Mechanical Thromboprophylaxis Research Articles

Variations in practice of thromboprophylaxis across general surgical subspecialties: a multicentre (PROTECTinG) study of elective major surgeries.

Despite guidelines recommending perioperative thromboprophylaxis for patients undergoing general surgery, we have observed significant variations in its practice. This may compromise patient safety. Here, we quantify the heterogeneity of perioperative thromboprophylaxis across all major general surgical operations, and place them in relation to their risk of bleeding and venous thromboembolism. Retrospective review of all elective major general surgeries performed between 1 January 2018 and 30 June 2019 across seven Victorian hospitals was conducted. A total of 5912 patients who underwent 6628 procedures were reviewed. Significant heterogeneity was found in the use of chemoprophylaxis, timing of its initiation, type of anticoagulant administered and application of extended chemoprophylaxis. These variations were observed within the same procedure, and between different surgeries and subspecialties. Contrastingly, there was minimal heterogeneity with the use of mechanical thromboprophylaxis. Oesophago-gastric, liver and colorectal cancer resections had the highest thromboembolic risk. Breast, oesophago-gastric, liver, pancreas and colon cancer resections had the highest bleeding risk. Perioperative chemoprophylaxis across general surgery is highly variable. This study has highlighted key areas of variance. Our findings also enable surgeons to compare their practices, and provide baseline data to inform future efforts towards optimizing thromboprophylaxis for general surgical patients.

Incidence of Silent Deep Venous Thrombosis after Laparoscopic Bariatric Surgery in Patients Who Received Combined Mechanical and Chemical Thromboprophylaxis Compared to Patients Who Received Mechanical Thromboprophylaxis Only.

Background. This prospective randomized study compares the incidence of silent deep venous thrombosis (DVT) among 2 groups of patients who underwent laparoscopic bariatric surgery. The first group received mechanical thromboprophylaxis only, while the second group received a combination of mechanical and chemical thromboprophylaxis. Methods. This study included 150 morbidly obese patients who underwent primary one-stage laparoscopic bariatric surgery (sleeve gastrectomy and mini-gastric bypass) over a 6-month period. Patients were randomly assigned to 2 groups: group A (n = 75) was subjected to mechanical thromboprophylaxis in the form of perioperative elastic stockings on both lower limbs and early postoperative ambulation, and group B (n = 75) was subjected to combined mechanical thromboprophylaxis and chemical thromboprophylaxis in the form of 40mg subcutaneous enoxaparin 12hours before surgery and postoperative enoxaparin (40mg subcutaneous every 24hours) for 2weeks. Bilateral lower limb venous duplex was done for all patients before discharge, on the second and fourth weeks postoperatively, to detect silent DVT. Results. Nine patients out of 150 patients developed silent DVT (6%). All patients among group A were subjected to mechanical thromboprophylaxis only (12%) [P = .247, relative risk: .45, 95% confidence interval; .37-.62]. There was no silent DVT among group B who received combined mechanical and chemical thromboprophylaxis. No bleeding complications were reported in both groups. Conclusion. Combined mechanical and mechanical thromboprophylaxis is effective and safe in the prevention of silent DVT after laparoscopic bariatric surgery. Trial registration: The trial was registered in the Thai Clinical Trials Registry (TCTR20200127002) on January 20, 2020 retrospectively.

RIVAROXABAN IN THE PROPHYLAXIS AGAINST VENOUS THROMBOEMBOLISM AFTER TOTAL KNEE ARTHROPLASTY- A PROSPECTIVE STUDY IN A TERTIARY CARE CENTRE

