Postoperative Pharmacologic Thromboprophylaxis Research Articles

Rivaroxaban for Postoperative Pharmacologic Thromboprophylaxis After Bariatric Surgery.

Rivaroxaban for Postoperative Pharmacologic Thromboprophylaxis After Bariatric Surgery.

Efficacy of pre-operative pharmacologic thromboprophylaxis on incidence of venous thromboembolism following major gynecologic and gynecologic oncology surgery: a systematic review and meta-analysis

IntroductionVenous thromboembolism remains a significant complication following major gynecologic surgery. Evidence is lacking on whether it is beneficial to give pharmacologic thromboprophylaxis pre-operatively. The aim of this meta-analysis was to...

Postoperative pharmacologic thromboprophylaxis with enoxaparin and thrombotic complications after liver surgery

Postoperative pharmacologic thromboprophylaxis with enoxaparin and thrombotic complications after liver surgery

Safety and efficacy of postoperative pharmacologic thromboprophylaxis with enoxaparin after pancreatic surgery.

Pharmacologic thromboprophylaxis is recommended for preventing pulmonary embolism according to some abdominal surgery guidelines. However, few reports have so far described pharmacologic thromboprophylaxis after pancreatic surgery. In addition, concern remains regarding postoperative bleeding due to pharmacologic thromboprophylaxis. We investigated the safety and efficacy of enoxaparin, a low-molecular-weight heparin, as postoperative pharmacologic thromboprophylaxis after pancreatic surgery. In this record-based retrospective study, the sample population comprised 151 consecutive patients who underwent pancreatic surgery and received enoxaparin postsurgery at our institute between November 2009 and March 2014. The primary outcome was the incidence of symptomatic pulmonary embolism after surgery, and the secondary outcome was the incidence of bleeding as an adverse effect of enoxaparin injection. No symptomatic pulmonary embolism events occurred during the study. Major and minor bleeding events were experienced in 5 (3.3%) cases each. Four of these major events were caused by the rupture of a pseudoaneurysm with a pancreatic fistula not related to enoxaparin, and all events were treated safely with no mortalities in the study period. We found no factors related to minor bleeding with enoxaparin injection in a statistical comparison. The use of enoxaparin is considered to be safe and effective for pulmonary embolism prophylaxis after pancreatic surgery.

Variation in Hospital Thromboprophylaxis Practices for Abdominal Cancer Surgery.

Venous thromboembolism remains a prominent cause of morbidity and mortality following cancer surgery. Although evidence-based guidelines recommend major cancer surgery thromboprophylaxis starts before incision and continues at least 7-10 days postoperatively, the extent to which the guidelines are followed is unknown. We assessed variation in thromboprophylaxis practices for abdominal cancer surgery in a regional surgical collaborative. We studied abdominal resections for primary gastrointestinal, hepatopancreatobiliary (HPB), and neuroendocrine malignancies in the Michigan Surgical Quality Collaborative from July 2012 to September 2013 (N=2967 patients in 52 hospitals). We obtained detailed perioperative and postoperative pharmacologic and mechanical thromboprophylaxis information for patients without documented exemptions (e.g., active bleeding, allergy), and compared differences in procedure mix and operative complexity across hospitals based on their perioperative thromboprophylaxis rates. Additionally, we surveyed hospitals to identify variations in perioperative practice and barriers to prophylaxis administration. Overall, 40.4% of eligible patients had perioperative pharmacologic thromboprophylaxis for abdominal cancer surgery, and 25.3% of the highest-risk patients had evidence of inadequate postoperative prophylaxis (under-prophylaxis, either by dose or duration). Hospital perioperative thromboprophylaxis rates ranged from 0 to 96.1%, and postoperative thromboprophylaxis rates ranged from 73.9 to 100%. Epidural use was not independently associated with hospital pharmacologic thromboprophylaxis rates. Fewer than half of patients undergoing abdominal cancer surgery receive perioperative thromboprophylaxis, and there is wide variation in hospital thromboprophylaxis utilization despite strong evidence-based guidelines supporting its use.

