Perioperative Chemoprophylaxis Research Articles

Towards standardized perioperative chemoprophylaxis in major elective abdominal surgery.

ANZ Journal of SurgeryEarly View PERSPECTIVE Towards standardized perioperative chemoprophylaxis in major elective abdominal surgery Emma Downie BMBS, Emma Downie BMBS orcid.org/0000-0002-2205-0397 Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia Department of General Surgery, The Royal Melbourne Hospital, Melbourne, Victoria, Australia Contribution: Data curation, Formal analysis, ​Investigation, Methodology, Visualization, Writing - original draft, Writing - review & editingSearch for more papers by this authorJames May MD, James May MD orcid.org/0000-0003-1533-1155 Department of General Surgery, The Royal Melbourne Hospital, Melbourne, Victoria, Australia Contribution: Data curation, Formal analysis, Methodology, Visualization, Writing - original draft, Writing - review & editingSearch for more papers by this authorSean Stevens MSurgEd, FRACS, Sean Stevens MSurgEd, FRACS orcid.org/0000-0003-3522-1412 Department of Surgery, Austin Precinct, Austin Health, The University of Melbourne, Melbourne, Victoria, Australia Division of Surgery, Anaesthesia, and Procedural Medicine, Austin Health, Melbourne, Victoria, Australia Department of Surgery, Austin Precinct, Austin Health, General and Gastrointestinal Surgery Research Group, The University of Melbourne, Melbourne, Victoria, Australia Contribution: Conceptualization, Formal analysis, Methodology, Supervision, Writing - review & editingSearch for more papers by this authorDavid S. Liu PhD, FRACS, David S. Liu PhD, FRACS orcid.org/0000-0001-8936-4123 Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia Department of Surgery, Austin Precinct, Austin Health, The University of Melbourne, Melbourne, Victoria, Australia Division of Surgery, Anaesthesia, and Procedural Medicine, Austin Health, Melbourne, Victoria, Australia Department of Surgery, Austin Precinct, Austin Health, General and Gastrointestinal Surgery Research Group, The University of Melbourne, Melbourne, Victoria, AustraliaSearch for more papers by this author Emma Downie BMBS, Emma Downie BMBS orcid.org/0000-0002-2205-0397 Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia Department of General Surgery, The Royal Melbourne Hospital, Melbourne, Victoria, Australia Contribution: Data curation, Formal analysis, ​Investigation, Methodology, Visualization, Writing - original draft, Writing - review & editingSearch for more papers by this authorJames May MD, James May MD orcid.org/0000-0003-1533-1155 Department of General Surgery, The Royal Melbourne Hospital, Melbourne, Victoria, Australia Contribution: Data curation, Formal analysis, Methodology, Visualization, Writing - original draft, Writing - review & editingSearch for more papers by this authorSean Stevens MSurgEd, FRACS, Sean Stevens MSurgEd, FRACS orcid.org/0000-0003-3522-1412 Department of Surgery, Austin Precinct, Austin Health, The University of Melbourne, Melbourne, Victoria, Australia Division of Surgery, Anaesthesia, and Procedural Medicine, Austin Health, Melbourne, Victoria, Australia Department of Surgery, Austin Precinct, Austin Health, General and Gastrointestinal Surgery Research Group, The University of Melbourne, Melbourne, Victoria, Australia Contribution: Conceptualization, Formal analysis, Methodology, Supervision, Writing - review & editingSearch for more papers by this authorDavid S. Liu PhD, FRACS, David S. Liu PhD, FRACS orcid.org/0000-0001-8936-4123 Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia Department of Surgery, Austin Precinct, Austin Health, The University of Melbourne, Melbourne, Victoria, Australia Division of Surgery, Anaesthesia, and Procedural Medicine, Austin Health, Melbourne, Victoria, Australia Department of Surgery, Austin Precinct, Austin Health, General and Gastrointestinal Surgery Research Group, The University of Melbourne, Melbourne, Victoria, AustraliaSearch for more papers by this author First published: 03 March 2023 https://doi.org/10.1111/ans.18364Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Early ViewOnline Version of Record before inclusion in an issue RelatedInformation

Postoperative Timing of Chemoprophylaxis and Its Impact on Thromboembolism and Bleeding Following Major Abdominal Surgery: A Multicenter Cohort Study