Background: Venous thromboembolism (VTE) is a major healthcare problem that affects more than 1.6 million persons each year worldwide. Patients undergoing major orthopedic surgery, total knee arthroplasty (TKA), and total hip arthroplasty (THA) are at high risk for developing VTE, which can manifest as deep vein thrombosis (DVT) or pulmonary embolism (PE), and PE can be life-threatening. It is a preventable complication of in-hospital mortality.
 The prophylaxis to prevent VTE varies from vitamin K antagonists like warfarin, low molecular weight heparin like enoxaparin, Fondaparinox sodium, direct factor Xa inhibitor like rivaroxaban and apixiban, mechanical thromboprophylaxis.
 Materials and Methods: Presented is a prospective study to see the efficacy of Oral rivaroxaban 10mg once daily dose for 14 days in the prevention of VTE in 60 elective cases total knee arthroplasty. The study was done from June 2017- October 2018 in the department of orthopaedics, Prathima institute of medical sciences, Nagunur, Karimnagar. All the operated cases were cemented with cruciate retaining prosthesis. Oral Rivaroxaban 10mg was given after 6-8 hours after wound closure and continued for 14 days. All the patients were closely monitored for signs and symptoms of DVT, PE with Wells DVT score followed by venous angiogram and signs of pulmonary embolism evaluated with modified Gurd and Wilson criteria and subsequent CT pulmonary angiogram.
 Results: In study involving 60 primary total knee replacement cases, only one patient developed deep venous thromboembolism (1.6%) with oral Rivaroxaban. No cases of bleeding manifestations or pulmonary embolism were reported.
 Conclusion: once daily oral dose of rivaroxaban 10mg for 14 days is an effective modality in preventing the number of cases of VTE after Total knee arthroplasty. The ease of administration of oral agents compared to subcutaneously given agents like Enoxaparin will lead to better patient compliance and early discharge from hospital.
 Key words: Venous thromboembolism, Total knee arthroplasty, Rivaroxaban, Deep vein thrombosis, Pulmonary embolism

Dual mechanical and pharmacological thromboprophylaxis decreases risk of pulmonary embolus after laparotomy for gynecologic malignancies

ObjectivesPatients with gynecologic malignancies have high rates of post-operative venous thromboembolism. Currently, there is no consensus for peri-operative thromboprophylaxis specific to gynecologic oncology. We aimed to compare rates of symptomatic...

An International Survey on the Use of Thromboprophylaxis in Urological Surgery

BackgroundThe use of perioperative thromboprophylaxis in urological surgery is common but not standardized. ObjectiveTo characterize international practice variation in thromboprophylaxis use in urological surgery. Design, setting, and participantsWe conducted a scenario-based survey addressing the use of mechanical and pharmacological thromboprophylaxis in urological cancer procedures (radical cystectomy [RC], radical prostatectomy [RP], and radical nephrectomy [RN]) among practicing urologists in Canada, Finland, and Japan. The survey presented patient profiles reflecting a spectrum of risk for venous thromboembolism; the respondents described their clinical practice. Outcome measurements and statistical analysisThe proportion of respondents who routinely used (1) mechanical, (2) pharmacological, and (3) extended pharmacological prophylaxis was stratified by procedure. A logistic regression identified characteristics associated with thromboprophylaxis use. Results and limitationsOf 1051 urologists contacted, 570 (54%) participated in the survey. Japanese urologists were less likely to prescribe pharmacological prophylaxis than Canadian or Finnish urologists (p < 0.001 for all procedures). Canadian and Finnish urologists exhibited large variation for extended pharmacological prophylaxis for RP and RN. Finnish urologists were most likely to prescribe extended prophylaxis versus Canadian and Japanese urologists (RC 98%, 84%, and 26%; Open RP 25%, 8%, and 3%; robotic RP 11%, 9%, and 0%; and RN 43%, 7%, and 1%, respectively; p < 0.001 for each procedure). Less variation was found regarding the prescription of mechanical prophylaxis, which was most commonly used until ambulation or discharge. The length of hospital stay was longer in Japan and may bias estimates of extended prophylaxis in Japan. ConclusionsWe found large variation in clinical practice regarding pharmacological thromboprophylaxis within and between countries. Knowledge translation of evidence-based guidelines may reduce problematic international variation in practice. Patient summaryUse of medications to decrease blood clots after urological cancer surgery differs within and between countries. Closer adherence to urology guidelines addressing the prevention of blood clots may decrease this variation and improve patient outcomes.

Thromboprophylaxis in elective spinal surgery: A protocol for systematic review.

