Preoperative Heparin Research Articles

Determinants of Surgical Outcomes in Tricuspid Valve Endocarditis

BackgroundCurrent treatment guidelines for infective endocarditis focus on left-sided infective endocarditis. Because right-sided infective endocarditis has different presentations and outcomes, it is crucial to further delineate surgical outcomes for isolated tricuspid valve endocarditis (TVE). MethodsThis retrospective study reviewed 374 surgically treated patients with isolated TVE from January 2012 through April 2022 who underwent isolated tricuspid valve surgical procedures. Primary outcomes were in-hospital mortality, permanent pacemaker need, and postsurgical inotropic support. ResultsThe in-hospital mortality was 4% (n = 15). Patients with liver disease had 3.81-times higher odds of death vs no liver disease (odds ratio [OR], 3.81; 95% CI, 1.22-12.17). A pacemaker was required in 17% of patients without a prior pacemaker, which was 4.07 times the odds with tricuspid valve replacement (OR, 4.07; 95% CI, 1.72-11.60) vs tricuspid valve repair. Each yearly increase in patient age demonstrated lower odds of permanent pacemaker requirement by 7% (OR, 0.93; 95% CI, 0.89-0.97). The odds for postoperative inotropic support increased 2.55-times higher in patients receiving preoperative inotropic agents (OR, 2.55; 95% CI, 1.29-5.05), 2.27-times higher with renal failure (OR, 2.27; 95% CI, 1.38-3.74), and 86% higher in patients administered preoperative heparin (OR, 1.86; 95% CI, 1.14-3.02). ConclusionsMortality of surgical treatment for TVE was 4%, with higher risks with liver disease. Tricuspid valve replacement was associated with higher odds for permanent pacemaker vs repair. Renal failure, preoperative inotropic support, and preoperative heparin were associated with higher odds for postoperative inotropic support. These findings further illustrate surgical outcomes with TVE.

Achieving durable compliance with venous thromboembolism prophylaxis in bariatric surgery: 3-year data from a major academic medical center

BackgroundMetabolic and bariatric surgery (MBS) venous thromboembolism (VTE) prescribing practices vary widely. Our institutional VTE prophylaxis protocol has historically been unstandardized. ObjectivesTo create a standardized MBS VTE prophylaxis protocol, track protocol compliance, and identify barriers to protocol compliance and address them with Plan-Do-Study-Act (PDSA) cycles. SettingSingle Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program-accredited academic hospital. MethodsWe conducted a retrospective study for all patients undergoing MBS (January 2019 to September 2022). A multidisciplinary group of bariatric clinicians reviewed literature and developed the following standardized VTE prophylaxis protocol: 5000 units preoperative subcutaneous (SC) heparin within 60 minutes of anesthesia induction and postoperative 40 mg SC low molecular weight heparin (LMWH) within 24 hours of surgery. This protocol was distributed to relevant clinical stakeholders. We assessed monthly compliance rates through chart review. Goal compliance was ≥90%. We identified sources of noncompliance and addressed them with PDSA methodology. ResultsA total of 796 patients were included. Preoperative heparin administration increased from a mean of 47% (107/228) preintervention to 96% (545/568) postintervention (P < .0001), and postoperative LMWH administration increased from 71% (47/66) to 96% (573/597, P = .0002). These compliance rates were sustained for 3 years. Barriers to protocol noncompliance included order set timing errors (n = 45), surgeon error (n = 44), surgeon discretion (n = 40), and nursing error (n = 20). No change in bleeding or VTE rates was observed. ConclusionsDeveloping a standardized VTE prophylaxis protocol, monitoring process measures, and engaging relevant stakeholders in PDSA cycles resulted in drastic and durable improvement in VTE prophylaxis compliance rates.

Risk Factors for Postoperative Bleeding Following Breast Cancer Surgery: A Nationwide Database Study of 477,108 Cases in Japan.