BackgroundMajor abdominal surgery is associated with bleeding and venous thromboembolism (VTE) risks. Chemoprophylaxis prevents VTE but increases bleeding risk. When compared with pre- and intra-operative chemoprophylaxis, recent evidence suggests that starting chemoprophylaxis postoperatively lowers the risk of bleeding without compromising VTE protection. This study investigates whether an optimal window exists in the postoperative period for initiating chemoprophylaxis in patients undergoing major abdominal surgery.MethodsAnalysis of pooled data from four multicenter PROTECTinG studies, which investigated the timing of perioperative chemoprophylaxis on bleeding and VTE outcomes following major abdominal surgery. Patients that commenced chemoprophylaxis postoperatively were separated into quartiles based on timing of administration within the first 24 h post-surgery.ResultsOverall, 4729 (Abdominal visceral resection N = 668, cholecystectomies N = 573, major ventral hernia repair N = 1701, antireflux surgery N = 1787) consecutive patients had chemoprophylaxis commenced within 24 h following elective surgery. Baseline characteristics were comparable between quartiles. Across quartiles and within each procedural type, the timing of starting chemoprophylaxis was not associated with bleeding (2.6, 1.7, 2.7 and 3.2%, p = 0.130) or clinical VTE (0.8, 0.2, 0.8 and 0.5%, p = 0.131), and did not predict their occurrences on multivariate analysis. ConclusionChemoprophylaxis can be safely started at any time within 24 h post-skin closure in major abdominal surgery, without affecting bleeding or VTE risks. This finding encourages the standardization of chemoprophylaxis timing in the postoperative period to pre-defined times during the day to improve workflow efficiency and chemoprophylaxis compliance.

30-Day Post-Discharge Prophylaxis with Rivaroxaban Prevents Porto-mesenteric Venous Thrombosis Following Laparoscopic Sleeve Gastrectomy.

Porto-mesenteric venous thrombosis (PMVT) is a significant complication that occurs more frequently after laparoscopic sleeve gastrectomy (SG) than other bariatric procedures and presents later than other venous thromboembolic (VTE) events often 2weeks after the operation. The common current practice in bariatric surgery of perioperative chemoprophylaxis until discharge may not adequately prevent PMVT. Therefore, a 30-day post-discharge chemoprophylaxis (PDC) might reduce the incidence of PMVT. The objective of this study is to determine whether 30-day PDC with rivaroxaban 10mg daily following SG can reduce the incidence of PMVT. In a retrospective cohort study, 292 consecutive patients undergoing SG by a single surgeon were either prescribed rivaroxaban 10mg daily for 30days upon discharge (group A) or did not receive any PDC (group B). Primary outcome was PMVT and secondary outcome was bleeding. Patients on chronic anticoagulation therapy were excluded from the study. PMVT events differences were significant between the groups while bleeding events were not. Group A had zero PMVT events, while group B had four (p = .045). There were 4 bleeding events in group A and 7 bleeding events on group B (p = .341). A 30-day PDC regimen of rivaroxaban 10mg daily is both safe and effective. This study demonstrated zero PMVT events without an increased risk of bleeding using this regimen.

Efficacy of intermittent compression devices for thromboembolic prophylaxis in major abdominal surgery: a systematic review and meta-analysis.

The benefits of mechanical prophylaxis for the prevention of venous thromboembolism (VTE) in abdominal and pelvic surgery are uncertain, with different guidelines stating that graduated compression stockings (GCS) and intermittent pneumatic compression devices (IPCDs) can be used either alone or in combination. To review the efficacy of IPCDs in preventing VTE following abdominal and pelvic surgery. A systematic review was conducted, identifying relevant literature reporting clinical trials conducted in abdominopelvic surgery, comparing the effect of IPCDs alone or in combination with no prophylaxis, GCS and chemical prophylaxis. The review identified studies reported from 1966 to 2022 in Medline, Embase, PubMed and Cochrane databases for randomized controlled trials. Thirteen RCTs involving 1914 participants were identified. IPCDs were superior to placebo (OR VTE 0.39; 95% CI 0.20-0.76) but not superior to other forms of prophylaxis (OR 0.83; 95% CI 0.30-2.27) or to GCS alone (OR 0.9; 95% CI 0.24-3.36). The addition of IPCDs to GCS compared with GCS alone was beneficial (OR 0.45; 95% CI 0.23-0.91) as was the addition of IPCDs to standard perioperative chemoprophylaxis (OR 0.25; 95% CI 0.09-0.74). The overall quality and reliability of trials were low, with high risk of bias. IPCDs are more effective than placebo in reducing VTE rates but are not more effective than other forms of thrombo-prophylaxis (chemical or mechanical) following abdominal and pelvic surgery. There is poor quality evidence to suggest that they might have a role as additional prophylaxis when combined with GCS and chemical prophylaxis.

AHPBA guidelines for managing VTE prophylaxis and anticoagulation for pancreatic surgery.

