Incidence Of Thromboembolic Complications Research Articles

Prothrombin Complex Concentrate Reversal of Coagulopathy in Emergency General Surgery Patients.

Coagulopathy can delay or complicate surgical diseases that require emergent surgical treatment. Prothrombin complex concentrates (PCC) provide concentrated coagulation factors which may reverse coagulopathy more quickly than plasma (FFP) alone. We aimed to determine the time to operative intervention in coagulopathic emergency general surgery patients receiving either PCC or FFP. We hypothesize that PCC administration more rapidly normalizes coagulopathy and that the time to operation is diminished compared to FFP alone. Single institution retrospective review was performed for coagulopathic EGS patients during 2/1/2008 to 8/1/2016. Patients were divided into three groups (1) PCC alone (2) FFP alone and (3) PCC and FFP. The primary outcome was the duration from clinical decision to operate to the time of incision. Summary and univariate analyses were performed. Coagulopathic EGS patients (n=183) received the following blood products: PCC (n=20, 11%), FFP alone (n=119, 65%) and PCC/FFP (n=44, 24%). The mean (±SD) patient age was 71±13years; 60% were male. The median (IQR) Charlson comorbidity index was similar in all three groups (PCC=5(4-6), FFP=5(4-7), PCC/FFP=5(4-6), p=0.33). The mean (±SD) dose of PCC administered was similar in the PCC/FFP group and the PCC alone group (2539±1454 units vs. 3232±1684, p=.09). The mean (±SD) time to incision in the PCC alone group was significantly lower than the FFP alone group (6.0±3.6 vs. 8.8±5.0h, p=0.01). The mean time to incision in the PCC+FFP group was also significantly lower than the FFP alone group (7.1±3.6 vs. 8.8±5.0, p=0.03). The incidence of thromboembolic complications was similar in all three groups. PCC, alone or in combination with FFP, reduced INR and time to surgery effectively and safely in coagulopathic EGS patients without an apparent increased risk of thromboembolic events, when compared to FFP use alone. IV single institutional retrospective review.

An unusual case of symptomatic deep vein thrombosis and pulmonary embolism after arthroscopic meniscus surgery

BackgroundAlthough thrombosis complication is rare after arthroscopic meniscus surgery, deep vein thrombosis and pulmonary embolism can be fatal. The associated risk factors and whether anticoagulant prevention after arthroscopic knee surgery is necessary have not reach consensus. Here we present a case of deep vein thrombosis and pulmonary embolism after a common arthroscopic meniscectomy.Case presentationThe patient had no risk factors except ipsilateral leg varicose veins. She present swell at knee and calf from postoperative 3 weeks, and developed dyspnea, palpitation, and nausea on 33th day, pulmonary embolism was confirmed with CT angiography at emergency department. After thrombolysis and anticoagulation therapy were administered, the patient improved well and discharged. And the intravenous ultrasound confirmed thrombosis of popliteal vein and small saphenous vein. Who don’t have common risk factors for venous thromboembolism.ConclusionsDespite the low incidence of thromboembolic complications after simple arthroscopy surgery, its life-threatening and devastating property make clinicians rethink the necessity of thromboprophylaxis and importance of preoperative relative risk factors screening.

Risk of thromboembolic complications associated with fertility treatment: A nationwide cohort study