Although postoperative bleeding is a common and serious complication in breast cancer surgery, the risk factors remain unclear. Therefore, we examined the risk factors using a Japanese nationwide database. Patients who underwent breast cancer surgery between July 2010 and March 2020 were identified from a Japanese nationwide database. Multivariable analyses for 47 candidate risk factors (4 patient characteristics, 32 comorbidities, 5 tumor characteristics, 3 preoperative drug uses, and 3 surgical procedures) were conducted to investigate risk factors associated with postoperative bleeding requiring reoperation. Two sensitivity analyses were conducted: an analysis for postoperative bleeding with or without reoperation and an analysis for patients who underwent total mastectomy without breast reconstruction. Among the 477,108 patients included, 7048 (1.5%) developed postoperative bleeding and 2357 (0.5%) underwent reoperation for postoperative bleeding. Male sex, old age, body mass index ≥ 25.0kg/m2, several comorbidities (deficiency anemia, cardiac arrhythmias, hypertension, liver disease, psychoses, and valvular disease), preoperative heparin use, and several procedures were identified as risk factors. Deficiency anemia showed the highest odds ratio among the risk factors (4.41 [95% confidence interval, 3.63-5.36]). High odds ratios were also observed in total mastectomy (2.32 [2.10-2.56]), flap reconstruction (1.93 [1.55-2.40]), and preoperative heparin use (1.64 [1.26-2.14]). The results corresponded with the sensitivity analyses. This study identified several risk factors for postoperative bleeding in breast cancer surgery, such as high body mass index, anemia, cardiovascular diseases, liver diseases, psychoses, preoperative heparin use, and surgical procedures.

Incidence of Heparin resistance after preoperative heparin therapy in patients undergoing open heart surgery

Aim: Incidence of Heparin Resistance after preoperative heparin therapy in patients undergoing open heart surgery. Methods: The Prospective Observational study included 124 patients of different heart diseases undergoing open heart surgery, at cardiac surgery department of Punjab Institute of Cardiology; Lahore Pakistan was performed between 5th October 2013 to 16 March 2014. Both genders age 18-75 were included. All those patients who present with diseases other than heart diseases, age &lt;18 and &gt; 75 were excluded in the study. Data was analyzed using Statistical Package for Social Sciences (SPSS) version 16.0. P-value ≤ 0.05 were considered significant. Results: Our results showed that out of 124 patients, 87(70.16%) were male while 37(29.84%) were females. Clinical characteristics i.e. (hypertension, diabetes mellitus, emergency bypass, smoking, alcohol intake, hyperlipidemias, obesity and family history) were insignificantly associated with heparin resistance. The clinical characteristics i.e. (baseline activated clotting time, albumin and cross clamp time) were significantly associated with the development of heparin resistance as (p-value &lt;0.05 .015, .041 and .025 respectively). Conclusion: The results indicate that the incidence of heparin resistance after preoperative heparin therapy was 8.06%.

What is the value of preoperative prophylactic heparin in reducing venous thromboembolism in major non-cardiac thoracic surgery?

BackgroundStudies have investigated the utility of preoperative heparin to mitigate venous thromboembolism risk after surgery. However, whether heparin reduces the risk of VTE following major thoracic surgery is undetermined. A national heparin shortage beginning in September 2019 provided the opportunity for a natural experiment to explore this question. MethodsA retrospective analysis was conducted including all major thoracic surgery cases at a single center from March 2019 to April 2020. The primary outcome was VTE. Two sample t-tests, Chi-Square analyses, and multivariable regressions were performed. ResultsThe study consisted of 890 patients, 391 before the heparin shortage and 499 afterwards. 398 total patients received heparin, 340 before the heparin shortage and 58 afterwards. On univariate analyses, there was no association between VTE and preoperative heparin (p > 0.90). This remained consistent on multivariable analyses (p > 0.1). ConclusionIn this single center analysis, there was no association between preoperative heparin and the occurrence of postoperative VTE. Analyses in larger cohorts will provide additional evidence to guide policies on the use of preoperative prophylactic heparin.

