitalizations in the United States between 2006 and 2012 (n = 2,673,986). We evaluated whether patients received either pharmacologic or mechanical prophylaxis. Hospital-level factors and patient characteristics were included in multivariable regression analysis that evaluated prophylaxis administration. We identified 2,673,986 women who underwent vaginal delivery. Incidence of VTE increased during the study period from 15.6-29.8 events per 100,000 delivery hospitalizations. Within the cohort, 2.6% of patients (n = 68,835) received VTE prophylaxis. Pharmacologic prophylaxis was rare; <1% of women received unfractionated or low-molecular-weight heparin. Although patients with thrombophilia or a previous VTE event were likely to receive prophylaxis (60.8% and 72.8%, respectively), patients with risk factors for VTE such as obesity, smoking, and heart disease were unlikely to receive prophylaxis (rates of 5.9%, 3.3%, and 6.2%, respectively). Our findings demonstrate that the administration of VTE prophylaxis outside a small group of women at extremely high risk for VTE is rare during vaginal delivery hospitalization. Given that VTE incidence is rising in this population, further research to determine whether broadening prophylaxis for VTE may reduce severe maternal morbidity and death is indicated.

Venous Thromboembolism Risk Assessment, Prophylaxis Practices and Interventions for its Improvement (AVAIL-ME Extension Project, Iran)

Venous thromboembolism (VTE) is a major health issue worldwide. Data about VTE prophylaxis practices in developing countries are scarce. The primary objectives of this survey were to define the VTE risk factors in hospitalized patients, to determine the rates of VTE prophylaxis administration and guideline compliance and to assess the effects of an educational program on VTE prophylaxis practices in Iran. Data on 1219 patients from twenty hospitals in Iran were extracted from the AVAIL-ME Extension project main databank. VTE risks were categorized according to the Caprini Risk Assessment Model. Logistic regression analysis was carried out to assess factors influencing VTE prophylaxis. We also examined the impact of an educational program which consisted of awareness, risk assessment, internal protocol implementation and re-assessment, on VTE prophylaxis practices. Of 1219 patients, 789 (65%) and 430 (35%) were surgical and medical, respectively. VTE risks, categorized in low, moderate, high and very high were detected in 14%, 17%, 26% and 43% of patients respectively with a total of 1042(85%) patients being at risk for VTE. Of 882 (85%) eligible patients for VTE prophylaxis, 737 (83.5%) received any drug prophylaxis of whom 265 (62%) were medical and 472 (60%) were surgical. ACCP guidelines compliance was 60% and 33% in surgical and medical patients respectively. Any VTE prevention, drug prophylaxis, mechanical prophylaxis and guideline adherence were, 48% vs. 64%, 45% vs. 60%, 6% vs. 9% and 34% vs. 45% respectively (p<00.1) before and after implementation of the VTE educational program. Despite an overall improvement in VTE prevention, areas such as inappropriate use of VTE prophylaxis in a large number of patients, significant under-use of mechanical devices and guideline adherence require closer attention. VTE awareness education is beneficial in improving VTE prophylaxis in Iran.

Physician and patient perceptions of the route of administration of venous thromboembolism prophylaxis: Results from an international survey

Introduction Acceptability of a prescribed treatment regimen is crucial to its clinical success, and the route of drug administration can play an important role in determining acceptability. This international survey explored physician and patient perceptions of injectable and oral treatments, and how these perceptions affect acceptability of treatments. Findings are discussed in the context of patient acceptance of treatments for venous thromboembolism (VTE) management. Methods Physicians who are regular prescribers of VTE prophylaxis and a randomly selected patient population were recruited to take part in a questionnaire. Patients had to answer 23 questions and physicians gave their predictions of patients’ responses. Results In total, 568 physicians and 825 patients from 5 countries took part in the survey. More patients considered injectable treatments effective than considered oral treatments effective (87% versus 76%, respectively). This trend was well predicted by the physicians (98% and 61%, respectively). Additionally, 46% of patients would accept an injectable treatment program lasting > 2 months (rising to 67% for life-threatening diseases), a figure underestimated by physicians (11% and 46%, respectively). Overall, 73% of patients stated they would never miss an injection, where as 54% of physicians expected patients to miss one injection in a month of therapy. Conclusions Physicians who are regular prescribers of VTE prophylaxis underestimate patients’ ability to accept injectable treatments as an alternative to oral therapy. This survey suggests that injectable treatments may be an acceptable, and often preferred, option over oral administration of therapeutic and preventive medicines.

Perioperative venous thromboembolism prophylaxis in Israel: a survey of academic surgical departments

Postoperative venous thromboembolism (VTE) represents a serious threat to patients undergoing surgical procedures. Without thromboprophylaxis, deep vein thrombosis occurs in up to 60% of patients undergoing major orthopedic surgery and 15% of patients undergoing major abdominal surgery. Although, many studies have shown the efficacy of pharmacologic and mechanical means of VTE prophylaxis, practice variations in this area abound worldwide. The purpose of this study was to determine the attitudes and practice of VTE prophylaxis of academic surgical department heads in Israel. A questionnaire covering various aspects of VTE prophylaxis was mailed to all surgical department heads of university teaching hospitals in Israel. Three months later, the same questionnaire was sent to department heads who had not yet replied. Data retrieved from the returned questionnaires were analyzed. A total of 250 departments in 23 hospitals affiliated to the four medical schools in Israel were identified; 130 department heads (52%) returned the questionnaires. The current study analyzes results obtained from the general surgical, orthopedic, urological, vascular and gynecological departments only. The total number of responses from these departments was 90 (69% response rate). Sixty-seven percent of the departments considered VTE to be a clinical problem. Ninety-four percent of departments have a policy for VTE prophylaxis. The most frequently used modalities for VTE prophylaxis (more than one option possible) were low-molecular-weight heparin (LMWH) (59%), unfractionated heparin (43%) and an intermittent pneumatic compression device (20%). VTE prophylaxis is begun 12 h preoperatively by 33% of departments, 2-4 h preoperatively by 20% of departments and with premedication by 8% of departments. VTE prophylaxis was continued during the postoperative period by all departments, with 52% stopping prophylaxis upon patient mobilization. Bleeding complications have been noted by 55% of departments, of these 9% were considered major. In general surgical, orthopedic and gynecologic departments, VTE prophylaxis was widely used for those procedures for which published guidelines exist, while considerable variation in VTE prophylaxis administration was demonstrated in a number of commonly encountered clinical situations for which there are no published recommendations. This study confirms that academic surgical departments in Israel conform to standard VTE prophylaxis guidelines. However, considerable variations in practice exist regarding the means of prophylaxis, onset of prophylaxis and its duration. These areas should be the focus of ongoing educational efforts including the development of uniform practice guidelines to improve the quality of care regarding VTE prophylaxis. Furthermore, attention should be given to methods for decreasing hemorrhage caused by LMWH and unfractionated heparin usage.