Perioperative Thromboprophylaxis Research Articles

Association of perioperative thromboprophylaxis on revision rate due to infection and aseptic loosening in primary total hip arthroplasty - new evidence from the Nordic Arthroplasty Registry Association (NARA).

Background and purposeResults regarding the impact of anticoagulants on revision rate are conflicting. We examined the association between the use of low molecular weight heparin (LMWH) or non-vitamin K oral anticoagulants (NOACs) as thromboprophylaxis after primary total hip arthroplasty (THA) and the revision rate due to infection, aseptic loosening, and all causes.Patients and methodsWe conducted a cohort study (n = 53,605) based on prospectively collected data from the national hip arthroplasty registries from Denmark and Norway. The outcome was time to revision due to infection, aseptic loosening, and all causes, studied separately. Kaplan– Meier (KM) survival analysis and a Cox proportional hazard model was used to estimate implant survival and cause-specific hazard ratios (HRs) with 95% confidence intervals (CI) adjusting for age, sex, Charlson Comorbidity Index, fixation type, start, and duration of thromboprophylaxis, and preoperative use of Vitamin K antagonists, NOAC, aspirin, and platelet inhibitors as confounders.ResultsWe included 40,451 patients in the LMWH group and 13,154 patients in the NOAC group. Regarding revision due to infection, the 1-year and 5-year KM survival was 99% in both the LMWH group and in the NOAC group. During the entire follow-up period, the adjusted HR for revision due to infection was 0.9 (CI 0.7–1.1), 1.6 (CI 1.3–2.1) for aseptic loosening, and 1.2 (CI 1.1–1.4) for all-cause revision for the NOAC compared with the LMWH group. The absolute differences in revision rates between the groups varied from 0.2% to 1%.InterpretationCompared with LMWH, NOACs were associated with a slightly lower revision rate due to infection, but higher revisions rates due to aseptic loosening and all-cause revision. The absolute differences between groups are small and most likely not clinically relevant. In addition, the observed associations might partly be explained by selection bias and unmeasured confounding, and should be a topic for further research.

Early Versus Postoperative Chemical Thromboprophylaxis Is Associated with Increased Bleeding Risk Following Abdominal Visceral Resections: a Multicenter Cohort Study

BackgroundAbdominal visceral resections incur relatively higher rates of postoperative bleeding and venous thromboembolism (VTE). While guidelines recommend the use of perioperative chemical thromboprophylaxis, the most appropriate time for its initiation is unknown. Here, we investigated whether early (before skin closure) versus postoperative commencement of chemoprophylaxis affected VTE and bleeding rates following abdominal visceral resection. MethodsRetrospective review of all elective abdominal visceral resections undertaken between January 1, 2018, and June 30, 2019, across four tertiary-referral hospitals. Major bleeding was defined as the need for blood transfusion, reintervention, or > 20 g/L fall in hemoglobin from baseline. Clinical VTE was defined as imaging-proven symptomatic disease < 30 days post-surgery. ResultsA total of 945 cases were analyzed. Chemoprophylaxis was given early in 265 (28.0%) patients and postoperatively in 680 (72.0%) patients. Mean chemoprophylaxis exposure doses were similar between the two groups. Clinical VTE developed in 14 (1.5%) patients and was unrelated to chemoprophylaxis timing. Postoperative bleeding occurred in 71 (7.5%) patients, with 57 (80.3%) major bleeds, requiring blood transfusion in 48 (67.6%) cases and reintervention in 31 (43.7%) cases. Bleeding extended length-of-stay (median (IQR), 12 (7–27) versus 7 (5–11) days, p < 0.001). Importantly, compared to postoperative chemoprophylaxis, early administration significantly increased the risk of bleeding (10.6% versus 6.3%, RR 1.45, 95% CI 1.05–1.93, p = 0.038) and independently predicted its occurrence. ConclusionsThe risk of bleeding following elective abdominal visceral resections is substantial and is higher than the risk of clinical VTE. Compared with early chemoprophylaxis, postoperative initiation reduces bleeding risk without an increased risk of clinical VTE.

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.