Venous thromboembolism (VTE) is a serious, sometimes life-threatening complication that can occur following spine surgery. The incidence of VTE, and the optimal type and timing of thromboprophylaxis for this complication in elective spine surgery is a matter of debate. To perform a systematic review with the aim of clarifying the efficacy and adverse effects of mechanical and chemical prophylaxis for preventing thromboembolic complications in elective spine surgery for conditions other than trauma and malignant disease. A search strategy of related articles up to March 2018 was designed and executed in Medline and Embase. adolescents (>10 years) and adults undergoing elective surgery for spinal deformity or degenerative disease (from C1 to S1). Perioperative mechanical and chemical thromboprophylaxis. Studies could be randomized controlled trials or observational studies that reported data on any relevant clinical outcomes. In total, 2451 uniquecitations were identified and 35 studies were ultimately included in the systematic review. The overall mean incidence of complications was 3.7% for deep venous thrombosis, 0.0% for pulmonary embolism, and 3.7% for bleeding in chemoprophylaxis group; 2.9% for deep venous thrombosis, 0.4% for pulmonary embolism and 0.0% for bleeding in mechanoprophylaxis; and 0.7% for deep venous thrombosis, 0.1% for pulmonary embolism and 0.2% for bleeding in mixed prophylaxis group with no specific data on these rates for the type of patient and type and location of surgery. None of the articles retrieved provided information on the adolescent population. The poor design and high variability among the studies regarding characteristics of study population, details of interventions, and definitions of outcomes, determines a low quality of the available evidence and limits the interpretation of the results. We were unable to identify a clear advantage of one type of thromboprophylaxis over the other, although there was an increased risk of bleeding with chemoprophylaxis, which could favor the use of mechanoprophylaxis in this scenario.

Outcome of Anticoagulant Therapy Following Bariatric Surgery

Abstract Background Bariatric surgery remains the most effective means of treating severe obesity. The number of severely obese patients is increasing and, consequently, more people are seeking bariatric surgery. Aim of the Work The Aim of This Study is to Outcome of Anticoagulant during Bariatric Surgery and Relation of Bariatric Surgery to Coagulopathy Disease. Patients and Methods This prospective study was conducted on 50 morbidly obese patients admitted to Hospital (Ahmed Maher Teaching Hospital and Ain Shams University Hospitals), for a primary one-stage laparoscopic bariatric surgery procedure over a 6-month period. The study is performed on 50 Patients, Who met all Inclusion criteria and none of Exclusion criteria. Results The study revealed no statistically significant difference between Enoxaparin and Rivaroxaban according to outcome of anti-coagulation therapy following bariatric surgery. Conclusion a high protective value of Chemical Thromboprophylaxis combined to Mechanical Thromboprophylaxis in preventing DVT safely. New Oral Anticoagulant drugs showed equal and may be superimposed the other traditional anticoagulant, but it needs more studies regarding its prophylactic dose, number of patient and its cost benefit in comparison with other Anticoagulant drugs were used in our study or other studies we mentioned above.

Relationship Between the Incidence of Deep Vein Thrombosis During Hospitalization and the Energy of Injury in Tibial Plateau Fractures.

This study aimed to investigate the relationship between the incidence of deep vein thrombosis (DVT) during hospitalization and the energy of injury in tibial plateau fractures (TPFs). One hundred and forty patients were enrolled between September 1, 2014, and October 1, 2017. According to Schatzker’s classification, they were classified into the low-energy (type I-III) and high-energy (type IV-VI) groups. For DVT evaluation, duplex ultrasonography was performed in the lower extremities preoperatively and postoperatively. The location and changes of DVT were recorded. All patients underwent mechanical and chemical thromboprophylaxis. The incidence of DVT in TPFs was 36.43% and 46.43% preoperatively and postoperatively, respectively. The DVT incidence was 31.75% (20/63) in the low-energy group and 40.26% (31/77) in the high-energy group preoperatively, and 44.44% (28/63) in the low-energy group and 48.05% (37/77) in the high-energy group postoperatively. There was no significant difference between the 2 groups preoperatively (P = .298) and postoperatively (P = .785). The days between operation and discharge (P = .016), blood loss during surgery (P = .016), and preoperative d-dimer level (P = .02) showed differences between the 2 groups. Additionally, 29 new thrombi (14 [48.28%] in the high-energy group and 15 [51.72%] in the low-energy group) appeared and 16 preoperative thrombi disappeared postoperatively. Despite mechanical and chemical thromboprophylaxis, the DVT risk in patients with TPFs remains high. Although the DVT incidence is not significantly different between high-energy and low-energy injuries, the occurrence of DVT should be carefully monitored.

