Postoperative Pulmonary Embolism Research Articles

Racial disparities in perioperative outcomes after metabolic and bariatric surgery: a case-control matched study.

Metabolic and bariatric surgery remains a safe and effective treatment for severe obesity. Ethnic minorities are disproportionately affected by obesity but are less likely to undergo metabolic and bariatric surgery. There remains controversy about outcomes among black patients compared with other ethnic groups after bariatric surgery. The purpose of this case-control matched study using the largest clinically available bariatric data was to determine if there is racial disparity in perioperative outcomes after primary bariatric surgery. University Hospital, United States. Patients who had a primary Roux-en-Y gastric bypass or sleeve gastrectomy in 2015 to 2016 were identified from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. Case controlled-matched analyses were performed. We compared 80,238 equally matched nonHispanic black and white patients. Operative length and hospital stay were longer in black patients. All-cause mortality was 2-fold higher in black patients (P = .003). Black patients had significantly higher rates of 30-day readmission and reintervention (P < .0001), pulmonary embolism (P =.0004), and aggregate renal (P = .01) and venous thromboembolic (P = .001) complications. Postoperative myocardial infarction, cardiac arrest, pulmonary embolism, and all-cause mortality were significant higher in black patients after sleeve gastrectomy, but not Roux-en-Y gastric bypass. In this study, pulmonary embolism and mortality were significantly higher in black patients after sleeve gastrectomy. Further studies are needed to determine causality.

Low-Dose Aspirin Is Safe and Effective for Venous Thromboembolism Prevention in Patients Undergoing Revision Total Hip Arthroplasty: A Retrospective Cohort Study

BackgroundCurrently, there is no established universal standard of care for prophylaxis against venous thromboembolism (VTE) in orthopedic patients undergoing revision total hip arthroplasty (rTHA). The aim of this study is to determine whether a protocol of 81-mg aspirin (ASA) bis in die (BID) is safe and/or effective in preventing VTE in patients undergoing rTHAs vs 325-mg ASA BID. MethodsIn 2017, a large academic medical center adopted a new protocol for VTE prophylaxis in arthroplasty patients at standard risk. Initially, patients received 325-mg ASA BID but switched to 81-mg ASA BID. A retrospective review (2011-2019) was performed to identify 1361 consecutive rTHA patients and their associated 90-day postoperative complications such as VTE, including pulmonary embolism (PE) and/or deep vein thrombosis (DVT), as the primary outcome; and gastrointestinal and wound bleeding, acute periprosthetic joint infection, and mortality as the secondary outcome. ResultsFrom 2011 to 2017, 973 rTHAs were performed and 13 total VTE cases were diagnosed (1.34%). From 2017 to 2019, 388 rTHAs were performed with 3 total VTE cases identified (0.77%). Chi-squared analyses and logistic regression models showed no differences in rates or odds in postoperative PE (P = .09), DVT (P = .79), PE and DVT (P = .85), and total VTE (P = .38) using either dose. There were also no differences between bleeding complications (P = .14), infection rate (P = .46), and mortality (P = .53). ConclusionUsing a protocol of 81-mg of ASA BID is noninferior to 325-mg ASA BID and may be safe and effective in maintaining low rates of VTE in patients undergoing rTHA.

Prevalence of venous thromboembolism at pretreatment screening and associated risk factors in 2086 patients with gynecological cancer.

Postoperative pulmonary embolism can be a fatal surgical complication and is thought to occur secondary to asymptomatic venous thromboembolism (VTE) that exists preoperatively in some patients. The purpose of this study was to clarify the frequency and risk factors of pretreatment VTE in gynecological cancer patients. This study investigated 2086 patients with gynecological cancer (cervix, n = 754; endometrium, n = 862; ovary, n = 470) who underwent initial treatment between 2004 and 2017. Pretreatment VTE screening was performed with D-dimer (DD) levels in these patients. Based on this, the associated risk factors were retrospectively analyzed. Pretreatment VTE was discovered in 7.3% of patients with cervical cancer, 11.5% of those with endometrial cancer and 27.0% of those with ovarian cancer. Significant independent risk factors were: age greater than or equal to 60 years and tumor long diameter greater than or equal to 40 mm for cervical cancer; age greater than or equal to 60 years, stage III/IV advanced disease, clear cell carcinoma and tumor long diameter greater than or equal to 60 mm for endometrial cancer; and age greater than or equal to 60 years, clear cell carcinoma and massive ascites for ovarian cancer. Pretreatment asymptomatic VTE is very frequent in gynecological cancer patients. It may be beneficial to consider measuring DD or performing venous ultrasonography in patients with the above risk factors.

