DVT Prophylaxis Research Articles

Disulfide HMGB1 derived from platelets coordinates venous thrombosis in mice

AbstractDeep venous thrombosis (DVT) is one of the most common cardiovascular diseases, but its pathophysiology remains incompletely understood. Although sterile inflammation has recently been shown to boost coagulation during DVT, the underlying molecular mechanisms are not fully resolved, which could potentially identify new anti-inflammatory approaches to prophylaxis and therapy of DVT. Using a mouse model of venous thrombosis induced by flow reduction in the vena cava inferior, we identified blood-derived high-mobility group box 1 protein (HMGB1), a prototypical mediator of sterile inflammation, to be a master regulator of the prothrombotic cascade involving platelets and myeloid leukocytes fostering occlusive DVT formation. Transfer of platelets into Hmgb1−/− chimeras showed that this cell type is the major source of HMGB1, exposing reduced HMGB1 on their surface upon activation thereby enhancing the recruitment of monocytes. Activated leukocytes in turn support oxidation of HMGB1 unleashing its prothrombotic activity and promoting platelet aggregation. This potentiates the amount of HMGB1 and further nurtures the accumulation and activation of monocytes through receptor for advanced glycation end products (RAGE) and Toll-like receptor 2, leading to local delivery of monocyte-derived tissue factor and cytokines. Moreover, disulfide HMGB1 facilitates formation of prothrombotic neutrophil extracellular traps (NETs) mediated by RAGE, exposing additional HMGB1 on their extracellular DNA strands. Eventually, a vicious circle of coagulation and inflammation is set in motion leading to obstructive DVT formation. Therefore, platelet-derived disulfide HMGB1 is a central mediator of the sterile inflammatory process in venous thrombosis and could be an attractive target for an anti-inflammatory approach for DVT prophylaxis.

Design and α-testing of an electronic rounding tool (CERTAINp) to improve process of care in pediatric intensive care unit.

Increasing process complexity in the pediatric intensive care unit (PICU) can lead to information overload resulting in missing pertinent information and potential errors during morning rounds. An efficient model using a novel electronic rounding tool was designed as part of a broader critical care decision support system-checklist for early recognition and treatment of acute illness and injury in pediatrics (CERTAINp). We aimed to evaluate its impact on improving the process of care during rounding. Prospective pre- and post-interventional data included: team performance baseline assessment, patient safety discussion, guideline adherence, rounding time, and a survey of Residents' and Nurses' perception using a Likert scale. Attending physicians were blinded to the components of the assessment. A total of 113 pre-intervention and 114 post-intervention roundings were recorded by direct observation. Pre-intervention (108) and post-intervention staff surveys (80) were obtained. Adherence to standard of care guidelines improved to >97% in all data points, with maximum increase seen in discussions of ulcer prophylaxis, bowel protocol, DVT prophylaxis, skin care, glucose control and head of bed elevation (2-28% pre-vs. 100% for all post-intervention, p<0.01). Significant improvement was noticed in spontaneous breathing trials, sedation breaks and need for devices (45-57% pre- vs. 100% for all post-intervention, p<0.01). Rounding time (mean±SD) increased by 2min/patient (8.0±5.8min pre-intervention vs. 9.9±5.7min post-intervention, p=0.002). Staff reported improved perception of all aspects of rounding. Utilization of the CERTAINp rounding tool led to perfect compliance to the discussion of best practice guidelines; had minimal impact on rounding time and improved PICU staff satisfaction.

Impact of VAP bundle adherence among ventilated critically ill patients and its effectiveness in adult ICU

Ventilator-associated pneumonia (VAP) is the most prevalent infection in intensive care units (ICU). To reduce this rate, the application of bundles – groups of individual practices and adherence to the best nursing practices from Association for Professionals in Infection Control and Epidemiology (APIC) guidelines (2009) is recommended. This study aimedThis study aimed to estimate the microbiology including; rate of VAP, mortality rate attributed to VAP, among (ICU) critically ill patients and evaluate the effectiveness of adherence to VAP bundle on elimination of infection, also cost effectiveness as reflection to length of stay in ICU. Subject and methodsA comparative interventional design was used to achieve the aim of the study. It is conducted in 14 bedded Adult Medical-surgical ICU.VAP Bundle Program was implemented by our multidisciplinary team (pulmonologist, microbiologist, intensivist and ICU nurses). The VAP bundle team starting the program implementation in January 2014 till the end of December 2015 (follow up prospective study), all those patients underwent daily 5 items 1- bed elevation, 2- DVT prophylaxis, 3- peptic ulcer prophylaxis, 4- oral hygiene and 5- sedation break and weaning assessment. Surveillance reports from ICU for the year 2013 were reviewed (retrospective study). Data were collected and analyzed for (VAP) and compared before and after VAP bundle intervention. ResultsAll ventilated patients who met the inclusion criteria were grouped in two groups, group A (130) patients non bundle used and group B (250) patient vap bundle used, then sub grouped to VAP and non VAP for statistical analysis, mean age in vap patients was higher in both groups, VAP incidence in group A 18.5% that decreased significantly to half of 9% in group B, p value <0.05, also VAP rate/1000 ventilated day showed a statistically significant difference between group A 25/1000day in 2013 to VAP rate in 2014 year, 8.5/1000 ventilator days, also to VAP rate 6/1000 ventilator days in 2015, p value <0.007. Strong significant negative correlation between compliance of VAP bundle and VAP rate was found, p<0.0001, VAP bundle compliance ranged from 94% to 100%. Male and medical patients were higher in both groups more than 62%, outcome improved after bundle as the death rate decreased in group B in both subgroups than that in group A, and length of stay in ICU was lowered significantly in group B about 2days subsequently lowering the cost. ConclusionThe application of VAP bundle is a feasible reality that produces improvement in microbiological measures and nosocomal infection rates resulting in lowering mortality, shortened lengths of hospitalization and decreased medical care costs. However, education and periodic training remain a fundamental process of improving health services. VAPs were reduced by improving bundle compliance and ensuring the same standard of care to all ICU patients. Direct, on-site observation was a more accurate method of monitoring.