Post-Operative Pharmacologic Thromboprophylaxis after Major Hepatectomy

BackgroundAlthough standard of care after most abdominal surgeries, post-operative pharmacologic thromboprophylaxis after major hepatectomy is commonly withheld due to bleeding risks. The objective of this retrospective study is to evaluate the benefits and risks of post-operative pharmacologic thromboprophylaxis after major hepatectomy at two high volume academic centers. MethodsDemographics, clinicopathologic data, treatments, and post-operative outcomes from patients who underwent major hepatectomy were reviewed. ResultsFrom 2005 to 2010, 419 patients underwent major hepatectomy; 275 (65.6%) were treated with pharmacologicthromboprophylaxis beginning a median of 1 day after resection. Post-operative symptomatic venous thromboembolism (VTE) occurred in 15 (3.6%) patients. Patients treated with pharmacologic thromboprophylaxis had lower rates of symptomatic VTE (2.2% vs. 6.3%, p = 0.03) and post-operative red blood cell (RBC) transfusion (16.7% vs. 26.4%, p = 0.02) with similar rates of overall RBC transfusion (35.0% vs. 30.6%, p = 0.36) compared to untreated patients. Specifically, isolated deep venous thrombosis (0% vs. 2.1%, p = 0.04) and pulmonary embolism (2.2% vs. 4.2%, p = 0.35) occurred less often in treated patients. Analysis of demographics, clinicopathologic data, and treatment factors revealed that pharmacologic thromboprophylaxis was the only variable associated with post-operative VTE. ConclusionsPost-operative pharmacologic thromboprophylaxis lowers the incidence of symptomatic VTE after major hepatectomy without increasing the rate of RBC transfusion.

Thromboprophylaxis in Traumatic and Elective Spinal Surgery

A survey on thromboprophylaxis in spinal surgery and trauma was conducted among spine trauma surgeons. Neurosurgeons and orthopedic surgeons from the Spinal Trauma Study Group were surveyed in an attempt to understand current practices in the perioperative administration of thromboprophylaxis in spinal surgery. Although much research has been invested in the prevention of thromboembolic events following surgical procedures, there have been few investigations specific to spinal surgery, especially in the context of trauma. A total of 47 spine surgeons were provided with a 24-question survey pertaining to deep vein thrombosis prophylaxis in spine surgical patients. There was 100% response to the survey, and 46 of the 47 physicians (98%) responded to the case scenarios. Institutional protocols for deep vein thrombosis prophylaxis existed for 42 (89%) of the respondents; however, only 27 (57%) indicated that these protocols included spinal cord injury (SCI) patients. Before surgery, no prophylaxis or mechanical prophylactic measures for SCI and non-SCI spinal fracture patients were routinely used by 36 (77%) and 40 (85%) respondents, respectively. After surgery, pharmacologic prophylaxis was prescribed by 42 (91%) and 28 (62%) surgeons for SCI and non-SCI spinal fracture patients, respectively. There was a statistically significant tendency to use more intensive prophylactic measures for patients with SCI (x2, 10.86; P < 0.01) as well as a statistically significant longer duration of proposed thromboprophylaxis (x2, 24.62; P < 0.001). Postoperative pharmacologic thromboprophylaxis for elective anterior thoracolumbar spine surgery was reported by 23 (51%) of the respondents, whereas only 18 (40%) used pharmacological prophylaxis in elective posterior thoracolumbar spine cases. Spine complications from low-molecular weight heparin were reported by 22 (47%) surgeons, including fatal pulmonary embolism by 19 (40%) surgeons. A basis for a consensus protocol on thromboprophylaxis in spinal trauma was attempted. No more than mechanical prophylaxis was recommended before surgery for non-SCI patients or after surgery for elective cervical spine cases. Chemical prophylaxis was commonly used after surgery in patients with SCI and in patients with elective anterior thoracolumbar surgery.

Thromboprophylaxis in spinal trauma surgery: consensus among spine trauma surgeons

Background context Although there are several studies evaluating the necessity and efficacy of thromboprophylaxis after spinal trauma with or without spinal cord injury (SCI), to date there is no established standard of practice pertaining to this specific patient population with regards to venous thromboembolism (VTE) prophylaxis. Purpose To reach a consensus opinion in the administration of thromboprophylaxis in both preoperative and postoperative care in the settings of spinal trauma and SCI. Study design A live survey on thromboprophylaxis after spinal surgery in the setting of trauma was conducted at a meeting among spine trauma surgeons. Methods Twenty-five spine surgeons (Neurosurgeons and Orthopedic surgeons), all members of the Spine Trauma Study Group, participated in a live survey in which they attempted to reach consensus pertaining to the management of deep vein thrombosis prophylaxis in patients with spine fractures (with and without a concomitant SCI). The consensus survey consisted of a 10-item questionnaire. Chi-square test was used for group comparisons in questionnaire responses. Results Complete agreement was reached for the need of postoperative pharmacologic thromboprophylaxis in cervical spine injuries with SCI and anterior thoracolumbar procedures with or without SCI. Postoperative pharmacologic thromboprophylaxis after cervical spine injuries without SCI was agreed not to be needed. In cases of delayed surgery for patients with SCI, pharmacologic thromboprophylaxis was recommended to be started as soon as possible in the presurgical period. The optimal duration of pharmacologic VTE prophylaxis was determined to be 3 months. Only 53% agreement was noted for the withholding of preoperative chemical prophylaxis in cervical or thoracolumbar spinal injuries with SCI (and 68% without SCI). Only 80% of the surgeons agreed that postoperative pharmacologic thromboprophylaxis is needed after posterior thoracolumbar procedures in patients with or without SCI. The use of vena cava filter after SCI was not universally recommended. Conclusions Postoperative pharmacologic thromboprophylaxis was opined to be unnecessary in patients with cervical spine injuries without SCI, however, it is recommended for cervical spine trauma with SCI or anterior thoracolumbar procedures irrespective of SCI. Pharmacologic thromboprophylaxis was recommended to start preoperatively as soon as possible in SCI cases or in cases with surgical delay. Pharmacologic prophylaxis was recommended to be administered for at least 3 months postinjury. Although these recommendations met complete consensus by this group, individual patient factors should also be considered in determining optimal thromboprophylaxis in this patient population. Future research recommendations on thromboprophylaxis in spinal trauma are proposed.