Major abdominal surgery and malignancy lead to a hypercoagulable state, with a risk of venous thromboembolism (VTE) of approximately 3% after pancreatic surgery. No guidelines exist to assist surgeons in managing VTE prophylaxis or anticoagulation in patients undergoing elective pancreatic surgery for malignancy or premalignant lesions. A systematic review specific to VTE prophylaxis and anticoagulation after resectional pancreatic surgery is herein provided. Six topic areas are reviewed: pre- and perioperative VTE prophylaxis, early postoperative VTE prophylaxis, extended outpatient VTE prophylaxis, management of chronic anticoagulation, anti-coagulation after vascular reconstruction, and treatment of VTE. A Medline and PubMED search was completed with systematic medical literature review for each topic. Level of evidence was graded and strength of recommendation ranked according to the GRADE (Grades of Recommendation Assessment, Development and Evaluation) system for practice guidelines. Levels of evidence and strength of recommendations are presented. While strong data exist to guide management of chronic anticoagulation and treatment of VTE, data for anticoagulation after reconstruction is inconclusive and support for perioperative chemoprophylaxis with pancreatic surgery is similarly limited. The risk of post-pancreatectomy hemorrhage often exceeds that of thrombosis. The role of universal chemoprophylaxis must therefore be examined critically, particularly in the preoperative setting.

Chemical thromboprophylaxis before skin closure increases bleeding risk after major ventral hernia repair: A multicenter cohort study

BackgroundMajor ventral hernia surgeries are commonly performed. Despite guideline recommendations for chemo-thromboprophylaxis in the perioperative period, the optimal timing for its initiation is unknown. We characterized the variability in perioperative chemoprophylaxis in elective major ventral hernia surgery and determine whether timing of chemoprophylaxis affects bleeding and symptomatic venous thromboembolism. MethodsRetrospective analysis of all elective major ventral hernia surgery undertaken between January 1, 2014, and December 31, 2019, at 14 hospitals across Australia. Major bleeding was defined as the need for blood transfusion, reoperation, or >20 g/L fall in hemoglobin. Clinical venous thromboembolism was defined as imaging-proven symptomatic disease <30 days postsurgery. Propensity score matched analysis was used to validate primary findings. ResultsIn the study, 3,384 hernia repairs were analyzed. Chemoprophylaxis was administered early (before skin closure), postoperatively, or not given in 856 (25.3%), 1,701 (50.3%), and 827 (24.4%) patients, respectively. This varied between surgeons, trainees, and institutions. Clinical venous thromboembolism occurred in 6 (0.2%) patients and was unrelated to chemoprophylaxis timing. 134 (4.0%) patients had postoperative bleeding, with 67 (50%) major bleeds, requiring surgical control in 41 (30.6%) cases. Bleeding extended duration of stay (mean [standard deviation], 7.0 (13.9) vs 2.6 (4.7) days, P < .001). Notably, compared with postoperative (odds ratio 1.98; 95% confidence interval, 1.36–2.88; P < .001) and no (odds ratio 2.83; 95% confidence interval, 1.70–4.89; P < .001) chemoprophylaxis, early initiation significantly increased bleeding risk and independently predicted its occurrence. ConclusionThe incidence of clinical venous thromboembolism after elective major ventral hernia repair is low. Variability in perioperative thromboprophylaxis is high. Early chemoprophylaxis increases bleeding risk without appreciable additional protection from venous thromboembolism.

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.

Pre-operative and intra-operative chemical thromboprophylaxis increases bleeding risk following elective cholecystectomy: a multicentre (PROTECTinG) study.

Cholecystectomy is commonly performed in general surgery. Despite guidelines recommending chemical thromboprophylaxis in the perioperative period, the most appropriate time for its initiation is unknown. Here, we investigated whether timing of chemoprophylaxis affected venous thromboembolism (VTE) and bleeding rates post-cholecystectomy. Retrospective review of all elective cholecystectomies performed between 1 January 2018 and 30 June 2019, across seven Victorian hospitals. Clinical VTE was defined as imaging-proven symptomatic disease within 30 days of surgery. Major bleeding was defined as the need for blood transfusion, surgical intervention or >20 g/L fall in haemoglobin from baseline. A total of 1744 cases were reviewed. Chemoprophylaxis was given early (pre- or intra-operatively), post-operatively or not given in 847 (48.6%), 573 (32.9%) and 324 (18.6%) patients, respectively. This varied significantly between surgeons, fellows, trainees and institutions. Clinical VTE occurred in 5 (0.3%) patients and was not associated with chemoprophylaxis timing. Bleeding occurred in 42 (2.4%) patients. Of this, half were major events, requiring surgical control in 5 (11.9%) patients and blood transfusion in 9 (21.4%) patients. Bleeding also extended length of stay (mean (SD), 3.1 (4.0) versus 1.4 (2.2) days, P < 0.001). One bleeding-related mortality was recorded. Importantly, when compared with post-operative (risk ratio 1.46, 95% confidence interval 1.21-1.62) and no (RR 1.23, 95% CI 1.03-1.35) chemoprophylaxis, early usage significantly increased bleeding risk and independently predicted its occurrence. Perioperative chemoprophylaxis is variable among patients undergoing elective cholecystectomy. The rate of clinical VTE post-cholecystectomy is low. Early chemoprophylaxis increases bleeding risk without an appreciable additional protection from VTE.