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

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

An International Consensus on the Appropriate Treatment for Adults with Spinal Deformity: An AOSpine Knowledge Forum Deformity Study

Introduction Appropriate care for adults with spinal deformity should be responsive to considerations of the patient, care provider, and healthcare system. The healthcare burden of adult spinal deformity is increasing significantly and re-operation rates are high (up to 50%). The objective of this study was to identify goals of care and management strategies that are appropriate, reasonable, and inappropriate to guide decision-making and patients’ informed choice. Material and Methods The AOSpine Knowledge Forum Deformity performed a modified Delphi survey of 53 experienced spine deformity surgeons (panelists) from 24 countries. Panelists rated appropriateness of procedures and management strategies for multiple clinical scenarios. Strategies were rated on a 9-point rating scale, collapsed into three categories: ‘inappropriate’ - expected negative consequences exceed the expected health benefit; ‘reasonable’ -balance of risk and benefit is unknown, but there is a reasonable chance of positive benefit; and ‘appropriate’ -expected health benefit exceeds the expected negative consequences by a wide margin. There were three anonymous web-based surveys and one physical meeting. Consensus was defined as ≥70% agreement. Results Panelists ranked the most important goals of surgery as; improvement of function, pain, and neural symptoms. Regarding preoperative evaluation, there was consensus that: it is appropriate to record severity and duration of symptoms, previous spinal surgeries, comorbidities (94%), and smoking status (87%) as part of the history; and perform a physical examination including, neurologic examination (96%), vascular status (77%), and hip ROM (92%). Pulmonary and cardiovascular tests are appropriate for patients at risk. It is appropriate to obtain full spine standing radiographs (89%) and MRI for all indications, and BMD (DEXA) for patients with risk factors for osteoporosis (≥89%). Intraoperatively: it is inappropriate to perform a decompression alone where there is a progressive (72%) or large curve (70%) or sagittal imbalance (75%). When long fusion is performed, it is appropriate to instrument to the ilium in large curves, osteoporotic bone, and sagittal imbalance; and inappropriate to fuse to L5 in case of L5-S1 disc degeneration (88%). It is inappropriate to augment the UIV (81%) or UIV+1 (79%) with cement if there is no osteoporosis. Long fusion is appropriate when there is sagittal imbalance (85%) or large curves (87%), when performed; L5-S1 interbody support is appropriate (90%). There was no consensus whether a unilateral decompression alone should be performed in a stable sagittally balanced 30° curve. Grafting with local bone is appropriate, as is neuromonitoring with MEP and SSEP. Postoperatively: mechanical DVT prophylaxis is appropriate for all patients and chemical prophylaxis for high-risk. Return to sedentary work is appropriate within 3 months where &lt; 5 segments are fused. Conclusion Management of adult spinal deformity is characterized by significant variability. We have been able to identify several pre-, intra- and post-operative management strategies that constitute (in-) appropriate care based on the consensus of experienced surgeons. Decision-making is driven not only by features of the deformity (e.g., curve magnitude, sagittal imbalance), but also by patient characteristics (e.g., osteoporosis, cardiac comorbidities, smoking) and some factors may indicate that surgery is not appropriate.

DVT prophylaxis strategies following total joint arthroplasty

Routine prophylaxis against venous thromboembolism is indicated following total joint arthroplasty. Prophylactic strategies differ in efficacy and safety, and variable risk exists among patients. Many strategies have been successfully used for chemoprophylaxis as well as mechanical prophylaxis with the use of pneumatic compression. Advances in battery technology and pump miniaturization have expanded the use of pneumatic compression in the post-discharge setting with mobile devices. Pneumatic compression is contraindicated in certain patients, and not all patients tolerate the devices. Mobile pneumatic compression is a valuable adjunct to venous thromboembolic risk mitigation strategies, but does not eliminate the need for pharmacologic agents.