Effectiveness of home-based preoperative pulmonary rehabilitation in COPD patients undergoing lung cancer resection.

To investigate the effectiveness of a home-based preoperative rehabilitation program for improving preoperative lung function and surgical outcome of patients with chronic obstructive pulmonary disease (COPD) undergoing lobectomy for cancer. This was a prospective, observational, single-center study including 59 patients with mild COPD who underwent lobectomy for lung cancer. All patients attended a home-based preoperative rehabilitation program including a minimum of 3 sessions each week for 4 weeks. Each session included aerobic and anaerobic exercises. Participants recorded the frequency and the duration of exercise performed in a diary. The primary end point was to evaluate changes in lung function including predicted postoperative (PPO) forced expiratory volume in 1 second (FEV1), 6-minute walking distance test (6MWD), PPO diffusing capacity for carbon monoxide (DLCO) %, and blood gas analysis values before and after the rehabilitation program. Postoperative pulmonary complications were recorded and multivariable analysis was used to identify independent prognostic factors (secondary end point). All patients completed the 4-week rehabilitation program. Thirteen of 59 (22%) patients (Group A) performed <3 sessions per week (mean sessions per week: 2.3±1.3); 46 of 59 (78%) patients (Group B) performed ⩾3 sessions per week (mean sessions per week: 3.5±1.6). The comparison of PPO FEV1% and 6MWD before and after rehabilitation showed a significant improvement only in Group B. No significant changes in PPO DLCO% or in blood gas analysis values were seen. Nine patients presented postoperative pulmonary complications, including atelectasis (n = 6), pneumonia (n = 1), respiratory failure (n = 1), and pulmonary embolism (n = 1). Group A presented higher number of postoperative pulmonary complications than Group B (6 vs 3; p = 0.0005). Multivariate analysis showed that the number of weekly rehabilitation sessions was the only independent predictive factor (p = 0.001). Our simple and low-cost rehabilitation program could improve preoperative clinical function in patients with mild to moderate COPD undergoing lobectomy and reduce postoperative pulmonary complications. All patients should be motivated to complete at least 3 rehabilitation sessions per week in order to obtain significant clinical benefits. Our preliminary results should be confirmed by larger prospective studies.

Complications and 5-year survival after radical resections which include urological organs for locally advanced and recurrent pelvic malignancies: analysis of 646 consecutive cases.

Extensive multi-visceral resection, including components of the urinary tract, is often required to achieve clear resection margins, which is now well established as a key predictor of long-term survival for locally advanced pelvic tumours. The aims of this study were to analyse major morbidity and factors predicting complications and long-term outcomes following a urological procedure within extended radical resections. Data were collected from prospective databases at two high-volume institutions specialising in extended radical resections for locally advanced and recurrent pelvic malignancies between 1990 and 2015. The primary endpoints were general major complications (Clavien-Dindo ≥ 3) and factors influencing complications and overall survival after urological resection. A total of 646 consecutive patients requiring an extended radical resection for locally advanced or recurrent pelvic malignancies were identified. The median age was 63years (range 19-89years) and the majority were female (371; 57.4%). A urological resection was performed as part of the resection in 226 patients (35.0%). The overall 30-day major complication rate was significantly higher in the urological intervention group (23%; n = 52) compared to the non-urological group (12.9%; n = 54 patients; p = 0.001). Intestinal anastomotic leak (p = 0.001) and intra-abdominal collections (p = 0.001) were more common in the urological cohort. Ileal conduit formation was an independent predictor of major morbidity (OR 1.95; 95% CI 1.24-3.07; p = 0.004). Independent prognostic markers for poor 5-year survival following urological procedures were recurrent tumour, cardiovascular disease, previous thromboembolic event and postoperative pulmonary embolism. Extended radical resections which include a urological resection are associated with significantly more major morbidity than those without urological resection. Ileal conduit formation is independently associated with the development of major morbidity. Five-year overall survival is no different for patients who had or did not have urological resection as part of extended radical surgery for locally advanced or recurrent pelvic malignancy.

Intra-operative blood transfusion significantly increases the risk of post-operative pulmonary embolism.

