Incidence Of Fatal Pulmonary Embolism Research Articles

Specifičnosti tromboprofilakse kod starijih pacijenata u ortopedskoj hirurgiji kuka i kolena

Elderly patients with a hip fracture are at significantly higher risk for developing venous thromboembolism (VTE). The incidence of fatal pulmonary embolism (PE) occurs in 2-3% of patients after elective hip and knee surgery and about 6-7% after hip fracture surgery, with a higher risk in men (10,2%) than in women (4,7%). The use of pharmacological prophylaxis significantly reduces the incidence of symptomatic VTE. Pharmacological prophylaxis includes the use of antiplatelet drugs (aspirin), unfractionated heparin (UFH), low molecular weight heparins (LMWH), vitamin K antagonists (VKA), Fondaparinux and direct oral anticoagulants (DOAC). The use of low molecular weight heparins (LMWH) - enoxaparin, represents the gold standard of thromboprophylaxis in orthopedic surgery, and for now, they are the only drugs that are recommended for thromboprophylaxis in hip fracture surgery. Rivaroxaban is used in the prophylaxis of VTE in elective hip and knee surgeries at a fixed dose of 10 mg once daily, and apixaban at a dose of 2,5 mg twice daily in knee arthroplasty for at least 14 days, and after hip arthroplasty for at least 35 days. Early hip fracture surgery as soon as possible, preferably within 24 hours, and no later than 48 hours after admission to the hospital, significantly reduces the morbidity and mortality of elderly patients.

THE IMPACT OF CHOICE OF TREATMENT TACTICS IN POLYTRAUMA PATIENTS WITH MULTIPLE LONG BONE FRACTURES OF LOWER EXTREMITIES ON THE COMPLICATIONS DEVELOPMENT

Introduction. The choice of treatment tactics in multiple trauma patients with multiple long bone fractures of lower extremities is a relevant and controversial issue nowadays. First of all, this is due to the contradictions regarding the choice of the term and method of primary and definitive fractures fixation.Objective: to determine the impact of the proposed treatment algorithm of the multiple trauma patients with multiple long bone fractures of the lower extremities on the duration of mechanical ventilation (MV), length of stay in intensive care unit (LOS ICU) and hospital length of stay (HLOS), the incidence of complications and mortality.Materials and methods: a prospective controlled trial was conducted from September 2016 to February 2020, and included adult patients with multiple trauma, Injury Severity Score (ISS) ≥ 18p, and multiple long bone fractures of lower extremities. Patients were divided into two groups: group I included patients who were treated according to the proposed treatment algorithm. Group II includes patients who were treated in accordance with generally accepted diagnostic and treatment measures.Results: the study included 95 patients (in group I – 43, in group II – 52). There were no statistically significant differences between patients in the compared groups in terms of demographics, mechanism of injury, severity of injury and general condition of the patient, the number and location of fractures. Patients in group II, compared with patients in group I, had a higher frequency of acute respiratory distress syndrome (ARDS) (19.2% vs. 11.6%, p = 0.002), pneumonia (25.0% vs. 16.3%), p = 0.007), longer terms of MV (15.1 ± 9.4 vs. 9.6 ± 7.2 days, p = 0.004), LOS ICU (19.4 ± 12.1 vs. 13.7 ± 8.5 days, p = 0.048) and HLOS (38.7 ± 18.9 vs. 29.1 ± 15.0 days, p = 0.023).Conclusions: Complications in multiple trauma patients with multiple long bone fractures of lower extremities are often the cause of worse treatment outcomes, but the application of a differential approach, based on the proposed treatment algorithm for this patient’s category, was reduced the incidence of pneumonia and ARDS, the duration of MV, LOS ICU, HLOS, without impact on the incidence of fatal pulmonary embolism, fat embolism syndrome, sepsis, multiple organ failure and mortality.

Detailed assessment of benefits and risks of retrievable inferior vena cava filters on patients with complicated injuries: the da Vinci multicentre randomised controlled trial study protocol

IntroductionRetrievable inferior vena cava (IVC) filters have been increasingly used in patients with major trauma who have contraindications to anticoagulant prophylaxis as a primary prophylactic measure against venous thromboembolism (VTE)....

