Perioperative Venous Thromboembolism Prophylaxis Research Articles

European guidelines on peri-operative venous thromboembolism prophylaxis: first update.: Chapter 3: Day surgery and fast-track surgery.

European guidelines on peri-operative venous thromboembolism prophylaxis: first update.: Chapter 3: Day surgery and fast-track surgery.

European guidelines on peri-operative venous thromboembolism prophylaxis: first update.: Chapter 9: Surgery during pregnancy and the immediate postpartum period.

European guidelines on peri-operative venous thromboembolism prophylaxis: first update.: Chapter 9: Surgery during pregnancy and the immediate postpartum period.

Variations in Perioperative Thromboprophylaxis Practices: Do the Guidelines Need a Closer Look?

BackgroundIn 2022, the American Association for Thoracic Surgery (AATS) and the European Society of Thoracic Surgeons (ESTS) published joint guidelines regarding the timing, duration, and choice of agent for perioperative venous thromboembolism prophylaxis for thoracic cancer patients. Now, 1 year after their release, we looked to assess practices and general adherence to these recommendations. MethodsWe conducted a survey among board-certified/board-eligible thoracic surgeons in the United States, between July and October 2023. ResultsA total of 103 board-certified thoracic surgeons responded to the survey. Over half of the surgeons reported using preoperative chemical thromboprophylaxis routinely for lobectomy/sublobar resections (56.3%), pneumonectomy/extended lung resections (64.1%), and esophagectomy (67%). Over two thirds of thoracic surgeons limited the duration of postoperative chemical thromboprophylaxis to the patient’s length of hospital stay and never administered chemoprophylaxis post-discharge. Among surgeons who always continued chemical thromboprophylaxis post-discharge, low-molecular-weight heparin (LMWH) was the most commonly used agent (>70%), followed by direct oral anticoagulants (13.8%-16.7%). Only 33.3% of surgeons prescribing post-discharge chemical thromboprophylaxis after lobectomy/sublobar resections continued prophylaxis up to 4 weeks postoperatively. ConclusionsContrary to the 2022 joint AATS/ESTS guidelines, the majority of surveyed thoracic surgeons in the United States do not routinely prescribe postoperative thromboprophylaxis after lung and esophageal cancer resections. The dogma of routine extended thromboprophylaxis must be reevaluated as modern minimally invasive thoracic surgery allows for very earlier ambulation and enhanced recovery. There is a need for randomized controlled trials exploring the utility of extended thromboprophylaxis and newer agents such as direct oral anticoagulants.

Enhanced recovery after endoscopic sinus surgery: Establishing comprehensive protocols for improvement of perioperative patient care

AbstractObjectivesEnhanced recovery after surgery (ERAS) protocols for endoscopic sinus surgery (ESS) have not been widely implemented, and a critical review of ERAS recommendations and a comprehensive analysis of the supporting literature has not been undertaken. We describe an ESS ERAS protocol including key perioperative interventions for patients undergoing ESS and assess the available evidence.Data SourcesA search was conducted of all relevant ERAS literature in otorhinolaryngology, anesthesia, and surgery using Medline (via PubMed), and Scopus. Keywords included “endoscopic sinus surgery,” “sinus surgery,” “FESS,” and “ESS” for each area of intervention. Where applicable, the authors considered high‐level evidence for recommendations devised for patient cohorts in otorhinolaryngology not undergoing ESS, as well as cohorts undergoing surgical procedures for which ERAS protocols have been extensively evaluated.MethodsStudies received grades of “low,” “moderate,” or “high” quality evidence based on the Oxford Centre for Evidence‐Based Medicine criteria. Each intervention was subsequently assigned a grade of “strong,” “weak,” or “conditional” based on the available evidence.ResultsStrong recommendations include comprehensive patient education and counseling, minimization of preoperative fasting, application of topical/local anesthetics and vasoconstrictors, use of total intravenous anesthesia, avoidance of pharyngeal packing, and use of postoperative nasal irrigation and multimodal analgesia. Conditional recommendations include antibiotic prophylaxis. Weak recommendations include perioperative venous thromboembolism prophylaxis, controlled hypotension, and use of postoperative nasal packing/dressing.ConclusionA comprehensive ERAS protocol for ESS can include a variety of high yield, evidence‐based interventions that would likely improve surgical outcomes and patient satisfaction.