Association Between Surgeon Practice Knowledge and Venous Thromboembolism.

The most common cause of mortality following bariatric surgery is venous thromboembolism. Our study aimed to (1) determine the practice patterns of venous thromboembolism (VTE) chemoprophylaxis among bariatric surgeons participating in a large statewide quality collaborative and (2) compare the results of surgeon self-reported chemoprophylaxis practices to actual practices from abstracted chart data. We administered a 13-question survey to 66 surgeons across a statewide collaborative aimed at revealing VTE practice patterns such as medication type, dosage, timing, duration, and level of trainee involvement (response rate 93%). We conducted on-site data audits to examine the charts of all patients that had developed VTE during the study period and 15 other randomly selected patient charts per site. We then evaluated both the ordered perioperative chemoprophylaxis and the actual administered chemoprophylaxis from nursing and electronic records. There was 31% overall discordance between self-reported and abstracted chart data for pre-operative VTE dosing regimens. Among patients who had a VTE, 39% of administered chemoprophylaxis did not match surgeon responses. Conversely, among patients who did not have a VTE, only 29% were discordant (p = 0.03). In contrast, for post-operative VTE dosing, there was no significant difference in the rate of discordance in patients with and without a VTE (47% discordance vs 38%, p = 0.0552, respectively). Greater discordance between surgeon self-reported and actual perioperative VTE chemoprophylaxis is associated with significantly increased risk of VTE. Further understanding of the system characteristics associated with these practices may yield insights into how best to improve appropriate VTE chemoprophylaxis.

Do the Benefits of Routine Perioperative Chemoprophylaxis for Prevention of Thrombotic Events in Multilevel Posterior Surgery of the Cervical or Thoracic Spinal Cord Outweigh the Risks?

Do the Benefits of Routine Perioperative Chemoprophylaxis for Prevention of Thrombotic Events in Multilevel Posterior Surgery of the Cervical or Thoracic Spinal Cord Outweigh the Risks?

Perioperative Chemoprophylaxis οr Treatment for Extensively Drug Resistant Gram-Negative Bacteria in Patients Undergoing Liver Transplantation Based on Preoperative Donor/Recipient Surveillance Cultures: A Prospective Study

IntroductionThe importance of preoperative donor/recipient colonization or donor infection by extensively drug-resistant Gram-negative bacteria (XDR-GNB) and its relation to serious post-transplantation infection pathogenicity in liver transplantation (LT) patients has not been clarified. AimPrevention of postoperative infection due to XDR-GNB with the appropriate perioperative chemoprophylaxis or treatment based on preoperative donor/recipient surveillance cultures in LT patients, as well as their outcome. Materials and MethodTwenty-six patients (20 male, 6 female) were studied (average preoperative Model for End-Stage Liver Disease score ≈15, range: 8–29) from January 2017 to January 2018. In all patients, blood, urine, and bronchial secretions culture samples as well as a rectal colonization culture were taken pre- and postoperatively, once weekly after LT, and after intensive care unit discharge. Recipients with positive XDR-GNB colonization and patients receiving a transplant from a donor with an XDR-GNB positive culture or colonization received the appropriate chemoprophylaxis one half hour preoperatively according to culture results. De-escalation of the antibiotic regimen was done in 2 to 5 days based on the colonization/culture results of the donor and recipient and their clinical condition. Evaluation for serious infection was done at 1 week and at 28 days for outcome results. ResultsFourteen out of 26 recipients (53.8%) were positive for XDR-GNB colonization preoperative, with 2/14 (14.28%) presenting serious infection due to the same pathogen. Intensive care unit length of stay was significantly longer in colonized with XDR-GNB patients (P < .0001). The outcome of colonized patients was 6/14 (42.8%) expired, but only in 2/14 (14.2%) was mortality attributable to infection. ConclusionAdministering appropriate perioperative chemoprophylaxis and treatment may limit the frequency of XDR-GNB infections and intensive care unit length of stay and may improve the outcome in LT recipients.

