Chemical Venous Thromboembolism Prophylaxis Research Articles

Meta-analysis and suggested guidelines for prevention of venous thromboembolism (VTE) in foot and ankle surgery.

Purpose To perform a meta-analysis investigating venous thromboembolism (VTE) following isolated foot and ankle surgery and propose guidelines for VTE prevention in this group of patients.MethodsFollowing a PRISMA compliant search, 372 papers were identified and meta-analysis performed on 22 papers using the Critical Appraisal Skills Programme and Centre for Evidence-Based Medicine level of evidence.Results 43,381 patients were clinically assessed for VTE and the incidence with and without chemoprophylaxis was 0.6 % (95 % CI 0.4–0.8 %) and 1 % (95 % CI 0.2–1.7 %), respectively. 1666 Patients were assessed radiologically and the incidence of VTE with and without chemoprophylaxis was 12.5 % (95 % CI 6.8–18.2 %) and 10.5 % (95 % CI 5.0–15.9 %), respectively. There was no significant difference in the rates of VTE with or without chemoprophylaxis whether assessed clinically or by radiological criteria. The risk of VTE in those patients with Achilles tendon rupture was greater with a clinical incidence of 7 % (95 % CI 5.5–8.5 %) and radiological incidence of 35.3 % (95 % CI 26.4–44.3 %).ConclusionIsolated foot and ankle surgery has a lower incidence of clinically apparent VTE when compared to general lower limb procedures, and this rate is not significantly reduced using low molecular weight heparin. The incidence of VTE following Achilles tendon rupture is high whether treated surgically or conservatively. With the exception of those with Achilles tendon rupture, routine use of chemical VTE prophylaxis is not justified in those undergoing isolated foot and ankle surgery, but patient-specific risk factors for VTE should be used to assess patients individually.Level of evidenceII.

Abstract WP363: DVT Prophylaxis in Intracerebral Hemorrhage Patients in a Large Health System: a 5 Year Analysis

Background: The percentage of deep vein thrombosis (DVT) prophylaxis in intracerebral hemorrhage (ICH) patients remains low despite American Stroke Association guidelines. As part of a multi-hospital system wide quality initiative, we sought to determine the compliance of DVT prophylaxis in our population of ICH patients retrospectively and resulting rate of DVT/ pulmonary embolism (PE) to establish a baseline for comparison in future years to further standardization and quality of care. Methods: Data from 25 facilities in the Providence Health System Stroke Registry were analyzed from 2010 to 2014. Patients included were those who had a principal diagnosis of ICH and documentation was present for whether DVT or PE had occurred. Patients who were placed on comfort measures at any time during hospitalization were excluded. Descriptive analysis was conducted to assess use of chemical versus mechanical venous thromboembolism (VTE) prophylaxis and whether or not patients had a documented DVT or PE. Results: There were 1,581 ICH patients included in the analysis. Mean age at hospitalization was 67.0 (±15.5) and 55.4% were male. Of those that received VTE prophylaxis, 72 patients (4.4%) received chemical prophylaxis, including low-dose unfractionated heparin (LDUH), low-molecular-weight heparin (LMWH), factor Xa inhibitor or warfarin. Mechanical VTE prophylaxis including intermittent pneumatic compression (IPC), graduated compression stockings, or venous foot pumps were administered to 1,427 patients (87.6%). 127 patients (7.8%) had no documentation of VTE prophylaxis. Among those who received either chemical or mechanical VTE prophylaxis, 35 patients (2.5%) had documentation of a DVT or PE during the hospital encounter. Of those patients who had a DVT or PE, one patient received both LDUH and IPC. The remaining 34 patients who had a DVT or PE (97.1%) received only mechanical VTE prophylaxis. Conclusion: Pharmacologic DVT prophylaxis rates were very low. The rate of DVT/PE was in line with other published rates. Pharmocologic DVT prophylaxis was superior to mechanical means alone. A large study documenting the safety and efficacy of pharmacologic DVT prophylaxis in these patients is needed.

Incidence and risk factors for deep venous thrombosis and pulmonary embolus after liver transplantation

BackgroundOmitting chemical venous thromboembolism prophylaxis in liver transplant recipients may lead to an increase incidence of deep venous thrombosis (DVT) and/or pulmonary embolus (PE). MethodsA retrospective comparison of liver transplant recipients who developed postoperative DVT/PE to an age-matched population. ResultsForty-three of eight hundred sixty-seven patients developed a DVT/PE. Study group patients received higher amounts of cryoprecipitate and fresh frozen plasma. Study group international normalized ratio (INR) was significantly higher, as was the incidence of postoperative complications. High-grade complication rates (bleeding, respiratory failure, and renal insufficiency) were increased in the study group at 16% vs 0%. ConclusionsThe present study demonstrates that the rate of DVT/PE after liver transplantation is similar to the rate after other major operations. Patients were more likely to develop DVT/PE if they received increased amounts of intraoperative cryoprecipitate/fresh frozen plasma (FFP) or had an elevated postoperative INR. Furthermore, patients with a complicated postoperative course have the highest risk of venous thromboembolism.