Comparison of Screening Scores for Heparin- Induced Thrombocytopenia After Cardiopulmonary Bypass

To compare screening scores for heparin-induced thrombocytopenia (HIT) after cardiopulmonary bypass (CPB). Retrospective cohort study. Cardiothoracic surgery units within a large tertiary healthcare facility from September 2010 to January 2020. All adult patients tested for heparin-induced platelet antibody (HIPA) within 2 weeks after surgery requiring CPB. Using data available to providers at the time HIPA were checked, the 4T's Score, a modified 4T's Score, and a score proposed by Lillo-Le Louet (LLL) etal. were calculated. A retrospective chart review was performed for each patient to determine actual presence of HIT, and screening scores were compared for accuracy. Criteria for inclusion were met in 266 patients. Of these, 34 (12.8%) were high likelihood of HIT, 16 (6.0%), additional patients were clinically ambiguous, and 216 (81.2%) were high likelihood of alternative cause for thrombocytopenia. HIPA tests done before postoperative day 5 were not associated with any high-likelihood cases of HIT regardless of preoperative heparin exposure. Although traditional 4T's ≥4, modified 4T's ≥3, and LLL ≥2 had statistically similar sensitivity for predicting HIT, the modified 4T's and LLL had superior specificity (p < 0.001). Appropriate screening for HIT curbed inappropriate HIPA testing, and reduced the need for empirical treatment while awaiting confirmatory test results. Traditional 4T's was statistically inferior to both the LLL score and a modified version of the 4T's to screen for HIT within 2 weeks of CPB.

Rate of venous thromboembolism in gynecologic patients on an ERAS pathway.

214 Background: Venous thromboembolism (VTE) is a serious and potentially life-threatening complication of surgery. An Enhanced Recovery After Surgery (ERAS) program is a multimodal care pathway meant to facilitate faster recovery from surgery. ERAS protocols include mechanical and pharmacologic VTE prophylaxis and rapid return to ambulation. Our objective was to evaluate the rate of symptomatic VTE on an ERAS pathway among patients undergoing open and minimally invasive gynecologic surgery (MIS). Methods: Data was collected prospectively on patients undergoing gynecologic surgery on the ERAS pathway at a single academic institution between November 1, 2014 and March 31, 2021. For patients undergoing MIS data were collected from February 1, 2016 to March 31, 2021. Patients undergoing emergency surgery or requiring therapeutic anticoagulation prior to surgery were excluded. For planned open surgery, patients received heparin prophylaxis prior to surgery, sequential compression device (SCD) during surgery and goal directed fluid management. If also diagnosed with malignancy, patients received extended VTE prophylaxis with low molecular weight heparin for 28 days after surgery starting postoperative day 1. For planned MIS, patients received SCD and goal directed fluid management. Descriptive statistics, univariate and multivariate statistical analyses were performed. Results: Of the 3,932 patients, 2,016 (51%) underwent laparotomy, 1,541 (39%) laparoscopy and 375 (10%) robotic approach. The incidence of thromboembolism was 0.5% (N = 21) overall, 0.8% (N = 17) with open approach and 0.2% (N = 4) with MIS approach. Among laparotomy patients, there was 88% compliance with preoperative heparin prophylaxis. Characteristics associated with developing a VTE were black race, malignancy, open surgical approach, surgical time, surgical complexity, and receipt of intraoperative blood transfusion. On multivariate analysis, black race and transfusion remained associated with VTE. Among laparotomy patients, the rate of intraoperative blood transfusion was 5.9% (N = 120), reoperation for bleeding 0.3% (N = 5) and reoperation for hematoma 0.2% (N = 3). Conclusions: We found a low rate of VTE among patients undergoing laparotomy and MIS under an ERAS pathway. The rate of VTE following MIS surgery was low without use of extended pharmacologic VTE prophylaxis or receipt of preoperative prophylactic heparin. Receipt of preoperative heparin prophylaxis prior to open surgery is safe with a low complication rate. This establishes a benchmark for the expected rate of VTE following gynecologic surgery on an ERAS pathway.

