Pharmacologic Venous Thromboembolism Prophylaxis Research Articles

Real-life use of thromboprophylaxis in patients hospitalized for pulmonary disorders: A single-center retrospective study.

Underuse of thromboprophylaxis in hospitalized medical patients is still common worldwide. Little is known about the use of thromboprophylaxis in patients with pulmonary diseases in everyday hospital practice. The aim of this study was to assess the use of pharmacological prophylaxis of venous thromboembolism (VTE) in real-life patients with pulmonary diseases. In this retrospective study, 2 validated scoring systems, i.e., the Padua prediction score and Caprini VTE risk assessment, were used to assess the VTE risk in 2011 patients (1133 men and 878 women), aged 18 years or more, hospitalized for pulmonary diseases (median 6 days) in a single tertiary pulmonary medical center from January to December 2014. Using the Padua prediction score, we identified 428 (21.28%) patients at a high risk for VTE, including 167 (39.01%) who received thromboprophylaxis with low-molecular-weight heparin, and 261 (60.98%) individuals at a high risk without thromboprophylaxis (p < 0.001). A total of 888 (44.16%) patients who scored 5 points or more using the Caprini VTE risk assessment were identified as subjects at a high risk for VTE, including 34.79% of patients receiving thromboprophylaxis. From among patients at a high risk for VTE, 579 (65.20%) did not receive appropriate thromboprophylaxis (p < 0.001). Underuse of thromboprophylaxis was observed more commonly among patients hospitalized for lung cancer or pneumonia (50.60% and 24.87% of patients at a high risk for VTE without prophylaxis, respectively). Thromboprophylaxis is underutilized in hospitalized patients with pulmonary diseases regardless of the scoring system used. Implementation of thromboprophylaxis should be markedly improved in this patient group.

Postpartum Thromboembolism Prophylaxis during Delivery Hospitalizations.

This article evaluates trends in venous thromboembolism (VTE) prophylaxis during delivery hospitalizations in the United States. We utilized an administrative database to determine if women hospitalized for vaginal or cesarean delivery received pharmacologic VTE prophylaxis, mechanical VTE prophylaxis, or both from January 2011 through March 2015. Mechanical prophylaxis included sequential compression devices, graduated compression stockings, and other pneumatic devices. Pharmacologic prophylaxis included unfractionated heparin, low molecular weight heparin, or fondaparinux. Probability of use of thromboprophylaxis for individual hospitals was estimated in an adjusted model. A total of 956,428 women who underwent cesarean and 1,914,142 women who underwent vaginal delivery were included in the analysis. Cesarean VTE prophylaxis declined between 2011 (50.3%) and 2015 (47.7%; p < 0.01). Of women undergoing vaginal delivery, 2.9% received prophylaxis. Delivery hospital was an important determinant of cesarean prophylaxis: in the adjusted model, one-third of hospitals used prophylaxis for less than 20% of deliveries, one-third of hospitals used prophylaxis for 20 to 80% of deliveries, and the final third of hospitals used prophylaxis in greater than 80% of deliveries. While many hospitals appear to be following best clinical practices, some do not provide routine cesarean VTE prophylaxis. Minimizing care quality variation may improve maternal safety.

Venous Thromboembolism Prophylaxis in Hospitalized Patients With Inflammatory Bowel Disease: Are We Falling Short?