Pulmonary embolism (PE) is a serious and preventable complication after surgery. Blood transfusion is a common event during surgery. The aim of the present study was to identify whether intra-operative blood product transfusions increase the risk of symptomatic post-operative PE. A retrospective, single-center case-control study at Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University between 1 January 2013 and 31 December 2016 was performed. Adult hospitalized patients with confirmed symptomatic PE after surgery were defined as case group. Each patient was matched with two adult patients without symptomatic PE who underwent the same procedure on the same day or within one week. Perioperative data especially detailed blood transfusion was collected. Forward stepwise logistic regression analysis was performed. During the study period, altogether 188,512 procedures were included, and postoperative PE were confirmed in 40 (0.02%) patients. Twelve (30.0%) case patients and 16 (20.0%) control patients received intra-operative blood transfusion. Intra-operative blood transfusion was revealed as a significant predictor for symptomatic post-operative PE (OR 80.669, 95% CI: 3.312-1,964.641, P=0.007), along with female sex (OR 86.921, 95% CI: 4.242-1,781.124, P=0.004), older age (OR 1.078, 95% CI: 1.005-1.156, P=0.035), longer length of stay before surgery (OR 1.124, 95% CI: 1.040-1.214, P=0.003) and longer operation time (OR 1.013, 95% CI: 1.002-1.025, P=0.024). Intra-operative blood transfusion was associated with an increased risk of symptomatic post-operative PE. PE prophylaxis and selective screening should be considered in patients who had received intra-operative blood transfusion, especially in female patients.

Risk of Pulmonary Embolism More Than 6 Weeks After Surgery Among Cancer-Free Middle-aged Patients

The risk of postoperative pulmonary embolism has been reported to be highest during the first 5 weeks after surgery. However, how long the excess risk of postoperative pulmonary embolism persists remains unknown. To assess the duration and magnitude of the late postoperative risk of pulmonary embolism among cancer-free middle-aged patients by the type of surgery. Case-crossover analysis to compute the respective risks of pulmonary embolism after 6 types of surgery using data from a French national inpatient database, which covers a total of 203 million inpatient stays over an 8-year period between 2007 and 2014. Participants were cancer-free middle-aged adult patients (aged 45 to 64) with a diagnosis of a first pulmonary embolism. Hospital admission for surgery. Surgical procedures were classified into 6 types: (1) vascular surgery, (2) gynecological surgery, (3) gastrointestinal surgery, (4) hip or knee replacement, (5) fractures, and (6) other orthopedic operations. Diagnosis of a first pulmonary embolism. A total of 60 703 patients were included (35 766 [58.9%] male; mean [SD] age, 56.6 [6.0] years). The risk of postoperative pulmonary embolism was elevated for at least 12 weeks after all types of surgery and was highest during the immediate postoperative period (1 to 6 weeks). The excess risk of postoperative pulmonary embolism ranged from odds ratio (OR), 5.24 (95% CI, 3.91-7.01) for vascular surgery to OR, 8.34 (95% CI, 6.07-11.45) for surgery for fractures. The risk remained elevated from 7 to 12 weeks, with the OR ranging from 2.26 (95% CI, 1.81-2.82) for gastrointestinal operations to 4.23 (95% CI, 3.01-5.92) for surgery for fractures. The risk was not clinically significant beyond 18 weeks postsurgery for all types of procedures. The risk of postoperative pulmonary embolism is elevated beyond 6 weeks postsurgery regardless of the type of procedure. The persistence of this excess risk suggests that further randomized clinical trials are required to evaluate whether the duration of postoperative prophylactic anticoagulation should be extended and to define the optimal duration of treatment with regard to both the thrombotic and bleeding risks.

Venous thromboembolism risk for the contemporary bariatric surgeon.

Postoperative venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), are the leading causes of morbidity and mortality after bariatric surgery. Although several studies have examined VTE, few have examined risk factors separately for DVT and PE after contemporary bariatric surgery, including laparoscopic sleeve gastrectomy (LSG). Our objective was to define risk factors for DVT and PE independently for both LSG and laparoscopic Roux-en-Y gastric bypass (LRYGB) patients using the largest validated bariatric surgery database. The metabolic and bariatric surgery accreditation and quality improvement program (MBSAQIP) database was queried to identify patients who underwent LSG or LRYGB between January 2015 and December 2017. Perioperative data were compared using bivariate analysis. Risk of DVT and PE after LSG or LRYGB was determined using multivariable logistic regression analysis. During the study period, 369,032 bariatric cases (72% LSG, 28% LRYGB) were performed. The incidence of DVT was similar between LSG and LRYGB (0.2% vs. 0.2%, p = 0.96), while the incidence of PE was decreased for LSG compared to LRYGB (0.1% vs. 0.2%, p < 0.001). Operative length was associated with increased risk of postoperative DVT (OR 1.1, CI 1.01-1.30, p = 0.04) and postoperative PE (OR 1.4, CI 1.16-1.64, p < 0.001) after surgery. The largest independent risk factors for DVT were history of DVT (OR 6.2, CI 4.44-8.45, p < 0.001) and transfusion (OR 4.2, CI 2.48-6.63, p < 0.001). The largest independent risk factors for PE were transfusion (OR 5.0, CI 2.69-8.36, p < 0.001) and history of DVT (OR 2.8, CI 1.67-4.58, p < 0.001). LSG was associated with a decreased risk of PE compared to LRYGB (OR 0.7 CI 0.55-0.91, p = 0.01). Prolonged operative length is associated with a higher risk of DVT and PE after either LSG or LRYGB. Transfusion and history of DVT are the largest risk factors for developing DVT and PE. There is a decreased risk of PE after LSG compared to LRYGB.