Fatal pulmonary embolism following elective total knee replacement using aspirin in multi-modal prophylaxis — A 12 year study

BackgroundThe National Institute for Health and Clinical Excellence (NICE) has issued guidelines on which thromboprophylaxis regimens are suitable following lower limb arthroplasty. Aspirin is not a recommended agent despite being accepted in orthopaedic guidelines elsewhere. We assessed the incidence of fatal pulmonary embolism (PE) and all-cause mortality following elective primary total knee replacement (TKR) with a standardised multi-modal prophylaxis regime in a large teaching district general hospital. MethodsWe utilised a prospective audit database to identify those that had died within 42 and 90days postoperatively. Data from April 2000 to 2012 were analysed for 42 and 90day mortality rates. There were a total of 8277 elective primary TKR performed over the 12year period. The multi-modal prophylaxis regimen used unless contraindicated for all patients included 75mg aspirin once daily for four weeks. Case note review ascertained the causes of death. Where a patient had been referred to the coroner, they were contacted for post mortem results. ResultsThe mortality rates at 42 and 90days were 0.36 and 0.46%. There was one fatal PE within 42days of surgery (0.01%) who was taking enoxaparin because of aspirin intolerance. Two fatal PE’s occurred at 48 and 57days post-operatively (0.02%). The leading cause of death was myocardial infarction (0.13%). ConclusionsFatal PE following elective TKR with a multi-modal prophylaxis regime is a very rare cause of mortality.

Evaluation of meteorological and epidemiological characteristics of fatal pulmonary embolism.

The objective of the present study was to identify risk factors among epidemiological factors and meteorological conditions in connection with fatal pulmonary embolism. Information was collected from forensic autopsy records in sudden unexpected death cases where pulmonary embolism was the exact cause of death between 2001 and 2010 in Budapest. Meteorological parameters were detected during the investigated period. Gender, age, manner of death, cause of death, place of death, post-mortem pathomorphological changes and daily meteorological conditions (i.e. daily mean temperature and atmospheric pressure) were examined. We detected that the number of registered pulmonary embolism (No 467, 211 male) follows power law in time regardless of the manner of death. We first described that the number of registered fatal pulmonary embolism up to the nth day can be expressed as Y(n) = α ⋅ n (β) where Y denotes the number of fatal pulmonary embolisms up to the nth day and α > 0 and β > 1 are model parameters. We found that there is a definite link between the cold temperature and the increasing incidence of fatal pulmonary embolism. Cold temperature and the change of air pressure appear to be predisposing factors for fatal pulmonary embolism. Meteorological parameters should have provided additional information about the predisposing factors of thromboembolism.

Role of prophylactic filter placement in the endovascular treatment of symptomatic thrombosis in the central veins

ObjectivesTo evaluate the role of filter implantation in reducing the incidence of fatal pulmonary embolism during the endovascular treatment of thrombosis in the major tributary of the superior vena cava (SVC). MethodsFrom October 2004 to October 2008, we conducted a cohort study of 40 patients with thrombosis of the central veins who were preparing for endovascular interventions and received or did not receive filter. The symptom scores were measured, the incidence of pulmonary embolism (PE) was observed, and patient follow-up studies were conducted for three years. ResultsOne week after therapy, the symptom score improved in both groups compared with before therapy (P <0.001), but no significant difference was found between the scores of the two groups (P >0.05). Four patients in the control group died from PEs after therapy, but no patients in the filter group presented evidence of PE. The survival rates at 1, 2, and 3years (72.9%, 50%, and 27.1%, respectively) for the filter group were higher than those for the control group (47.6%, 19.0% and 14.3%, respectively; P =0.015). The survival time of patients in the filter group with bronchogenic carcinoma (18±2months) was longer than that of the patients in the control group (12±2months) after the endovascular treatment (P <0.001). ConclusionsProphylactic filter placement could be a safe and effective method for preventing PE in pre- or post-endovascular-treated patients with thrombi in their central veins.