Abstract WP285: Sex Disparities in Stroke Care in Puerto Rico Hospitals Participating in the Florida-Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study

Background: Sex is a contributing factor to inequalities in stroke care. In line with the aims of the FL-PR CReSD Study to assess Get With The Guidelines-Stroke (GWTG-S) quality improvement data, we sought to compare stroke performance metrics by sex among 9 GWTG-S participating Puerto Rico hospitals from 2010-2014. Methods: Age and NIHSS-adjusted hierarchical generalized linear models, stratified by sex, were evaluated for the following GWTG-S performance metrics: IV tPA treatment, early antithrombotic therapy, DVT prophylaxis, antithrombotic therapy at discharge, anticoagulation therapy for atrial fibrillation (AF) at discharge, statin medication at discharge, smoking cessation counseling, defect-free care (compliance with all performance measures), in addition to CT scan ≤25 minutes and door-to-IV tPA administration ≤60 minutes of hospital arrival. Results: Among 3,277 acute ischemic stroke cases, 48% were women. As compared to men, women were older (72±14 vs. 68±13 years, P&lt;0.0001) with higher NIHSS scores (10±8.5 vs. 9±7.7, P=0.005). Women were less likely to receive IV tPA ≤ 4.5 hours among eligible patients arriving ≤ 3.5 hours (OR 0.71, 95% CI 0.51-0.98, P=0.04), early antithrombotic therapy (OR 0.86, 95% CI 0.75-0.97, P=0.02), DVT prophylaxis (OR 0.93, 95% CI 0.88-0.99, P=0.03), statin medication at discharge (OR 0.85, 95% CI 0.78-0.93, P=0.0001), and anticoagulation for AF at discharge (OR 0.67, 95% CI 0.49-0.92, P=0.01) despite having higher rates of AF at admission (11% vs. 7%, P=0.001). Rates of IV tPA for patients arriving ≤ 2 hours, antithrombotic therapy at discharge, and smoking cessation counseling showed no sex differences. While women were less likely to have a CT scan ≤ 25 minutes of hospital arrival compared to men (OR 0.83, 95% CI 0.74-0.93, P=0.002), no difference was found in door-to-IV tPA administration ≤ 60 minutes. Although an overall temporal improvement in defect-free care was observed from 2010-2014 (31% to 63%, P&lt;.0001), women were less likely to receive this measure than men (OR 0.91, 95% CI 0.85-0.97, P=0.007). Conclusions: Overall, stroke care remains lower for Puerto Rican women than men. Continued adoption of the GWTG-S quality improvement program may help reduce sex disparities in quality of care across the island.

Abstract TMP66: Sex Disparity in Stroke Quality of Care in a Community-Based Study

Introduction: Studies have suggested that women may receive lower quality of care (QOC) than men, although population-based studies are lacking. We investigated sex disparities in QOC in the Brain Attack Surveillance in Corpus Christi Project. Methods: All ischemic stroke patients admitted to one of six Nueces County community hospitals between Feb 2009 and Jun 2012 were prospectively identified. Data regarding compliance with seven performance measures (PMs) were extracted from the medical records. A composite score of QOC representing the number of achieved PMs over all patient-appropriate PMs was calculated. Multivariable models with generalized estimating equations assessed the association between sex and the composite score and between sex and individual PMs. Models were adjusted for hospital clustering, age, and ethnicity, while the model assessing composite score was also adjusted for insurance status, education, pre-stroke functional status (Rankin 0-2), initial NIH stroke scale score, and comorbidity index. Results: Compared to men, women were older (median age 72 vs 65), less likely to have a pre-stroke Rankin 0-2 (69% vs 83%), and less likely to identify as married/living together (38% vs 61%). Results for the association of sex with individual PMs are shown below. Women were less likely to receive DVT prophylaxis at 48 hours, an antithrombotic at 48 hours, and to be discharged on an antithrombotic. Women were less likely to be discharged on a cholesterol medication, although this finding was of borderline significance. Women had a lower composite score (mean difference -0.030, 95% CI -0.057 to -0.003). Conclusions: In this population-based study, women had a lower overall stroke QOC, although absolute differences in most individual PMs were small. Further investigation into the factors contributing to the gender disparity in guideline-concordant stroke therapy should be pursued.

Is Routine Use of VTED Chemical Prophylaxis Ever Warranted in Foot and Ankle Surgery? Results of a Cost-Effectiveness Analysis

INTRODUCTION AND OBJECTIVES: The purpose of this study was to determine whether some foot/ankle surgeries would benefit from routine use of low molecular weight heparin (LMWH) as postoperative DVT prophylaxis. METHODS: We conducted a formal cost-effectiveness analysis using a decision analytic tree to represent the risk of complications under a scenario of no prophylaxis and a scenario of routine LMWH prophylaxis for 4 weeks. The two scenarios were compared for five procedures: 1) Achilles tendon repair (ATR), 2) total ankle replacement (TAR), 3) hallux valgus surgery (HVS), 4) hindfoot arthrodesis (HA), and 5) ankle fracture surgery (AFS). Outcomes assessed included short and long-term costs, quality-adjusted life-years (QALYs), and incremental cost per QALY gained. Costs were evaluated from the health care system perspective and expressed in US dollars at a 2015 price base. In the short-term, routine prophylaxis was always associated with greater costs compared to no prophylaxis. RESULTS: For ATR, TAR, HA and AFS prophylaxis was associated with slightly better health outcomes; however, the gain in QALYs was minimal compared to the cost of prophylaxis (ICER was well above $50,000/QALY threshold). For HVS, prophylaxis was associated with both worse health outcomes and greater costs. In the long-term, routine prophylaxis was always associated with worse health outcomes. CONCLUSIONS: We conclude that the decision to use LMWH prophylaxis should not be based solely on the type of foot/ankle surgery planned. Patient factors also need to be carefully weighed.