Caprini Model Integration into an Electronic Medical Record to Improve Perioperative Venous Thromboembolism Prophylaxis.

This quality-improvement retrospective cohort study of patients undergoing major elective nononcologic gynecologic surgery compares the proportion of patients receiving appropriate perioperative venous thromboembolism (VTE) chemoprophylaxis before and after a novel integration of the Caprini risk-assessment model (RAM) into the electronic medical record (EMR). A sample size of 83 patients in each group (166 total) was calculated to provide 80% power and show a 20% increase in appropriate administration of VTE prophylaxis, with an alpha of 0.05. Heparin was appropriately used in 24 patients (28.9%) in the pre-Caprini-RAM group and 39 patients (47.0%) in the post-Caprini-RAM group ( P =.016). There were no differences in bleeding events, transfusions, or other secondary outcomes. Integrating the Caprini-RAM into an EMR for patients undergoing nononcologic gynecologic surgery significantly improved appropriate use of VTE chemoprophylaxis.

Effect of perioperative anticoagulant prophylaxis in patients with traumatic subdural hematoma and a history of anticoagulant use: a propensity-matched National Trauma Data Bank analysis.

The use of anticoagulation to prevent venous thromboembolism (VTE) is controversial in the setting of neurosurgical decompression for traumatic subdural hematoma (SDH). In these patients, there is concern that anticoagulation may cause secondary hemorrhage, increasing the risk of death and other complications. Patients with a history of anticoagulant use are at further risk of VTE, but the effect of VTE prophylaxis (VTEP) following neurosurgery for SDH has not been thoroughly investigated in this population. This study aims to investigate the differences in in-hospital outcomes in patients with SDH and preexisting anticoagulant use who received VTEP following neurosurgical intervention compared with those who did not. The National Trauma Data Bank was queried from 2017 to 2019 for all patients with preexisting anticoagulant use presenting with an SDH who subsequently underwent neurosurgical intervention. Patients who received VTEP were propensity score matched with patients who did not based on demographics, insurance type, injury severity, and comorbidities. Paired Student t-tests, Pearson's chi-square tests, and Benjamini-Hochberg multiple comparisons correction were used to compare differences in in-hospital complications, length of stay (LOS), and mortality rate between the two groups. A logistic regression model was developed to identify risk factors for in-hospital mortality. Two thousand seven hundred ninety-four patients matching the inclusion criteria were identified, of whom 950 received VTEP. Following one-to-one matching and multiple comparisons correction, the VTEP group had a lower mortality rate (18.53% vs 34.53%, p < 0.001) but longer LOS (14.09 vs 8.57 days, p < 0.001) and higher rates of pressure ulcers (2.11% vs 0.53%, p = 0.01), unplanned intensive care unit admission (9.05% vs 3.47%, p < 0.001), and unplanned intubation (9.47% vs 6.11%, p = 0.021). The multivariable logistic regression showed that use of unfractionated heparin (UH; OR 0.36, p < 0.001) and low-molecular-weight heparin (LMWH; OR 0.3, p < 0.001) were associated with lower odds of in-hospital mortality. In patients with traumatic SDH and a history of anticoagulant use, perioperative VTEP was associated with increased LOS but provided a mortality benefit. LMWH and UH use were the strongest predictors of survival.

Incidence and Risk Factors for Postoperative Venous Thromboembolism After Gender Affirming Vaginoplasty: A Retrospective Analysis of a Large Insurance Claims Database

To investigate the incidence and associated risk factors of venous thromboembolism (VTE) after gender affirming vaginoplasty. We searched International Business Machines Corporation (IBM) Marketscan, a commercial claims database, for Current Procedural Terminology and International Classification of Diseases (ICD) procedure codes to identify patients who underwent gender affirming vaginoplasty from 2011-2020. We quantified deep venous thrombosis and pulmonary embolism using ICD-9 and ICD-10 codes found within 90days after surgery. Univariate and multivariate analyses were performed to establish association between VTE events and age, residency location, and comorbidities. We identified 1588 patients who underwent gender affirming vaginoplasty. Overall, 1.1% of patients experienced a VTE within 90days following surgery. Patients who experienced postoperative VTE were older, more likely to have had a prior VTE, less likely to be from an urban area, and more likely to have a higher Charlson Comorbidity Index score. Among patients with postoperative VTE, 47.1% had previous VTE. Among patients without a postoperative VTE, 1.3% had previous VTE. In patients undergoing gender affirming vaginoplasty, the incidence of postoperative VTE was 1.1%. Older age, rurality, increased comorbidities, and prior VTE were associated with increased risk of postoperative VTE. Current guidelines do not recommend cessation of gender affirming hormone therapy (GAHT) prior to vaginoplasty. Further research is needed to evaluate if certain high-risk patients would benefit from perioperative adjustment of GAHT or perioperative VTE prophylaxis.