Creation of an individualized algorithm for venous thromboembolism prophylaxis on a gynecologic oncology service

<h3>Objectives:</h3> To evaluate implementation of a venous thromboembolism (VTE) prophylaxis algorithm on adherence to evidence-based guidelines including the rate of administration of preoperative heparin and the overall VTE rate on the gynecologic-oncology service at a single institution. <h3>Methods:</h3> Prior to 2018, no consensus VTE prophylaxis protocol existed on the gynecologic oncology service at the authors' academic institution. ACOG and Chest guidelines were used to modify a published gynecology VTE risk algorithm. Interventions to improve preoperative heparin administration included: ID badge algorithm attachments, placards in operating rooms, integration of algorithm into the H&P template and order set in the electronic medical record. Surgical, anesthesia, and nursing teams were contacted to investigate cases in which pre-operative heparin was indicated but not administered. In 2020, three retrospective cohorts of 100 patients each (2016-2017, 2018, and 2019) spanning the pre-, intra- and post-QI implementation periods were consecutively identified using cancer and radical surgery-specific CPT codes to evaluate performance in these highest risk cases; cohorts were filled to 100 using randomly selected additional gynecologic oncology cases. Perioperative heparin administration and VTE rates were evaluated. Proportions were compared using chi-square tests; continuous factors were compared using ANOVA or Kruskal-Wallis tests. <h3>Results:</h3> A total of 3 retrospective surgical cohorts totaled 312 patients (2016-2017: 100, 2018: 110, 2019: 102); mean age was 60. Indications for surgery were ovarian (36.9%), endometrial (35.6%), and cervical cancer (11.9%), and benign (15.6%). Minimally invasive cases comprised 52% of the cohort in 2016-7, 42.7% in 2018, and 42.2% in 2019 (p=0.070). The mean (SD) number of risk factors for VTE was similar across cohorts (2016-2017: 3.7 (1.6), 2018: 3.6 (1.4), 2019: 3.5 (1.7); p=0.87). When retrospectively applied to all surgical cases reviewed, adherence to VTE algorithm improved from 31.0% in 2016-2017 to 69.1% in 2018 and 82.4% in 2019 (p<0.001). Appropriate administration of pre-operative heparin in high-risk patients improved over time with each cohort: 34.8% in 2016-2017, 83.3% in 2018, and 92.5% in 2019 (p<0.001). The VTE rate within 30 days of surgery was 5.0% in 2016-2017, 3.6% in 2018, and 1.0% in 2019; this was not statistically significant (p=0.25). Adverse event rates were not significantly different between cohorts; peri-operative blood transfusion was 17.0% in 2016-7, 16.4% in 2017, and 10.8% in 2019 (p=0.385). Superficial and subfascial surgical site infections, hematomas, and vaginal cuff dehiscence were rare across cohorts. <h3>Conclusions:</h3> Implementation of an individualized perioperative VTE prophylaxis algorithm has resulted in improved adherence to evidence-based prophylaxis guidelines and improvement in rates of preoperative heparin administration; observed trends in VTE rates have not achieved significance.

Acute progressive arterial thrombosis after coronary artery bypass graft in a COVID-19 patient

The longer the SARS-CoV-2 pandemic takes, the greater the prothrombotic effects of the disease, which varies from venous thromboembolic events to limb arterial thrombosis and stroke. How we deal with the effects of the COVID-19 disease, is still unclear. In this study, researchers will report the clinical presentation, outcome and management of the patient with COVID-19 after coronary artery bypass graft (CABG) surgery, which led to rapid progression of arterial thrombosis. The COVID-19 positive patient underwent emergency CABG, due to developed coronary artery disease. Despite receiving high-dose preoperative Plavix and heparin and also postoperative aspirin, the patient developed progressive thrombosis in both lower extremities 4 days after surgery. It then spread to bilateral iliac arteries, aorta, abdominal and renal artery. Femoral endarterectomy was performed two times for atheromatous plaque removal which was unsuccessful and the patient died few days later due to multi-organ failure. COVID-19 is a risk factor for arterial thrombosis with high mortality and morbidity rate. If thrombosis happens, the prognosis will be poor. Comprehensive treatments have to be started immediately after diagnosis. In patients undergoing surgery for extensive arterial thrombosis due to poor prognosis, not only surgical revascularization is needed but also thrombolysis treatments may be considered as off-label use. As the pandemic continues, new approaches and interventions may be applied.