Significance of Phlebography in Phlebothrombosis

Few complications in medicine and surgery are as unpredictable, treacherous and dramatically tragic as the thromboembolic phenomena. Fatal pulmonary embolism in a patient apparently convalescing uneventfully and preparing to leave the hospital is a fearsome and pathetic catastrophe. Whereas the mortality rate in surgical patients has steadily decreased since the introduction of asepsis and continued improvement in surgical technic and anesthesia as well as the more recent development of the sulfonamides, little has actually been accomplished in the control of pulmonary embolism until relatively recently. Indeed there is some statistical evidence to support the belief that the thromboembolic incidence is increasing. That the condition occurs with sufficient frequency to deserve the assiduous and intensive efforts of investigators has been clearly demonstrated by repeated observations. Thus Snell at the Mayo Clinic and Dietrich in Germany found that pulmonary embolism was considered the cause of death in approximately 8 per cent of all autopsies. In a statistical consideration of this subject Gibbon was able to express the incidence of fatal pulmonary embolism as follows: Of every thousand patients admitted to the surgical wards, 1 will die of pulmonary embolism; of every thousand operated on, 2 will die from pulmonary embolism; and of every hundred postoperative deaths, eight will be due to pulmonary embolism.…

Algorithm-based management of bleeding in patients with extracorporeal membrane oxygenation

We read with interest the paper published by Represse and colleagues [1]. Coagulation management is a challenge during extracorporeal membrane oxygenation (ECMO) due to complex hemostatic and infl ammatory responses associated with the underlying conditions that include infection, sepsis, surgery, and/or traumatic injury [2]. Represse and colleagues present the fi rst algorithmbased approach to bleeding in ECMO patients. However, additional perspectives are important to consider. First, activated partial thromboplastin time or antiacti vated factor X monitoring are routinely used to monitor heparin therapy in ECMO patients, despite intraindividual and inter-individual variability [3]. Rotational thromboelasto metry (ROTEM®; TEM® International GmbH, Munich, Germany) is also increasingly used in the ICU to rapidly assess the coagulation status, including clotting factors, fi brinogen levels, and whole blood clotting [4]. Moreover, this test also facilitates fi brinolytic pathway evaluation, which cannot be easily explored by routine laboratory tests. We believe ROTEM® could be used to design an algorithm-based approach to bleeding in ECMO patients and follow fi brinogen consumption associated with hyperfi brinolysis, an important cause of bleeding. For this reason, anti-fi brinolytic agents should be considered in the multimodal approach (Figure 1), an important point the authors omitted in their algorithm. Second, adverse events includin g 32% venous thrombosis and a 2.5% incidence of fatal pulmonary embolism have already been reported in ECMO patients [5]. In another series, Combes and colleagues reported a 10% incidence of femoral vein and 7% incidence vena cava thrombosis [6]. Recombinant activated factor VII is associated with thromboembolic events [7] and should be used with caution until additional data help us evaluate the benefi t-to-risk administration in bleeding ECMO patients.

Thirty-day mortality rate in women with cancer and venous thromboembolism. Findings from the Registro Informatizado de la Enfermedad Trombo Embólica Registry

Cancer patients with venous thromboembolism (VTE) are at increased risk of mortality. Estimating the risks for specific causes of death may help to weigh the risks and benefits of different therapeutic strategies in an individual patient. In the Registro Informatizado de la Enfermedad Trombo Embólica Registry of 15 520 consecutive patients with VTE, cancer was present in 20% and was associated with a two-fold increase in the risk of fatal pulmonary embolism. In a subsequent study including 2474 women with cancer, 329 (13%) died during the first month. The incidence of fatal pulmonary embolism (n = 71) exceeded that of fatal bleeding (n = 22), except in women with cancer of the bladder or vulva. Then, we compared the mortality rate according to initial presentation in 3978 women with cancer and VTE, of whom 438 (11%) died during the first month. The risk of fatal bleeding was twice as high as the risk of fatal pulmonary embolism (12 vs. 5 deaths) in those with deep-vein thrombosis alone. The higher risk of dying from bleeding than from pulmonary embolism in some women with cancer and VTE suggests that a less aggressive anticoagulant strategy might reduce fatal bleeding more than it would increase fatal pulmonary embolism during this period.

Venous thromboembolism in immobilized patients with dementia. Findings from the RIETE registry