PD41-11 NATIONWIDE UTILIZATION OF CHEMOPROPHYLAXIS FOR THE PREVENTION OF VENOUS THROMBOEMBOLISM FOLLOWING RADICAL CYSTECTOMY

You have accessJournal of UrologyBladder Cancer: Invasive V1 Apr 2018PD41-11 NATIONWIDE UTILIZATION OF CHEMOPROPHYLAXIS FOR THE PREVENTION OF VENOUS THROMBOEMBOLISM FOLLOWING RADICAL CYSTECTOMY Stephen Reese, Matthew Mossanen, Dimitar Zlatev, Daniel Pucheril, Benjamin I. Chung, and Steven L. Chang Stephen ReeseStephen Reese More articles by this author , Matthew MossanenMatthew Mossanen More articles by this author , Dimitar ZlatevDimitar Zlatev More articles by this author , Daniel PucherilDaniel Pucheril More articles by this author , Benjamin I. ChungBenjamin I. Chung More articles by this author , and Steven L. ChangSteven L. Chang More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1950AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Venous thromboembolism (VTE), comprising deep venous thrombosis (DVT) and pulmonary embolism (PE), is a major preventable source of postoperative complications. The risk of VTE in patients undergoing radical cystectomy (RC) for bladder cancer has been estimated at 6%, and the American Urological Association, American Society of Clinical Oncology, and National Comprehensive Cancer Network all recommend perioperative chemoprophylaxis. We performed a population-based analysis to determine the utilization of chemoprophylaxis against VTE in patients undergoing RC. METHODS Using the Premier Hospital Database (Premier, Inc., Charlotte, NC), we retrospectively identified patients who underwent RC for bladder cancer in the US between 2006 and 2015. Administration of chemoprophylaxis within 24 hours of surgery was deemed consistent with recommendations. A subgroup analysis of higher volume hospitals (≥10 RC annually) compared outcomes of DVT, PE, and bleeding between patients in hospitals with uniform use versus no use of chemoprophylaxis. Multivariate analysis was used to evaluate predictors of under-utilization of chemoprophylaxis. RESULTS Among the cohort of 9,133 patients (48,714 patients after weighting adjustment) undergoing RC, 35.1% were administered recommended chemoprophylaxis, with an increase in utilization from 20.7% in 2006 to 49.6% in 2015. Characteristics associated with decreased likelihood of chemoprophylaxis administration included patient age ≥ 65 years, Charlson Comorbidity Index score ≥ 2, rural hospital location, commercial insurance, and year of surgery prior to 2010. Patients who received recommended chemoprophylaxis had significantly lower rates of VTE (5.1% vs. 6.0%) and PE (2.0% vs. 3.1%), but elevated rates of bleeding (12.8% vs. 7.7%). CONCLUSIONS Although there has been a progressive increase in the utilization of chemoprophylaxis following RC, this recommendation by multiple medical groups has been adopted in a limited fashion in the United States. Greater compliance with recommended use of chemoprophylaxis following RC may be associated with decreased risk of PE and VTE, but also with increased risk of bleeding. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e813 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Stephen Reese More articles by this author Matthew Mossanen More articles by this author Dimitar Zlatev More articles by this author Daniel Pucheril More articles by this author Benjamin I. Chung More articles by this author Steven L. Chang More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Risk Stratification for Postoperative Venous Thromboembolism after Endoscopic Sinus Surgery.

Objectives Venous thromboembolism (VTE) contributes to significant patient morbidity, yet the incidence of VTE following endoscopic sinus surgery (ESS) is unknown. Quality improvement criteria are prompting increased standardization of perioperative VTE prophylaxis. Risk stratification for VTE may better define best practice measures to balance limiting VTE development with avoiding unnecessary chemoprophylaxis. Study Design Retrospective cohort study. Setting Tertiary institution. Subjects and Methods Adult patients who underwent ESS without perioperative chemoprophylaxis from 2008 to 2016 were evaluated. Identification of VTE was performed via screening diagnosis and procedure codes and clinical records, with subsequent confirmation of true-positive VTE. Data for individual Caprini scores were abstracted from electronic medical records. The primary outcome was development of VTE within 30 days following ESS relative to the Caprini score. Results A total of 2369 ESS cases were evaluated. While initial screening identified multiple potential VTE events, in-depth medical record review confirmed only 4 true VTE (0.17%). The VTE rate among cases with a Caprini score of <8 (0.09%, 2/2278) was significantly less ( P = .008) than the rate with a score of ≥8 (2.2%, 2/91). Beyond overall score, specific risk factors associated with development of postoperative VTE included stroke, central venous access, sepsis, and inpatient status (all P < .025), while prior VTE and hypercoagulability were not associated with postoperative VTE (all P > .5). Conclusions In the absence of perioperative chemoprophylaxis, postoperative VTE following ESS is extremely rare, particularly for patients carrying low-to-moderate Caprini scores. Risk stratification based on these data can assist in the design of VTE prophylaxis guidelines for ESS patients.