Mechanical prophylaxis, early mobilisation and risk stratification: as effective as drugs for low risk patients undergoing primary joint replacement. Results in 13,384 patients

IntroductionCurrent NICE Guidelines state that all patients undergoing total hip and knee arthroplasty should be given both mechanical and chemical prophylaxis. At our institution, a targeted thromboprophylaxis policy has been in place since October 1999. The aim of this study was to calculate our venous thromboembolism rates and compare these to published rates in the literature. MethodsAll patients are pre-operatively assessed for their VTE risk. Patients are stratified into high or low risk: all patients received mechanical thromboprophylaxis and the higher risk patients now receive chemical and mechanical thromboprophylaxis post op. Patients are reviewed at 2, 6 and 52 weeks and with annual postal questionnaires and clinical and radiological review at 5 and 10yrs. Results13,384 primary THA and TKAs were entered into the database. The overall rate of clinically apparent DVT and overall PE rates of 0.48% and 0.42% respectively. 86.16% of our patients were low risk, of these 23.3% of patients were on Aspirin/Clopidogrel with mechanical thromboprophylaxis and 76.7% of patients had mechanical prophylaxis alone. There was no statistical difference between the DVT or PE rates in the low risk groups. ConclusionOur results show that use of early mobilisation and mechanical prophylaxis within an Enhanced Recovery Programme results in comparable VTE rates to chemical prophylaxis for all, which is reflected in the literature. Our results question the need for chemical thromboprophylaxis or extended use of mechanical thromboprophylaxis in “lower risk” patients if a risk stratification policy is used in the context of modern surgical approaches.

PCV8 EFFICACY OF VENOUS EXERCISE FOR THE CHANGE OF VENOUS FLOW VELOCITY AMONG PREGNANT WOMEN

Thromboembolism is one of the main causes of pregnancy-related deaths, which is preventable. Our aim was to measure the efficacy of a 2-month venous exercising on the venous flow velocity (VFV) among pregnant women. The study was preformed between 2018-2019. There were 11 women in the intervention and 5 in the control group (mean age: 21-33 years). The VFV was measured with a Hadeco BIDOP ES-100 V II Doppler ultrasound. The circumference of the thigh and calf were tested by tape measure, and body weight was registered. For statistical analysis SPSS 22.0 version was used. In the intervention group at the 1st (5.20, 6.18 cm/s; p=0.005), 8th (5.82, 7.12 cm/s; p=0.040) and 16th (6.48, 7.5cm/s; p=0.004) training occasion the post-exercise VFV was significantly higher than the pre-exercise in the left leg. There was a significant increase in VFV of the right leg at the 1st (5.22, 5.98 cm/s; p=0.009) and 16th (6,50, 7,48 cm/s; p=0.013) occasion. At the 16th training occasion, the measured pre-exercise VFV was significantly higher than the pre-exercise VFV measured at the 1st occasion (left leg: 6.48, 5.20 cm/s; p=0.007), (right leg: 6.50, 5.22 cm/s; p=0.010). The post-exercise circumference of the thigh was significantly lower at the 8th (right leg: 51.60, 48.20 cm; p=0.028) and 16th (left leg: 51.40, 49.60 cm; right leg: 51.00, 49.20 cm; p=0.009) occasion than prior to the exercise. In the calf at the 8th and 16th occasion pre-exercise VFV for the left and right leg was significantly (p<0.05) higher than in the control group. In the intervention group, pre-exercise VFV measured at the 16th occasion was significantly higher in the left and right leg (p<0.05) than in the control group. Venous exercise can also be an effective method from active mechanical thromboprophylaxis treatments for pregnant women.

Antithrombotic prophylaxis for surgery-associated venous thromboembolism risk in patients with inherited platelet disorders. The SPATA-DVT Study.

Major surgery is associated with an increased risk of venous thromboembolism (VTE), thus the application of mechanical or pharmacologic prophylaxis is recommended. The incidence of VTE in patients with inherited platelet disorders (IPD) undergoing surgical procedures is unknown and no information on the current use and safety of thromboprophylaxis, particularly of low-molecular-weight-heparin in these patients is available. Here we explored the approach to thromboprophylaxis and thrombotic outcomes in IPD patients undergoing surgery at VTE-risk participating in the multicenter SPATA study. We evaluated 210 surgical procedures carried out in 155 patients with well-defined forms of IPD (VTE-risk: 31% high, 28.6% intermediate, 25.2% low, 15.2% very low). The use of thromboprophylaxis was low (23.3% of procedures), with higher prevalence in orthopedic and gynecological surgeries, and was related to VTE-risk. The most frequently employed thromboprophylaxis was mechanical and appeared to be effective, as no patients developed thrombosis, including patients belonging to the highest VTE-risk classes. Low-molecular-weight-heparin use was low (10.5%) and it did not influence the incidence of post-surgical bleeding or of antihemorrhagic prohemostatic interventions use. Two thromboembolic events were registered, both occurring after high VTE-risk procedures in patients who did not receive thromboprophylaxis (4.7%). Our findings suggest that VTE incidence is low in patients with IPD undergoing surgery at VTE-risk and that it is predicted by the Caprini score. Mechanical thromboprophylaxis may be of benefit in patients with IPD undergoing invasive procedures at VTE-risk and low-molecular-weight-heparin should be considered for major surgery.