BACKGROUND: Venous Thromboembolism (VTE) in hospitalized Inflammatory Bowel Disease (IBD) patients increases length of stay by 48% and leads to a 59% increase in hospital charges1. Analyses show30% of gastroenterologists are unaware of ACG guidelines for VTE prophylaxis in hospitalized IBD patients; only 34% reported they would give prophylaxis to patients with an active flare2. We hypothesize that we under-prescribe prophylaxis in IBD patients due to misguided fear of poor outcomes such as bleeding. Our primary objective is to determine if Lankenau Medical Center adheres to guidelines set forth by gastroenterology societies as well as the American College of Chest Physicians in implementing VTE prophylaxis among hospitalized IBD patients. METHODS: We conducted a retrospective cohort study reviewing inpatient medical records for admissions to Lankenau Medical Center from January 1st, 2009 to December 31st, 2014 with an ICD diagnosis of IBD. Patients were evaluated regardless of admitting diagnosis. Exclusion criteria included age <18 and >90, and patients on long term systemic anticoagulation for any reason, including those with a history of VTE. We subsequently excluded charts from 2009 secondary to a lack of data within the electronic medical record. We collected data on IBD diagnosis (UC vs Crohns), and choice of VTE prophylaxis including enoxaparin, unfractionated heparin, sequential compression devices, Aspirin 81mg BID or none. Additional variables were collected for future analysis. We categorized VTE prophylaxis on admission as follows: a.) Appropriate VTE prophylaxis with heparin or Lovenox; b.) Inappropriate VTE prophylaxis, with sequential compression devices or aspirin; or c.) No VTE prophylaxis. RESULTS: 568 inpatient charts were evaluated. 182 of these met exclusion criteria; 386 were included. 99% (N=384) had a confirmed diagnosis of Crohn's disease while 1% (N=4) had Ulcerative Colitis. 49% of patients were placed on appropriate pharmacologic VTE prophylaxis (N= 189). Subcutaneous heparin was implemented in 12% while 37% were started on enoxaparin. The remaining 50% of our population was started on either inappropriate VTE prophylaxis or no prophylaxis at all. Of those started on inappropriate VTE prophylaxis on admission 20% received sequential compression devices while 2% received twice daily aspirin therapy. 27% of our study population was not started on any VTE prophylaxis on admission. CONCLUSION(S): Appropriate VTE prophylaxis in hospitalized IBD patients has been shown to decrease morbidity, length of stay, and cost. Nevertheless, even experts remain unaware of guideline recommendations for VTE prophylaxis in this population. We showed that our institution is currently falling short of recommendations. Further analysis will determine any significant variables influencing use of VTE prophylaxis in the 50% of our population with inadequate therapy; we hope to define the barriers to VTE prophylaxis initiation, in order to develop a comprehensive intervention to improve our compliance with these guidelines.

European Guidelines on perioperative venous thromboembolism prophylaxis: Executive summary.

European Guidelines on perioperative venous thromboembolism prophylaxis: Executive summary.

European guidelines on perioperative venous thromboembolism prophylaxis: Surgery in the elderly.

: The risk for postoperative venous thromboembolism (VTE) is increased in patients aged more than 70 years and in elderly patients presenting with co-morbidities, for example cardiovascular disorders, malignancy or renal insufficiency. Therefore, risk stratification, correction of modifiable risks and sustained perioperative thromboprophylaxis are essential in this patient population. Timing and dosing of pharmacoprophylaxis may be adopted from the non-aged population. Direct oral anti-coagulants are effective and well tolerated in the elderly; statins may not replace pharmacological thromboprophylaxis. Early mobilisation and use of non-pharmacological means of thromboprophylaxis should be exploited. In elderly patients, we suggest identification of co-morbidities increasing the risk for VTE (e.g. congestive heart failure, pulmonary circulation disorder, renal failure, lymphoma, metastatic cancer, obesity, arthritis, post-menopausal oestrogen therapy) and correction if present (e.g. anaemia, coagulopathy) (Grade 2C). We suggest against bilateral knee replacement in elderly and frail patients (Grade 2C). We suggest timing and dosing of pharmacological VTE prophylaxis as in the non-aged population (Grade 2C). In elderly patients with renal failure, low-dose unfractionated heparin (UFH) may be used or weight-adjusted dosing of low molecular weight heparin (Grade 2C). In the elderly, we recommend careful prescription of postoperative VTE prophylaxis and early postoperative mobilisation (Grade 1C). We recommend multi-faceted interventions for VTE prophylaxis in elderly and frail patients, including pneumatic compression devices, low molecular weight heparin (and/or direct oral anti-coagulants after knee or hip replacement) (Grade 1C). : This article is part of the European guidelines on perioperative venous thromboembolism prophylaxis. For details concerning background, methods, and members of the ESA VTE Guidelines Task Force, please, refer to:Samama CM, Afshari A, for the ESA VTE Guidelines Task Force. European guidelines on perioperative venous thromboembolism prophylaxis. Eur J Anaesthesiol 2018; 35:73-76.A synopsis of all recommendations can be found in the following accompanying article: Afshari A, Ageno W, Ahmed A, et al., for the ESA VTE Guidelines Task Force. European Guidelines on perioperative venous thromboembolism prophylaxis. Executive summary. Eur J Anaesthesiol 2018; 35:77-83.