Postoperative pulmonary embolism, risk factors, and medical thromboprophylaxis

Background and aim The major surgical procedures have a significant risk of venous thromboembolism (VTE), especially pulmonary embolism (PE), leading to poor prognosis and life-threatening conditions. The major surgical procedure has 20-fold risk increase in VTE and the risk is increased by 30% in the absence of optimal prophylaxis. This study aimed to estimate the incidence of PE among surgical patients undergoing preoperative thromboprophylaxis according to Caprini score, these considerations can improve the clinical outcome and allow optimal use of thromboprophylactic strategies against VTE. Patients and methods We performed retrospective analysis of records of patients admitted to surgical wards at our hospital and identified those who developed postoperative PE. We calculated Caprini score to assess the risk for VTE. Results Among patients admitted to surgical wards, we identified 107 cases of postoperative PE. Most of them had major surgeries, most of them were females, and a considerable proportion of those who developed PE did not receive thromboprophylaxis although being at moderate or high risk for VTE according to Caprini score. Few patients had poor outcome. Conclusion Perioperative thromboprophylaxis is crucial to avoid complication with VTE. Caprini score may be a good clinical score to decide which patients to receive perioperative thromboprophylaxis.

From guidelines to clinical practice: current recommendations for the management of cardiac patients undergoing non-cardiac surgery

Non-cardiac surgeries account for nearly 85% of the to­tal 300 million surgeries that are performed annually world­wide, cardiovascular events representing the main source of perioperative morbidity and mortality. Considering that often patients suffering from cardiovascular (CV) di­sea­ses tend be clinically fragile, clear recommendations are needed to guide clinical decisions, in order to minimize their perioperative risk. The current ESC guideline main­tains some of the classic indications, emphasizing the im­por­tance of preoperative risk assessment and clinical exa­mi­na­tion of the patients suffering from a CV disease. It also introduces new concepts regarding the preoperative use of biomarkers, the perioperative thromboprophylaxis and the management of patients newly diagnosed with mur­murs, dyspnea, oedema or angina. Furthermore, other sec­tions, approaching complex clinical situations, as peri-ope­ra­tive management of antiplatelet and anti­coagulant the­ra­pies, have been revised, according to the latest studies. This review is meant to concisely present these new recom­men­da­tions, in a simplified and more accessible manner.

Effect of perioperative thromboprophylaxis on postoperative venous thromboembolism of the lower limbs in patients with lung cancer

Effect of perioperative thromboprophylaxis on postoperative venous thromboembolism of the lower limbs in patients with lung cancer

O-L04 Peri-operative thrombophilia in patients undergoing liver resection for colorectal metastases

Abstract Background The risk of major haemorrhage during liver surgery has decreased considerably in the modern era. However, there remains reluctance amongst liver surgeons to give routine peri-operative chemical thromboprophylaxis, either because of the perceived risk of bleeding, or transient post-operative abnormalities in conventional coagulation studies. The aim of this study was to ask whether a defined, homogeneous population of patients undergoing liver resection for colorectal metastases (CRM) were at risk from venous thromboembolism (VTE) prior to surgery, and what the impact of liver resection was on that risk. Methods A single-centre prospective observational cohort study comparing pre-, peri- and post-operative haemostasis variables in patients undergoing liver resection for CRM. Patients with cirrhosis, history of VTE or anticoagulated were excluded, as were patients undergoing small wedge, or laparoscopic liver resections. Blood samples for coagulation assays were collected pre-operatively, peri-operatively (after transection) and first post-operative day (13–20 hours post-operatively). Pre- and post-operative Tissue Factor messenger ribonucleic acid (TFmRNA) activation was measured from peripheral blood mononuclear cells (PBMCs) using semi-quantitative polymerase chain reaction (PCR). Patients received peri-operative mechanical thromboprophylaxis until mobile, plus chemical thromboprophylaxis on the first post-operative day, after venesection. Results Of 336 hepatectomies performed October 2017-December 2019, 60 resections in 57 patients were recruited. This included 46.7% major resections, with median (interquartile range [IQR]) blood loss 150.0mls (76.3-263.7), no blood transfusions, post-operative VTE events or deaths. Patients were prothrombotic pre-operatively (high factor VIIIC and thrombin generation velocity index), an effect exacerbated post-hepatectomy. Major hepatectomies had a significantly greater drop in Protein C, rise in Factor VIIIC and von Willebrand Factor, versus minor resections (p = 0.001,0.005,0.001 respectively). Patients with transection times greater than median (40minutes), had significantly increased median (IQR) PMBC-TFmRNA expression [1.65 (0.93-2.70)2ddCt], versus quicker transections [0.99 (0.69-1.28)2ddCt, p = 0.020]. Conclusions These data show the risk of major haemorrhage in elective liver resection in a high volume unit is low and administration of chemical thromboprophylaxis within 13-20 hours of surgery is safe and effective. The study demonstrates that patients with CRM are prothrombotic pre-operatively. Furthermore, this thrombophilia is exacerbated by liver resection, and most marked in patients with longer, more complex operations. These data suggest that chemical thromboprophylaxis should be considered earlier in the patient pathway, and has resulted in a change in practice for the authors.