Chemoprophylaxis in addition to mechanical prophylaxis after total knee arthroplasty surgery does not reduce the incidence of venous thromboembolism

BackgroundVenous thromboembolism (VTE) of the lower limbs is an important complication post total knee arthroplasty (TKA). Current guidelines recommend routine chemical prophylaxis to all patients undergoing this procedure but this is rarely done in Asia as it is believed that Asians have a lower risk of VTE. However, recent evidence suggests otherwise.AimsWe evaluated the incidence of DVT after TKA in a multi-ethnic Asian population with and without pharmacological prophylaxis, as well as the management and outcome of patients with post-operative DVTs.MethodsWe conducted a retrospective study of consecutive patients who underwent TKA in our hospital from 1st January 2004 to 30th December 2014. All patients were on mechanical thromboprophylaxis via calf pumps after TKA with a postoperative day 3 to 5 doppler ultrasound (DUS) of bilateral lower limbs. 2258 (80.7%) patients did not receive additional chemoprophylaxis, while 540 (19.3%) received chemoprophylaxis on top of mechanical thromboprophylaxis. All patients who received chemoprophylaxis were administered the drug until they were ambulating, with a median administration duration of 6 days. Patients were followed up for a period of 3 months for recurrence of DVTs and 24 months for postoperative outcome scores.ResultsTwo thousand nine hundred seventy-eight patients had DUS of the lower limbs with 134 diagnosed with DVT giving an incidence of 4.5%. Six of these patients had concurrent PEs. There were 26 (19.4%) proximal DVTs and 108 (80.6%) distal DVTs. After 3 months of follow up, no additional VTE occurred. None of the DVTs or PEs progressed.All DVTs with accompanying PE were proximal. 102 out of 2200 patients (4.6%) without chemoprophylaxis developed DVT as compared to 32 out of 540 patients (5.9%) with chemoprophylaxis, which was not statistically significant (p = 0.13). 19 (0.8%) proximal and 83 (3.8%) distal DVT developed in the patient group without chemoprophylaxis while 4 (0.7%) proximal and 28 (5.2%) distal DVT developed in the patient group with (p = 0.62). Comparison of the incidence of PEs between the two groups, revealed a similar incidence with 5 out of 2200 patients (0.2%) without chemoprophylaxis developing PE as compared to 1 out of 540 patients (0.2%) with chemoprophylaxis (p = 0.87).In addition, patients with chemoprophylaxis showed an association with higher post-operative outcome scores such as post op 6 months SF36 (PCS), post op 12 months SF36 (PCS), post op 12 months SF36 (MCS), post op 24 months SF36 (MCS) and post op 24 months WOMAC.ConclusionIn one of the largest Asian studies specifically investigating the incidence of DVT after TKA, we found that the incidence is low at 4.5%. This is in contrast to recent studies that showed higher post-operative VTE rates similar to Western populations. In addition, patients who were administered chemoprophylaxis did not have a statistically significant difference in incidence of VTE although it did show a correlation with higher post-operative outcome scores which may indicate better function. This was seen in functional outcome scores such as post op 6 months SF36 (PCS), post op 12 months SF36 (PCS), post op 12 months SF36 (MCS), post op 24 months SF36 (MCS) and post op 24 months WOMAC.