Utilization and outcomes of chemoprophylaxis for the prevention of venous thromboembolism following radical cystectomy: A population-based study.

491 Background: Venous thromboembolism (VTE), comprising deep venous thrombosis (DVT) and pulmonary embolism (PE), is a major preventable source of postoperative complications. The risk of VTE in patients undergoing radical cystectomy (RC) for bladder cancer has been estimated at 6%, and the American Society of Clinical Oncology, American Urological Association, and National Comprehensive Cancer Network all recommend perioperative chemoprophylaxis. We performed a population-based analysis to determine the utilization of chemoprophylaxis against VTE in patients undergoing RC. Methods: Using the Premier Hospital Database (Premier, Inc., Charlotte, NC), we retrospectively identified patients who underwent RC for bladder cancer in the US between 2006 and 2015. Administration of chemoprophylaxis within 24 hours of surgery was deemed consistent with recommendations. A subgroup analysis of higher volume hospitals (³10 RC annually) compared outcomes of DVT, PE, and bleeding between patients in hospitals with uniform use versus no use of chemoprophylaxis. Multivariate analysis was used to evaluate predictors of under-utilization of chemoprophylaxis. Results: Among the cohort of 9,133 patients (48,714 patients after weighting adjustment) undergoing RC, 35.1% were administered recommended chemoprophylaxis, with an increase in utilization from 20.7% in 2006 to 49.6% in 2015. Characteristics associated with decreased likelihood of chemoprophylaxis administration included patient age ≥65 years, Charlson Comorbidity Index score ≥2, rural hospital location, commercial insurance, and year of surgery prior to 2010. Patients who received recommended chemoprophylaxis had significantly lower rates of VTE (5.1% vs 6.0%) and PE (2.0% vs 3.1%), but elevated rates of bleeding (12.8% vs 7.7%). Conclusions: The recommended utilization of chemoprophylaxis in a contemporary nationwide cohort of patients undergoing RC is limited despite its notable increase over the course of the study period. Greater compliance with recommended use of chemoprophylaxis following RC may be associated with decreased risk of PE and VTE, but also with increased risk of bleeding.

Perioperative bleeding and blood transfusion are major risk factors for venous thromboembolism following bariatric surgery.

Morbidly obese patients are at increased risk for venous thromboembolism (VTE) after bariatric surgery. Perioperative chemoprophylaxis is used routinely with bariatric surgery to decrease the risk of VTE. When bleeding occurs, routine chemoprophylaxis is often withheld due to concerns about inciting another bleeding event. We sought to evaluate the relationship between perioperative bleeding and postoperative VTE in bariatric surgery. The American College of Surgeons-National Surgical Quality Improvement Program (NSQIP) dataset between 2012 and 2014 was queried to identify patients who underwent bariatric surgery. Gastric bypass (n = 28,145), sleeve gastrectomy (n = 30,080), bariatric revision (n = 324), and biliopancreatic diversion procedures (n = 492) were included. Univariate and multivariate regressions were used to determine perioperative factors predictive of postoperative VTE within 30 days in patients who experience a bleeding complication necessitating transfusion. The rate of bleeding necessitating transfusion was 1.3%. Bleeding was significantly more likely to occur in gastric bypass compared to sleeve gastrectomy (1.6 vs. 1.0%) (p < 0.0001). For all surgeries, increased age, length of stay, operative time, and comorbidities including hypertension, dyspnea with moderate exertion, partially dependent functional status, bleeding disorder, transfusion prior to surgery, ASA class III/IV, and metabolic syndrome increased the perioperative bleeding risk (p < 0.05). Multivariate analysis revealed that the rate of VTE was significantly higher after blood transfusion [Odds Ratio (OR) = 4.7; 95% CI 2.9-7.9; p < 0.0001). Predictive risk factors for VTE after transfusion included previous bleeding disorder, ASA class III or IV, and COPD (p < 0.05). Bariatric surgery patients who receive postoperative blood transfusion are at a significantly increased risk for VTE. The etiology of VTE in those who are transfused is likely multifactorial and possibly related to withholding chemoprophylaxis and the potential of a hypercoagulable state induced by the transfusion. In those who bleed, consideration should be given to reinitiating chemoprophylaxis when safe, extending treatment after discharge, and screening ultrasound.