Effect of tranexamic acid combined flexion position of hip and knee on perioperative bleeding following unilateral total knee arthroplasty

To explore clinical efficacy and safety of application of tranexamic acid for two times combined with postoperative hip and knee on flexion position for reducing blood loss during total knee arthroplasty. From January 2015 to January 2018, 90 patients with knee osteoarthritis underwent unilateral total knee arthroplasty, including 33 males and 57 females, aged from 61 to 85 years old with an average of(72.3±6.9) years old. The patients were randomly divided into three groups according to random number table, 30 patients in each group. In group A, there were 11 males and 9 females, aged from 61 to 84 years old with an average of (71.60±6.04) years old, body mass index was (26.04±1.95) kg/m², hemoglobin was(128.57±5.98) g/L, treated by 7.5 mg/kg tranexamic acid was injected intravenously before upper tourniquet, and 7.5 mg/kg tranexamic acid after closure of incision and before loosening tourniquet, meanwhile combined with flexion position of hip for 30° to 45° and flexion position of knee for 60° for 70°. In group B, there were 10 males and 20 females aged from 61 to 85 years old with an average of (72.04±7.47) years, body mass index was (25.92±1.70) kg/m², hemoglobin was (127.58±4.37) g/L, treated by 15 mg/kg tranexamic acid injected intravenously before loosening tourniquet. In group C, there were 12 males and 18 females aged from 62 to 85 years old with an average of (73.23±7.36) years, body mass index was (26.07±1.49) kg/m², hemoglobin was (128.31±5.61) g/L, treated with the same amount of normal saline before loosening tourniquet. Intraoperative bleeding volume, postoperative drainage volume, recessive blood loss, total blood loss volume, blood transfusion cases, activated partial thromboplastin time(APTT), prothrombin time(PT), prothrombin international standardized ratio (PT-INR) and indexes of D-dimer(D-D) were compared among three groups, as well as postoperative deep venous thrombosis and pulmonary embolism were observed among three groups. No incision infection occurred in all 90 patients, and all patients were followed up from 4 to 8 months with an average of 6 months without pulmonary embolism occurred. There was no statistical difference in itraoperative bleeding volume among three groups(F=0.299, P=0.742), while there were significant differences in postoperative drainage volume, recessive blood loss, and total blood loss among three groups. The number of blood transfusion were as following, 2 cases in group A, 8 cases in group B, and 16 cases in group C, there were statistically significant differences among three groups(χ² =16.01, P<0.001). There were no differences in APTT, PT, PT-INR and D-D after operation among three groups(P>0.05), and no difference in occurrence of lower limb vein thrombosis after operation. The method of using tranexamic acid before upper tourniquet, after closure of incision and before loosening tourniquet-combined with the flexion position of hip and knee could effectively reduce postoperative drainage volume, recessive bleeding, total blood loss and blood transfusion cases after total knee arthroplasty, while it does not increase risk of deep vein thrombosis and pulmonary embolism.

Postoperative Myocardial Injury in Middle-Aged and Elderly Patients Following Curative Resection of Esophageal Cancer With Aggressive or Standard Body Temperature Management: A Randomized Controlled Trial.