Primary thromboprophylaxis in hospitalized children: A multi-center retrospective analysis

Background/objectivesHospital acquired venous thromboembolism in children is associated with significant morbidity/mortality. Prevention strategies include sequential compression devices and prophylactic anticoagulation but these interventions carry risk and are poorly studied in children.Objectives were to evaluate primary thromboprophylaxis use in hospitalized children over time and the associated bleeding risk. Materials and methodsRetrospective study of hospitalized patients aged 10–18 years within the Pediatric Health Information System administrative database from January 2008–September 2015. Factors associated with thromboprophylaxis receipt and bleeding were identified using generalized linear mixed effects models. ResultsOf 1,075,383 hospitalizations, 10,544 (1%) received prophylactic enoxaparin and 58,768 (5%) received mechanical compression. Mechanical thromboprophylaxis increased slightly over time (4.3% in 2008, 6.2% in 2015), enoxaparin use did not (0.8% in 2008, 1.2% in 2015). Patients aged 16–18 were more likely than younger children (10−12) to receive pharmacologic (adjusted odds ratio [aOR] 3.1, 95% confidence interval [CI] 2.9–3.3) or mechanical thromboprophylaxis (aOR 2.9, 95% CI 2.9–3). Patients on rehabilitation medical service were more likely to receive prophylactic enoxaparin (aOR 53, 95% CI 44.1–64.5). 5.6% (589/10,544) of patients receiving enoxaparin prophylaxis had bleeding. Thromboprophylaxis use by hospital varied with a range of 0.25–3.3% for enoxaparin and 2–26.2% for mechanical compression. ConclusionThromboprophylaxis is infrequently utilized in hospitalized children. Pharmacologic prophylaxis with enoxaparin remains low and has not substantially increased over time. Significant variability exists across hospitals and services in the administration of both mechanical and pharmacologic thromboprophylaxis highlighting the need for further evidence to standardize practice.

Absence d’efficacité de la compression pneumatique dans la thromboprophylaxie des arthroplasties totales de genou à faible risque

IntroductionPurpose of this study was to assess whether the intermittent pneumatic compression (IPC) device would be an effective prophylaxis for deep vein thrombosis (DVT) following total knee arthroplasty (TKA) in a low incidence population.Hypothesis The mechanical thromboprophylaxis could reduce the incidence of DVT compared to non-prophylaxis group and would have similar efficacy as the chemoprophylaxis following TKA in a low DVT incidence population. Materials and methodsFrom January 2009 to June 2016, 1259 elective primary TKA with preoperative diagnosis of primary osteoarthritis in a single institute were enrolled. Patients were divided into three groups: those who were managed with chemoprophylaxis (CPX group, 414 cases), with mechanical prophylaxis (IPC group, 425 cases), or without pharmacological and mechanical prophylaxis (control group, 420 cases). All patients underwent preoperative ultrasonography and computed tomographic venography on postoperative day 6 to assess development of DVT. The incidence of overall, proximal, symptomatic DVT and symptomatic pulmonary embolism (PE) were compared among the groups. Major and minor bleeding complications were also evaluated. ResultsThe incidence of overall DVT was 14.8% in control group, 6.3% in CPX group and 11.3% in IPC group respectively and CPX group showed significantly lower incidence than other two groups (p<0.001). The incidence of proximal DVT was 1.9% in control group, 0.7% in CPX group and 0.9% in IPC group respectively (p>0.05). The incidence of symptomatic DVT was 0.7% in control group, 0% in CPX group and 0.7% in IPC group respectively (p>0.05). There was no case of symptomatic PE diagnosed during hospital stay in all patients. DiscussionSingle use of IPC device could not reach significant level of DVT prophylaxis compared to control group and only chemoprophylaxis showed significantly reduce the incidence of overall DVT following TKA. Single use of IPC device does not show effective thromboprophylaxis in a low DVT incidence population. Level of evidenceIII, Case control study.

Effect of Active and Passive Mechanical Thromboprophylaxis and Consensual Effect on the Venous Blood Flow Velocity Among Hemiparetic Patients.

Our aim was to measure the venous blood flow velocity (VBFV) in case of hemiparetic patients, after passive and active thromboembolic methods, as well as the consensual effect in the hemiparetic limb following the active venous exercises in the healthy limb. We examined 215 patients, with the median age of 58.0 (55.0-63.0) years. The VBFV was measured with a HADECO BIDOP ES-100 V II type Doppler ultrasound device, using an 8 MHz head, on the femoral vein at the level of the hip joint. For statistical analysis, SPSS version 22 was used. After passive movement, on the hemiparetic side, compared to the value in resting state, the VBFV significantly (12.6; 11.6-13.5 cm/s; P < .001) increased. Following active venous exercises performed on the healthy side, the VBFV significantly (18.0; 15.6-19.6 cm/s; P < .001) increased compared to the value in resting state. Following the active venous exercises performed on the healthy side, the VBFV measured on the hemiparetic side (consensual effect) was significantly (15.1 [14.1-16.5] cm/s; P < .001) higher than the value on the hemiparetic side in resting state. Active and passive mechanical thromboprophylaxis methods can be effective. Movements of the healthy limb significantly increase the VBFV in the inactive limb, and patients can perform it themselves several times a day.