A quality improvement initiative to reduce venous thromboembolism on a gynecologic oncology service

ObjectiveTo describe and evaluate the effects of implementation of a venous thromboembolism (VTE) prophylaxis quality improvement (QI) initiative on a gynecologic oncology service at a single institution. MethodsPrior to 2018, no consensus gynecologic oncology VTE prophylaxis protocol existed at the authors' academic institution. Published, evidence-based guidelines were reviewed to create a standardized VTE risk stratification algorithm. Interventions to improve perioperative heparin administration and sequential compression device (SCD) compliance as well as provider/patient education efforts were introduced in January 2018. Initial efforts included nursing and patient SCD education, internal dissemination of VTE prophylaxis guidelines, and creation of a VTE ‘dashboard’ to track performance. During a second phase, VTE prophylaxis guidelines were reviewed and further refined, non-compliant operative cases reviewed weekly, and guidelines incorporated into the electronic medical record. Performance was measured using Tableau data software (www.tableau.com) and by separately evaluating adherence to the developed guidelines in three retrospective cancer-enriched surgical cohorts (2016–2017, 2018, 2019). ResultsCompared to the baseline period, we observed a reduction in VTE rate during the 2018–2019 VTE QI implementation period from 2.1% (19/905) to 1.0% (20/2015, p = 0.02) among gynecologic oncology inpatients. In the retrospective cancer-enriched cohorts, adherence to evidence based guidelines improved: 31.0% in 2016–2017, 69.1% in 2018, and 82.4% in 2019 (p < 0.001). There were no significant differences in rates of peri-operative blood transfusion, surgical site infections, hematomas, or vaginal cuff dehiscences. ConclusionsImplementation of a robust VTE prophylaxis QI initiative has resulted in improved VTE prophylaxis guideline adherence and higher rates of pre-operative heparin administration.

Impact of antithrombotic therapy on the perioperative outcomes with focus on bleeding and thromboembolic complications in patients undergoing pancreticoduodenectomy

Introduction: We assessed perioperative outcomes of pancreaticoduodenectomy (PD) in patients receiving antithrombotic therapy (ATT). Methods: Seventy-seven patients who underwent PD at our institution between 2013 and 2019 were retrospectively reviewed. Clinical findings and surgical outcomes including hemorrhagic and thromboembolic events were compared in patients with or without ATT. Interruption of ATT and preoperative heparin bridging were based on our hospital protocol. Results: Among ATT (30) and non-ATT (47) groups, patients receiving ATT had a significantly higher age (p=0.019) and history of (H/O) cardio-cerebrovasucular diseases (p< 0.001). Operative time and surgical blood loss were not significantly different between the groups. ATT group was associated with significantly higher rate of postoperative complications, Clavien-Dindo (CD) classification≥II (66.7 vs. 40.4%, p=0.025) and thromboembolic events (13.3 vs. 0%, p=0.020). Operative mortality in ATT and non-ATT groups was 2 (6.7%) and 1 (2.1%), respectively. Multivariate analysis showed that the increased 1) surgical blood loss (≥1,000 mL), 2) post-pancreatectomy hemorrhage (≥grade B), 3) thromboembolic events, and 4) postoperative major complications (CD≥III) were independently associated with 1) diabetes mellitus (p=0.001) and H/O percutaneous coronary intervention (PCI) (p=0.037), 2) H/O upper abdominal surgery (p=0.019) and coronary arterial bypass grafting (p=0.033), 3) age≥80 years (p=0.035) and H/O PCI (p=0.011), and 4) American Society of Anesthesiologists Physical Status (ASA-PS) class 3 (p=0.010). Conclusions: In patients with ATT under thromboembolic risks, PD is still a feasible procedure. ATT group appears to have higher age with cardio-cerebrovascular diseases and low level of ASA-PS warranting optimization of management to prevent hemorrhagic and thromboembolic complications.

Venous thromboembolism prophylaxis on a gynecologic oncology service: A quality improvement initiative

Objective: The purpose of this study was to evaluate the effects of implementation of a multiarm venous thromboembolism (VTE) prophylaxis quality improvement initiative on the rate of administration of preoperative heparin and the overall VTE rate on the gynecologic oncology service at a single institution.