Thromboelastography demonstrates perioperative hypercoagulability in hepato-pancreato-biliary patients and supports routine administration of preoperative and early postoperative venous thromboembolism chemoprophylaxis

BackgroundWe hypothesized hepato-pancreato-biliary (HPB) surgery patients are more likely to be hypercoagulable than hypocoagulable, and that bleeding risks from VTE chemoprophylaxis are low. This study sought to use thromboelastography (TEG) to compare coagulation profiles with bleeding/thrombotic events in HPB patients receiving standardized perioperative chemoprophylaxis. MethodsConsecutive patients undergoing HPB resections by three surgeons at one institution (January 2014–December 2015) received preoperative and early postoperative VTE chemoprophylaxis and were evaluated with TEGs. Coagulation profiles were compared to bleeding/thrombotic events. ResultsOf 87 total patients, 83 (95.4%) received preoperative chemoprophylaxis and 100% received it postoperatively. Median estimated blood loss was 190 ml. Only 2 (2.3%) patients received intraoperative transfusions. None required transfusions at 72-hours. Only 2 were transfused within 30 days. There was 1 (1.1%) 30-day VTE event. Of 83 preoperative TEGs, 29 (34.9%) were hypercoagulable and only 8 (9.6%) were hypocoagulable/fibrinolytic. Of 73 postoperative TEGs, 34 (46.6%) were hypercoagulable and just 8 (11.0%) were hypocoagulable/fibrinolytic. . ConclusionWith routine perioperative chemoprophylaxis, both VTE and bleeding events were negligible. Perioperative TEG revealed a considerable proportion (46.6%) of HPB patients were hypercoagulable. HPB patients can receive standardized preoperative/early postoperative VTE chemoprophylaxis with effective results and minimal concern for perioperative hemorrhage.

Chemoprophylaxis for venous thromboembolism in otolaryngology.

Venous thromboembolism (VTE) causes significant morbidity and mortality in surgical patients. Despite strong evidence that thromboprophylaxis reduces the incidence VTE, guidelines for prophylaxis in otolaryngology are not well established. Key to the development of VTE prophylaxis recommendations are effective VTE risk stratification and evaluation of the benefits and harms of prophylaxis. To evaluate the effectiveness and safety of VTE chemoprophylaxis among a population of otolaryngology patients stratified by risk. Retrospective cohort study of 3498 adult patients admitted for otolaryngologic surgery at a single-institution academic tertiary care medical center between September 1, 2003, and June 30, 2010. Patients were stratified into 2 groups based on whether they received VTE chemoprophylaxis. Incidence of VTE and bleeding-related complications within 30 days after surgery. Of 1482 patients receiving VTE chemoprophylaxis, 18 (1.2%) developed a VTE compared with 27 of 2016 patients (1.3%) who did not receive prophylaxis (P = .75). Patients with Caprini VTE risk scores greater than 7 were less likely to have a VTE with perioperative chemoprophylaxis (5.3% vs 10.4%; P = .06). Of patients with VTE chemoprophylaxis, 3.5% developed a bleeding complication compared with 1.2% of patients without prophylaxis (P < .001). Bleeding complications were associated with concomitant use of antiplatelet medications and chemoprophylaxis. Among patients undergoing free tissue transfer, chemoprophylaxis significantly decreased the incidence of VTE (2.1% vs 7.7%; P = .002) and increased bleeding complications (11.9% vs 4.5%; P = .01). In all other patients, VTE chemoprophylaxis did not significantly influence the likelihood of VTE (1.0% vs 0.6%; P = .12) or bleeding (1.5% vs 0.9%; P = .15). Effectiveness and safety of VTE chemoprophylaxis differed between patient subgroups, defined by Caprini risk score and by procedure. Effectiveness was most evident in patients with high Caprini risk scores and microvascular free tissue reconstruction. Bleeding complications were associated with VTE chemoprophylaxis administered in close proximity to potent antiplatelet therapy. The Caprini risk assessment model appears to be an effective tool to stratify otolaryngology patients by risk for VTE. Patients undergoing free tissue reconstruction merit further study before developing recommendations for VTE prophylaxis because of their higher risk of both VTE and bleeding.

Thrombin Generation During Abdominal Surgical Procedures: Effect of Prophylactic Anticoagulation Therapy