Pneumatic compression device does not show effective thromboprophylaxis following total knee arthroplasty in a low incidence population

IntroductionPurpose of this study was to assess whether the intermittent pneumatic compression (IPC) device would be an effective prophylaxis for deep vein thrombosis (DVT) following total knee arthroplasty (TKA) in a low incidence population. HypothesisThe mechanical thromboprophylaxis could reduce the incidence of DVT compared to non-prophylaxis group and would have similar efficacy as the chemoprophylaxis following TKA in a low DVT incidence population. Materials and methodsFrom January 2009 to June 2016, 1259 elective primary TKA with preoperative diagnosis of primary osteoarthritis in a single institute were enrolled. Patients were divided into three groups: those who were managed with chemoprophylaxis (CPX group, 414 cases), with mechanical prophylaxis (IPC group, 425 cases), or without pharmacological and mechanical prophylaxis (control group, 420 cases). All patients underwent preoperative ultrasonography and computed tomographic venography on postoperative day 6 to assess development of DVT. The incidence of overall, proximal, symptomatic DVT and symptomatic pulmonary embolism (PE) were compared among the groups. Major and minor bleeding complications were also evaluated. ResultsThe incidence of overall DVT was 14.8% in control group, 6.3% in CPX group and 11.3% in IPC group respectively and CPX group showed significantly lower incidence than other two groups (p<0.001). The incidence of proximal DVT was 1.9% in control group, 0.7% in CPX group and 0.9% in IPC group respectively (p>0.05). The incidence of symptomatic DVT was 0.7% in control group, 0% in CPX group and 0.7% in IPC group respectively (p>0.05). There was no case of symptomatic PE diagnosed during hospital stay in all patients. DiscussionSingle use of IPC device could not reach significant level of DVT prophylaxis compared to control group and only chemoprophylaxis showed significantly reduce the incidence of overall DVT following TKA. Single use of IPC device does not show effective thromboprophylaxis in a low DVT incidence population. Level of evidenceIII, case control study.

Relationship between the incidence of deep vein thrombosis during hospitalization and the energy of injury in tibial plateau fractures

Objective To investigate the relationship between the incidence of deep vein thrombosis (DVT) during hospitalization and the energy of injury in tibial plateau fractures(TPFs). Methods 140 patients were enrolled in the study between September, 2014, and October, 2017 in Honghui Hospital, Xi′an Jiaotong University. According to the Schatzker classification, the low-energy group (Schatzker Ⅰ-Ⅲ) X-ray showed a simple or lateral fracture or compression fracture of the lateral plateau (n=63); the high-energy group (Schatzker Ⅳ-Ⅵ) X-ray showed the medial tibia or double of the tibial plateau (n=77). Duplex Ultrasonography was performed in lower extremities before and after surgical intervention for DVT evaluation and record the incidence of DVT, the days during hospitalization, the blood loss during surgery and the level of D-Dimer. All patients received mechanical and chemical thromboprophylaxis. The patient was followed up for one month after surgery, and the lower extremity ultrasound was reviewed and recorded. The measurement data were expressed as (±s), and the categorical variables were expressed in composition ratio. The measurement data were all in accordance with the normal distribution and the variance was uniform. The t-test was used, and the Chi-square test was used for comparison between groups. Results The incidence of thrombosis of tibial plateau fracture in TPFs was 36.43% and 46.43% pre-operation and post-operation respectively. The thrombosis incidence was 31.75%(20/63) in the low-energy group and 40.26%(31/77) in the high-energy group pre-operation. The thrombosis incidence was 44.44%(28/63) in the low-energy group and 48.05% (37/77) in the high-energy group post-operation. Statistical analysis showed no significant difference between the two groups pre-operation (P=0.298) and post-operation(P=0.785). The days during hospitalization [(11.94±4.18) d, (9.56±2.54) d], the blood loss during surgery [(208.96±224.43) ml, (129.68±142.14) ml] and the level of D-Dimer [(2.39±3.38) mg/L, (1.21±2.32) mg/L]at pre-operation showed differences in the high energy group and the low energy group, respectively. Conclusions The incidence of DVT in TPFs is high during the hospital, but most of DVT is concentrated in the distal to the knee. Although the incidence of high energy injury and low energy injury DVT is not significantly different in TPFs, we should also be alert to the occurrence of DVT. Key words: Venous thrombosis; Tibial fractures; Ultrasonography, doppler; Low energy injury; High energy injury