High Rates of Pediatric Venous Thromboembolism After Elective Laparoscopic Splenectomy Suggest Need for Perioperative Prophylaxis

IntroductionIn adult populations, postoperative venous thromboembolism (VTE) is a reported complication of up to 8% of elective laparoscopic splenectomy (LS) cases. VTE is a rare event in the pediatric population, affecting less than 1% of all pediatric surgical patients. We hypothesized that pediatric patients are at a higher risk of postoperative VTE after undergoing elective LS relative to other laparoscopic procedures and may warrant prophylactic treatment. Materials and methodsWe queried the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database from 2012 to 2020. Patients were identified using the Current Procedural Terminology code 38120 and only elective cases were analyzed. ResultsThe incidence of VTE in all pediatric patients undergoing surgery in the American College of Surgeons NSQIP-P database was 0.13%. The incidence of VTE in pediatric patients undergoing elective laparoscopic abdominopelvic procedures was 0.17%. There were seven total cases of VTE (0.41%) in pediatric patients undergoing elective LS, more than twice the rate of the general population (P = 0.001). Eighty percent of pediatric patients undergoing elective LS had an underlying hematological disorder. ConclusionsBy analyzing the NSQIP-P database, we evaluated the largest cohort of pediatric patients undergoing elective LS to date. We identified a higher incidence of VTE following this procedure relative to the rate of VTE in the overall population in the NSQIP-P database, as well as those undergoing elective laparoscopic abdominopelvic operations. The relatively higher incidence of VTE after elective LS is likely due to the presence of underlying hematological conditions. Given the low incidence of complications associated with pharmacologic VTE prophylaxis, the results of this study suggest that further research is warranted to establish the efficacy of perioperative pharmacological VTE prophylaxis in pediatric patients undergoing elective LS.

Venous Thromboembolism Prophylaxis Use by Pediatric Orthopedic Surgeons in Canada for the Pediatric Orthopedic Surgical Population.

Introduction A novel pediatric venous thromboembolism (VTE) screening tool was implemented in 2016 at the Izaak Walton Killam (IWK) Health Centre, which safely reduced the use of thromboprophylaxis by 47.9% with no increase in VTE in the pediatric orthopedic surgical population (POSP). There is presently no data on the current practices or protocols for VTE prophylaxis for POSP in Canada. The present survey was designed to assess current practices regarding VTE prophylaxis for POSP in Canada. Methods After research ethics board (REB) approval, a 22-question survey was administered electronically to all Canadian Pediatric Orthopedic Group (CPOG) members. The survey contained questions on respondent demographics and background, current VTE prophylaxis practices and experiences including indications for prophylaxis, the existence of VTE protocols, and interest in utilizing VTE protocols. Descriptive statistical analyses and analysis of variance (ANOVA) were completed on the survey responses. Results Of the 100 CPOG members, 49 (49%) responded. Most respondents (51%, n=25/49) practice in Central Canada, 39% (n=19/49) practice in Western Canadian provinces, and a smaller portion practice in Atlantic Canada (10%, n=5/49). Of the respondents,43% (n=21/49) indicated that they use pharmacologic VTE prophylaxis in their practice, and 93% (n=27/29) stated that specific risk factors are indications of initiating pharmacologic VTE prophylaxis. Additionally, 57% (n=16/28) did not have a defined protocol for VTE prophylaxis, and 18% (n=5/28) were uncertain if they do. Of the respondents, 85% (n=22/26) were open to utilizing a VTE prophylaxis screening tool, and 12% (n=3/26) were uncertain if they would be. Conclusion This study has demonstrated that a uniform protocol for VTE prophylaxis does not exist in most Canadian centers, despite its need. There is nationwide interest in adopting a perioperative VTE prophylaxis screening tool to optimize pharmacologic thromboprophylaxis use in POSP. The goal of future research is the national implementation and standardization of such a screening tool through collaboration in a multicenter study.