Fertility treatments (FT) have been associated with an increased risk of thromboembolic complications (TEC). However, whether this excess risk exists for arterial thrombosis and whether it differs by type of ART remains poorly documented. The objectives were to estimate TEC rates following unsuccessful FT cycle (TC) and FT-related pregnancy, according to type of FT. Women aged 18–45 years with an FT between 2012 and 2015 were selected in the French health insurance claim database. TC were classified into simple ovulation induction (OI) or ovulation stimulation (OS). All hospitalisations in women with FT, with a diagnosis of venous thromboembolism (VTE) or arterial thrombosis (AT) were identified in the French hospital discharge database. Separate analyses were performed for unsuccessful and successful TC. Poisson regressions were used to estimate incidence rate ratios (IRR) comparing both incidence of TEC following unsuccessful TC versus incidence in all non-pregnant women of same age range, and TEC incidence during FT-related pregnancy versus incidence in spontaneous pregnancy. During the study period, 280,000 women underwent FT (total of 809,913 TC) with 82,821 FT-related pregnancies. Among unsuccessful TC, 75 VTE and 43 AT were observed. OS TC but not OI TC was associated with a higher risk of VTE compared with the reference group [1.7, 95% CI (1.3–2.3)]. Among FT-related pregnancies, 207 VTE and 35 AT were reported. The IRR adjusted for age and multiple pregnancy showed significant higher rates of VTE and AT during first trimester comparing to spontaneous pregnancy [IRR = 3.3, 95% CI (2.2–4.8) and IRR = 2.6, 95%CI (1.1–6.5) respectively]. This study highlights the importance of monitoring women undergoing FT, especially OS TC, regardless of pregnancy status. In FT-related pregnancy, the first trimester seems to be a high-risk period for TEC compared with spontaneous pregnancies.

Postoperative Thromboembolic Prophylaxis with Low-Molecular-Weight Heparin and Risk of Rebleeding in Patients with Chronic Subdural Hematomas: A Comparative Retrospective Cohort Study.

Early postoperative administration of low-molecular-weight heparin (LMWH) to prevent thromboembolic events in patients with chronic subdural hematoma (CSDH) is controversial. Our goal was to investigate impact of early postoperative LMWH administration on recurrence rate of CSDHs. Retrospective review was performed of 136 patients with CSDHs who were operated on during an 18-month period. Early postoperative administration of LMWH was at the discretion of the treating surgeon. This resulted in patients treated (heparin [H] group) or not treated with LMWH (no heparin [NH] group). All patients underwent imaging 4 weeks after surgery or earlier in cases of deterioration. The primary outcome variable was reoperation. Secondary outcomes were reoperation, important residual hematoma (defined as hematoma depth of more than one third of original size), and incidence of thromboembolic complications. Relative risk and absolute risk reduction were calculated. We included 105 patients, 50 (47.6%) in the NH group and 55 (52.4%) in the H group. Nine patients (18%) in the NH group and 6 patients (10.9%) in the H group required secondary surgery (relative risk 0.61, 95% confidence interval 0.23-1.58, P= 0.404, absolute risk reduction 0.07). Eleven patients (22%) in the NH group and 15 patients (27.3%) in the H group presented with important residual hematoma or underwent surgery for hematoma recurrence (relative risk 1.24, 95% confidence interval 0.63-2.44, P=0.532, absolute risk reduction-0.05). Our data provide preliminary evidence that early postoperative administration of LWMH does not increase risk of clinically relevant recurrence of CSDHs.

Is combined use of intravenous and intraarticular tranexamic acid superior to intravenous or intraarticular tranexamic acid alone in total knee arthroplasty? A meta-analysis of randomized controlled trials

BackgroundTranexamic acid (TXA) has been proven to be effective in reducing blood loss and transfusion rate after total knee arthroplasty (TKA) without increasing the risk of deep vein thrombosis (DVT) and pulmonary embolism (PE). Recently, an increasing number of studies have been interested in applying combined intravenous (IV) with intraarticular (IA) tranexamic acid in total knee arthroplasty. The purpose of this meta-analysis was to compare the blood loss and complications of combined TXA with IV TXA or IA TXA on TKA.MethodsSystematic search of literatures were conducted to identify related articles that were published in PubMed, MEDLINE, Embase, the Cochrane Library, SpringerLink, ClinicalTrials.gov, and Ovid from their inception to September 2016. All studies that compare blood loss and complications of combined TXA and IV TXA or IA TXA on TKA were included. Main outcomes were collected and analyzed by the Review Manager 5.3.ResultsFive studies were included in the present meta-analysis. There was significant difference in total blood loss and blood volume of drainage when compared combined TXA group with IV TXA group or IA TXA group (P < 0.05). There was no difference in transfusion rate and thromboembolic complications when comparing combined TXA with IV TXA or IA TXA alone (P > 0.05).ConclusionsCompared with administration of IA TXA or IV TXA alone on TKA, combined use of TXA has advantages in reducing total blood loss and blood volume of drainage without increasing the incidence of thromboembolic complications. We recommend combined TXA as the preferred option for patients undergoing TKA.