An Phase 2 Study of Lenalidomide in Combination with Oral Dexamethasone in Previously Untreated, Symptomatic Patients with Chronic Lymphocytic Leukemia (CLL)

Abstract Introduction: Although lenalidomide, as an immunomodulatory agent, has anti-tumor activity in CLL, its use in this disease is complicated by tumor lysis (TLS) and tumor flare (TF), especially when used frontline. From our experience using low-dose lenalidomide (10mg daily), TLS can be prevented but TF remains frequent and few CRs are achieved (Chen et al. 2010). The current trial tests the combination of lenalidomide and dexamethasone, aiming to enhance anti-tumor activity through synergy and mitigation of toxicities such as TF, enabling escalation to higher doses of lenalidomide. We hypothesized that higher doses of lenalidomide with dexamethasone, given over a finite 18 cycles, may achieve deeper and more durable responses, without requiring long term continuous treatment. Final analysis of 31 patients is presented. Methods: Eligible patients had treatment-naïve, symptomatic CLL. The starting dose for lenalidomide was 5mg daily continuously, with 5mg escalations every 28 days to a maximum of 25 mg, and dexamethasone 12 mg daily orally days 1-7, 14, 21 of each 28 day cycle, both to a maximum of 18 cycles. Supportive measures: allopurinol for TLS prophylaxis, DVT prophylaxis with ASA, sulfatrim for pneumocystis prophylaxis. Results: Demographics: 31 pts were enrolled: median age 59 yrs (range 40-84), male 21 pts (68%), Rai stage III-IV 18 pts (58%), median peripheral lymphocytes 185 x109/L (range 9.3-509), β2M 4.1 mg/L (range 1.7-10.9); normal &lt;3.2), bulky nodes 3 pts (10%), organomegaly 16 pts (52%). High risk features included: del17p/del11q on FISH in 6 pts (19%), ZAP70+ in 17 of 27 pts tested (63%) and unmutated IgVH in 16 of 26 pts tested (62%). All 31 pts received at least 1 cycle and were evaluable for toxicity and response. Hematologic toxicity: 19pts (61%) developed Gr 3-4 neutropenia during at least 1 cycle; 6 pts (19%) developed febrile neutropenia. Nine pts (29%) developed Gr 3-4 thrombocytopenia, without bleeding. Gr 3-4 neutropenia occurred in 14% and Gr 3-4 thrombocytopenia in 5% of the 431 cycles administered to all patients. Nonhematologic toxicity: Most common toxicities (all grades) included: non-desquamating rash (64%), diarrhea (61%), insomnia (55%), fatigue (52%), and edema (51%). Infections (all grades) were frequent (25 pts; 80%) but Grade 3-4 infections developed in only 4 pts (13%), including pneumonia (3 pts), and bacteremia (1 pt). Other common grade 3-4 toxicities included rash (3 pts), tumor flare (3 pts), abdominal pain (2 pts), and fatigue (2 pts). In contrast to the high rate of TF from our previous single-agent lenalidomide trial (88%), TF was considerably less common (9 pts; 29%). No TLS was noted. Dose modifications/study withdrawals: The median number of cycles received was 18 (range 1-18), with 58% completing protocol treatment. A median daily dose of 20mg (range 2.5-25mg) was reached. Dose reductions of lenalidomide were required in 14 pts (45%), most due to cytopenias. Reasons for early study discontinuation: toxicity (5 pts), patient withdrawal (5 pts), progressive disease (1 pt), and unrelated death (1 pt). Efficacy: All 31 pts achieved stable disease (SD) or better on study. Overall response rate was 74%: 21 PR (68%), 8 SD (26%), 2 CR (6%). Responses were reached at a median of 3.7 mos (range 0.8-13.7), though best response was not achieved until median 5 mos (range 0.8-25). At a median follow-up of 26 mos, 9 pts have progressed, only one during the treatment period. Duration of response was prolonged with greater depth of response: CR 28.6 mos, PR 17.9 mos, SD 4.6 mos. Median PFS was 27.8 months (95%CI: 22.1%-NA). The median OS has not been reached. Correlatives: Cereblon (CRBN) is a direct target of lenalidomide with expression required for anti-tumor activity. CRBN protein was detected by Western blot analysis in CD19-selected cells from screening blood samples of all 28 pts evaluated. Expression of CRBN substrates IKZF1 (Ikaros) and IKZF3 (Aiolos) pre and post-treatment and correlation with response and PFS are under evaluation and will be reported. Conclusion: Final results from this phase 2 study suggests that lenalidomide plus dexamethasone has significant activity in previously untreated CLL, is generally well-tolerated, and dramatically reduces the incidence of TF symptoms. This approach facilitates dose escalation beyond the 10mg daily dose used in our previous single agent study and achieves durable responses, without continuing therapy until progression. Disclosures Chen: Lundbeck: Honoraria; Janssen: Honoraria; Roche: Honoraria; Sanofi: Research Funding; Celgene: Honoraria, Research Funding; Glaxo Smith Kline: Honoraria. Off Label Use: Lenalidomide is not currently approved for use in CLL.. Trudel:BMS: Honoraria; Merck: Research Funding; Novartis: Consultancy, Honoraria; Amgen: Honoraria, Speakers Bureau; GSK: Honoraria, Research Funding; Celgene: Consultancy, Equity Ownership, Honoraria, Speakers Bureau.