BackgroundThe natural history of venous thromboembolism (VTE) in patients with dementia has not been thoroughly studied. MethodsWe used the RIETE Registry data to assess the clinical characteristics, treatment strategies and outcome during the first 3months after acute VTE in all immobilized patients with dementia. ResultsAs of August 2011, 37988 patients had been enrolled, of whom 1316 (3.5%) had dementia. Most patients in both subgroups were initially treated with low-molecular-weight heparin (LMWH). Then, 48% of patients with dementia and 25% of those without dementia received LMWH as long-term therapy. During the first 3months of anticoagulant therapy, patients with dementia had a higher incidence of fatal pulmonary embolism (PE): 4.0% vs. 1.2% (odds ratio: 3.3; 95% CI: 2.5-4.4) and fatal bleeding: 1.4% vs. 0.5% (odds ratio: 2.9; 95% CI: 1.8-4.6) than those without dementia. In demented patients initially presenting with PE, the incidence of fatal PE during the first week outweighed that of fatal bleeding (42 vs. 4 deaths), but from Day 8, the incidence of fatal PE was similar to the incidence of fatal bleeding. In patients initially presenting with deep vein thrombosis (DVT), there were 4 fatal PE and 8 fatal bleeding events. ConclusionsVTE patients with dementia had a high incidence of fatal PE and fatal bleeding. In those initially presenting with PE, the risk of dying of PE far outweighed that of fatal bleeding. In patients presenting with DVT alone, the risk of fatal PE was lower than that of fatal bleeding.

Clinical characteristics of italian patients with venous thromboembolism enrolled in the RIETE Registry

Introduction: The clinical characteristics, treatment strategies and outcome of patients with venous thromboembolism (VTE) may vary from country to country. Materials and methods: The RIETE (Registro Informatizado su la Enfermedad TromboEmbolica) is an ongoing, prospective registry of consecutive patients with acute, objectively confirmed, symptomatic VTE. Our aim was to assess the influence of surgery and immobility for non-surgical reasons on 3-month outcomes of all Italian patients registered in the RIETE. Results: Through July 2008, 21,397 patients with acute VTE were registered in the RIETE. Of these, 896 (4.2%) were Italian, and 360 (40%) presented with pulmonary embolism (PE). Overall, 137 (15%) developed VTE after surgery; 156 (17%) developed VTE after &gt;4 days of immobility, and 603 (67%) developed VTE in the absence of surgery or immobility. Most patients (83%) received initial therapy with low-molecular-weight heparin; 15% received unfractionated heparin. For long-term therapy, 63% of patients received vitamin K antagonists. The incidence of fatal PE during the first 3 months of therapy was 1.5% for patients with postoperative VTE, 7.7% for who developed VTE after immobility, and 1.2% for the remaining patients. The incidence of fatal bleeding among these patients was 1.5%, 1.9% and 0.3%, respectively. Of the 137 patients with postoperative VTE, 61% had received VTE prophylaxis. Of the 156 patients with recent immobility, 24% had received VTE prophylaxis. Conclusions: VTE arising after a period of immobility was associated with the highest rates of fatal PE and fatal bleeding during the first 3 months of therapy. The use of thromboprophylaxis in this population should be improved.

Prophylaxis against venous thromboembolism in hospitalized medical patients: an evidence‑based and practical approach

To discuss the evidence regarding the efficacy and safety of anticoagulant prophylaxis against deep vein thrombosis (DVT) in hospitalized medical patients; to understand barriers to implementation of prophylaxis and how they can be overcome; and to have a practical approach as to which patients should and should not receive anticoagulant prophylaxis. The frequency of DVT in hospitalized medical patients, in the absence of prophylaxis varies from 10-15%. Autopsy studies have shown that pulmonary embolism (PE) is associated with 5-10% of deaths in hospitalized patients. With appropriate use of anticoagulant prophylaxis, there is a 57% reduction in the risk for symptomatic PE (relative risk [RR] 0.43, 95% CI 0.26-0.71), a 62% reduction in the risk for fatal PE (RR 0.38, 95% CI 0.21-0.69), and a 53% reduction in the risk for symptomatic DVT (RR 0.47, 95% CI 0.22-1.00). Anticoagulant prophylaxis is also associated with a non-significant increased risk for major bleeding (RR 1.32, 95% CI 0.73-2.37). Risk factors for DVT and bleeding in medical patients may help to identify patients in whom anticoagulant prophylaxis is indicated or contraindicated but validated risk stratifications schemes are lacking. Among hospitalized medical patients, randomized trials have established an acceptable therapeutic benefit-to-risk ratio of anticoagulant prophylaxis to reduce the incidence of clinically silent and symptomatic venous thromboembolism, including a reduction in the incidence of fatal PE. Additional research is needed to develop a validated risk stratification model for hospitalized medical patients that can help identify patients who would benefit most from anticoagulant prophylaxis.