Risk factors and pharmacologic prophylaxis for venous thromboembolism in elective spine surgery

Background ContextVenous thromboembolism (VTE) is a known complication after spine surgery, but prophylaxis guidelines are ambiguous for patients undergoing elective spine surgery. PurposeThe objective of this study was to characterize the incidence and risk factors for VTE and the association of pharmacologic prophylaxis with VTE and bleeding complications after elective spine surgery. Study Design/SettingThis is a retrospective cohort study of patients undergoing elective spine surgery in the National Surgical Quality Improvement Program (NSQIP) database and a retrospective cohort analysis at an academic medical center. Patient SampleThis study included 109,609 patients in the NSQIP database from 2005 to 2014 and 2,855 patients at the authors' institution from January 2013 to March 2016 who underwent elective spine surgery. Outcome MeasuresThe incidence and risk factors for VTE were assessed in both cohorts based on the NSQIP criteria. The incidence of bleeding complications requiring reoperation was assessed based on operative reports in the institutional cohort. Materials and MethodsAssociations of patient and procedure factors with VTE were characterized in the NSQIP population. In the single-institution cohort, in addition to NSQIP variables, a chart review was completed to determine the use of VTE prophylaxis, the history of prior VTE, and the incidence of hematoma requiring reoperation. The association of patient and procedure variables, including pharmacologic prophylaxis and history of prior VTE, with VTE and hematoma requiring reoperation were determined with multivariate regression. ResultsAmong 109,609 elective spine surgery patients in NSQIP, independent risk factors for VTE were greater age, male gender, increasing body mass index, dependent functional status, lumbar spine surgery, longer operative time, perioperative blood transfusion, longer length of stay, and other postoperative complications. There were 2,855 patients included in the institutional cohort. Pharmacologic prophylaxis was performed in 56.3% of the institutional patients, of whom 97.1% received unfractionated heparin. When controlling for patient and procedural variables, pharmacologic prophylaxis did not significantly influence the rate of VTE, but was associated with a significant increase in hematoma requiring a return to the operating room (relative risk=7.37, p=.048). ConclusionsPharmacologic prophylaxis, primarily with unfractionated heparin, after elective spine surgery was not associated with a significant reduction in VTE. However, there was a significant increase in postoperative hematoma requiring reoperation among patients undergoing prophylaxis. This raises questions about the routine use of unfractionated heparin for VTE prophylaxis and supports the need for further consideration of risks and benefits of chemoprophylaxis after elective spine surgery.

Reducing the Missed Doses of VTE Pharmacological Prophylaxis is Associated With Reduction in VTE Rate