Risk of intraoperative hypothermia is relatively high in middle-aged and elderly patients undergoing curative resection of esophageal cancer, which may cause myocardial ischemia during the early postoperative period. The objective of this study was to compare aggressive or standard body temperature management for lowering the incidence of postoperative myocardial injury that was assessed by troponin levels collected at a priori defined set times in these patients. Seventy patients undergoing elective curative resection of esophageal cancer were randomly assigned to undergo aggressive body temperature management (nasopharyngeal temperature ≥36°C) or standard body temperature management (n = 35 in each arm). The primary outcome was myocardial injury, defined as the occurrence of elevated troponin I (>0.06 µg/L) or elevated high-sensitivity troponin T (≥0.065, or 0.02 µg/L≤ high-sensitivity troponin T <0.065 µg/L, but with an absolute change of at least 0.005 µg/L) or both during 2 days after surgery. Secondary outcomes included (1) severe arrhythmia, including atrial fibrillation, supraventricular tachycardia, frequent premature ventricular contractions intraoperatively or during 3 days postoperatively; (2) hypoxemia or metabolic acidosis during the first 12 h postoperatively; and (3) deep vein thrombosis or pulmonary embolism during 3 days postoperatively. Incidence of postoperative 2-day myocardial injury was 8.6% (3/35) among patients receiving aggressive body temperature management and 31.4% (11/35) among patients receiving standard body temperature management (P = .017, χ). Relative risk of myocardial injury in the aggressive body temperature management group was 0.27 (95% CI, 0.08-0.89). Incidence of intra- and postoperative 3-day severe cardiac arrhythmia was 2.9% (1/35) among patients receiving aggressive body temperature management and 28.6% (10/35) among patients receiving standard body temperature management. Incidence of postoperative 12-h hypoxia was 17.1% (6/35) with aggressive body temperature management and 40.0% (14/35) with standard body temperature management. Incidence of postoperative 12-h metabolic acidosis was 20% (7/35) among patients receiving aggressive body temperature management and 48.6% (17/35) among patients receiving standard body temperature management. Incidence of postoperative 3-day deep vein thrombosis or pulmonary embolism was 0% (0/35) with aggressive body temperature management and 2.9% (1/35) with standard body temperature management. Aggressive body temperature management may be associated with a lower incidence of postoperative myocardial injury.

Catheter Directed Lysis and Thrombectomy Are Equally Effective for Extensive Deep Vein Thrombosis

BackgroundThere is currently little consensus on the role of thrombectomy compared with catheter-directed lysis (CDL) for acute, extensive, proximal deep vein thrombosis (DVT). We sought to determine whether any differences in outcomes exist between thrombectomy and CDL in terms of postoperative venous patency, pulmonary emboli (PE), and bleeding/hematoma. MethodsIn an institutional review board-approved retrospective cohort study, patients from a single academic medical center with confirmed lower extremity DVT were divided into thrombectomy and CDL cohorts. Demographic information, comorbidities and laboratory data, postoperative patency, postoperative bleeding, postoperative PE, popliteal hematoma, and recurrence of DVT were collected. Type I error level was set at 0.05. ResultsEighty-seven patients were identified, 51.7% received CDL, and 48.3% underwent thrombectomy. Patient comorbidities and hypercoagulable states were not significantly different among the groups. The two techniques did not have significantly different postoperative patency (P = 0.472), bleeding (P = 0.598), PE (P = 0.868), popliteal hematoma (P = 0.331), or recurrence of DVT (P = 0.835). ConclusionsIn selecting optimum treatment for acute, extensive, proximal DVT, our retrospective cohort study found no significant differences among treatment groups in safety, efficacy, recurrence, and progression to PE. We conclude that modality of treatment should be decided based on hospital resources, surgeon experience, and comfort with each technique, patient's physiologic status, and associated costs.

Effect of remote ischemic preconditioning on hemostasis and fibrinolysis in head and neck cancer surgery: A randomized controlled trial.

IntroductionThe aim of this randomized controlled trial was to investigate if remote ischemic preconditioning (RIPC) reduced platelet aggregation and increased fibrinolysis in cancer patients undergoing surgery and thereby reduced the risk of thrombosis.Materials and methodsHead and neck cancer patients undergoing tumor resection and microsurgical reconstruction were randomized 1:1 to RIPC or sham intervention. RIPC was administered intraoperatively with an inflatable tourniquet by four cycles of 5-min upper extremity occlusion and 5-min reperfusion. The primary endpoint was collagen-induced platelet aggregation measured with Multiplate as area-under-the-curve on the first postoperative day. Secondary endpoints were markers of primary hemostasis, secondary hemostasis, and fibrinolysis. Clinical data on thromboembolic and bleeding complications were prospectively collected at 30-day follow-up. An intention-to-treat analysis was performed.ResultsSixty patients were randomized to RIPC (n = 30) or sham intervention (n = 30). No patients were lost to follow-up. The relative mean [95% confidence interval] collagen-induced platelet aggregation was 1.26 [1.11;1.40] in the RIPC group and 1.17 [1.07;1.27] in the sham group on the first postoperative day reported as ratios compared with baseline (P = 0.30). Median (interquartile range) 50% fibrin clot lysis time was 517 (417–660) sec in the RIPC group and 614 (468–779) sec in the sham group (P = 0.25). The postoperative pulmonary embolism rate did not differ between groups (P = 1.0).ConclusionsRIPC did not influence hemostasis and fibrinolysis in head and neck cancer patients undergoing surgery. RIPC did not reduce the rate of thromboembolic complications.