Variability in the structure and care processes for critically injured children: A multicenter survey of trauma bay and intensive care units

PurposeEvaluate national variation in structure and care processes for critically injured children. MethodsInstitutions with pediatric intensive care units (PICUs) that treat trauma patients were identified through the Virtual Pediatric Systems (n=72). Prospective survey data were obtained from PICU and Trauma Directors (n=69, 96% response). Inquiries related to structure and care processes in the PICU and emergency department included infrastructure, physician staffing, team composition, decision making, and protocol/checklist use. ResultsAbout one-third of the 69 institutions were ACS-verified Level-1 Pediatric Trauma Centers (32%); 36 (52%) were state-designated Level 1. The surgeon was the primary decision maker in the trauma bay at 88% of sites, and in the PICU at 44%. The intensivist was primary in the PICU at 30% of sites and intensivist consultation was elective at 11%. Free-standing pediatric centers used checklists more often than adult/pediatric centers for DVT prophylaxis (75% vs. 50%, p=0.039), cervical spine clearance (75% vs. 44%, p=0.011), and pain control (63% vs. 34%, p=0.024). Otherwise, protocols/checklists were infrequently utilized by either center type. ConclusionVariability exists in structure and care processes for critically injured children. Further investigation of variation and its causal relationship to outcomes is warranted to provide optimal care.

Thromboembolic events in patients with severe pandemic influenza A/H1N1

BackgroundThe 2009 pandemic influenza A/H1N1 developed as a novel swine influenza which caused more diseases among younger age groups than in the elderly. Severe hypoxemic respiratory failure from A/H1N1 pneumonia resulted in an increased need for ICU beds. Several risk groups were identified that were at a higher risk for adverse outcomes. Pregnant women were a particularly vulnerable group of patients The CDC reported on the first ten patients with severe illness and acute hypoxemic respiratory failure associated with A/H1N1 infection, none of whom were pregnant, but they noticed that half of the patients had a pulmonary embolism. MethodsDuring a four-month period from September to December 2009, 252 patients were admitted to our hospital with confirmed pandemic influenza H1N1 by real-time reverse transcriptase-polymerase chain reaction test (rRT-PCR). We cared for twenty patients (7.9%) admitted to MICU with severe A/H1N1. Results on Thrombotic events were identified in five (25%) of our critically ill patients. ConclusionsWe recommend that patients with severe influenza A/H1N1 pneumonitis and respiratory failure be administered DVT prophylaxis in particular if there are additional risk factors for TVE. Further prospective studies on the relationship of influenza A/H1N1 and VTE are needed.

Incidence of Venous Thromboembolic Events in Mandated Risk Assessment versus Optional DVT Prophylaxis Era at a Large Tertiary Cancer Center

Cancer patients are thought to be at high risk for venous thromboembolic events (DVT/PE). Beginning in October 2007, our tertiary cancer center instituted "mandated risk assessment" computerized DVT prophylaxis order entry, for all hospital admissions with an option for active opt out by the physician with a stated reason. Retrospective review of all DVT/PE events within 30 days of a hospital admission [any inpatient admission (IA) and outpatient surgery (OPS)] in comparable "optional (O)" (January 2005-September 2007) vs "mandated risk assessment (M)" (October 2007-May 2010) DVT prophylaxis order eras. Patient demographics, admission details, type of prophylaxis, treatment, and outcome were also analyzed. There were 16,363 for the O (11,944 IA/4,419 OPS) and 17,757 for the M (12,957 IA/4,800 OPS) DVT prophylaxis order eras. The number of DVT/PE events in the O era was 67 (prevalence 0.41%) versus 102 for the M era (prevalence 0.57%), P = 0.037. In the DVT/PE patients, DVT prophylaxis had been ordered during the index admission in 66 per cent for O versus 83 per cent for M (P = 0.008). Low-molecular-weight heparin was increasingly used in M era (33% vs 16%, P = 0.009). There was also no difference between O vs M era for status at DVT/PE diagnosis (outpatient 36% vs 24%) or associated symptoms. There were no deaths attributable to DVT/PE in the O era versus 3 deaths in the M era. Although DVT prophylaxis use improved with "mandated risk assessment" ordering, the DVT/PE incidence did not decrease. It may be difficult to overcome the surprisingly low baseline prevalence and multiple risk factors in this population.