Timely Anticoagulant Thromboprophylaxis is Safe and Effective in the Care of Patients Suffering Traumatic Brain Injury

Abstract Despite the high prevalence and associated morbidity of Venous Thromboembolism (VTE) development, thromboprophylaxis in the neurosurgical setting remains a source of contention due to concerns of iatrogenic haemorrhage progression associated with anticoagulant thromboprophylaxis. Opinions of ideal time to initiate chemical prophylaxis for VTE within the neurosurgical community vary between clinicians. It is nevertheless rarely disputed that timely and appropriate prophylaxis of VTE reduces morbidity. This review aims to determine the safety and efficacy of chemical VTE prophylaxis within the neurosurgical setting. The consequences of VTE can be devastating and patients with neurotrauma are amongst those at greatest risk. With this in mind, the neuroscience nurse must be meticulously conscientious for the prevention of VTE in the neurosurgical setting. The neurosurgical nurse has a close affiliation to the patient, is often the first to observe the clinical signs and symptoms associated with VTE, is responsible for implementing prevention strategies and assisting with treatment for those who unfortunately develop a Deep Vein Thrombosis or Pulmonary Embolism (PE).

Chemical venous thromboembolic prophylaxis is safe and effective for patients with traumatic brain injury when started 24 hours after the absence of hemorrhage progression on head CT

Venous thromboembolism (VTE) continues to be an important complication for patients with trauma, including patients with intracranial hemorrhage. We implemented a protocol starting chemical prophylaxis 24 hours after the absence of progression of hemorrhage on computed tomography (CT) to increase consistency with the use of chemical venous thromboembolic prophylaxis in this population. The objective of this study was to review the protocol of VTE prophylaxis for patients with traumatic brain injury at our institution to determine whether it has been effective and safe in preventing VTE without increasing intracranial hemorrhage. A retrospective case series was conducted to study 205 patients with intracranial hemorrhage admitted to a Level I trauma center during a 24-month period. These patients were reviewed with respect to type of intracranial injury, need for surgery, injury severity, time to initiation of chemical prophylaxis, and progression of injury on brain CT. Patients with a hospital length of stay less than 3 days or nonstable CT were excluded in the analysis of administration of chemical prophylaxis. Time to chemical prophylaxis in relation to absence of progression on brain CT was examined as well as the subsequent risk of progression of hemorrhage and risk of VTE events. The overall rate of venous thromboembolism was compared with that of matched historical controls. All patients received mechanical prophylaxis in the form of sequential compression devices. One hundred sixty-two intracranial hemorrhages were identified in 122 patients who met the study's inclusion criteria. Of this group of patients who did not have progression of hemorrhage on follow-up CT, 76.2% received chemical prophylaxis during their hospitalization.No patients had progression of intracranial hemorrhage after initiation of chemical VTE prophylaxis, and no patients developed VTE. This represents a decrease of VTE from previous years. No other complications related to chemical VTE prophylaxis were identified. A protocol based on an early use of chemical venous thromboembolic prophylaxis after the absence of progression of tramatic intracranial hemorrhage does not result in increased progression of intracranial hemorrhage and reduced the rate of venous thromboembolic events at our institution.

The Safety and Feasibility of Low-Molecular-Weight He-parin Prophylaxis in Major Abdominal Surgery Combined with Neuraxial Anesthesia

Background: Global guidelines for venous thromboembolism (VTE) prophylaxis of patients undergoing major surgery are well established. However, their applicability and safety in patients receiving neuraxial anesthesia is unproven. We sought to evaluate the safety and feasibility of chemical VTE prophylaxis in a prospective group of patients undergoing major foregut procedures under a combination of epidural and general anesthesia. Methods: A prospective database of all patients undergoing major foregut surgery from 2004-2009 was maintained and analyzed. Epidural catheters were placed pre-operatively and used for post-operative analgesia for three days in all patients. Factors evaluated included age, ethnicity, sex, length of stay, duration of epidural placement, complications of epidural placement and post-operative management, and VTE events. A uniform protocol was followed regarding the timing of low-molecular-weight heparin (LMWH) administration with epidural catheter insertion/removal. Results: A total of 237 patients formed the study group. The mean age was 57 years (range, 19 - 88) among 121 (51.1%) women and 65 years (range, 20 - 95) among 116 (48.9%) men. One hundred and sixty-six patients were Caucasian (70%), 37 Black (15.6%), 15 Hispanic (6.3%), 12 Asian/Pacific (5.1%), and 7 other (3%). All epidural catheters were removed on the third post-operative day. There were a total of five VTE (2.1%) events postoperatively. No peri-operative or post-operative epidural catheter associated complications occurred. Conclusions: Concomitant epidural catheterization and LMWH anticoagulation is safe and feasible in major abdominal surgery patients, including those undergoing major hepatic resection. Guidelines for VTE prophylaxis and LMWH administration in the setting of neuraxial anesthesia are well established and applicable to this unique patient population.