Do no harm: the role of perioperative heparin in urethroplasty.

To examine the safety of single modality mechanical venous thromboembolism (VTE) prophylaxis in patients undergoing urethroplasty. VTE is a perioperative complication with significant morbidity. Routine use of peri-operative VTE prophylaxis is common guideline-driven practice across multiple surgical specialties. There is a discrepancy between guideline recommendations and clinical practice in the administration of peri-operative low-dose unfractionated heparin (LDUH) for urethroplasty. Patients were identified from an IRB-approved database of patients undergoing urethral reconstruction by a single surgeon at MedStar Washington Hospital Center from 2012 to 2020. All patients had sequential compression devices (SCD) prior to anesthesia induction. Select patients received LDUH as dual prophylaxis. Primary endpoint was perioperative VTE within 30days. We identified 345 patients who met inclusion criteria. Sixty-nine patients received peri-operative LDUH. One patient had a deep vein thrombosis in the SCD only group. Routine LDUH administration likely overtreats men undergoing urethroplasty. There may be a subset of men in whom dual prophylaxis with LDUH and SCD is beneficial for prevention of VTE. Current guidelines do not offer adequate criteria to identify these men. We offer clinical considerations to help guide further study to identify these patients.

Venous thromboembolism (VTE) prophylaxis following transurethral resection of the prostate (TURP): An audit of practice in Scotland

Objectives: To establish the current practice of urologists in Scotland with regard to venous thromboembolism (VTE) prophylaxis following transurethral resection of the prostate (TURP). Methods: An electronic survey was distributed to all practicing urology consultants and trainees in Scotland. Participants were asked questions regarding their current practice with regard to peri-operative VTE prophylaxis and were offered free-text responses. Findings were compared with a previous UK-wide study from 2002, and with current European Association of Urology (EAU) guidelines. Results: 56/113 (49.6%) of urologists responded to the survey. Overall, 71.4% of responding urologists prescribed pharmacological VTE prophylaxis following TURP. No urologists routinely prescribe VTE prophylaxis on discharge. 94.6% of responding urologists utilise mechanical prophylaxis in the form of thromboembolic deterrent (TED) stockings, with 35.7% of urologists discharging patients with TED stockings. No urologists reported a death from uncontrollable bleeding after TURP in the previous 10 years, whereas 10% of respondents had a patient whom had suffered a death or serious complication from a thromboembolic event following TURP in the past 10 years. A range of free-text responses were given. Conclusion: Our national audit has identified a wide variation between practice and current published guidance. These results contrast dramatically with a previous UK wide audit from 2002, which found 14% of urologists utilised pharmacological prophylaxis, 50% utilised mechanical prophylaxis only and 23% used no thromboprophylaxis at all. Recent guidance from the EAU recommends against using pharmacological prophylaxis due to the increased bleeding risk. Given that current practice does not marry with published recommendations; we believe that further research is required in this area for stronger evidence-based guidelines to be developed. Level of evidence: 4

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.

PD10-05 PERIOPERATIVE BLOOD TRANSFUSION IS ASSOCIATED WITH INCREASED RISK OF VENOUS THROMBOEMBOLISM AFTER RADICAL CYSTECTOMY