Sex, age, and time to cardioversion. Risk factors for cardioversion of acute atrial fibrillation from the FinCV study

Background: Female sex, old age, and time to cardioversion increase the risk of thromboembolic complications (TEC) after cardioversion of atrial fibrillation (AF) < 48 h. The interaction of these variables is not known. We investigated the interaction of sex, age, and time to electrical cardioversion (ECV) on TEC in anticoagulant-naive patients with acute AF.Methods and results: The primary outcome was a TEC within 30 days following ECV. Patients were divided into three age groups and time to cardioversion into <12 h and ≥12 h in 4715 ECVs. TEC occurred in 40 (0.8%) patients. In multivariate analysis, female sex, time to ECV, and vascular disease were independent predictors of TEC. For patients ≤75 cardioverted within 12 h, the incidence of TEC was low. In patients >75 TEC increased in both sexes and particularly in women (1.4% vs. 0.9%, p = 0.03). When ECVs exceeded 12 h, the risk of TEC was two- to four-fold higher in women in all age groups.Conclusions: The risk of TEC increases substantially in patients >75 and ECVs ≥12 h, particularly in women. Time to cardioversion should be added to risk-stratification of ECVs of acute AF.Key messagesThe ideal timing of cardioversion is still unknown and not based on solid evidence. Delay to cardioversion ≥12 h should be added to the risk stratification of atrial fibrillation cardioversion.Female sex increases the risk of complications and failure of cardioversion after electrical cardioversion of atrial fibrillation <48 h, especially with age >75 years and time to cardioversion exceeding 12 h.

OS 27-05 FRAILTY ASSESSMENT IN OLDER ATRIAL FIBRILLATION PATIENTS

Objective: Atrial fibrillation is the common arrhythmia in the elderly, and the average age of atrial fibrillation patients is rising. Elderly patients with atrial fibrillation have high incidence of thromboembolic complication and increasing age is associated with stroke severity. Assessing CHADS-VASc score is pivotal to evaluate substantial morbidity and mortality, especially regarding the increased risk of stroke. In addition, considering bleeding risk with HAS-BLED score is important to balance the benefit against the risk of bleeding. However in addition to CHADS-VASc and HAS-BLED score, the roll of frailty assessment in older atrial fibrillation patients is not known. Design and Method: We evaluate 365 older (≥ 65 years old) atrial fibrillation patients who underwent comprehensive geriatric assessment (CGA) from 2007 to 2014 in a single tertiary hospital retrospectively. Taking anti-coagulant or anti-platelet agents on the point of CGA were reviewed. CHADS-VASc and HAS-BLED scores were calculated based on electronic medical records, and frailty index was computed from CGA. The primary outcome was the 3-year all-cause mortality. Results: Patients with high CHADS-VASc score were more likely to be treated with anticoagulant rather than antiplatelet agent (P Conclusions: Frailty assessment along with CHADS-VASc and HAS-BLED score can provide fine resolution for predicting mortality in older atrial fibrillation patients.

The Risk of Thromboembolic Complications in Fontan Patients with Atrial Flutter/Fibrillation Treated with Electrical Cardioversion.