The Incidence of Venous Thromboembolism in Postoperative Plastic and Reconstructive Surgery Patients with Chronic Spinal Cord Injury

The purpose of this study was to investigate the incidence of postoperative venous thromboembolism in chronic spinal cord injury patients undergoing plastic and reconstructive surgery. Previous studies show a venous thromboembolism incidence of 9.3 percent; however, based on anecdotal evidence, the authors hypothesize that the incidence is actually much lower. As postoperative venous thromboembolism prophylaxis is becoming mandated by the Surgical Care Improvement Project, more data are necessary so that recommendations for chronic spinal cord injury patients can be given. A retrospective chart review was undertaken using electronic medical records from a Veterans Affairs hospital from 2004 through 2009 in which the perioperative course of the chronic spinal cord injury cohort was evaluated for the primary endpoint of venous thromboembolism evolution. The Pearson correlation was used for statistical analysis. Of the 415 operative cases evaluated, 155 cases were excluded secondary to operative time under 1 hour, use of mechanical or chemical venous thromboembolism prophylaxis, unknown operative time, or unknown prophylaxis use. Of the 260 cases evaluated without venous thromboembolism prophylaxis, there were no cases where venous thromboembolism developed within a 2-month postoperative time period. Postoperative venous thromboembolism is a common surgical complication with significant morbidity and mortality. This study demonstrates that in the chronic spinal cord injury patient cohort, the incidence of postoperative venous thromboembolism evolution is extremely low and that a benefit from perioperative mechanical or chemical prophylaxis is not evidence based. Further prospective studies are required to fully elucidate the true venous thromboembolism incidence in these patients and give recommendations on this issue. Therapeutic, IV.

Venous Thromboembolism in Coagulopathic Surgical Intensive Care Unit Patients: Is There a Benefit From Chemical Prophylaxis?

Coagulation abnormalities in critically ill surgical patients cause confusion in administration of venous thromboembolism (VTE) prophylaxis. Pharmaceutical VTE prophylaxis is often withheld because of presumed increased risk for bleeding and assumption that these patients would not benefit from it. Coagulopathic critically ill surgical patients are at risk for VTE and should be treated with chemical prophylaxis. A retrospective review was performed of all coagulopathic patients (international normalized ration >1.5 or platelets <100,000 per μL) admitted for at least 72 hours to the surgical intensive care units of a tertiary care center between January 2008 and January 2009. Patients were divided into two groups based on providing (group 1) or withholding (group 2) chemical prophylaxis. The incidence of VTE was then compared between the two groups. A total of 513 patients were included in the study: 241 patients in group 1 and 272 patients in group 2. The overall incidence of VTE was 16.4%. The incidence of VTE in the patients who received chemical prophylaxis was 17.0%, whereas the incidence in patients without chemical prophylaxis was 15.8% (p = 0.72). Coagulopathic critically ill surgical patients remain at significant risk for VTE. Unfortunately, chemical VTE prophylaxis does not seem to decrease this risk. Further research is warranted to investigate the nature of this increased risk of VTE and the reason chemical VTE prophylaxis has no benefit.

Venous thromboembolic prophylaxis for hip fractures

Patients with hip fractures are at very high risk for the development of venous thromboembolism (VTE). To provide an overview of cause, risk factors, current treatment strategies, and complications associated with VTE prophylaxis, we reviewed the most current, best available evidence on VTE prophylaxis for patients with hip fractures. We comprehensively reviewed the literature to assess the efficacy of VTE prophylaxis in patients with hip fractures, including the most recent published guidelines by national medical and surgical health organizations from the UK, USA, and Canada. Mechanical devices are effective in reducing the risk of VTE for hip fracture, but poor patient compliance is common and the devices are not recommended for sole VTE prophylaxis. Aspirin reduces the risk of VTE but does not provide optimal protection compared with other chemical agents; therefore, it is not recommended for sole VTE prophylaxis. Fondaparinux, warfarin, low-molecular-weight heparin, and unfractionated heparin reduce the risk of venographic deep vein thrombosis, but there is insufficient evidence that they reduce fatal pulmonary embolism or all-cause mortality. Fondaparinux is considered to be cost effective and more efficacious than low-molecular-weight heparin. At present, most major health organizations advocate at least 28days of postoperative chemical prophylaxis. Chemical VTE prophylaxis should be administered to all patients with hip fractures unless contraindicated. Additional research is required to establish an agent that has a significant impact on fatal pulmonary embolism and all-cause mortality, without increasing bleeding complications, in this group of patients.