Clinical characteristics of italian patients with venous thromboembolism enrolled in the RIETE Registry

The clinical characteristics, treatment strategies and outcome of patients with venous thromboembolism (VTE) may vary from country to country. The RIETE (Registro Informatizado su la Enfermedad TromboEmbolica) is an ongoing, prospective registry of consecutive patients with acute, objectively confirmed, symptomatic VTE. Our aim was to assess the influence of surgery and immobility for non-surgical reasons on 3-month outcomes of all Italian patients registered in the RIETE. Through July 2008, 21,397 patients with acute VTE were registered in the RIETE. Of these, 896 (4.2%) were Italian, and 360 (40%) presented with pulmonary embolism (PE). Overall, 137 (15%) developed VTE after surgery; 156 (17%) developed VTE after ≥4 days of immobility, and 603 (67%) developed VTE in the absence of surgery or immobility. Most patients (83%) received initial therapy with low-molecular-weight heparin; 15% received unfractionated heparin. For long-term therapy, 63% of patients received vitamin K antagonists. The incidence of fatal PE during the first 3 months of therapy was 1.5% for patients with postoperative VTE, 7.7% for who developed VTE after immobility, and 1.2% for the remaining patients. The incidence of fatal bleeding among these patients was 1.5%, 1.9% and 0.3%, respectively. Of the 137 patients with postoperative VTE, 61% had received VTE prophylaxis. Of the 156 patients with recent immobility, 24% had received VTE prophylaxis. VTE arising after a period of immobility was associated with the highest rates of fatal PE and fatal bleeding during the first 3 months of therapy. The use of thromboprophylaxis in this population should be improved.

Pulmonary embolism in patients over 90 years of age

There is some uncertainty about the management of pulmonary embolism in nonagenarians. Immobility plays an important role in the pathogenesis of venous thromboembolism in the elderly. Of 858 nonagenarians with acute venous thromboembolism enrolled in Registro Informatizado de la Enfermedad TromboEmbolica venosa registry, 41% had recent immobility and only 7.7% had recent surgery. Comorbidity is common: 19% of patients had chronic heart failure, 9.8% chronic lung disease, 14% cancer, and 63% had abnormal creatinine levels. Most (92%) of the patients were initially treated with low-molecular-weight heparin and then 46% switched to antivitamin K drugs. During follow-up, the proportion of patients who developed recurrent venous thromboembolism (4.9%) or major bleeding complications (6.2%) was similar, but the 5.9% of fatal pulmonary embolisms by far exceeded the 2.2% of fatal bleeding events. The most common clinical symptoms are isolated dyspnea and syncope, and presentation as pulmonary infarction (with hemoptysis and pleuritic chest pain) is rare. In patients aged at least 90 years presenting with acute pulmonary embolism, the incidence of fatal pulmonary embolism by far outweighs the incidence of fatal bleeding, and pulmonary embolism is the most common cause of death. Thus, there seems to be more reason to be concerned about fatal pulmonary embolism than about bleeding in elderly patients presenting with pulmonary embolism.

The Influence of Junctional Competence on Primary Saphenous Reflux

The Influence of Junctional Competence on Primary Saphenous Reflux

The incidence of fatal pulmonary embolism after primary hip and knee replacement in a consecutive series of 4253 patients

We studied 4253 patients undergoing primary joint replacement between November 2002 and November 2007, of whom 4060 received aspirin only as chemical prophylaxis; 46 were mistakenly given low molecular weight heparin initially, which was stopped and changed to aspirin; 136 received no chemoprophylaxis and 11 patients received warfarin because of a previous history of pulmonary embolism. We identified the rate of clinical thromboembolism before and after discharge, and the mortality from pulmonary embolism at 90 days. The overall death rate was 0.31% (13 of 4253) and the rate of fatal pulmonary embolism was 0.07% (3 of 4253). Our data suggest that fatal pulmonary embolism is not common following elective primary joint replacement, and with modern surgical practice elective hip and knee replacement should no longer be considered high-risk procedures.