Atrial flutter or fibrillation (AFF) remains a major chronic complication of the Fontan procedure. This complication further predisposes this patient population to thromboembolic events. However, the incidence of thromboembolic complications in Fontan patients with AFF prior to or acutely after electrical cardioversion is unknown. This study aimed to characterize the risk of post-cardioversion thromboembolic events in this population. We performed a retrospective medical record review of all patients with a history of Fontan operation treated with direct current cardioversion for AFF at Riley Children's Hospital between June 1992 and March 2014. A total of 57 patients were identified and reviewed. A total of 216 episodes of AFF required electrical cardioversion. Patients were treated with anticoagulation/antiplatelet therapy in 86.1% (N=186) of AFF episodes. Right atrial or Fontan conduit clots were observed in 33 patients (57.9%) with 61 episodes of AFF. Approximately half (49.2%, N=30) of these episodes were treated immediately with electrical cardioversion. Twenty-five of 33 (75.8%) patients with intracardiac thrombi had an atriopulmonary Fontan. Five (15.2%) patients with a lateral caval tunnel had clots in the Fontan conduit, and three (9.1%) patients with right atrium to right ventricular outflow tract (RVOT) connections presented with right atrial mural thrombi. Nine of the 57 (15.8%) patients had documented stroke, and three (5.3%) patients had pulmonary emboli during follow-up, although none of these emboli were associated with electrical cardioversion. The risk of thrombus and thromboembolism associated with AFF is high in the Fontan population. However, the risk of thromboembolism associated with cardioversion in the setting of anticoagulation is very low.

Incidence of Thromboembolic ComplicationsWithin 30 Days of Electrical Cardioversion Performed Within 48Hours of Atrial Fibrillation Onset.

This study sought to compare the risk of thromboembolism after cardioversion within 48 h of atrial fibrillation (AF) onset in patients therapeutically versus not therapeutically anticoagulated. Although guidelines do not mandate anticoagulation for cardioversion within 48 h of AF onset, riskofthromboembolism in this group has been understudied. Patients undergoing cardioversion within 48 h after AF onset were identified from a prospectively collected database and retrospectively reviewed to determine anticoagulation status and major thromboembolic events within 30 days of cardioversion. Among 567 cardioversions in 484 patients without therapeutic anticoagulation (mean CHA2DS2-VASc score, 2.3 ± 1.7), 6 had neurological events (1.06%), all in patients on aspirin alone. Among 898 cardioversions in 709 patients on therapeutic anticoagulation (mean CHA2DS2-VASc score, 2.6 ± 1.7; p= 0.017), 2 neurological events occurred (0.22%; OR: 4.8; p= 0.03), both off anticoagulation at the time of stroke. No thromboembolic events occurred in patients with CHA2DS2-VASc score<2 (p= 0.06) or in patients with postoperative AF. In patients with acute-onset AF, odds of thromboembolic complications were almost 5 times higher in patients without therapeutic anticoagulation at the time of cardioversion. However, no events occurred in post-operative patients and in those with CHA2DS2-VASc scores of<2, supporting the utility of accurate assessment of AF onset and risk stratification in determining the need for anticoagulation for cardioversion of AF<48 h in duration.

Pregnancy after heart surgery – challenges

Purpose: Advances in cardiac surgery significantly improve life expectancy and quality of life of patients with congenital or acquired heart disease. Materials and Methods: The present study included 146 pregnant women who had antenatal care and gave birth at the Institute of Gynecology and Obstetrics in an interval of ten years from 1994-2004. Patients were divided in four groups according to the type of heart surgery. Group I included four patients with surgically corrected coarctation of the aorta. Group II included 27 patients with correction of the ostial stenosis. Group III had 68 patients with correction of congenital heart diseases, and group IV had 47 patients with artificial heart valves. Results: There was 4% of heart failure after delivery. The incidence of hemorrhagic complications during pregnancy was 2.7% and 4.1% after delivery. The incidence of thromboembolic complications after delivery was 6%. Four newborns died, one of hydrocephalus and three of hypoxic ischemic encephalopathy. Two patients died. Conclusion: Patients with artificial heart valves need an enhanced level of medical care during pregnancy and labor.

Bilateral iliac and popliteal arterial thrombosis in a child with focal segmental glomerulosclerosis.

Thromboembolic complications (TECs) are clinically important sequelae of nephrotic syndrome (NS). The incidence of TECs in children is approximately 2%–5%. The veins are the most commonly affected sites, particularly the deep veins in the legs, the inferior vena cava, the superior vena cava, and the renal veins. Arterial thrombosis, which is less common, typically occurs in the cerebral, pulmonary, and femoral arteries, and is associated with the use of steroids and diuretics. Popliteal artery thrombosis in children has been described in cases of traumatic dissection, osteochondroma, Mycoplasma pneumoniae infection, and fibromuscular dysplasia. We report of a 33-month-old girl with bilateral iliac and popliteal arterial thrombosis associated with steroid-resistant NS due to focal segmental glomerulosclerosis. Her treatment involved thrombectomy and intravenous heparinization, followed by oral warfarin for 8 months. Herein, we report a rare case of spontaneous iliac and popliteal arterial thrombosis in a young child with NS.