SESSION TITLE: Diffuse Lung Disease 2 SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: Venous thromboembolism is one of the most common preventable condition in hospitalized patients. Literature review suggest that there is association between interruption of pharmacological VTE prophylaxis dose and VTE. [1-3] Quality improvement projects in our institutes led to improvement in compliance of the pharmacological VTE prophylaxis. The aim of this study was to determine whether the reduction in inappropriate missed doses of scheduled pharmacological VTE prophylaxis reduces the rate of VTE development. METHODS: The retrospective review was conducted in a high risk surgical intenisive care unit (ICU) of a 1,000 bed level 1 trauma center. VTE prophylaxis was based on American College of Chest Physicians 9th edition (ACCP) guidelines. [4] We implemented the quality improvement projects in December 2014 to reduce the incidences of missed doses and increase the compliance of the pharmacological VTE prophylaxis. The baseline data (pre-implementation group) was collected from July 2014 to December 2014. The post QI data was collected from January 2015 to February 2016 (post-implementation group). RESULTS: The total number of patients admitted to surgical unit were 506 and 1110 in pre- and post-implementation groups respectively. The total number of anticoagulant prophylaxis doses in pre-and post-implementation group was 5,695 and 15,616 respectively. Total of 165 scheduled doses were missed inappropriately and missed dose rate was 2.89% in pre-implementation group. Whereas total of 353 scheduled doses were missed inappropriately and the missed dose rate was 2.26% in post-implementation group. The VTE prophylaxis adherence compliance increased from 95.23% to 98.34%. The missed dose rate was reduced by 21.80% and VTE rate reduced by 20.2%. The reduction in missed dose rate was significantly associated with reduction in VTE rate (p<0.05). CONCLUSIONS: Reducing the inappropriate missed doses of scheduled pharmacological VTE prophylaxis is associated with reduction in VTE rates. Improving the VTE prophylaxis by preventing the inappropriate missed doses can significantly contribute to the improvement of health care quality and patient safety. CLINICAL IMPLICATIONS: It is very important for health care providers to take all necessary measures to prevent the event of VTE in the hospitalized patients. Missing of the VTE prophylactic dose can lead to sub-therapeutic level of the drug, which may cause changes in the delicate homeostatic balance between coagulants and anti-coagulants. Therefore prevention of the missed doses is an important measure of optimal pharmacological VTE prophylaxis and prevent VTE. Additional studies are needed to further investigate the outcomes. DISCLOSURE: The following authors have nothing to disclose: Shekhar Patil, Mary Ayad, Shivtej Kaushal, Kavitha Gopal, Bela Patel No Product/Research Disclosure Information

P25 - Pharmacologic Prophylaxis for Venous Thromboembolism in Elective Spine Surgery

P25 - Pharmacologic Prophylaxis for Venous Thromboembolism in Elective Spine Surgery

An Electronic Alert System Is Associated With a Significant Increase in Pharmacologic Venous Thromboembolism Prophylaxis Rates Among Hospitalized Inflammatory Bowel Disease Patients.

Utilization of pharmacologic venous thromboembolism (VTE) prophylaxis in inflammatory bowel disease (IBD) patients seems to be suboptimal with reported rates as low as 50% in some studies. Implementation of an electronic alert system seems to be an effective tool for increasing VTE prophylaxis rates in medical inpatients. To date, no studies have assessed whether this approach is associated with improved rates of pharmacologic VTE prophylaxis specifically in IBD patients. To determine the efficacy of an electronic alert in improving VTE prophylaxis rates in hospitalized IBD patients. We conducted a retrospective cohort study of 576 hospitalized IBD patients. The medical record of each patient was then examined to determine whether pharmacologic VTE prophylaxis was both ordered and administered, the timing of pharmacologic VTE prophylaxis, and reasons for any missed doses. The VTE pharmacologic prophylaxis rate was improved from 60% to 81.2% following the implementation of the electronic alert system (p < .001). An increase in prophylaxis rates was seen in both medical (26.3% vs. 62.8%, p < .001) and surgical services (83.7% vs. 95.5%, p < .001). In patients who received pharmacologic VTE prophylaxis, 16% of all ordered doses were not administered and 57.3% of missed doses were the result of patient refusal. Hospitalization after implementation of the electronic alert system (odds ratio [OR] 4.71, 95% confidence interval [CI] 2.94-7.57) and admission to a surgical service (OR 14.3, 95% CI 8.62-24.39) were predictive of VTE pharmacologic prophylaxis orders. The introduction of an electronic alert system was associated with a significant increase in rates of pharmacologic VTE prophylaxis. However, orders were often delayed and doses not always administered. The most common reason that ordered doses were not given was patient refusal.

Early Versus Delayed Initiation of Pharmacological Venous Thromboembolism Prophylaxis After an Intracranial Hemorrhage