Prevention of venous thromboembolism in hospitalized medical patients: addressing some practical questions

To demonstrate that venous thromboembolism is an important and common problem in hospitalized medical patients; to outline anticoagulant prophylaxis management options and the evidence for efficacy and safety; and to identify medical patients in whom anticoagulant prophylaxis should be considered. In at-risk medical patients who do not receive anticoagulant prophylaxis, the incidence of deep vein thrombosis is 10.5-14.9%. Prophylaxis with low-dose anticoagulant therapy confers a 57% reduction in the risk for symptomatic pulmonary embolism (relative risk, 0.43; 95% confidence interval: 0.26-0.71), a 62% reduction in the risk for fatal pulmonary embolism (relative risk, 0.38; 95% confidence interval: 0.21-0.69), and a 53% reduction in the risk for symptomatic deep vein thrombosis (relative risk, 0.47; 95% confidence interval: 0.22-1.00). Anticoagulant prophylaxis is also associated with a nonsignificant increased risk for major bleeding (relative risk, 1.32; 95% confidence interval: 0.73-2.37). Risk factors for venous thromboembolism and bleeding in medical patients have been proposed and may help identify patients in whom anticoagulant prophylaxis is indicated or contraindicated. However, validated risk-stratifications schemes are lacking. Among hospitalized medical patients, randomized trials have established an acceptable therapeutic benefit-to-risk ratio of anticoagulant prophylaxis to reduce the incidence of clinically silent and symptomatic venous thromboembolism, including a reduction in the incidence of fatal pulmonary embolism. Additional research is needed to identify patients who would benefit most from anticoagulant prophylaxis.

Clinical presentation and time-course of postoperative venous thromboembolism: Results from the RIETE Registry

There is little literature about the clinical presentation and time-course of postoperative venous thromboembolism (VTE) in different surgical procedures. RIETE is an ongoing, prospective registry of consecutive patients with objectively confirmed, symptomatic acute VTE. In this analysis, we analysed the baseline characteristics, thromboprophylaxis and therapeutic patterns, time-course, and three-month outcome of all patients with postoperative VTE. As of January 2006, there were 1,602 patients with postoperative VTE in RIETE: 393 (25%) after major orthopaedic surgery (145 elective hip arthroplasty, 126 knee arthroplasty, 122 hip fracture); 207 (13%) after cancer surgery; 1,002 (63%) after other procedures. The percentage of patients presenting with clinically overt pulmonary embolism (PE) (48%, 48%, and 50% respectively), the average time elapsed from surgery to VTE (22 +/- 16, 24 +/- 16, and 21 +/- 15 days, respectively), and the three-month incidence of fatal PE (1.3%, 1.4%, and 0.8%, respectively), fatal bleeding (0.8%, 1.0%, and 0.2%, respectively), or major bleeding (2.3%, 2.9%, and 2.8%, respectively) were similar in the three groups. However, the percentage of patients who had received thromboprophylaxis (96%, 76% and 52%, respectively), the duration of prophylaxis (17 +/- 9.6, 13 +/- 8.9, and 12 +/- 11 days, respectively) and the mean daily doses of low-molecular-weight heparin (4,252 +/- 1,016, 3,260 +/- 1,141, and 3,769 +/- 1,650 IU, respectively), were significantly lower in those undergoing cancer surgery or other procedures. In conclusion, the clinical presentation, time-course, and three-month outcome of VTE was similar among the different subgroups of patients, but the use of prophylaxis in patients undergoing cancer surgery or other procedures was suboptimal.

Dalteparin Vs Low-Dose Unfractionated Heparin for Prophylaxis Against Clinically Evident Venous Thromboembolism in Acute Traumatic Spinal Cord Injury: A Retrospective Cohort Study

Background: When venous thromboembolism (VTE) includes deep-vein thrombosis (DVT) and pulmonary embolism (PE), patients with acute traumatic spinal cord injury (SCI) have the highest incidence of VTE among all hospitalized groups, with PE the third most common cause of death. Although low-molecular-weight heparin (LMWH) outperforms low-dose unfractionated heparin (LDUH) in other patient populations, the evidence in SCI remains less robust.Objective: To determine whether the efficacy for LMWH shown in previous SCI surveillance studies (eg, routine Doppler ultrasound) would translate into real-world effectiveness in which only clinically evident VTE is investigated (ie, after symptoms or signs present).Methods: A retrospective cohort study was conducted of 90 patients receiving LMWH dalteparin (5,000 U daily) or LDUH (5,000 U twice daily) for VTE prophylaxis after acute traumatic SCI. The incidence of radiographically confirmed VTE was primarily analyzed, and secondary outcomes included complications of bleeding and heparin-induced thrombocytopenia.Results: There was no statistically significant association (p = 0.7054) between the incidence of VTE (7.78% overall) and the type of prophylaxis received (LDUH 3/47 vs dalteparin 4/43). There was no significant differences in complications, location of VTE, and incidence of fatal PE. Paraplegia (as opposed to tetraplegia) was the only risk factor identified for VTE.Conclusions: There continues to be an absence of definitive evidence for dalteparin (or other LMWH) over LDUH as the choice for VTE prophylaxis in patients with SCI. Novel approaches to VTE prophylaxis are urgently required for this population, whose risk of fatal PE has not decreased over the last 25 years.