Efficiency of tranexamic acid in perioperative blood loss in hip arthroplasty: A systematic literature review and meta-analysis

Introduction and objectiveTranexamic acid (TXA) is an antifibrinolytic drug used to reduce bleeding in mortality risk situations such as trauma. Our objective was to conduct a systematic literature review to evaluate the effectiveness and safety of TXA in reducing bleeding in hip arthroplasty. Materials and methodsA systematic literature review and meta-analysis of primary studies similar to controlled trials was performed. Literature was searched in MEDLINE, Embase, Cochrane, LILACS, SciELO and Google Scholar. The review was proposed and undertaken by two reviewers and the inclusion criteria were: (a) patients undergoing arthroplasty for primary unilateral hip replacement; (b) comparison of a treatment group with TXA to a control group that received a placebo or no treatment at all, and (c) outcome measures, total blood loss, number of patients receiving allogeneic transfusion and/or incidence of thromboembolic complications. The search was restricted to studies published from 1966 to June 2013. ResultsA total of 16 studies with 246 patients were retrieved for this review. The total blood loss outcome evidenced a weighted mean difference in favor of TXA vs. controls undergoing hip arthroplasty (−0.45 [P<0.001, 95% CI −0.65 to −0.24]). Weighted relative risk was estimated for the allogeneic transfusion requirement outcome, showing a trend in favor the TXA arm, with fewer patients requiring allogeneic transfusion in hip surgery (0.8 [P<0.02, 95% CI 0.57–1.11]); however, this trend was not statistically significant. LimitationsThere is a noticeable difference in methods for quantifying total blood loss across the studies reviewed. The need for transfusion outcomes is probably not significant taking into account the number of events in the TXA group. ConclusionsTXA can be routinely used to reduce intra- and post-operative blood loss in primary hip arthroplasty.

Incidence of venous thromboembolic complications in instrumental spinal surgeries with preoperative chemoprophylaxis.

ObjectiveVenous thromboembolism (VTE) after spinal surgery affects a patients' postoperative recovery and also carries a mortality risk. Some studies recommended chemical prophylaxis for high-risk patients and for those after complex spinal surgeries. However, chemoprophylaxis for VTE in spinal surgery is underemployed and there is no agreement on the use of VTE prophylaxis in spinal surgery. The aim of this study was to document the incidence of VTE after an elective instrumental spinal surgery, among those receiving preoperative chemoprophylaxis as compared with patients who did not receive it.MethodsThis study was carried out on eighty-nine patients allocated randomly to receive either low molecular weight heparin (LMWH) or no prophylaxis before elective instrumental spinal surgery. All patients received postoperative compression stockings. A compression Doppler ultrasonography was performed for all patients to detect postoperative deep vein thrombosis. In addition, further imaging studies were performed for patients suspected of VTE.ResultsThree (3.3%) patients were diagnosed with VTE. One of them had received preoperative chemoprophylaxis. There were no significant difference in incidence of VTE between the two groups (p>0.95; 95% confidence interval, 0.06-8.7). Laterality of gender and postsurgical recumbence duration were all independent predictors of VTE (p=0.01 and p<0.001, respectively).ConclusionThe difference in the incidence of thromboembolic complications between the two groups was not significant. Moreover, we found that preoperative prophylactic LMWH injection has no major bleeding complications altering postoperative course; still, the issue concerning the initiation time of chemoprophylaxis in spinal surgery remains unclear.