Antithrombotic Management in Adult Kidney Transplantation: A European Survey Study

In kidney transplantation (KTx), renal graft thrombosis (RGT) is one of the main reasons for early graft loss. Although evidence-based guidance on prevention of RGT is lacking, thromboprophylaxis is widely used. The aim of this survey was to obtain a European view of the different thromboprophylactic strategies applied in KTx. An online 22-question survey, addressed to KTx professionals, was distributed by email and via platforms of the European Society for Organ Transplantation. Seventy-five responses (21 countries, 51 centers) were received: 75% had over 10 years’ clinical experience, 64% were surgeons, 29% nephrologists, and 4% urologists. A written antithrombotic management protocol was available in 75% of centers. In 8 (16%) centers, respondents contradicted each other regarding the availability of a written protocol. Thromboprophylaxis is preferred by 78% of respondents, independent of existing antithrombotic management protocols. Ninety-two percent of respondents indicated that an anticipated bleeding risk is the main reason to discontinue chronic antithrombotic therapy preoperatively. Intraoperatively, 32% of respondents administer unfractionated heparin (400–10,000 international units with a median of 5,000) in selected cases. Despite an overall preference for perioperative thromboprophylaxis in KTx, there is a high variation within Europe regarding type, timing, and dosage, most likely due to the paucity of high-quality studies. Further research is warranted in order to develop better guidelines.

Splenectomy Results in Venous Thromboembolic Events in Women: A Nurses Health Study

Background:Splenectomy is a therapy for many conditions the most common of which are trauma, Hodgkin lymphoma, thalassemia and hereditary or autoimmune hemolytic anemia, and immune thrombocytopenia (ITP). By 1960 splenectomy had been known to create a risk of over-whelming post splenectomy sepsis (OPSS) with a high mortality rate. More recently population-based studies from Denmark have suggested that there is also an increased risk of thromboembolic (TEE) complications. Thromboembolic events generally include venous thrombosis (deep vein thrombosis (DVT) and pulmonary embolism (PE)) and arterial thrombosis (stroke and myocardial infarction [MI]). ITP and hemolytic anemias have been shown to independently have increased risks of arterial and venous TEE which has complicated assessment of additive effects of splenectomy. While splenectomized patients appear to be at increased risk of arterial and venous thromboses, the incidence and which TEEs predominate remains unclear as does the timing of occurrence of the TEEs.Method:The Nurses' Health Study (NHS) was established in 1976 and enrolled 121,700 female nurses between 30-55 years old. The nurses completed baseline questionnaires and biennial follow up questionnaires. In 2004, NHS participants were asked whether they had undergone splenectomy. The primary outcomes of this study included DVT,PE, and MI, which were identified through self-report on biennial questionnaires. MIs were confirmed through medical record review. End of follow-up for this study went through 2016, date of death, or diagnosis of outcome, whichever came first. Loss to follow up was very low and causes of deaths were carefully tracked.Descriptive statistics compared the splenectomy vs non-splenectomy participants with respect to basic demographic factors and variables that may be related to the outcomes. Cox proportional hazards models were run to evaluate incidence rates for primary and secondary outcomes. We conducted age-adjusted, as well as multivariable adjusted models. Multivariate models were adjusted for age, body mass index, smoking history, diabetes mellitus, high blood pressure, and high cholesterol, thus taking into account known predictors of the specific TEEs. Multivariate models were updated every two years to account for time varying confounders.Results：In 2004, 323 participants reported having had a splenectomy, out of 96,000 completing the questionnaire. There was a strong, significant association between splenectomy and subsequent DVT (n=613) and PE (n=840). The multivariate adjusted HR was 3.73 (95%CI: 1.77-7.86) and 3.80 (95%CI: 2.04-7.10) respectively. When considered together as a composite outcome, the splenectomized participants had a 3.52-fold higher risk (95%CI: 2.12-5.85) of PE/DVT compared with non-splenectomy. There was no association between splenectomy and MI (n=1011; HR = 0.97, 95% CI: 0.31-3.01). Given the very limited number of stroke cases in the splenectomized population, we were underpowered/unable to evaluate the association of splenectomy and subsequent risk of stroke.Conclusion:This study found that splenectomized patients are at a 4-fold increased risk of PE and DVT as compared to not-splenectomized individuals. These findings were not dependent on any of the potentially confounding variable analyzed. We found no association between splenectomy and MI. There are limitations to these results. No information was available on family history and perioperative thrombo-prophylaxis. Also we do not know exactly when or why splenectomy was performed; there were at least 34 women who had splenectomy for ITP but in most cases the underlying disease was unknown. Since the nurses in 1976 were already between 30-55 years old, it is no longer possible to retrospectively obtain sufficient information. Therefore, the splenectomy question has been added to the current survey for NHS#2. We will pursue the relevant information in a follow up letter to respondents who reported having undergone splenectomy while seeing if the findings of NHS#2 confirm those of NHS#1. [Display omitted] DisclosuresBussel: Principia/Sanofi: Consultancy, Membership on an entity's Board of Directors or advisory committees; UCB: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: DSMB; Momenta/Janssen: Consultancy, Membership on an entity's Board of Directors or advisory committees; Argenx: Consultancy, Membership on an entity's Board of Directors or advisory committees; Dova/Sobi: Consultancy, Membership on an entity's Board of Directors or advisory committees; CSL: Other: DSMB; RallyBio: Consultancy, Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees; Amgen: Consultancy, Membership on an entity's Board of Directors or advisory committees; Rigel: Consultancy, Membership on an entity's Board of Directors or advisory committees; UptoDate: Honoraria.