Intracranial hemorrhage (ICH) accounts for up to 20% of all strokes with and carries an approximate 50% 30-day mortality. The risk of venous thromboembolism (VTE) is markedly higher in patients with ICH compared with ischemic strokes, but the optimal time to initiate pharmacological prophylaxis is ill-defined. Retrospective analysis. University-affiliated, tertiary care center. Patients admitted for a nontraumatic ICH who received pharmacological VTE prophylaxis during their first 30 hospital days. Of the 793 patients evaluated, 400 were included [142 (35.5%) early]. Rebleeding event rates were similar for early versus late [8 (5.6%) vs. 13 (5.0%), P=0.80] and rates of hospital-acquired VTEs were not statistically different [1 (0.7%) vs. 8 (3.1%), P=0.17]. The median time from admission to the first dose of pharmacological prophylaxis was similar in patients who experienced rebleeding versus those that did not [74 h (range, 38 to 110.5 h) vs. 63 h (range, 45 to 90.5 h), P=0.69]. There was a longer median time from admission to the first dose of pharmacological prophylaxis in patients who developed a VTE during the initial hospitalization versus those who did not [108 h (range, 73.3 to 187 h) vs. 63 h (range, 44.5 to 90 h), P=0.005]. Initiation of early pharmacological prophylaxis in ICH patients did not appear to increase the risk of rebleeding nor decrease the risk of VTE. Among those patients who did develop VTE during hospitalization, there was a longer median time from admission to the first dose of pharmacological prophylaxis.

Pharmacologic Venous Thromboembolism Prophylaxis in Total Knee and Hip Arthroplasty: A Literature Review

Pharmacologic Venous Thromboembolism Prophylaxis in Total Knee and Hip Arthroplasty: A Literature Review

Epidemiology, Risk Factors and Risk Stratification of Venous Thromboembolism in Pregnancy and the Puerperium

Venous thromboembolism (VTE) remains a leading cause of direct maternal deaths in the developed countries. The incidence of VTE has increased significantly during the past two decades. The absolute risk of VTE is estimated 0.6-2.2 per 1000 deliveries. Compared with age-matched non-pregnant women, the daily risk of VTE is increased 7- to 10-fold for antepartum VTE, but it is 15- to 35-fold for postpartum VTE. The incidence of pulmonary embolism (PE) during the first 6 weeks postpartum is nearly 15-fold higher compared to the incidence in pregnancy, and remains significantly increased up to 12 weeks postpartum. The case fatality rate of PE ranges from 2.2 to 6.6%.The basis of VTE prevention is careful assessment of individual risk factors of VTE and proper risk stratification.It is necessary to differentiate preexisting maternal from transient pregnancy-specific risk factors. Women with previous VTE or hereditary high-risk thrombophilias or with the antiphospholipid syndrome have the highest risk for VTE in pregnancy and the puerperium.Other most important pregnancy-specific risk factors in the antenatal period are severe ovarian hyperstimulation syndrome, hyperemesis, major surgery, severe comorbidities (e.g., systemic lupus erythematodes), hospitalization in women with a body mass index > 25 kg/m2, and inflammatory bowel diseases.Heart diseases, stillbirth, systemic infections, severe postpartum hemorrhage in combination with blood product replacement and/or surgery and emergency caesarean section are predominant risk factors in the postpartum period.Recommendations for risk stratification vary among current international guidelines. According to the SOGC (Society of Obstetricians and Gynaecologists of Canada) 2014, pharmacologic VTE prophylaxis is recommended if the estimated absolute risk of one or multiple risk factors is greater than 1%.The ACCP (American College of Chest Physicians) Guideline 2012 presents specific recommendations only for post-caesarean risk-factor-based prophylaxis.The recent RCOG (Royal College of Obstetricians and Gynaecologists) Guideline No. 37a 2015 recommends risk stratification for VTE prophylaxis on the basis of a special risk scoring system weighting individual risk factors between one point (low risk) to a maximum of 4 points (very high risk).A check list of important risk factors and a management plan for thromboprophylaxis based on current guidelines should be readily available in each obstetric unit.

Pharmacological thromboprophylaxis and its impact on venous thromboembolism following total knee and hip arthroplasty in Korea: A nationwide population-based study.