Venous Thromboembolism Prophylaxis for Patients Having Elective Spine Surgery: When, Why, and How Much.

➤ The prevalence of venous thromboembolism (VTE) events varies widely following elective spine surgery, with reported rates ranging from 0.21% to 13.6%.➤ Risk factors for the development of VTE after spine surgery include patient or family history, obesity, longer operative time, manipulation of the great vessels, and decreased mobility postoperatively.➤ There is limited consensus regarding the selection and initiation of postoperative chemoprophylaxis, which should be implemented thoughtfully because of the bleeding risk and, specifically, the development of epidural hematoma.➤ Prophylactic use of inferior vena cava filters in low-risk patients having elective spine surgery has not been well supported in the literature. Further investigation is needed to determine its utility as an additional modality to prevent postoperative pulmonary embolus in elective spine surgery.

Which Postoperative Day After Total Joint Arthroplasty Are Catastrophic Events Most Likely to Occur?

BackgroundDespite lacking granularity, large database registries can help provide important information on rare outcomes following total joint arthroplasty (TJA). In an era of short stay and outpatient arthroplasty, an awareness of the timeframe for most common catastrophic complications can help providers maintain an appropriate degree of suspicion for these significant events. MethodsPatients undergoing primary TJA between 2011 and 2016 were identified in the National Surgical Quality Improvement Program and queried for 4 adverse postoperative outcomes: pulmonary embolism (PE), myocardial infarction or cardiac arrest, cerebrovascular accident, and death. The timing of postoperative events was compared, and also their association with medical comorbidities and timing in inpatient vs outpatient arthroplasty. ResultsA total of 341,601 patients met inclusion criteria. Of them, 1631 (0.48%) patients sustained a postoperative PE, 1033 (0.3%) patients had a cardiac event, 304 patients had a cerebrovascular accident (0.09%), and 608 (0.18%) patients expired. Greater than 60% of all these complications occurred between postoperative days 0 and 5, including 65% of PE. On postoperative day 0, a catastrophic event is 13 times more likely to be a cardiac event (80.7%) compared to a PE (6%). However, by postoperative day 1, a cardiac event (41.2%) is only 1.03 times more likely than a PE (40%) and by postoperative day 2, a PE (62%) is twice as likely as a cardiac event (30%). ConclusionRisk assessment for catastrophic event and timeliness of occurrence may guide providers to recommend enhanced observation for specific patients undergoing TJA.

Role of nurses in improving patient safety: Evidence from surgical complications in 21 countries

ObjectivesTo analyze the role of nurse staffing in improving patient safety due to reducing surgical complications in member countries of Organization for Economic Co-operation and Development (OECD). MethodsThe number of practicing nurses’ density per 1000 population and five surgical complications indicators including foreign body left in during procedure (FBL), postoperative pulmonary embolism (PPE) and deep vein thrombosis (DVT) after hip and knee replacement, postoperative sepsis after abdominal surgery (PSA) and postoperative wound dehiscence (PWD) were collected in crude rates per 100,000 hospital discharges for age group of 15 years old and over within 30 days after surgery based on surgical admission-related and all admission-related methods. The observations of 21 OECD countries were collected from OECD Health Statistics during 2010-2015 period. The statistical technique of panel data analysis including unit root test, co-integration test and dynamic long-run analysis were used to estimate the possible relationship between our panel series. ResultsThere were significant relationships from nurse-staffing level to reducing FBL, PPE, DVT, PSA and PWD with long-run magnitudes of −2.91, −1.30, −1.69, −2.81 and −1.12 based on surgical admission method as well as −6.12, −14.57, −7.29, −1.41 and −0.88 based on all admission method, respectively. ConclusionsA higher proportion of nurses is associated with higher patient safety resulting from lower surgical complications and adverse clinical outcomes in OECD countries. Hence, we alert policy makers about the risk of underestimating the impact of nurses on improving patient safety as well as the quality of health care services in OECD countries.

Venous thromboprophylaxis after total hip arthroplasty: aspirin, warfarin, enoxaparin, or factor Xa inhibitors?