Venous Thromboembolism in Plastic Surgery: Where Are We Now?

Venous Thromboembolism in Plastic Surgery: Where Are We Now?

Factors influencing activated clotting time following heparin administration for the initiation of cardiopulmonary bypass.

Initiation of cardiopulmonary bypass (CPB) for open-heart surgery requires that heparin be administered and reach an adequate value of activated clotting time (ACT). We previously introduced a new heparin formula that considered the preoperative ACT. In this study, we determined other factors affecting ACT. Adult patients who underwent cardiac surgery using CPB were divided into two groups according to their ACT value after the initial administration of heparin during surgery. ACT above 450s was defined as "Reach", and this group was compared to the "Short" group with ACT below 450s. The Reach and Short groups included 334 (64.7%) and 182 (35.3%) cases, respectively. Univariate analysis indicated that preoperative heparin use, age ≥ 80years, New York Heart Association classification 4, white blood cell counts above the higher limit, hematocrit below the lower limit, platelet cell counts below the lower limit, low albumin levels, moderate renal dysfunction, high C-reactive protein levels, high brain natriuretic peptide levels, and moderate deterioration of left ventricular ejection fraction were associated with the effects of heparin. Multivariate analysis revealed that age ≥ 80years (odds ratio [OR] 2.53, 95% confidence interval [95%CI] 1.41-5.24), New York Heart Association classification 4 (OR = 4.44, 95%CI 1.59-15.35), and platelet count below the lower limit (OR 0.37, 95%CI 0.31-0.85) were associated with the effects of heparin. Old age, heart failure, and lower platelet counts affected heparin activity. The dose of heparin should be considered in those patients to reach the target ACT.

Application of goal-directed therapy for the use of concentrated antithrombin for heparin resistance during cardiac surgery.

The maintenance of anticoagulation in adult patients undergoing cardiopulmonary bypass is dependent upon a number of factors, including heparin concentration and adequate antithrombin activity. Inadequate anticoagulation increases the risk of thrombosis and jeopardizes both vascular and extracorporeal circuit integrity. The purpose of this study was to evaluate a goal-directed approach for the use of antithrombin in patients who were resistant to heparin. Following institutional review board approval, data were obtained from quality improvement records. A goal-directed protocol for antithrombin was established based upon heparin dosing (400 IU kg-1 body weight) and achieving an activated clotting time of ⩾500 seconds prior to cardiopulmonary bypass. Two groups of patients were identified as those receiving antithrombin and those not receiving antithrombin. Outcome measures included activated clotting time values and transfusion rates. Consecutive patients (n = 140) were included in the study with 10 (7.1%) in the antithrombin group. The average antithrombin dose was 1,029.0 ± 164.5 IU and all patients had restoration to the activated clotting time levels. Patients in the antithrombin group were on preoperative heparin therapy (80.0% vs. 24.6%, p = 0.001). Prior to cardiopulmonary bypass the activated clotting time values were lower in the antithrombin group (417.7 ± 56.1 seconds vs. 581.1 ± 169.8 seconds, p = 0.003). Antithrombin patients had a lower heparin sensitivity index (0.55 ± 0.17 vs. 1.05 ± 0.44 seconds heparin-1 IU kg-1, p = 0.001), received more total heparin (961.3 ± 158.5 IU kg-1 vs. 677.5 ± 199.0 IU kg-1, p = 0.001), more cardiopulmonary bypass heparin (22,500 ± 10,300 IU vs. 12,100 ± 13,200 IU, p = 0.016), and more protamine (5.4 ± 1.2 vs. 4.1 ± 1.1 mg kg-1, p = 0.003). The intraoperative transfusion rate was higher in the antithrombin group (70.0% vs. 35.4%, p = 0.035), but no differences were seen postoperatively. Utilization of a goal-directed algorithm for the administration of antithrombin for the treatment of heparin resistance is effective in patients undergoing cardiac surgery.

Perioperative management of patients receiving non-vitamin K antagonist oral anticoagulants: up-to-date recommendations.