BackgroundLimited data is available regarding the pharmacological prophylaxis for venous thromboembolism (VTE) in Asian patients undergoing total knee arthroplasty or total hip arthroplasty (TKA/THA).MethodsWe performed a population-based epidemiological study using the Health Insurance Review and Assessment Service database to estimate the rate of pharmacological thromboprophylaxis and its impact on VTE in Korean patients who underwent TKA/THA between 2009 and 2013.ResultsWe identified 306,912 cases (TKA, 261,260; THA, 45,652). The pharmacological thromboprophylaxis rate was 57.16% (TKA, 58.32%; THA, 50.51%), which increased from 42.81% in 2009 to 65.92% in 2013 (P = 0.0165). Both low-molecular-weight-heparin (22.42%) and rivaroxaban (22.71%) were the most common drugs for prophylaxis. The number of patients aged ≥ 60 years (87.31% vs. 81.01%, P < 0.0001), cases requiring general anesthesia (20.70% vs. 18.37%, P < 0.0001), and cases requiring long hospital stay (median, 13 days vs. 12 days, P < 0.0001) were significantly greater in the pharmacological prophylaxis group. The incidence of VTE within 3 months of surgery was 1.52% (TKA, 1.46%; THA, 1.87%). Patients with pharmacological prophylaxis had higher VTE rates (TKA, 1.69% vs. 1.14%; THA, 2.30% vs. 1.43%) than those without prophylaxis, with advanced age, use of general anesthesia, and a longer hospital stay increasing the risk of VTE. However, rivaroxaban significantly reduced the incidence of VTE following TKA (0.82% vs. 1.14%; odd ratio [OR], 0.72; 95% CI, 0.65–0.79). Moreover, ≥ 10 days of pharmacological thromboprophylaxis was significantly associated with lower incidence of VTE after TKA (1.33% vs. 1.52%; OR, 0.87; 95% CI, 0.81–0.94).ConclusionThis represents the largest epidemiological study showing a gradual increase in the use of pharmacological prophylaxis in Korean patients undergoing TKA/THA. Although the incidence of VTE is still low without pharmacological prophylaxis, this study demonstrates that the incidence of VTE can be reduced further using appropriate pharmacological thromboprophylaxis strategies.

Evaluation of guidelines for injured children at high risk for venous thromboembolism: A prospective observational study.

Pharmacologic prophylaxis for venous thromboembolism (VTE) is a widely accepted practice in adult trauma patients to prevent associated morbidity and mortality. However, VTE prophylaxis has not been standardized in injured pediatric patients. Our institution identified factors potentially associated with a high risk of VTE in critically injured children that led to prospective implementation of VTE prophylaxis guidelines. We hypothesize that the guidelines are accurate in predicting children at risk for VTE. Data were prospectively collected on injured children from August 2010 to August 2015. Pharmacologic prophylaxis was indicated for patients identified by the guidelines as high risk for VTE. Prophylaxis was deferred and a screening ultrasound was performed if the high-risk VTE patients were also at high risk for bleeding. To assess the accuracy of predicting confirmed cases of VTE, stepwise logistic regression analysis was used to measure the association of individual risk factors with VTE controlling for age (≥13 years). A receiver operating characteristic curve measured the accuracy of the final model to predict a VTE. Of 4,061 trauma patients, 588 were admitted to the ICU, with the guidelines identifying 199 as high risk for VTE. VTE occurred in 3.9% (23/588) of the ICU population and 10% (20/199) of the high risk group. The median age of VTE patients in the ICU was 9.7 years. Statistically significant predictors (p < 0.05) of VTE in the multivariate model included presence of a central venous catheter (OR = 5.2), inotropes (OR = 7.7), immobilization (OR = 5.5), and a Glasgow Coma Scale of <9 (OR = 1.3). The area under receiver operating characteristic curve of this model was 0.92, demonstrating its excellent predictive ability. Specific clinical factors in critically injured children are associated with a high risk for VTE. Incorporating these risk factors in VTE prophylaxis guidelines facilitates more accurate risk stratification and may allow for improved VTE prevention in pediatric trauma. Prognostic study, level II.

The Michigan Trauma Quality Improvement Program: Results from a collaborative quality initiative.