D-dimer screening for deep venous thrombosis in traumatic cervical spinal injuries

Background contextDeep venous thrombosis (DVT) in spinal cord injury (SCI) patients is a life-threatening comorbidity. Despite its seriousness, prophylaxis and screening for DVT in SCI patients are still not sophisticated. PurposeThis study aimed to define the epidemiology and incidence of DVT in acute traumatic cervical SCI in a Japanese population, determine the best timing for DVT screening, and determine the optimal D-dimer threshold level for use as an easy and minimally invasive screening tool. Study designThis is a prospective clinical study. Patient sampleThe patient sample included acute traumatic cervical SCI patients who were admitted to our facility within 2 weeks after injury. Outcome measureMultivariate logistic regression was performed for outcome measure. MethodsWe enrolled 268 patients (223 men and 45 women), from April 2007 to December 2012. After excluding early drop-out patients, 211 patients remained. Assessment for neurological status and blood chemistry, especially blood coagulation levels (prothrombin time, prothrombin time-international normalized ratio, activated partial thromboplastin time, and serum D-dimer), was performed every week until 1 month after injury. Ultrasonography was performed for DVT detection every 2 weeks. ResultsDeep venous thromboses were detected in 22 patients (10.4% of patients studied). All DVT-positive patients demonstrated severe paralysis classified as C or greater on the American Spinal Injury Association (ASIA) Impairment Scale. Multivariate logistic regression of clinical and laboratory parameters revealed that only the D-dimer level at 2 weeks after injury was an accurate predictor of DVT formation. The optimal threshold of D-dimer for prediction was determined to be 16 μg/dL. The sensitivity and specificity for detecting DVT were 77.3% and 69.2%, respectively. ConclusionsD-dimer levels may be used to predict the likelihood of DVT development in patients with acute cervical SCI. Furthermore, the optimal timing for screening test by D-dimer is 2 weeks after injury, and optimal threshold level for D-dimer for diagnosing DVT is 16 μg/dL. Such a screening test would be cost-efficient and simple to administer and could then be followed with additional investigations, such as ultrasonography or venography.

PWE-397 What is the correct prophylactic dose of tinzaparin in general surgical patients?

<h3>Introduction</h3> Thrombophylaxis should be prescribed in accordance with risk of thrombosis. The manufacturers of Tinzaparin recommend 3500 units for prophylaxis of DVT in all general surgical patients. Orthopaedic patients are classified as high risk and should receive a weight based calculated dose of 50 IU/kg body or 4500 units. Currently there is no consideration of tinzaparin dose for general surgical patients who are at high risk of thrombosis i.e. cancer patients or emergency surgery patients. Furthermore, there is no guidance for patients who are under or overweight. <h3>Method</h3> A prospective audit was conducted over 8 weeks on one ward. All emergency and elective surgical patients were considered. Data collected included patients’ demographics, weight and tinzaparin dose. This was compared to a theoretical weight calculated dose (TWCD). <h3>Results</h3> 100 general surgical patients were included. Median age 69 years (25–95). Median weight 74 Kg (41–100). 30% of patients underwent surgery and were considered high risk of DVT. 70% were managed conservatively and considered low risk. 13% of patients received 3500 units. 87% received 4500 units. 57% of general surgical patients received too high a dose of tinzaparin on risk criteria alone by 1000 units. Median TWCD 3650 units (2095 -6487). All high risk patients received the recommended 4500 units. Median TWCD 3640 units (2750- 4800). Considering TWCD; 71.2% patients were over anti-coagulated by median 1109 units. 20.7% of overweight patients were under anti-coagulated by median 1560 units. Four patients bled significantly post surgery. They received 4500 units. According to weight based calculations they were over anti-coagulated by a median of 638 units. <h3>Conclusion</h3> The correct dose of tinzaparin needs clarification in general surgical patients. We recommend consideration of a weight calculated dose of tinzaparin. <h3>Disclosure of interest</h3> None Declared.

What neurosurgeons need to know about dabigatran etexilate (pradax(®)/pradaxa(®)/prazaxa(®)).

Dabigatran etexaliate is a novel oral anticoagulant that directly inhibits thrombin. It offers a number of substantial medical benefits over other oral and parenteral anticoagulants but its advent raises important neurosurgical considerations. Dabigatran has important potential benefits. Unlike warfarin, it does not require routine blood tests to monitor its anticoagulative effect and there is no need for dose titration. Drug interactions are greatly simplified when compared to warfarin as dabigatran is not metabolized by cytochrome p450 isoenzymes. As a result, dabigatran has been approved in many jurisdictions for DVT prophylaxis after orthopaedic surgery and also for the prevention of embolic events associated with non-valvular atrial fibrillation. There are, however, important neurosurgical challenges associated with regular dabigatran use. Unlike current anti-coagulants, there is no specific reversal agent for dabigatran. Known reversal options include activated charcoal (within one to two hours of intake) and renal dialysis. Protamine sulfate and vitamin K are unlikely to affect the activity of dabigatran. Platelet concentrates will not inactivate dabigatran's anti-thrombin properties. Assessing the degree of anticoagulation is difficult as conventional markers of serum coagulability are typically normal in patients taking dabigatran. The potential neurosurgical challenges of dabigatran were cast in sharp relief by a recent case report from the United States that is considered in this note. In the absence of a clear reversal pathway, we propose a treatment algorithm for chronic dabigatran use based on the replacement of any deficient factors and rapid access to renal dialysis.