Indications of non-vitamin K antagonist oral anticoagulants (NOACs), consisting of two types: direct thrombin inhibitor (dabigatran) and direct factor Xa inhibitor (rivaroxaban, apixaban, and edoxaban), have expanded over the last few years. Accordingly, increasing number of patients presenting for surgery are being exposed to NOACs, despite the fact that NOACs are inevitably related to increased perioperative bleeding risk. This review article contains recent clinical evidence-based up-to-date recommendations to help set up a multidisciplinary management strategy to provide a safe perioperative milieu for patients receiving NOACs. In brief, despite the paucity of related clinical evidence, several key recommendations can be drawn based on the emerging clinical evidence, expert consensus, and predictable pharmacological properties of NOACs. In elective surgeries, it seems safe to perform high-bleeding risk surgeries 2 days after cessation of NOAC, regardless of the type of NOAC. Neuraxial anesthesia should be performed 3 days after cessation of NOACs. In both instances, dabigatran needs to be discontinued for an additional 1 or 2 days, depending on the decrease in renal function. NOACs do not require a preoperative heparin bridge therapy. Emergent or urgent surgeries should preferably be delayed for at least 12 h from the last NOAC intake (better if > 24 h). If surgery cannot be delayed, consider using specific reversal agents, which are idarucizumab for dabigatran and andexanet alfa for rivaroxaban, apixaban, and edoxaban. If these specific reversal agents are not available, consider using prothrombin complex concentrates.

Preoperative Heparin for Lung Cancer Resection Increases Risk of Reoperation for Bleeding

Lung cancer patients are at risk for venous thromboembolism (VTE). Preoperative heparin administration may increase the risk of bleeding requiring reoperation. The purpose of this study was to evaluate preoperative heparin's effect on reoperation for bleeding. A retrospective review compared outcomes for patients undergoing pulmonary resection for primary lung cancer from January 2006 to April 2018. Preoperative heparin was administered at the discretion of the attending surgeon. Comparisons were performed between preoperative subcutaneous heparin (5000 U) and no heparin groups. A total of 3325 lung resections were reviewed, 1.4% (n = 48) required reoperation for bleeding. VTE occurred in 1.1% (n = 38). Four hundred sixty-four patients (14.0%) did not receive preoperative heparin. The preoperative heparin group had increased rates of prior thoracic surgery (5.1% [n = 146] vs 1.7% [n = 8], P < 0.001), minimally invasive approach (40.2% [n = 1150] vs 10.6% [n = 49], P < 0.001), and sublobar resections (17.7% [n = 506] vs 10.6% [n = 49], P < 0.001). There were no differences in blood loss/transfusions. Reoperation for bleeding was significantly increased in the preoperative heparin group (1.6% [n = 47] vs 0.2% [n = 1], P = 0.017). There were no differences in VTE (1.5% [n = 7] vs 1.1% [n = 31], P = 0.424). On logistic regression, preoperative heparin was independently associated with increased reoperation for bleeding (odds ratio 8.13, P = 0.039); however, preoperative heparin was not independently associated with VTE. Preoperative heparin was associated with increased reoperation for bleeding. VTE rates are low after pulmonary resection for lung cancer and are not decreased by preoperative heparin. Preoperative heparin use should be determined by risk factor stratification for VTE and reoperation for bleeding in patients undergoing lung cancer resection.

Does preoperative pharmacologic prophylaxis reduce the rate of venous thromboembolism in pancreatectomy patients?

BackgroundWhether the risk of venous thromboembolism (VTE) may be reduced by preoperative administration of prophylactic heparin is unknown. We hypothesized that timing of heparin administration does not significantly alter the incidence of VTE in pancreatic surgery. MethodsAn analysis was conducted using data from Massachusetts General Hospital's National Surgical Quality Improvement Program from 2012 to 2017. All patients admitted for elective pancreatic resection were included. The primary outcome was development of VTE. Multivariable regression was performed, adjusting for patient demographics and various clinical factors. ResultsIn total, 1448 patients were analyzed, of whom 1062 received preoperative heparin (73.3%). Overall, 36 (2.5%) patients developed VTE. On unadjusted analysis, there was no statistically significant difference between patients who received preoperative heparin compared with those who did not (2.6% vs. 1.3%, respectively; p = 0.079). On adjusted analysis, there was an association with increased VTE rates among patients who received preoperative heparin (OR 2.93, 95% CI 1.10–7.81; p = 0.031). ConclusionThere was an association between preoperative heparin administration and increased incidence of VTE on adjusted analysis, possibly reflecting appropriate surgical judgment in patient selection for prophylaxis. These data question the inclusion of preoperative VTE pharmacologic prophylaxis as a reliable quality indicator.