Anticoagulants for thrombosis prophylaxis following surgery: A continuing saga

Thromb Haemost 2008; 99: 993–994 More than 30 years ago the landmark multicenter trial from 28 medical centers demonstrated in 4,000 patients that the administration of small doses of unfractionated heparin (UFH) to surgical patients reduced the deep vein thrombosis (DVT) rate from 24.6% in the placebo group to 7.7% in the heparin arm with a corresponding reduction in fatal pulmonary emboli from 0.8% to 0.1% (1). Even more remarkable was the meta-analysis by Collins 13 years later involving more than 13,000 patients from 70 medical centers that reaffirmed the original multicenter trial results. The incidence of DVT was reduced from 22.4% to 9.0% by administration of small doses of UFH in general, gynecologic, orthopedic, and urologic surgery patients. Again the incidence of fatal pulmonary embolism (PE) was reduced from 0.9% in the control group to 0.3% in the heparin group (2). Seventeen years later Hass et al. reported the results of a randomized, double-blind comparison of UFH and low-molecularweight heparin (LMWH) in 23,078 surgical patients which demonstrated that the fatal PE incidence in either group was 0.15% (3). Over the years multiple consensus conferences have concluded that high-risk patients having surgical operations should be protected by anticoagulants. The latest consensus guidelines indicate that the incidence of DVT without prophylaxis is 40–80% and the fatal PE rate is as high as 5% in some of these patients without prophylaxis (4–6). One would assume that after all these years and in light of overwhelming evidence from around the world prophylaxis would be uniformly administered to high-risk surgical patients. Recently the results of a registry of 30,827 surgical patients revealed that 64% of these individuals were at risk for developing venous thromboembolism (VTE) and only a disappointing 59% received appropriate thrombosis prophylaxis (7). This observer wonders what additional evidence is necessary to convince physicians to protect their high-risk patients. The problem has been compounded in this era of outpatient and laparoscopic surgery that may markedly shorten hospital stay. High-risk patients may be given prophylaxis before and after the surgical procedure, but it is rarely continued for the full seven days if earlier discharge has occurred. All of the above studies in thousands of patients have included a 7–10 day treatment period. There are no data to suggest that shortening the period of prophylaxis is justified. Cancer patients in particular may not have resumed normal mobility and may spend considerable time in the recliner resting from their operation. Often they are taking narcotics for pain control and may have indwelling lines for chemotherapy, antibiotics for ongoing infection, etc. These patients remain at risk and, while no randomized trials have been done, there is evidence from several studies that outof-hospital prophylaxis is necessary. One study involving 28,953 patients documented 90 patients with symptomatic PE during their hospital stay. Within 30 days of hospital discharge, 29 patients were readmitted because of PE and the delayed embolic events were seen a median of six days after discharge and 18 days after surgery. A number of these patients had low-risk surgical procedures. The authors suggested that post-discharge prophylaxis may be important in some surgical patients (8). Fourteen years later the incidence of clinical VTE in 1,238 patients undergoing operations for cancer was 2.1%. Forty percent of the thromboembolic events occurred more than three weeks postoperatively. In-hospital prophylaxis was given in 81.6% and post-discharge prophylaxis in 30.7% of the patients. The authors conclude that “VTE remains a common complication of cancer surgery, with a remarkable proportion of events occurring late after surgery. In patients undergoing cancer surgery, VTE is the most common cause of death at 30 days after surgery” (9). An incidence-based model by Heit et al. (10) estimated that 613,423 non-fatal VTE events occur annually and 296,370 fatal VTE events in a given year in the US. It was estimated that of these totals 193,598 non-fatal VTE and 106,550 fatal VTE occurred out-of-hospital. The authors emphasized the importance of these findings, particularly the events occurring in the community (10). The study by Bottaro et al. (11) in this issue of the Thrombosis and Haemostasis is a meta-analysis of three clinical studies that compare the efficacy and safety of extended LMWH pro© 2008 Schattauer GmbH, Stuttgart