G582(P) Operative note quality improvement – examining compliance with the royal college of surgeons of england guidelines in a paediatric general surgical unit

Context Operative notes should be documented “ clearly, accurately and legibly ” – as endorsed by the GMC’s Good Medical Practice. The RCS Eng. Guidelines (2014) advocate contemporaneous, complete surgical records. This audit identified significant shortcomings in operative documentation amongst paediatric general surgical cases in a tertiary care centre. Data collection was performed by two FY1s and a Surgical Registrar. Problem Surgical operation notes necessitate accurate documentation from both a medico-legal and professional perspective; whilst comprehensive records facilitate post-operative patient management. However; in practice they are frequently sub-standard, thus raising concerns towards patient safety. Current operative note templates within our unit fail to comply with relevant guidelines. Assessment of problem and analysis of its causes We identified poorly-documented details within general surgical operation notes using a data collection tool incorporating pertinent, recently-published guidance. Areas for improvement included: patient’s weight, type of procedure performed (i.e. emergency vs. elective), whether surgery was with or without complication, and antibiotic prophylaxis. Results attained were compared against data from previous audits of a similar nature (carried out in 2010 and 2011 respectively). Intervention Our proposed intervention involves promoting typed documentation of operative notes, whilst advocating their transition from paper text to an electronic format. We plan to achieve this through usage of a unique, pre-existing computerised system developed by a consultant within the department, which additionally populates our current Trakcare system upon document creation. We hope to educate the entire general surgical team in its practice. Furthermore, we will introduce informative posters highlighting the RCS Eng. guidelines and reiterating imperative operative details within the main theatres and day surgery unit. Letters detailing the audit’s key findings and our intended strategy for change were sent to all consultants and surgical trainees. Study design Prospective analysis of 138 general surgical operative notes identified over a 2-week period. We created a 26-point core checklist incorporating both RCS (Eng.) 2014 and GMC “ Good Medical Practice ” 2013 guidance. We then audited elective and emergency operative documentation against this standardised proforma. Data collected was subsequently evaluated once compiled onto a computerised spreadsheet (Table 1). Strategy for change Our findings were presented at the weekly departmental meeting, where we emphasised the need for operative note improvement. Proposed interventions were then implemented at the earliest opportunity. In particular, details not previously recorded, yet strongly advocated, by the RCS Eng. were promoted (e.g. anticipated blood loss, DVT prophylaxis etc.). Measurement of improvement We intend to re-audit operation notes in 2–3 months’ time, using an identical proforma to record data, once the proposed interventions have been implemented. We will determine whether results attained are statistically significant by calculating p-values and using simple statistical data analysis. Effects of changes We anticipate enhanced operative note standards as a result of introducing the proposed interventions. Our aspiration is to generate discussion in computerised documentation of surgeries and inspire greater numbers of surgeons to make use of electronic systems to ensure operative notes are both standardised and increasingly legible. Lessons learnt Surgeons were receptive to this study’s findings and were genuinely keen to improve upon their own operative documentation. Concerns were raised as to whether certain areas of documentation advised by the RCS Eng. are applicable to the paediatric populace e.g. DVT prophylaxis. This highlighted the importance of considering your patient cohort when formulating an operative note template. Message for others We envisage the future of operative notes to be an electronic format. However, until this is achieved we recognise that the majority of surgeons will continue to use our current paper-based arrangement. Thus, we believe that typed operative documentation (using the methods described above) is an acceptable platform towards ameliorating the existing Trakcare system.

Compression in acute stroke: nursing considerations

British Journal of Neuroscience NursingVol. 11, No. Sup2 CommentCompression in acute stroke: nursing considerationsEmma GeeEmma GeeSearch for more papers by this authorEmma GeePublished Online:27 Apr 2015https://doi.org/10.12968/bjnn.2015.11.Sup2.20AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References CLOTS trial collaboration (2009) Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS Trial 1): a multicentre, randomised controlled trial. Lancet 373(9679): 1958–65 Crossref, Google ScholarCLOTS trials collaboration (2010) Thigh-length versus below-knee stockings for DVT prophylaxis after stroke: a randomised trial. Ann Intern Med 153(9): 553–62 Crossref, Google ScholarCLOTS (Clots in Legs Or sTockings after Stroke) Trials Collaboration et al. (2013) Effectiveness of intermittent pneumatic compression in reduction of risk of deep vein thrombosis in patients who have had a stroke (CLOTS3): a multicentre randomised controlled trial. Lancet 382(9891): 516–24 Crossref, Google ScholarCLOTS (Clots in Legs Or sTockings after Stroke) Trials Collaboration (2014) Effect of intermittent pneumatic compression on disability, living circumstances, quality of life, and hospital costs after stroke: secondary analyses from CLOTS 3, a randomised trial. Lancet Neurol 13(12): 1186–92 Crossref, Google ScholarKearon C (2003) Natural History of Venous Thromboembolism. Circulation 107(23): 122–30 Google ScholarKelly J, Rudd A, Lewis RR, Coshall C et al. (2004) Venous Thromboembolism after acute ischaemic stroke; a prospective study using magnetic resonance direct thrombus imaging. Stroke 35: 2320–25 Crossref, Google ScholarKohro S, Yamakage M, Sato K et al. (2005) Intermittent pneumatic foot compression can activate blood fibrinolysis without changes in blood coagulability and platelet activation. Acta Anaesthesiologica Scandinavica 49: 660–4 Crossref, Google ScholarLankeit M, Konstantinides S (2011) Mortality risk assessment and the role of thrombolysis in pulmonary embolism. Critical Care Clinics 27(4): 953–67 Crossref, Google ScholarNational Institute for Health and Care Excellence (2010) NICE clinical guidance 92. Venous thromboembolism: reducing the risk: Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital. https://www.nice.org.uk/guidance/cg92 (accessed 26 March 2015) Google ScholarNational Institute for Health and Care Excellence (2015) Addendum to NICE clinical guidance CG92. Reducing the risk of venous thromboembolism in patients admitted to hospital (Chapter 24-stroke patients). Draft for consultation. http://tinyurl.com/pdyk9xz (accessed 26 March 2015) Google ScholarStevens S, Woller S (2013) Intermittent pneumatic compression in patients with stroke. Lancet 382(9891): 484–6 Crossref, Google Scholar FiguresReferencesRelatedDetails 1 April 2015Volume 11Issue Sup2ISSN (print): 1747-0307ISSN (online): 2052-2800 Metrics History Published online 27 April 2015 Published in print 1 April 2015 Information© MA Healthcare LimitedPDF download