Using long term mortality to determine which perioperative risk factors of mortality following hip and knee replacement may be causal

Observational studies have identified surgical factors that are associated with a reduced risk of mortality after joint replacement. It is not clear whether these are causal or reflect patient selection. Data on the first primary hip (n = 424,156) and knee replacements (n = 469,989) performed for osteoarthritis in the National Joint Registry were analysed. Flexible parametric survival modelling was used to determine if risk factors for mortality in the perioperative period persisted. To explore selection bias, standardised mortality ratios were calculated for all-cause, respiratory and smoking related cancer mortality using population rates. Selection was apparent for hip resurfacing, combined spinal and general anaesthetic and unicondylar knee implants; reduced mortality was observed for many years for both all and other causes of mortality with a waning effect. Mechanical thromboprophylaxis was also suggestive of selection although patients receiving aspirin had sustained reduced mortality, possibly due to to a cardioprotective effect. Posterior approach for hips was ambiguous with a possible causal component. Spinal anaesthesia was suggestive of a causal effect. We are reliant on observational data when it is not feasible to undertake randomised trials. Our approach of looking at long term mortality risks for perioperative interventions provides further insights to differentiate causal interventions from selection. We recommend the use of aspirin chemothromboprophylaxis, the posterior approach and spinal anaesthetic in total hip replacement due to the apparent causal effect on reduced mortality.

Mechanical thromboprophylaxis would suffice after total knee arthroplasties in Asian patients?

Our prospective study evaluated the incidence and location of deep vein thrombosis (DVT), the risk factors for PE and the natural history of DVT after TKA in patients who have received only mechanical compression device without having any chemical thromboprophylaxis or therapeutic treatment. We studied 408 consecutive patients (691 knees) who underwent primary TKA; 283 patients had one-stage bilateral TKAs and 125 had unilateral TKAs. Coagulation assays, the full blood count and blood typing tests, and serum chemical profiles were undertaken in all patients on three separate occasions. Molecular genetic testing was performed preoperatively to detect the genetic traits involving DVT. Bilateral simultaneous or unilateral venograms were carried out at 6 or 7 days after operation. Perfusion lung scanning was undertaken before and at 7 or 8 days after operation. In the 691 venograms in 408 patients, only 4 knees (0.6%) were positive for fresh thrombi. In the 4 knees with DVT, thrombi were located in the calf veins. We observed factor V Leiden mutation, antithrombin-III level, and prothrombin promoter G20210A mutation were absent in all patients. We saw no relationship between DVT and coagulation or thrombophilic data. No pulmonary embolism (PE) occurred as shown by negative perfusion lung scan and absence of symptoms. We concluded that the combinations of absent thrombophilic polymorphisms with low clinical prothrombotic risk factors led to low prevalence of DVT and virtually absent PE after TKA in the current series of patients, who had received mechanical compression device only without chemical thromboprophylaxis.

Thromboprophylaxis in Intensive Care Unit Patients: A Literature Review.

Thromboembolism is a major complication in hospitalized patients. Intensive care unit (ICU) patients have a greater risk of thrombotic events due to additional risk factors such as immobilization, mechanical ventilation, and central catheters. The diagnosis and management of deep vein thrombosis (DVT) and pulmonary embolism (PE) in critically ill patients are challenging and these conditions are associated with high mortality. Medical thromboprophylaxis with low molecular weight heparin (LMWH) as well as unfractionated heparin (UFH) has been shown to reduce the incidence of thromboembolic events in such patients. For patients with high risk of bleeding, mechanical thromboprophylaxis can be used. Literature database was conducted on Medline for articles published up to 2018 using particular search terms such as thromboprophylaxis and venous thromboembolism in ICU patients. The following review summarizes the existing data regarding thromboprophylaxis in ICU patients with special consideration to the use of mechanical prophylaxis and pharmacologic prophylaxis using heparin products.