Effects of Heparin on Early Patency of Arteriovenous Fistula in Angioaccess Surgery of Patients with End-Stage Renal Disease

Background: Arteriovenous fistula (AVF) is now the optimal method of obtaining vascular access for dialysis. Measures such as systemic anticoagulation have been proposed as means of increasing patency rates but enough evidence does not exist to support their application. We aimed to evaluate the efficacy of preoperative heparin injection on patency of AVF during the first 24 hours after surgery and to determine whether such measure can be used to prevent early thrombosis of the vascular access.Methods: The study was carried out on 150 patients admitted to Shohada-e-Tajrish hospital for permanent vascular access placement during 2011-2012. 75 patients were randomly assigned to receive 100 units/kg of heparin intraoperatively and at 24 hours post-surgery AVF patency rate was assessed and compared to the control group. Results: All the 75 patients who had received heparin intraoperatively had a patent arteriovenous fistula 24 hours post-surgery which showed a statistically significant difference compared to the control group among which only 69 (92%) patients had a functioning AV fistula (p-value= 0.028).Conclusions: Our results show that systemic anticoagulation with heparin can be considered as an effective option in preventing vascular access failure. However, considering the contradictory data on the usefulness of heparin injection, larger trials are needed to evaluate efficacy and adverse effects of systemic intraoperative anticoagulation in End-Stage Renal Disease (ESRD) patients before qualifying it as a method of increasing AVF patency in these patients

Venous thromboembolism after laparoscopic or robotic biliopancreatic diversion with duodenal switch. Ninety-days outcome of a 10 years’ experience

BackgroundVenous thromboembolism (VTE) is a feared complication after bariatric surgery. Biliopancreatic diversion with duodenal switch (BPD-DS) is a complex bariatric procedure that is offered typically to super morbidly obese patients. Scarce data exist in reporting VTE outcome and identifying the risk factors associated with it after BPD-DS. ObjectiveTo determine the risk factors for VTE after BPD-DS at 90-day follow-up. SettingA nonprofit regional referral center and teaching hospital in Pennsylvania. MethodsA retrospective chart review was performed on prospectively collected data over 10 years, between January 1, 2006 and December 31, 2016. Patients who underwent laparoscopic or robotic BPD-DS were included. Preoperative variables, selected risk factors, and methods of VTE prophylaxis were analyzed. ResultsA total of 662 patients who underwent BPD-DS were identified. The mean age was 44.7 ± 10.4 (20–72) years; 474 patients were female (71.7%), and the mean body mass index of the cohort was 50.5 ± 7.5 (34–98) kg/m2. Overall, 16 patients (2.4%) experienced VTE complication at 90-days follow-up post–BPD-DS with 100% follow-up rate; deep vein thrombosis was experienced by 10 patients (1.5%), and 6 patients (0.9%) experienced pulmonary embolism (1 patient experience both). None of those patients had a previous history of VTE. Only operative time (P value = .009) and length of stay (P value ≤ .001) were associated with VTE events. Other factors such as age, sex, body mass index, previous history of VTE, preoperative heparin injection, preoperative inferior vena cava filter insertion, intermittent compressive device use, interval heparin time, and postoperative chemical prophylaxis did not show a statistical association. A logistic regression analysis showed a statistically significant increase of VTE outcome with length of stay; odds ratio of 1.161, (95% confidence interval, 1.048–1.285), P value = .004. ConclusionWith proper preoperative evaluation and aggressive VTE prophylaxis protocol, the risk of VTE post–BPD-DS is comparable to other bariatric procedures. Every effort should be adopted to shorten the length of stay, and thus reduce VTE risk.