Timing of Perioperative Pharmacologic Thromboprophylaxis Initiation and its Effect on Venous Thromboembolism and Bleeding Outcomes: A Systematic Review and Meta-Analysis

Perioperative thromboprophylaxis guidelines offer conflicting recommendations on when to start thromboprophylaxis. As a result, there is considerable variation in clinical practice, which can lead to worse patient outcomes. The objective of this study was to evaluate the association between the start time of perioperative thromboprophylaxis with venous thromboembolism (VTE) and bleeding outcomes. Embase, Medline, and CENTRAL (Cochrane Central Register of Controlled Trials) databases were searched on October 23, 2020. Randomized controlled trials that evaluated VTE and/or bleeding among groups receiving the initial dose of pharmacologic thromboprophylaxis at different times preoperatively, intraoperatively, or postoperatively were included. Only trials that randomized patients to the same medication among groups were eligible. Studies on any type of operation were included. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. The Cochrane Collaboration risk of bias tool was used. The review was registered with PROSPERO (International Prospective Register of Systematic Reviews; CRD42019142079). The outcomes of interest were VTE and bleeding. Prespecified subgroup analyses of studies including orthopaedic and nonorthopaedic operations were performed. A total of 22 trials (n= 17,124 patients) met eligibility criteria. Pooled results showed a nonstatistically significant decrease in the rate of VTE with preoperative initiation of thromboprophylaxis compared with postoperative initiation (risk ratio 0.77; 95% CI, 0.55 to 1.08; I2= 0%, n=1,933). There was also a nonstatistically significant increase in the rate of bleeding with preoperative compared with postoperative initiation (risk ratio 1.17; 95% CI, 0.94 to 1.46; I2= 35%, n= 2,752). Risk of bias was moderate. Heterogeneity between studies was low (I2= 0% to 35%). This meta-analysis found a nonstatistically significant decrease in the rate of VTE and an increase in the rate of bleeding when thromboprophylaxis was initiated preoperatively compared with postoperatively.

Perioperative thromboprophylaxis is highly variable in general surgery: results from a multicentre survey.

Perioperative thromboprophylaxis is highly variable in general surgery: results from a multicentre survey.