You have accessJournal of UrologyCME1 May 2022PD10-05 PERIOPERATIVE BLOOD TRANSFUSION IS ASSOCIATED WITH INCREASED RISK OF VENOUS THROMBOEMBOLISM AFTER RADICAL CYSTECTOMY Amanda Myers, Igor Frank, Paras H. Shah, Robert F. Tarrell, Giovanni A. Gonzalez, R. Jeffrey Karnes, Houston Thompson, Matthew K. Tollefson, Stephen A. Boorjian, and Timothy D. Lyon Amanda MyersAmanda Myers More articles by this author , Igor FrankIgor Frank More articles by this author , Paras H. ShahParas H. Shah More articles by this author , Robert F. TarrellRobert F. Tarrell More articles by this author , Giovanni A. GonzalezGiovanni A. Gonzalez More articles by this author , R. Jeffrey KarnesR. Jeffrey Karnes More articles by this author , Houston ThompsonHouston Thompson More articles by this author , Matthew K. TollefsonMatthew K. Tollefson More articles by this author , Stephen A. BoorjianStephen A. Boorjian More articles by this author , and Timothy D. LyonTimothy D. Lyon More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002536.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Venous thromboembolism (VTE) is increasingly used as a quality indicator after radical cystectomy (RC). However, the role of perioperative blood transfusion (PBT) in VTE risk adjustment remains unclear. While transfusion has been associated with an increased risk of VTE in administrative datasets, these analyses are limited by inability to adjust for several risk factors for VTE including cancer stage and receipt of neoadjuvant chemotherapy which may confound the observed associations. The objective of this study was to examine whether perioperative blood transfusion is associated with VTE following RC after adjusting for both patient- and disease-related factors. METHODS: Patients who underwent RC for bladder cancer from 1980-2020 were identified in the Mayo Clinic cystectomy registry. PBT was defined as intraoperative and/or postoperative blood transfusion during the initial hospital stay. The primary outcome was VTE within 90 days of RC, inclusive of either deep venous thrombosis or pulmonary embolism. Perioperative VTE prophylaxis varied according to institutional standard at the time, but generally consisted of sequential compression devices and subcutaneous heparin while inpatient. In April 2013, we began using intraoperative tranexamic acid, and in May 2014, we began prescribing outpatient extended duration VTE prophylaxis with enoxaparin in all patients without contraindications. Associations between clinicopathologic variables and 90-day VTE were assessed using multivariable logistic regression. PBT was analyzed as both a categorical and a continuous variable. RESULTS: We identified 3958 patients with RC, of whom 162 (4%) experienced a VTE within 90 days of RC. 2244 patients (57%) received a PBT, with a median of 1 (range: 0-69, IQR: 0-3) unit transfused. Median follow up among survivors was 6.7 years (IQR 2.4-12.7). On multivariable analysis adjusting for year of surgery, BMI, robotic approach, neoadjuvant chemotherapy, diversion type, pathologic tumor stage and pathologic nodal stage, the receipt of PBT remained significantly associated with an increased risk of VTE (adjusted OR 1.46, 95% CI 1.01-2.09, p=0.04). When further analyzed as a continuous variable, each unit of blood was associated with 6% higher odds of a VTE (adjusted OR 1.06, 95% 1.01-1.10, p=0.01). CONCLUSIONS: PBT was independently associated with VTE within 90 days of RC after adjusting for disease-related factors. Each unit transfused was associated with higher odds of a VTE. Continued effort to limit blood transfusion in these patients is warranted. Source of Funding: none © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e185 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Amanda Myers More articles by this author Igor Frank More articles by this author Paras H. Shah More articles by this author Robert F. Tarrell More articles by this author Giovanni A. Gonzalez More articles by this author R. Jeffrey Karnes More articles by this author Houston Thompson More articles by this author Matthew K. Tollefson More articles by this author Stephen A. Boorjian More articles by this author Timothy D. Lyon More articles by this author Expand All Advertisement PDF DownloadLoading ...

Red Blood Cell Transfusions and Risk of Postoperative Venous Thromboembolism

Postoperative venous thromboembolism (VTE) is a major risk for orthopaedic surgery and associated with notable morbidity and mortality. Knowing a patient's risk for VTE may help guide the choice of perioperative VTE prophylaxis. Recently, red blood cells (RBCs) have been implicated for their role in pathologic thrombosis. Therefore, we examine the association between perioperative RBC transfusion and postoperative VTE after orthopaedic surgery. A retrospective cohort study was done by conducting a secondary analysis of data obtained from the 2016 American College of Surgeons National Surgical Quality Improvement Program database. Our population consisted of 234,608 adults who underwent orthopaedic surgery. The exposure was whether patients received a perioperative RBC transfusion. The primary outcome was postoperative VTE within 30 days of surgery that warranted therapeutic intervention, which was subsequently split into symptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE). Odds ratios (ORs) were estimated using a multivariate logistic regression model. At baseline, 1,952 patients (0.83%) had postoperative VTE (DVT in 1,299 [0.55%], PE in 801 [0.34%], and both DVT and PE in 148 [0.06%]). Seven hundred ninety-five patients (0.3%) received preoperative RBC transfusions only, 11,587 patients (4.9%) received postoperative RBC transfusions only, and 848 patients (0.4%) received both preoperative and postoperative RBC transfusions. Postoperative RBC transfusion was associated with higher odds of VTE (adjusted OR [aOR], 1.47; 95% confidence interval [CI], 1.19-1.81), DVT (aOR, 1.40; 95% CI, 1.09-1.79), PE (aOR, 1.59; 95% CI, 1.14-2.22), and 30-day mortality (aOR, 1.21; 95% CI, 1.01-1.45) independent of various presumed risk factors. When creating subgroups within orthopaedics by Current Procedural Terminology codes, postoperative transfusions in spine (aOR, 2.03; 95% CI, 1.13-3.67) and trauma (aOR, 1.40; 95% CI, 1.06-1.86) were associated with higher odds of postoperative VTE. Our results suggest that postoperative RBC transfusion may be associated with an increased risk of postoperative VTE, both symptomatic DVT and life-threatening PE, independent of confounders. Additional prospective validation in cohort studies is necessary to confirm these findings. In addition, careful perioperative planning for patients deemed to be at high risk of requiring blood transfusion may reduce these postoperative complications in orthopaedic patients. III.