AbstractAbstract 3183 Background:One of the most serious complications of cosmetic surgery is a thromboembolic event (TE). Although the incidence of TE in most cosmetic procedures is <1 percent, the rate in massive weight loss patients presenting for circumferential contouring surgery is as high as 9 percent. Little evidence currently exists to determine the biochemical cause of this hypercoagulable process. Furthermore, there is little data to assess whether chemoprophylaxis prevents the hypercoagulable state. In this study, we use thrombin generation to assess activation of the coagulation cascade in patients undergoing excisional abdominal contouring procedures. Thrombin generation is a novel tool for studying the coagulation cascade and may better reflect in vivo coagulation activation than currently available laboratory measurements. Methods:Twenty-one consecutive patients from two surgeons were enrolled prospectively to assess thrombin generation at three time points: baseline/pre-operative, intra-operative after rectus plication or hernia repair, and 24 hours post-operative. Patients' intra-operative and post-operative values were normalized to their baseline value. All patients wore pneumatic compression devices for mechanical prophylaxis against TE. Nine patients received no chemoprophylaxis and 12 patients received pre-operative and post-operative chemoprophylaxis with unfractionated heparin or dalteparin according to surgeon preference based on the patient's risk profile. Results:Nine patients with a median age of 43 (range: 24–64) and BMI of 24.9 (range: 21.1–31.4) underwent abdominoplasty without TE chemoprophylaxis. Twenty percent had massive weight loss. Seventy-seven percent had liposuction and 67 percent had simultaneous procedures (liposuction as well as hernia repair or some other surgical intervention). The average operative time was 3.7 hours. In this group, the total thrombin generation increased by a mean (SD) of 997 (+/− 835) nM intra-operatively and 1404 (+/− 914) nM post-operatively. Twelve patients with a median age of 43 (range: 28–60) and BMI of 29.2 (range: 22.2–39.9) underwent panniculectomy or abdominoplasty with TE chemoprophylaxis. Eighty percent of these patients had massive weight loss. Fifty percent of patients had liposuction and 75 percent had simultaneous procedures. The average operative time was 5 hours. In this group receiving chemoprophylaxis, the total thrombin generation increased by a mean (SD) of 75 (+/− 781) nM intra-operatively and 186 (+/− 510) nM post-operatively. A t test was used to compare these two arms and the increase in thrombin generation was significantly less in patients receiving chemoprophylaxis compared to those who received no prophylaxis (intra-op: p<0.02 and post-op: p<0.004). There were no TEs or bleeding complications in any patient in the immediate post-operative period. Conclusion:Thrombin generation increases in patients undergoing abdominal contouring procedures. The magnitude of change may be decreased by giving peri-operative chemoprophylaxis. Further studies are warranted to determine the clinical relationship between thrombin generation, chemoprophylaxis and risk of thromboembolism and bleeding. Disclosures:No relevant conflicts of interest to declare.

The value of perioperative chemoprophylaxis in colorectal surgery

The value of perioperative chemoprophylaxis in colorectal surgery

Evaluation of amoxicillin plasma and tissue levels in pediatric patients undergoing tonsillectomy

Objective Tonsillectomy is the most common surgery performed in the pediatric and young adult populations. Although recent guidelines based on meta-analysis suggest that perioperative chemoprophylaxis plays a role in reducing bacteraemia-related post-tonsillectomy complications, there is no evidence or agreement upon which specific antibiotic, dosage or administration route should be preferred. Since few previous studies have assessed the effectiveness of prophylaxis by direct measurement of antibiotic levels both in plasma and tissue, we designed an experimental study to quantitatively evaluate amoxicillin concentrations in children ready for tonsillectomy and compare these plasma and tissue levels with the Minimal Inhibitory Concentrations (MIC) of the bacteria more commonly involved in the upper airway infections. Methods Thirty-three pediatric patients under 14 years of age (median 5.0, IQR 4–7, range 3–11; M:F 18:15) with recurrent tonsillitis were treated with 3 doses (established on patient's weight) of amoxicillin-clavulanic acid given orally the day before plus a further dose 2 h before tonsillectomy. Amoxicillin concentrations on both homogenated tonsillar cores and plasma were measured by HPLC-UV. Bacterial epidemiology and susceptibility were derived respectively from survey data collected by Microbiology Unit and MIC according to the National Committee for Clinical Laboratory Standards (NCCLS). Results Median plasma and tissue amoxicillin concentrations were respectively 4.7 μg/ml (IQR 2.1–8.0; min–max 0.4–14.3) and 1.1 μg/g (IQR 0.4–2.1; min–max 0.4–12.9), considerably below the selected target MIC of pathogens involved in the upper respiratory tract infections ( S. aureus, H. influenzae, M. catarrhalis). 20 Children showed undetectable amoxicillin levels in one or both tonsils. Interestingly, 7 out of these patients (35%) had plasma concentrations higher than the target MIC (8 μg/ml). No patient displayed plasma concentrations under the limit of sensitivity of the method. Poor core-plasma and left–right core correlation was observed among patients, suggesting that fibrosis developed after recurrent tonsillitis may hamper antibiotic penetration. Conclusions Based upon direct measurement of antibiotic levels in plasma and tissue, this study suggests that a revision of the oral prophylaxis in children is required in order to reduce microbial charge in the operative field and accordingly improve the recovery after tonsillectomy.