Risk of venous thromboembolism in patients with elevated INR undergoing hepatectomy: an analysis of the American college of surgeons national surgical quality improvement program registry

BackgroundPatients undergoing hepatectomy can have elevated INR and may have venous thromboembolism (VTE) prophylaxis withheld as a result. We sought to examine the association between preoperative INR elevation and VTE following hepatectomy. MethodsHepatectomies captured in the American College of Surgeons National Surgical Quality Improvement Program registry between 2007 and 2016 were analyzed. Univariable and multivariable models examined the effect of incremental increases in preoperative INR on 30-day VTE, perioperative transfusion, serious morbidity, and mortality, adjusting for potential confounders. ResultsWe included 25,220 elective hepatectomies (62.4% partial lobectomies, 10.1% left hepatectomies, 18.6% right hepatectomies, 9.2% trisegmentectomies). The median age of the patients was 60 years and 49% were male. INR was elevated in 3089 patients (12.2%): 1.1–1.2 in 8.1%, 1.2–1.4 in 3.3%, and 1.4–2.0 in 0.9%. Incremental elevations in INR were independently associated with increasing risk for postoperative VTE [odds ratio (OR) 1.15, 95% confidence intervals 1.01–1.31], perioperative transfusion [OR 1.35 (1.28–1.43)], serious morbidity [OR 1.35 (1.28–1.43)], and mortality [OR 1.76 (1.56–1.98)]. ConclusionElevation in preoperative INR was counter-intuitively associated with increased risk of both VTE and perioperative transfusion following hepatectomy. The role of perioperative thromboprophylaxis warrants further investigation to determine optimal care in patients with elevated preoperative INR.

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.

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.

Perioperative Thromboprophylaxis in Digital Replantation: A Systematic Review.

A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)--compliant prospectively registered (PROSPERO, CRD42018108695) systematic review was conducted. Cochrane Central Register of Controlled Trials, Medline, EMBASE, and Scopus were searched up until December 2019. Articles were assessed for eligibility in duplicate by 2 independent reviewers. All comparative studies that examined the use of perioperative thromboprophylaxis in digital replantation were eligible for inclusion. Collectively, 1,025 studies were identified of which 7 met full inclusion criteria reporting data from 635 patients (908 digital replants, 86% men, average age 37.3 years). Laceration was the most commonly reported mechanism of injury (68%), with 33% of replantation occurring in Tamai zone III. Fourteen distinct perioperative protocols were identified. One study reported significantly higher digital survival with continuous heparin infusion versus bolus heparin. Five studies demonstrated a significantly higher incidence of complications among patients treated with systemic heparin. The clinical efficacy and safety of perioperative antithrombotic therapy following digital replantation remains equivocal. The perceived benefits of improved digital survival must be tempered against the adverse systemic side effects of antithrombotic and anticoagulant therapies until further prospectively collected data sets become available.

Perioperative vs. postoperative thromboprophylaxis in liver surgery

Background: Liver surgery is associated with a simultaneous risk of venous thromboembolism (VTE) and haemorrhage. There is no consensus how thromboprophylaxis should be performed in liver surgery. Most centers give patients thromboprophylaxis postoperatively, some protocols include preoperative prophylaxis (Aloia et al., 2015 J Gastrointest Surg). In early 2016, preoperative prophylaxis was added to the thromboprophylaxis protocol of liver surgery in Helsinki University Hospital. The aim of this study is to compare the incidence of thromboembolic and bleeding complications before and after the change of protocol. Material & Methods: Electronic patient records of patients undergoing liver resection during 2014 - 2017 were reviewed retrospectively. Patients were classified into two groups for analyses: patients receiving 1) postoperative thromboprophylaxis, usually enoxaparin 40mg once a day starting from 1. postoperative day (Postop-group, n=260) OR 2) perioperative thromboprophylaxis, usually enoxaparin 40mg once a day starting the day before the operation (Periop-group, n=253). The incidences of pulmonary embolism and bleeding complications within 1 month of surgery were compared between the two groups. Bleeding complications were classified using the ISGLS post-hepatectomy haemorrhage -definition. Patients with permanent anticoagulation (warfarin, LMWH or novel oral anticoagulant), emergency operation, or exploration-only were excluded. Results: A total of 513 liver resection patients were included to the study. Mean age was 63.1 years. 184 patients underwent major hepatectomy (hemihepatectomy/resection of =4 segments). 284 patients had colorectal carcinoma metastases. The incidence of pulmonary embolism within 1 month of surgery was significantly lower in the Periop-group compared to the Postop-group (1.2% vs. 9.6%, respectively, p<0.0001). There was no difference in rates of total (15% Periop-group vs. 14% Postop-group, p=0.800) nor severe (class B and C) postoperative haemorrhage (3.5% Periop-group vs. 2.8% Postop-group, p=0.651). Conclusion: Perioperative thromboprophylaxis reduces the incidence of pulmonary embolism without affecting the incidence of post-hepatectomy haemorrhage in patients undergoing liver surgery.