Prophylaxis for Venous Thromboembolic Events in Elective Total Hip and Total Knee Arthroplasty.

Venous thromboembolism (VTE) is a serious complication after major orthopaedic operations, such as a total hip (THA) and knee (TKA) arthroplasty. Therefore, perioperative VTE prophylaxis is recommended; a multitude of modern options are available, including both pharmacologic (aspirin, unfractionated and lowmolecular- weight heparin, vitamin K antagonists, and novel oral anticoagulants) and/or mechanical interventions (early mobilization, graduated compression stockings, intermittent pneumatic compression devices, and venous foot pumps). However, because of the abundance of these possibilities, it is crucial to understand the benefits and drawbacks of each VTE prophylaxis option to ensure that the optimal treatment plan is developed for each patient. The American College of Chest Physicians (AACP) and the American Academy of Orthopaedic Surgeons (AAOS) have both published individual guidelines on VTE prophylaxis regimens, alongside numerous studies evaluating the efficacy and outcomes of the different prophylaxis modalities. The purpose of this review is to provide a summary of the evidence on VTE prophylaxis after elective total hip and knee arthroplasty based on current guidelines and highlight the major concerns and potential complications.

The American Society for Metabolic and Bariatric Surgery (ASMBS) updated position statement on perioperative venous thromboembolism prophylaxis in bariatric surgery

The following position statement is the second update by the American Society for Metabolic and Bariatric Surgery (ASMBS) on prophylactic measures for reducing the risk of venous thromboembolism (VTE) in bariatric surgery patients, after the previous update in 2013 [ [1] Clinical Issues Committee of the American Society for Metabolic and Bariatric SurgeryASMBS updated position statement on prophylactic measures to reduce the risk of venous thromboembolism in bariatric surgery patients. Surg Obes Relat Dis. 2013; 9: 493-497 Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar ]. The purpose of this statement is to enhance the quality of care in bariatric surgery by reviewing the available evidence on VTE prophylaxis. Since there is limited high-quality data, these practice guidelines suggest some recommendations that are based on available knowledge, peer-reviewed scientific literature, and expert opinion regarding reasonable use of prophylactic measures for VTE in bariatric surgery patients. The intent of issuing such a statement is to provide objective information regarding the use of VTE prophylaxis and its possible role in the prevention of such complications. The statement will be revised in the future when additional evidence becomes available. VTE prevention in bariatric surgery: from where have we come, and how did we get here?Surgery for Obesity and Related DiseasesVol. 18Issue 2PreviewThe American Society for Metabolic & Bariatric Surgery (ASMBS) Clinical Issues Committee (CIC) has published 3 position statements on the issue of venous thromboembolism (VTE) prevention in bariatric surgery, including the most recent in this issue of the journal [1]. The authors of this accompanying editorial are the 3 previous chairs of the ASMBS CIC who served during the timeframe in which the previous statements were issued. The purpose of this editorial is to add some perspective to publication of the current position statement that updates the ASMBS position. Full-Text PDF

Venous thromboembolism rates and risk factors following endoscopic skull base surgery.