Thromboembolic Prophylaxis in Neurosurgical Practice: A Review

Purpose: Literature is ambiguous on the incidence of deep venous thrombosis and pulmonary embolism by neurosurgical patients. The objective of this systematic review is to assess the incidence of thromboembolic complications associated with neurosurgical interventions, evaluate current prophylaxis methods and propose a prophylaxis strategy. Methods: PubMed, Embase and Cochrane Central were searched systematically and studies involving neurosurgical procedures describing postoperative complications DVT and PE. The risk of bias was assessed using (adjusted) Cowley criteria. Results: Twenty studies (14 case series, 3 comparative studies, 3 RCT’s) were included, describing 8905 neurosurgical patients. Without prophylaxis the incidence of DVT was reported in 28% of neurosurgical cases (range 21-34%). Studies that provided any kind of prophylaxis, in which clinical evaluation was used to diagnose DVT, reported a 2.5% incidence of DVT (range 0 to 5%), however, when systematically assessed with ultrasound the occurrence was 6.4% (range 0-17%). Pulmonary embolism was presented in 0 to 4% of all cases. Venous thromboembolic events were more frequent in intracranial procedures compared to spinal procedures. Patients, receiving a combination of low molecular weight heparins and compression stockings, showed a 50% lower incidence of DVT than patients receiving mechanical or chemical prophylaxis alone. Conclusion: Optimal antithrombotic prophylaxis regime in neurosurgical interventions lowers the incidence of DVT’s from 28% to about 3 to 6%. We recommend a combination of LMWH and compression stockings for intracranial procedures. For spinal procedures this same prophylactic regimen is indicated, however it is defendable to choose single treatment with LMWH or compression stockings alone.

Efectividad del ácido tranexámico en las pérdidas sanguíneas perioperatorias en la artroplastia de cadera: revisión sistemática de la literatura y metaanálisis

Introduction and objectiveTranexamic acid (TXA) is an antifibrinolytic drug used to reduce bleeding in mortality risk situations such as trauma. Our objective was to conduct a systematic literature review to evaluate the effectiveness and safety of TXA in reducing bleeding in hip arthroplasty. Material and methodsA systematic literature review and meta-analysis of primary studies similar to controlled trials was performed. Literature was searched in MEDLINE, Embase, Cochrane, LILACS, SciELO and Google Scholar. The review was proposed and undertaken by 2 reviewers and the inclusion criteria were: a) patients undergoing arthroplasty for primary unilateral hip replacement; b) comparison of a treatment group with TXA to a control group that received a placebo or no treatment at all, and c) outcome measures, total blood loss, number of patients receiving allogeneic transfusion and/or incidence of thromboembolic complications. The search was restricted to studies published from 1966 to June 2013. ResultsA total of 16 studies with 246 patients were retrieved for this review. The total blood loss outcome evidenced a weighted mean difference in favor of TXA vs. controls undergoing hip arthroplasty (−0.45 [P<0.001, 95% CI −0.65 to −0.24]). Weighted relative risk was estimated for the allogeneic transfusion requirement outcome, showing a trend in favor the TXA arm, with fewer patients requiring allogeneic transfusion in hip surgery (0.8 [P<0.02, 95% CI 0.57 to 1.11]); however, this trend was not statistically significant. LimitationsThere is a noticeable difference in methods for quantifying total blood loss across the studies reviewed. The need for transfusion outcomes are probably not significant taking into account the number of events in the TXA group. ConclusionsTXA can be routinely used to reduce intra- and post-operative blood loss in primary hip arthroplasty.

Low-dose recombinant factor VIIa for reversing coagulopathy in patients with isolated traumatic brain injury