Patterns, risk factors and treatment associated with PICC-DVT in hospitalized adults: A nested case–control study

BackgroundPeripherally inserted central catheters (PICCs) are associated with upper extremity-deep vein thrombosis (DVT). However, patterns, risk factors and treatment associated with this event remain poorly defined. ObjectiveTo determine patterns, risk factors and treatment related to PICC-DVT in hospitalized patients. Design, Setting & PatientsBetween 2012–2013, consecutive cases of ultrasound-confirmed, symptomatic PICC-DVT were identified. For each case, at least two contemporaneous controls were identified and matched by age and gender. Patient- and device-specific data were obtained through electronic-medical records. Using variables selected a priori, multivariable logistic regression models were fit to the outcome of PICC-DVT, comparing cases to controls. Results909 adult hospitalized patients (268 cases, 641 controls) were included in the study. Indications for PICC placement included long-term intravenous antibiotic therapy (n=447; 49.1%), in-hospital venous access for blood draws or infusion of medications (n=342; 44.2%), and total parenteral nutrition (n=120; 6.7%). Patients with PICC-DVT were more likely to have a history of venous thromboembolism (OR 1.70, 95% CI=1.02-2.82) or have undergone surgery while the PICC was in situ (OR 2.17, 95%CI=1.17-4.01 for surgeries longer than two hours). Treatment for PICC-DVT varied and included heparin bridging, low molecular weight heparin only and device removal only; the average duration of treatment also varied across these groups. Compared to 4-Fr PICCs, 5- and 6-Fr PICCs were associated with greater risk of DVT (OR 2.74, 95%CI=0.75-10.09 and OR 7.40 95%CI=1.94-28.16, respectively). Patients who received both aspirin and statins were less likely to develop PICC-DVT than those that received neither treatment (OR 0.31, 95%CI=0.16-0.61). Receipt of pharmacological DVT prophylaxis during hospitalization showed a non-significant trend towards reduction in risk of PICC-DVT (OR=0.72, 95%CI=0.48-1.08). ConclusionSeveral factors appear associated with PICC-DVT. While some of these characteristics may be non-modifiable, future studies that target potentially modifiable variables to prevent this adverse outcome would be welcomed.

Abstract T P261: Stroke Care Improvement Trends in Puerto Rico Hospitals Participating in the Florida-Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study - the NINDS Stroke Prevention Intervention Research Program

Background: Racial and ethnic disparities in stroke care are known to contribute to inequality in stroke outcomes. The goal of the FL-PR CReSD Study is to assess and evaluate Get With The Guidelines-Stroke (GWTG-S) quality improvement data collected among Florida and Puerto Rico hospitals to evaluate for race-ethnic, sex, and regional disparities in stroke performance metrics. We sought to analyze the temporal trends in stroke performance metrics among the 9 hospitals located in Puerto Rico from 2010 to 2013. Methods: Age-adjusted temporal trends were evaluated in the following GWTG-S pre-defined performance measures (IV tPA treatment within 3 hours among eligible patients arriving in 2 hours, in-hospital antithrombotic therapy, DVT prophylaxis, antithrombotic therapy at discharge, anticoagulation therapy, statin medication at discharge, and smoking cessation counseling) and defect-free care (compliance with all 7 performance measures). Results: The mean age of 3,094 registered stroke cases was 69.5 ± 14.0 years, 50% were men, and 2,184 (71%) were diagnosed as ischemic strokes. Defect-free care occurred in 60% of ischemic stroke patients. Lower performance metrics were found for IV tPA treatment (78%), DVT prophylaxis (64%), and statin medication at discharge (83%). An additional IV tPA measure of treatment by 4.5 hours when arriving by 3.5 hours was observed in 65% of patients. The performance metrics that significantly improved over time from 2010 to 2013 included: IV tPA treatment within 3 hours (64% to 87%, p=0.04), DVT prophylaxis (33% to 87%, p&lt;0.0001), statin medication at discharge (78% to 87%, p=0.01), and defect-free care (37% to 79%, p&lt;0.0001). Conclusions: In only four years, Puerto Rico hospitals participating in GWTG-S showed significant improvement across all pre-defined acute stroke performance measures. Wider implementation of quality improvement programs like GWTG-S among the 3.7 million inhabitants of Puerto Rico could further improve acute stroke care.