Debate over the ideal agent for venous thromboembolism (VTE) prophylaxis after total hip arthroplasty (THA) has led to changes in prescribing trends of commonly used agents. We investigate variation in utilisation and the differences in VTE incidence and bleeding risk in primary THA after administration of aspirin, warfarin, enoxaparin, or factor Xa inhibitors. 8829 patients were age/sex matched from a large database of primary THAs performed between 2007 and 2016. Utilisation was calculated using compound annual growth rate. Incidence of postoperative deep venous thrombosis (DVT), pulmonary embolism (PE), bleeding-related complications, postoperative anaemia, and transfusion were identified at 2 weeks, 30 days, 6 weeks, and 90 days. Aspirin use increased by 33%, enoxaparin by 7%, and factor Xa inhibitors by 31%. Warfarin use decreased by 1%. Factor Xa inhibitors (1.7%) and aspirin (1.7%) had the lowest incidence of DVT followed by enoxaparin (2.6%), and warfarin (3.7%) at 90 days. Factor Xa inhibitors (12%) and aspirin (12%) had the lowest incidence of blood transfusion followed by warfarin (15%) and enoxaparin (17%) at 90 days. There was no difference in incidence of blood transfusion or bleeding-related complications nor any detectable difference in symptomatic PE incidence. The utilisation of aspirin and factor Xa inhibitors increased over time. Aspirin and factor Xa inhibitors provided improved DVT prophylaxis with lower rates of postoperative anaemia compared to enoxaparin and warfarin.

SUN-420 Pituitary Apoplexy Associated With Apixaban

Background: Pituitary apoplexy (PA) is a relatively rare condition associated with sudden hemorrhagic pituitary infarction, and usually occurs in the setting of a pituitary adenoma. Patients typically present with the acute onset of headache, visual changes and pituitary hormonal deficiencies. Oral anticoagulation therapy is a known risk factor for PA and has recently been described in association with the newer anticoagulants, including both thrombin and Factor Xa inhibitors. Clinical Case: An 82 year-old woman with a history of renal cell carcinoma and recent post-operative pulmonary embolism treated with apixiban, presented with acute-onset headache, diplopia, and vomiting. Mental status remained intact. Vital signs were normal. Her physical exam was significant for a left superior temporal quandrantanopsia and was otherwise normal. Brain imaging revealed an 8 x 11 x 12 mm hyperdense mass within the sella representing hemorrhage. She had no known history of pituitary disease. The patient was admitted to the neurosurgical service for close monitoring of her neurologic and hemodynamic status. She was treated with conservative management and empiric glucocorticoids. Pituitary hormone assessment on admission was significant for inappropriately low LH of 0.5 mIU/mL (reference range 10-60) and FSH of 8.6 mIU/mL (reference range 17-114) in a postmenopausal woman. TSH was <0.03 mIU/L (reference range 0.4-5), and free T4 was elevated at 3.31 ng/dL (reference range 0.6-1.2). IGF-1 was within normal limits at 85ng/mL (reference range 31-208). Serum prolactin level was 13.7 ng/mL (normal <20). Cortisol and ACTH were measured after the patient had received empiric stress dose steroids and were thus unreliable. Of note, the patient did not exhibit signs or symptoms of adrenal insufficiency, such as hypotension or electrolyte derangements. Her headache and visual field deficit resolved with conservative treatment and she was discharged on physiologic glucocorticoid replacement therapy. Approximately two months after her initial presentation, the patient generally felt well except mild tremor and insomnia. Repeat endocrine evaluation confirmed central hypogonadism and primary hyperthyroidism. She was diagnosed with Graves’ disease and treated with methimazole. An ACTH stimulation test was normal and hydrocortisone replacement was discontinued. A repeat pituitary MRI demonstrated resolution of the hemorrhage and no evidence of a pituitary adenoma. Conclusion: Anticoagulation therapy, including the newer anticoagulants, is a risk factor for PA and is typically associated with an underlying pituitary tumor. To our knowledge, this is the first case of pituitary hemorrhage in a patient treated with apixaban without evidence of a pituitary tumor.

High Altitude Is an Independent Risk Factor for Developing a Pulmonary Embolism, but Not a Deep Vein Thrombosis Following a 1- to 2-Level Lumbar Fusion.