American College of Surgeons verified trauma centers and a third-party payer within the state of Michigan built a regional collaborative quality initiative (CQI). The Michigan Trauma Quality Improvement Program began as a pilot in 2008 and expanded to a formal program in 2011. Here, we examine the performance of the collaborative over time with regard to patient outcomes, resource utilization, and process measures. Data from the initial 23 hospitals that joined the CQI in 2011 were analyzed. Performance trends from 2011 to 2015 were evaluated for outcomes, resource utilization, and process measures using univariate analysis. Risk-adjustment was performed to confirm results observed in the unadjusted data. To calculate the potential number of patients impacted by the CQI program, the maximum absolute change was multiplied by the number of trauma patients treated in the 23 hospitals during 2015. Membership in a CQI program significantly reduced serious complications (8.5 vs. 7.3%, p = 0.002), decreased resource utilization, and improved process measure execution in trauma patients over 5 years time. Similar results were obtained in unadjusted and risk-adjusted analyses. The CQI program potentially avoided inferior vena cava filter placement in 167 patients annually. Decreased venous thromboembolism rates mirrored increased compliance with venous thromboembolism pharmacologic prophylaxis. This study confirms our hypothesis that participation in a regional CQI improves patient outcomes and decreases resource utilization while promoting compliance with processes of care. Economic/therapeutic care, level V.

The risk of venous thromboembolism with aspirin compared to anticoagulants after hip and knee arthroplasty

BackgroundRecent guidelines include aspirin as an option to prevent venous thromboembolism (VTE) in selected patients undergoing hip or knee replacement surgery. However, the efficacy of aspirin after arthroplasty has not been well-defined, particularly in more contemporary patient populations. We compared rates of post-operative VTE between patients who received aspirin-only versus anticoagulants after hip or knee arthroplasty, using data from a large US-based administrative database. Materials and methodsWe conducted a retrospective cohort study of 231,780 adults who underwent total knee arthroplasty and 110,621 who underwent total hip arthroplasty in 2009–2012 and who received pharmacologic VTE prophylaxis (aspirin or anticoagulant) within the first 7days after surgery. We compared the risk of post-operative VTE between patients receiving aspirin-only vs. anticoagulants, controlling for clinical and hospital characteristics using multivariable logistic regression with propensity score adjustment. ResultsAspirin-only prophylaxis was administered to 7.5% of patients after knee arthroplasty and 8.0% after hip arthroplasty. Post-operative VTE was diagnosed in 2217 (0.96%) patients after knee arthroplasty and 454 (0.41%) after hip arthroplasty. Compared to anticoagulants, aspirin was not associated with a higher risk for post-operative VTE either after knee arthroplasty (adjusted odds ratio and 95% confidence interval [OR] 0.34 [0.24–0.48]) or hip arthroplasty (OR 0.82 [0.45–1.51]). ConclusionsAspirin was uncommonly administered as the sole prophylactic agent after hip or knee arthroplasty in this study. However, patients who received aspirin-only had similar rates of post-operative VTE compared to patients who received anticoagulants. Further research should focus on distinguishing which patients benefit more from anticoagulants versus aspirin after arthroplasty.

Documenting the decision-making process for initiation of pharmacological VTE prophylaxis in patients admitted to an adult psychiatry ward background

BackgroundVenous thromboembolism (VTE) is a condition that causes a blood clot to form within the venous blood system. If this blood clot forms in the peripheral venous system, it can cause symptoms such as calf pain and swelling. If this clot becomes dislodged, it may travel through the vessels into the pulmonary artery which can have much more severe consequences.ObjectivesThere has been a great deal of effort in recent years to increase the percentage of in-patients receiving a VTE assessment; and for those patients to receive appropriate VTE prophylaxis. VTE is a significant cause of inpatient deaths. This audit aims to compare current working practice to local standards and identify learning points.MethodVTE assessment data were collected from two acute psychiatric in-patient wards within a specified, random date range in 2016. Data was collected by checking paper admission documentation. NICE guidelines also state that all patients should be assessed for VTE on admission, with a standard of 100%.ResultsOverall, 6.25% of general adult psychiatry patients had a VTE assessment done within 24 hours of admission.ConclusionThis audit shows that the necessary standards are not met. Importance of these assessments will be communicated during induction programmes for all staff and the results of this audit communicated to current staff on all in-patient psychiatry wards.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Point-of-Care Testing in Burn Patients.