Pulmonary Embolism After Adult Spinal Deformity Surgery

Retrospective review. To determine the incidence and identify the associated risk factors of pulmonary embolism (PE) in patients who receive pharmacologic thromboprophylaxis after adult spinal deformity surgery. The risk of PE after adult spinal deformity surgery is reported to be as high as 2.2%. However, the incidence and associated risks of PE in the same patient population who receive postoperative pharmacologic thromboprophylaxis is unknown. The study included 361 adult patients with spinal deformity who underwent 407 corrective spinal procedures for scoliosis, kyphosis, or kyphoscoliosis. The incidence of PE was determined and compared with a study (historical control) of similar patients undergoing similar surgery but without postoperative pharmacologic thromboprophylaxis. Their demographic information, American Society of Anesthesiologists score, operative time, surgical approach, surgical complexity, and intraoperative blood loss were also analyzed to determine the presence of associated risk factors. Despite universal pharmacologic thromboprophylaxis, 10 pulmonary emboli (2.4%) were diagnosed. Patients undergoing anterior spinal surgery were at a significantly higher risk than those undergoing posterior spinal surgery (P = 0.024). The right-side anterior approach was also associated with a significantly higher incidence of PE compared with the left-sided anterior approach (P = 0.018). Although the rate of PE after posterior spinal surgery did not differ from the historical control, the rate of PE after anterior surgery was reduced by 50% compared with the historical control. Age, gender, estimated blood loss, operative time, revision status, and the number of fusion levels were not significant variables for PE. There were 2 epidural hematomas requiring decompression (0.48%) and 1 wound hematoma (0.24%). Although pharmacologic thromboprophylaxis probably does not have a role after posterior spinal surgery, the data in this study suggest that it does lower the incidence of PE after anterior spinal surgery.

Perioperative management of MYH9 hereditary macrothrombocytopenia (Fechtner syndrome)

Hereditary thrombocytopenias characterized by mutations in the gene for non-muscle myosin heavy chain IIA (NMMHC-IIA) are known as MYH9-related hereditary macrothrombocytopenia, and include the May-Hegglin anomaly, Sebastian platelet syndrome, Fechtner syndrome, and Epstein syndrome. Despite the presence of thrombocytopenia, these patients often have only mild or non-bleeding phenotypes. A major risk for these patients can be inappropriate treatment with long-term corticosteroids or splenectomy for misdiagnosed chronic autoimmune thrombocytopenia, as well as inadequate peri- and postoperative management. Using the case of a 44-yr-old male with Fechtner syndrome (macrothrombocytopenia, leukocyte inclusions, sensorineural deafness, glomerulonephritis) who underwent neurosurgery for an intracerebral arteriovenous malformation, we describe current methods to diagnose hereditary MYH9-related macrothombocytopenia by analysis of the blood smear, immunofluorescence staining of the NMMHC-IIA in leucocytes, and by MYH9-gene sequencing. Clusters of NMMHC-IIA in granulocytes and a R1165C mutation in the MYH9-gene in two macrothrombocytopenic family members confirmed the diagnosis of a MYH9-related disease. The patient had no bleeding diathesis by history or physical examination. Thus no perioperative prohemostatic pharmacologic therapies or transfusions were given, with only minimal bleeding observed. Postoperative antithrombotic thromboprophylaxis was not given because of anticipated enhanced risk for bleeding. However, the patient developed symptomatic pulmonary embolism on postoperative day 6, which was successfully managed with 8 months of anticoagulation. MYH9-related hereditary macrothrombocytopenia does not necessarily protect against postoperative venous thromboembolism, and affected patients who do not evince bleeding diathesis should be considered for routine postoperative pharmacologic thromboprophylaxis.