Venous thromboembolism (VTE) is a potentially fatal perioperative complication. The objective of this study was to assess the rate and risk factors for VTE in endoscopic skull base surgery (ESBS). This was a retrospective review of adults undergoing ESBS at a tertiary academic center. Incidence of VTE in the 30-day postoperative period was recorded. Logistic regression analyses identified factors associated with VTE. A total of 1122 ESBS cases performed at Stanford University School of Medicine between 2009 and 2019 were studied. Almost all cases (96.1%) did not employ perioperative VTE chemoprophylaxis. The overall incidence of VTE was 2.3% (26/1122). Malignant pathologies had a higher rate of VTE compared with nonmalignant pathologies (4.5% vs 2.0%, odds ratio [OR] 2.85, 95% confidence interval [CI] 1.22-6.66). Factors associated with an increased risk of VTE included a Caprini score greater than 5 (OR 1.53, 95% CI 1.28-1.83); multiple preoperative endocrinopathies such as the syndrome of inappropriate antidiuretic hormone secretion (SIADH) (OR 22.48, 95% CI 3.93-128.70), adrenal insufficiency (OR 5.24, 95% CI 1.82-15.03), hypercortisolism (OR 4.46, 95% CI 1.47-13.56), and hypothyroidism (OR 3.69, 95% CI 1.66-8.20); each 10-hour increment of lumbar drain duration (OR 1.16, 95% CI 1.08-1.25); and each 10-hour increment for duration of hospitalization (OR 1.05, 95% CI 1.03-1.06). The incidence of VTE following ESBS is relatively low at 2.3%. Factors with a higher association of VTE include malignancy, preoperative endocrinopathies, higher Caprini score, prolonged lumbar drain duration, and prolonged hospitalization. Larger, multi-institutional studies are needed to validate these findings and to better refine clinical decision-making regarding perioperative VTE prophylaxis.

Evaluation of Perioperative Venous Thromboembolism Prophylaxis after Minimally Invasive Hysterectomy

Study Objective Evaluate appropriate utilization of postoperative venous thromboembolism prophylaxis using recommendations from the Modified Caprini Risk model. Design We performed an IRB-approved retrospective cohort study. Setting Academic medical institution. Patients or Participants Patients who underwent a robotic -assisted total laparoscopic hysterectomy and were admitted for postoperative care with the gynecologic oncology service from January 2019 to May 2020. Interventions Patients were stratified into VTE risk categories using the Modified Caprini Risk model. We analyzed VTE prophylaxis received and trends in following recommendations. Measurements and Main Results A total of 171 patients met inclusion criteria and were stratified into risk categories – 2 low risk, 42 moderate risk, 45 high risk, 82 high risk with cancer. Intermittent pneumatic compression (IPC) devices were used in 50%, 85.7%, 88.9%, and 90.2% of patients in the low, moderate, high, and high risk with cancer categories. Immediate chemoprophylaxis was used in 45.2%, 40%, and 63.4% of patients in the moderate, high, and high risk with cancer categories. Extended chemoprophylaxis was used in 2.4%, 8.9%, and 9.8% of patients in the moderate, high, and high risk with cancer categories. Patients were more likely to receive immediate and extended chemoprophylaxis with increasing risk (P=.001 and P=.02). Conclusion Our analyses indicate we appropriately utilize IPC devices with the majority of minimally invasive hysterectomies on the gynecologic oncology service. However, identification of high-risk patients and use of pharmacologic interventions to prevent VTE are lacking. These findings highlight an opportunity for a quality improvement initiative on perioperative VTE prophylaxis. Evaluate appropriate utilization of postoperative venous thromboembolism prophylaxis using recommendations from the Modified Caprini Risk model. We performed an IRB-approved retrospective cohort study. Academic medical institution. Patients who underwent a robotic -assisted total laparoscopic hysterectomy and were admitted for postoperative care with the gynecologic oncology service from January 2019 to May 2020. Patients were stratified into VTE risk categories using the Modified Caprini Risk model. We analyzed VTE prophylaxis received and trends in following recommendations. A total of 171 patients met inclusion criteria and were stratified into risk categories – 2 low risk, 42 moderate risk, 45 high risk, 82 high risk with cancer. Intermittent pneumatic compression (IPC) devices were used in 50%, 85.7%, 88.9%, and 90.2% of patients in the low, moderate, high, and high risk with cancer categories. Immediate chemoprophylaxis was used in 45.2%, 40%, and 63.4% of patients in the moderate, high, and high risk with cancer categories. Extended chemoprophylaxis was used in 2.4%, 8.9%, and 9.8% of patients in the moderate, high, and high risk with cancer categories. Patients were more likely to receive immediate and extended chemoprophylaxis with increasing risk (P=.001 and P=.02). Our analyses indicate we appropriately utilize IPC devices with the majority of minimally invasive hysterectomies on the gynecologic oncology service. However, identification of high-risk patients and use of pharmacologic interventions to prevent VTE are lacking. These findings highlight an opportunity for a quality improvement initiative on perioperative VTE prophylaxis.