Severe burn injury has an impact on the coagulation system, but a unique definition regarding these changes is still missing. The results of conventional coagulation assays (CCAs) measured in daily clinical practice are often interpreted as coagulopathic, which implies a bleeding tendency. However, viscoelastic coagulation assays (VCA) like Rotational Thromboelastometry (ROTEM) and Thromboelastography (TEG) depict a hypercoagulable state. Therefore, hemostatic interventions should not be indicated according to deranged CCA results, but only in case of clinically relevant bleeding plus indicative VCA results. Massive blood loss mainly results from surgical excision of burn wounds. VCAs seem to be capable of guiding target-oriented coagulation management in this context. Owing to the increased thromboembolic risk, it appears rational to individualize pharmacologic venous thromboembolism prophylaxis by using sensitive laboratory tests and drug monitoring. Studies evaluating the use of new VCA test modifications are highly warranted and may substantially improve outcome in this difficult-to-treat patient population.

Venous Thromboembolism in Critical Illness and Trauma: Pediatric Perspectives.

Critically ill children and those sustaining severe traumatic injuries are at higher risk for developing venous thromboembolism (VTE) than other hospitalized children. Multiple factors including the need for central venous catheters, immobility, surgical procedures, malignancy, and dysregulated inflammatory state confer this increased risk. As well as being at higher risk of VTE, this population is frequently at an increased risk of bleeding, making the decision of prophylactic anticoagulation even more nuanced. The use of pharmacologic and mechanical prophylaxis remains variable in this high-risk cohort. VTE pharmacologic prophylaxis is an accepted practice in adult trauma and intensive care to prevent VTE development and associated morbidity, but it is not standardized in critically ill or injured children. Given the lack of pediatric specific guidelines, prevention strategies are variably extrapolated from the successful use of mechanical and pharmacologic prophylaxis in adults, despite the differences in developmental hemostasis and thrombosis risk between children and adults. Whether the burden of VTE can be reduced in the pediatric critically ill or injured population is not known given the lack of robust data. There are no trials in children showing efficacy of mechanical compression devices or prophylactic anticoagulation in reducing the rate of VTE. Risk stratification using clinical factors has been shown to identify those at highest risk for VTE and allows targeted prophylaxis. It remains unproven if such a strategy will mitigate the risk of VTE and its potential sequelae.

Prophylaxis against venous thromboembolism in pediatric trauma: A practice management guideline from the Eastern Association for the Surgery of Trauma and the Pediatric Trauma Society.

Despite the increasing incidence of venous thromboembolism (VTE) in hospitalized children, the risks and benefits of VTE prophylaxis, particularly for those hospitalized after trauma, are unclear. The Pediatric Trauma Society and the Eastern Association for the Surgery of Trauma convened a writing group to develop a practice management guideline on VTE prophylaxis for this cohort of children using the Grading of Recommendations Assessment, Development, and Evaluation framework. A systematic review of MEDLINE using PubMed from January 1946 to July 2015 was performed. The search retrieved English-language articles on VTE prophylaxis in children 0 to 21 years old with trauma. Topics of investigation included pharmacologic and mechanical VTE prophylaxis, active radiologic surveillance for VTE, and risk factors for VTE. Forty-eight articles were identified and 14 were included in the development of the guideline. The quality of evidence was low to very low because of the observational study design and risks of bias. In children hospitalized after trauma who are at low risk of bleeding, we conditionally recommend pharmacologic prophylaxis be considered for children older than 15 years old and in younger postpubertal children with Injury Severity Score (ISS) greater than 25. For prepubertal children, even with ISS greater than 25, we conditionally recommend against routine pharmacologic prophylaxis. Second, in children hospitalized after trauma, we conditionally recommend mechanical prophylaxis be considered for children older than 15 years and in younger postpubertal children with ISS greater than 25 versus no prophylaxis or in addition to pharmacologic prophylaxis. Lastly, in children hospitalized after trauma, we conditionally recommend against active surveillance for VTE with ultrasound compared with routine daily physical examination alone for earlier detection of VTE. The limited pediatric data and paucity of high-quality evidence preclude providing more definitive recommendations and highlight the need for clinical trials of prophylaxis. Systematic review/meta-analysis, level III.