Study Design:Retrospective study.Objective:To identify if a 1- to 2-level posterior lumbar fusion at higher altitude is an independent risk factor for postoperative deep vein thrombosis (DVT) and pulmonary embolism (PE).Methods:A national Medicare database was queried for all patients undergoing 1- to 2-level lumbar fusions from 2005 to 2014. Those with a prior history of DVT, PE, coagulopathy, or peripheral vascular complications were excluded to better isolate altitude as the dependent variable. The groups were matched 1:1 based on age, gender, and comorbidities to limit potential cofounders. Using ZIP codes of the hospitals where the procedure occurred, we separated our patients into high (>4000 feet) and low (<100 feet) altitudes to investigate postoperative rates of DVTs and PEs at 90 days.Results:Compared with lumbar fusions performed at low-altitude centers, patients undergoing the same procedure at high altitude had significantly higher PE rates (P = .010) at 90 days postoperatively, and similar rates of 90-day postoperative DVTs (P = .078). There were no significant differences in age or comorbidities between these cohorts due to our strict matching process (P = 1.00).Conclusion:Spinal fusions performed at altitudes >4000 feet incurred higher PE rates in the first 90 days compared with patients receiving the same surgery at <100 feet but did not incur higher rates of postoperative DVTs.

The case of Patient Safety Indicator 12 (PSI12): use of administrative data to estimate the incidence of "Postoperative Pulmonary Embolism or Deep Vein Thrombosis". A pilot study in a General Hospital.

The AHRQ Quality Indicators (QIs) were created in order to both identify the performance and to track the improvement of patient safety. Patient Safety Indicator 12 (PSI12) is relative to the risk of Post Operatory Pulmonary Embolism or Deep Venous Thrombosis (PO DVT/PE). This pilot study has three main objectives. Firstly, to perform an analysis of the performance of different hospital wards by using administrative data; secondly, to analyze defects in the process that led to the occurrence of the adverse event; thirdly, reviewing the single PO DVT/PE. Data were extracted from a Hospital Information data flow (SIO) and compared to Clinical Discharge Record. PSI12 estimates were computed before and after the screening. Control Charts allowed the static analysis of performance between different hospital wards in 2014. The Ishikawa diagram was drawn for the analysis of the underlying causal process. The number of PSI12 cases provided by DRGs through SIO data flow decreased from 45 to six after the comparison with the correspondent clinical records. Four clinical records provided full information allowing the analysis of process. The Ishikawa Diagram identified the defects in the process of prophylaxis that resulted into a PO DVT/PE. The clinical records screening revealed a lower incidence of PO DVT/PE with respect to the DRGs statistics. Overall the PO DVT/PE occurrence in 2014 fell into the control limits, although the result could be undermined by the low quality of clinical records compilation. The failure in the prophylaxis procedure was imputable to pitfalls in the health care management and to the individual attitude towards patient safety procedures. In conclusion, the reliability and validity of administrative data in monitoring quality and safety are worthy to be explored in the context of further validation studies.

Complex major hepatectomy by thunderbeat with the pringle maneuver and infra-hepatic inferior vena cava clamping

Introduction: Complex major hepatectomy (CMH) equivalent to major liver resection with high complexity classification is a demanding operation. Parenchymal transection represents a crucial step during liver resection and the use of energy devices has gained popularity for faster and safer hepatectomy. Thunderbeat (TB) is a novel device that uses both ultrasonic and advanced bipolar energies. We report the CMH with TB assisted by the Pringle maneuver and infra-hepatic inferior vena cava (IVC) clamping. Method: During parenchymal transection, only the pedicles equal or larger than 3rd branches of Glissonian pedicles or main branches of major hepatic veins were ligated, the other vessels were sealed with TB. Parenchymal transection time was defined as the duration recorded from the beginning of the parenchymal resection to the removal of the en-bloc specimen of the liver. Clavien-Dindo (CD) classification ≥3a was applied to define postoperative complication. The postoperative liver dysfunction was assessed on the basis of Balzan 50-50 criteria. Result: Four patients underwent CMH with TB assisted by the Pringle maneuver and infra-hepatic IVC clamping, including extended right hepatectomy with caudate resection and hepaticojejunostomy for perihilar chalangiocarcinoma (n=2) and colon cancer liver metastasis with central biliary invasion (n=1), and anatomic middle hepatectomy for hepatocellular carcinoma (n=1). The median parenchymal transection time, operation time, and estimated blood loss was 16.5 (range: 13-45) min, 415 (range: 260-596) min, and 1,928 (range: 1,380-2,730) mL, respectively Postoperative complications were hepaticojejunostomy failure in one (CD 3a) and heparin-induced postoperative bleeding (CD 3b) in one. There were no postoperative liver dysfunction, pulmonary embolism, and hospital mortality. Conclusion: TB assisted by the Pringle maneuver and infra-hepatic IVC clamping can be feasible and offer the combination of simplicity and rapidity during CMH.