PurposeThe purpose of this study was to investigate the role of low-dose recombinant factor VIIa (rFVIIa) (20 μg/kg) in reversing coagulopathy in patients with isolated traumatic brain injury (TBI). Materials and methodsPatients with isolated TBI and coagulopathy at admission were enrolled prospectively from January 2010 to December 2011. The patients were divided into 2 groups: the rFVIIa and the no-rFVIIa groups. In the rFVIIa group, patients received a single dose of 20 μg/kg rFVIIa intravenously to reverse their coagulopathy in addition to blood products. Patients in the no-rFVIIa group received only blood products to correct the coagulopathy. The clinical outcome variables evaluated included changes in coagulation parameters after administration for reversing coagulopathy, the occurrence of progressive hemorrhagic injury (PHI), intensive care unit length of stay, the incidence of thromboembolic complications, inhospital mortality, and 90-day Glasgow Outcome Scale. ResultsEighty-seven patients were ultimately included in this study. Of them, 49 patients were treated with blood products alone, whereas 38 patients also received rFVIIa to reverse their coagulopathy. The improvement in international normalized ratio was greater in the rFVIIa group (0.26 [0.18-0.39]) than in the no-rFVIIa group (0.06 [−0.11 to 0.30]) (P = .001). In addition, the improvement in lactate was also greater in the rFVIIa group (0.33 [−0.18 to 0.54]) than in the no-rFVIIa group (0.04 [−0.25 to 0.20]) (P = .029). During the period after we began to correct the coagulopathy, PHI occurred in 19 patients (38.8%) in the no-rFVIIa group, which was significantly higher than that in the rFVIIa group (7, 18.4%; P = .040). The rate of cerebral infarction was similar in both groups (10.2% vs 5.3%). There was a trend indicating that low-dose rFVIIa therapy was associated with a lower mortality, but the association was not statistically significant (P = .266). ConclusionsThe use of low-dose rFVIIa (20 μg/kg) is effective for correcting coagulopathy in patients with TBI without an increase in thromboembolic events. Moreover, it is more effective for preventing the occurrence of PHI.

Thromboembolic complications in children after spinal fusion surgery.

Retrospective review. To identify the incidence of venous thromboembolic (VTE) complications and pulmonary embolism (PE) in children undergoing spinal fusion surgery, to report associated mortality, and to analyze factors associated with their development. The incidence of these complications after pediatric spinal fusion surgery is unknown. The Nationwide Inpatient Sample database was queried from 2001 through 2010 to identify children (≤18 yr) who had spinal fusion surgery. Patients who had deep venous thrombosis or PE during the hospital stay were identified using appropriate International Classification of Diseases, Ninth Revision, Clinical Modification codes. Univariate and multivariate logistic regression models were used for analysis; statistical significance was set at P less than 0.05. Depending on the year, the incidence of VTE in children varied from 9.6 to 38.5 events per 10,000 spinal fusions (mean: 21 events per 10,000 spinal fusions), and the incidence of PE varied from 0 to 6 events per 10,000 spinal fusions (mean: 2 events per 10,000 spinal fusions); there were no in-hospital VTE-associated mortalities. On multivariate logistic regression analysis, only patient diagnosis was found to be significantly associated with VTE development. VTE incidence was significantly higher in children with congenital scoliosis, syndromic scoliosis/kyphoscoliosis, and thoracolumbar fractures than in children with idiopathic scoliosis (odds ratios: 4.21, 7.14, and 12.59, respectively). On univariate analysis, in addition to diagnosis, age was also found to be significantly associated with VTE development. For each year of age, the VTE incidence increased 1.37-fold (P < 0.01). The incidence of thromboembolic complications in children was approximately 21 events per 10,000 spinal fusions. A higher incidence of VTE in children was associated with older age and certain diagnoses (congenital scoliosis, syndromic scoliosis/kyphoscoliosis, and thoracolumbar fractures). PE in children was rare and not associated with fatality.

Topical versus intravenous tranexamic acid as a blood conservation intervention for reduction of post-operative bleeding in hemiarthroplasty.

Background:This study was performed to test the effectiveness of topical tranexamic acid (TXA) in reducing blood loss in pelvic hemiarthoplasty surgeries compared with intravenous TXA, regarding the incidence of thromboembolic complications (deep vein thrombosis [DVT], pulmonary embolism (PE) and cerebrovascular stroke [CVS]).Patients and Methods:After obtaining institutional ethical approval 60 patients divided into three groups. Group A: Received intravenous TXA Group B: Received topical TXA Group C: Control group (placebo saline). All patients were received general anesthesia and post-operative bleeding, immediate and 24 h post-operatively, hemoglobin concentration, hematocrit, platelets and coagulation profile (prothrombin time, activated partial thromboplastin time and international normalized ratio) baseline, immediate and 24 h post-operatively. Thromboelastography was recorded baseline, immediate and 24 h post-operatively. Incidence of DVT, PE and CVS was recorded.Results:There was statistical significant elevation hemoglobin concentration and hematocrit in both Groups A and B, significant increase in blood loss in Group C, significant increase in number of patients receiving blood in Group C, there was a significant decrease in “r” and “k” times and a significant increase in maximum amplitude and α-angle in Group A, statistically significant increase in the incidence of thromboembolic events in the form of DVT, PE and CVS in Group A.Conclusion:Topical TXA is effective in decreasing post-operative blood loss with possible side-effects of this route of administration.