The Effect of Deep Vein Thrombosis Prophylaxis on Bleeding in Periorbital Surgery in Trauma Patients.

The aim of this study is to assess if there is an increase in postoperative venous thromboembolism (VTE) or bleeding complications in patients who received perioperative chemical thromboprophylaxis compared with patients in whom chemical thromboprophylaxis was held during periorbital trauma surgery. This is a retrospective chart review of patients undergoing periorbital surgery treated in three different city hospitals, by the Department of Oral and Maxillofacial Surgery, University of Texas, between August 2014 and December 2016. A total of 237 patients were included in this study. None of these patients suffered a postoperative VTE. A total of 102 patients received perioperative pharmacologic thromboprophylaxis in the form of enoxaparin or heparin. In this group, one patient suffered a buccal space hematoma. Chemical thromboprophylaxis was held in 135 patients preoperatively and for at least 24 hours postoperatively. In this group, one patient suffered a retrobulbar hematoma after repair of an orbital floor fracture. The rate of postoperative bleeding complications was compared by the chi-square test and was not statistically significant ( p = 0.8417).

Anaesthetic management of Castleman\u2019s disease associated with paraneoplastic pemphigus: report of a rare case

BackgroundCastleman’s disease is a rare lymphoproliferative disease which can mimic other malignant tumours and can be associated with paraneoplastic pemphigus especially in the paediatric age group. This presentation can be challenging even to the seasoned anaesthesiologist when it comes to managing such a case presenting for laparotomy.Case presentationHere such a case in a 12-year-old who was initially diagnosed as retroperitoneal sarcoma complicated with paraneoplastic pemphigus and inferior venacaval thrombus is presented and its anaesthetic management and challenges are discussed. Special care needs to be taken while anaesthetizing such a patient keeping in mind the difficult airway, adrenocortical suppression, and exacerbation of skin lesions due to various anaesthetic procedures. For this case, the histopathology turned out to be Castleman’s disease.ConclusionThe anaesthetic challenges associated with paraneoplastic pemphigus in paediatric age group receiving perioperative thromboprophylaxis need special mention. Here we are discussing the challenges and anaesthetic management of such a case as literature on this aspect is few.

Fondaparinux Sodium Compared With Low-Molecular-Weight Heparins for Perioperative Surgical Thromboprophylaxis: A Systematic Review and Meta-analysis.

BackgroundFondaparinux sodium has been compared with low‐molecular‐weight heparins (LMWH) in randomized controlled trials for perioperative surgical thromboprophylaxis. However, the results from these studies are inconsistent in terms of efficacy and safety to reach a clinical decision. The objective of this study was to systematically review the randomized controlled trials comparing the efficacy and safety of fondaparinux and LMWH for perioperative surgical thromboprophylaxis.Methods and ResultsSystematic search in various databases was done to identify randomized controlled trials comparing fondaparinux and LMWH published during the years 2000 to 2017. Outcomes of interest in this study included venous thromboembolism up to day 15, all‐cause mortality up to day 90, major bleeding, and minor bleeding during the treatment period. Analyses were performed with the relative odds based on a random‐effects model using Mantel‐Haenszel statistics. Results were presented as odds ratios with their 95% CIs. The assessment of study quality was performed as per Cochrane collaboration. After screening 10 644 articles, 12 randomized controlled trials including 14 906 patients were included in the final analyses. Pooled analyses showed the odds of venous thromboembolism in the fondaparinux group were 0.49 times the odds in LMWH group (OR=0.49 [0.38–0.64]). However, the odds of major bleeding in the fondaparinux group were 1.48 times the odds in the LMWH group (OR=1.48 [1.15–1.90]).ConclusionsFondaparinux was associated with a superior efficacy in terms of reduction of venous thromboembolism in this meta‐analysis. However, it was also associated with increased odds of major bleeding.