Rationale and design of a prospective, multicenter, randomized controlled trial of postoperative venous thromboembolism prophylaxis in Chinese adult patients with inguinal hernia (CHAT-3 trial).

Venous thromboembolism (VTE) is one of the most common causes of preventable harm for patients in hospitals. Nearly half of all VTE events was estimated to occur after surgical procedure. The Caprini risk score is the most extensively used risk assessment tool in predicting postoperative VTE, which is too complicate for surgeons to use properly in their clinical practice. The CHAT-3 trial will be a prospective, multicenter, randomized, parallel-group trial, which is designed to identify patients at moderate or high risk of VTE after inguinal hernia surgery using the previously established three-factor model, and to use low molecular weight heparin (LMWH) for VTE prevention, in comparison to the current routine assessment and practice used in those patients. Totally, 1,008 patients planned to undergo inguinal hernia surgery will be enrolled, with cluster randomization at 1:1 ratio into intervention arm and control arm. The primary outcomes are the accordance of perioperative VTE prophylaxis based on current guidelines and the rate of pharmacological prophylaxis for VTE. The secondary outcomes are the occurrences of perioperative VTE, major bleeding, mortality of patients after inguinal hernia surgery, and trend of D-dimer during the follow-up period. This study will create evidence that whether the administration based on a simple model is of efficacy and safety for VTE prophylaxis among Chinese patients underwent inguinal hernia surgery. The CHAT-3 trial (Trial registration number: ChiCTR2000033769).

MP23-11 DO NO HARM: THE ROLE OF PERIOPERATIVE HEPARIN IN ANTERIOR URETHROPLASTY

You have accessJournal of UrologyHealth Services Research: Practice Patterns, Quality of Life and Shared Decision Making III (MP23)1 Sep 2021MP23-11 DO NO HARM: THE ROLE OF PERIOPERATIVE HEPARIN IN ANTERIOR URETHROPLASTY Harry Lee, Nathan Shaw, Erin Hays, and Krishnan Venkatesan Harry LeeHarry Lee More articles by this author , Nathan ShawNathan Shaw More articles by this author , Erin HaysErin Hays More articles by this author , and Krishnan VenkatesanKrishnan Venkatesan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002014.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Venous thromboembolism (VTE) is a perioperative complication with significant morbidity. Routine use of peri-operative VTE prophylaxis is common guideline-driven practice across multiple surgical specialties. There is a discrepancy between guideline recommendations and clinical practice in the administration of peri-operative heparin for anterior urethroplasty. The purpose of this study was to examine the necessity of peri-operative heparin in patients undergoing anterior urethroplasty. METHODS: Patients were identified from an IRB-approved, prospectively maintained database of patients undergoing anterior urethral reconstruction by a single surgeon at MedStar Washington Hospital Center (MWHC) from 2012-2020. All patients had sequential compression devices (SCDs) prior to anesthesia induction. Patients received heparin based on hospital policy as dual prophylaxis. Primary endpoint was perioperative VTE within 30 days with secondary outcomes of peri-operative complications and stricture recurrence. RESULTS: We identified 342 patients who met inclusion criteria. 68 patients received peri-operative heparin. One patient had a DVT in the SCD only group. There were statistically significant increases in hospital length of stay, stricture recurrence, and post-operative complications in the group that received heparin. CONCLUSIONS: Routine heparin administration likely overtreats men undergoing anterior urethroplasty. There may be a subset of men in whom dual prophylaxis with heparin and SCD is beneficial for prevention of VTE. Currently guidelines do not offer adequate criteria to identify these men. We offer an algorithm to help guide further study to identify these patients. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e405-e406 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Harry Lee More articles by this author Nathan Shaw More articles by this author Erin Hays More articles by this author Krishnan Venkatesan More articles by this author Expand All Advertisement Loading ...