Tranexamic acid and the reduction of blood loss in total knee and hip arthroplasty: a meta-analysis

BackgroundTranexamic acid (TXA) is an antifibrinolytic drug used as a blood-sparing technique in many surgical specialties. The principal objective of our meta-analysis was to review randomized, controlled trials (RCT) comparing total blood loss and the number of patients receiving allogeneic blood transfusions with and without the use of TXA for knee (TKA) and hip (THA) arthroplasty.MethodsStudies were included if patients underwent primary unilateral TKA or THA; the study involved the comparison of a TXA treatment group to a control group who received either a placebo or no treatment at all; outcome measures included total blood loss TBL, number of patients receiving allogeneic blood transfusions, and/or incidence of thromboembolic complications; the study was a published or unpublished RCT from 1995 – July 2012.ResultsData were tested for publication bias and statistical heterogeneity. Combined weighted mean differences in blood loss favoured TXA over control for TKA and THA patients respectively [ −1.149 (p < 0.001; 95% CI −1.298, -1.000), -0.504 (p < 0.001; 95% CI, -0.672, -0.336)]. Combined odds ratios favoured fewer patients requiring allogeneic transfusions for TKA and THA with the use of TXA respectively [0.145 (p < 0.001; 95% CI, 0.094, 0.223), 0.327 (p < 0.001; 95% CI, 0.208, 0.515)]. Combined odds ratios indicated no increased incidence of DVT with TXA use in TKA and THA respectively [1.030 (p = 0.946; 95% CI, 0.439, 2.420), 1.070 (p = 0.895; 95% CI, 0.393, 2.911)].ConclusionsTXA should be considered for routine use in primary knee and hip arthroplasty to decrease blood loss.

Continuous Flow Left Ventricular Assist Device Patients Are Not at Higher Risk of Gastrointestinal Bleeding with More Aggressive Anticoagulation

Purpose Continuous flow left ventricular assist devices (CF-LVADs) have become a cornerstone of heart failure therapy. The risk of gastrointestinal bleeding has been noted to be higher in these CF-LVAD patients than in previous generations of pulsatile flow LVADs. A more aggressive anticoagulation regimen could reduce the incidence of thromboembolic complications. Our aim was to evaluate the risk of gastrointestinal bleeding (GIB) before and after the initiation of an aggressive anticoagulation regimen. Methods and Materials 137 consecutive patients received a CF- LVAD with either a Heartmate II, Heartware or VentrAssist device. We undertook a retrospective review of our database of our single institution experience. We divided patients into two groups, one group was implanted prior to 3/15/2011 under a more conservative anticoagulation protocol and the second group was implanted after 3/15/2011 under a more aggressive anticoagulation protocol. Results The 6 month and 1 year mortality in our patients were 14.3% and 30.9% respectively. Gastrointestinal bleeding occurred in 25 patients with a total of 45 bleeding episodes for an overall rate of 0.53 bleeding episodes per patient year on support. When broken out into conservative and aggressive anticoagulation groups the bleeding rate was 0.51 and 0.63 per patient years on support, which was not statistically different. There were 9 patients (36%) with recurrent GIBs. In patients who suffered a GIB the average INR at the time of the bleeding episode was 2.1, and 57.8% of patients were on a full anticoagulation regimen at the time of their bleeding event. Conclusions CF-LVADs will continue to play a major role in the management of end stage heart failure. We have shown that a more aggressive management strategy for anticoagulation in an effort to reduce thromboembolic complications is safe and does not lead to a significant increase in GIB events in our population.