Treatment of Glenohumeral Osteoarthritis

This clinical practice guideline is based on a systematic review of published studies on the treatment of glenohumeral osteoarthritis in the adult patient population. Of the 16 recommendations addressed, nine are inconclusive. Two were reached by consensus-that physicians use perioperative mechanical and/or chemical venous thromboembolism prophylaxis for shoulder arthroplasty patients and that total shoulder arthroplasty not be performed in patients with glenohumeral osteoarthritis who have an irreparable rotator cuff tear. Four options were graded as weak: the use of injectable viscosupplementation; total shoulder arthroplasty and hemiarthroplasty as treatment; avoiding shoulder arthroplasty by surgeons who perform fewer than two shoulder arthroplasties per year (to reduce the risk of immediate postoperative complications); and the use of keeled or pegged all-polyethylene cemented glenoid components. The single moderate-rated recommendation was for the use of total shoulder arthroplasty rather than hemiarthroplasty. Management of glenohumeral osteoarthritis remains controversial; the scientific evidence on this topic can be significantly improved.

Venous thromboembolism: a need for more public awareness and research into mechanisms.

Articles in this Series: Heit J. The epidemiology of venous thromboembolism in the community. Arterioscler Thromb Vasc Biol. 2008;28:370-372. Moll S. A clinical perspective of venous thromboemobolism. Arterioscler Thromb Vasc Biol. 2008;28:373-379. Gross P and Weitz J. New anticoagulants for treatment of venous thromboemobolism. Arterioscler Thromb Vasc Biol. 2008;28:380-386. Wakefield TW, Myers DD, Henke PK. Mechanisms of venous thrombosis and resolution. Arterioscler Thromb Vasc Biol. 2008;28:387-391. Link RP. National heart, lung, and blood institute programs for deep vein thrombosis. Arterioscler Thromb Vasc Biol. 2008;28:392-393. Beckman MG, Critchley SE, Hooper WC, Grant AM, Kulkarni R. CDC division of blood disorders: public health research activities in venous thromboembolism. Arterioscler Thromb Vasc Biol. 2008;28:394-395. Fenninger R. Patient advocacy to promote public awareness about thrombosis and thrombophilia. Arterioscler Thromb Vasc Biol. 2008;28:396-397. Hunt BJ. The awareness and politics of venous thromboembolism in the United Kingdom. Arterioscler Thromb Vasc Biol. 2008;28:398-399. In 2005, the US Senate declared March as deep vein thrombosis (DVT) awareness month in the United States to increase the American public’s understanding of deep vein thrombosis.1 This was triggered by the death of 39-yr-old David Bloom, a National Broadcasting Company (NBC) reporter who died on April 6, 2003 from a massive pulmonary embolism (PE), and the activities of his widow, Melanie Bloom.2 Two days before his death David Bloom had developed cramping leg pain that was not recognized as a DVT2—leg DVT was only found postmortem. He had several risk factors for DVT and PE (collectively called venous thromboembolism [VTE)]): (1) prolonged immobility (working and sleeping in a cramped position in a tank in the war in Iraq); (2) long distance flights between the US and Kuwait, (3) dehydration, and (4) postmortem the discovery that he was heterozygous for the prothrombotic variant of factor V called factor V …

Extended Travel after Hip Arthroplasty Surgery. Is it Safe?

Hip arthroplasty and extended travel are each recognized as risk factors for venous thromboembolism (VTE). The safety of travel after hip arthroplasty is currently unknown. Patients who had traveled more than 200 miles within 6 weeks of a hip arthroplasty or hip resurfacing were identified and contacted. All patients received VTE chemoprophylaxis with enoxaparin, dalteparin, fondaparinox, or warfarin. A total of 608 patients traveled an average of 1377 miles at an average of 6.5 days after surgery. Among these patients, 462 traveled by airplane, 143 by car, and 3 by train. There were no deaths, no symptomatic pulmonary embolisms, and only 5 (0.82%) symptomatic deep venous thromboses. Nine (1.5%) patients experienced bleeding complications. With chemical VTE prophylaxis, extended travel within 6 weeks of hip arthroplasty surgery is associated with a low rate of symptomatic deep venous thrombosis, with no known pulmonary embolisms and no deaths.