Venous Thromboembolic Events Prophylaxis Research Articles

Total Shoulder Arthroplasty in Patients With Hemophilia A: Greater Odds of Postoperative Bleeding and Thromboembolic Events but No Difference in 5-year Implant Survival.

Patients with hemophilia A can develop joint hemarthroses, degenerative changes, and eventually undergo total shoulder arthroplasty (TSA). Few data exist concerning complications and prosthesis survival after TSA in this population. (1) Is hemophilia A associated with more bleeding and thromboembolic adverse events after TSA relative to matched controls? (2) Is 5-year TSA prosthesis survival reduced in patients with hemophilia A compared with matched controls? The 2010 to 2022 PearlDiver M161 database was used to identify patients who underwent primary anatomic or reverse TSA. Given that the X-linked recessive condition hemophilia A presents nearly exclusively in males, male patients with hemophilia A who underwent TSA were matched 1:10 with male patients without hemophilia who underwent TSA based on age and Elixhauser comorbidity index (ECI). This yielded 73 patients with hemophilia A who underwent TSA who were matched 1:10 with 729 patients without hemophilia. Ninety-day adverse events were compared with multivariable analysis. Revision within 5 years was assessed using Kaplan-Meier analysis. Compared with the control cohort, patients with hemophilia had greater odds of bleeding issues (hematoma, OR 6.8 [95% CI 3.0 to 15.3]; p < 0.001; anemia, OR 2.5 [95% CI 1.5 to 4.2]; p < 0.001, transfusion, OR 5.0 [95% CI 2.4 to 10.3]; p < 0.001), venous thromboembolic events (VTE) (OR 1.9 [95% CI 1.1 to 3.1]; p = 0.01), and prosthetic loosening (OR 3.5 [95% CI 1.4 to 8.0]; p = 0.004). Based on available data, 5-year implant survival was not different in patients with hemophilia (97.3% [95% CI 93.6% to 100.0%]) relative to matched controls (95.2% [95% CI 93.4% to 97.2%]; p = 0.60). The elevated risks of both 90-day bleeding complications (hematoma, anemia, and transfusion) and VTE (DVT and PE) in patients with hemophilia emphasize the special challenges of carefully balancing factor replacement and VTE prophylaxis pre-, intra-, and postoperatively on an individual patient basis with careful hematologist coordination. Further study on Factor VIII levels and targets as well as tranexamic acid and VTE prophylaxis in this population is necessary to provide further guidance. Furthermore, 5-year implant survival was not different between patients with hemophilia and matched controls (patients without hemophilia) based on available data, suggesting that TSA survivorship remains durable and may be offered to patients in this population as indicated. Level III, therapeutic study.

Safety and efficacy of extended thrombophilia screening directed venous thromboembolic events (VTE) prophylaxis in live liver donors: do we really need extended thrombophilia screening routinely?

The study aimed to determine the prevalence of hereditary thrombophilia, and stratify its severity among live liver donors in Pakistan. Also, the authors evaluated the safety and efficacy of thrombophilia profile testing directed venous thromboembolic events (VTE) prophylaxis while balancing bleeding risk and the need for routine thrombophilia testing before live liver donation among living donor candidates. Protein S (PS), protein C (PC), anti-thrombin (AT) III, and anti-phospholipid antibody panel (APLA) levels were measured in 567 potential donor candidates. Donors were divided into normal, borderline and high-risk groups based on Caprini score. The safety endpoints were VTE occurrence, bleeding complications or mortality. Among 567 donors, 21 (3.7%) were deficient in protein C, and 14 (2.5%) were deficient in anti-thrombin-III. IgM and IgG. Anti-phospholipids antibodies were positive in 2/567 (0.4%) and 2/567 (0.4%), respectively. IgM and IgG lupus anticoagulant antibodies were positive in 3/567 (0.5%) and 3/567 (0.5%), respectively. VTE events, bleeding complications and postoperative living donors liver transplantation-related complications were comparable among the three donor groups (P>0.05). One donor in the normal donor group developed pulmonary embolism, but none of the donors in either borderline or high-risk group developed VTE. The mean length of ICU and total hospital stay were comparable. No donor mortality was observed in all donor groups. Due to thrombophilia testing directed VTE prophylaxis, VTE events were comparable in normal, borderline and high-risk thrombophilia donor groups, but more evaluations are required to determine the lower safe levels for various thrombophilia parameters including PC, PS and AT-III before surgery among living donor candidates.

Is extended venous thromboprophylaxis required in patients undergoing ileal pouch procedure for ulcerative colitis?

Venous thromboembolic events (VTEs) are relatively common adverse surgical complications. Extended VTE prophylaxis for 4 weeks is recommended after colorectal cancer surgery, but its use in inflammatory bowel disease surgery lacks high-quality evidence. This retrospective study aimed to assess and characterize VTEs within the first 30 days after ileal pouch-anal anastomosis (IPAA) procedures and subtotal colectomies (STCs) for ulcerative colitis (UC). All patients who underwent IPAA for UC between 1 January 2017 and 31 December 2021 were included. VTE rates after IPAA, in-hospital or at-home occurrences, utilization of in-hospital thromboprophylaxis, and prescribed anticoagulant treatment were evaluated. Retrospectively, the same variables were analysed if patients of the cohort underwent STC before the IPAA construction. In all, 204 patients underwent IPAA (61.8% men, 73% laparoscopic), with an average hospital stay of 6.8 days. Among them, 116 patients underwent STC prior to IPAA. Thirteen patients (6.3%) experienced VTEs after IPAA, with 76.9% (10/13) of cases occurring during hospitalization and under adequate thromboprophylaxis. The VTE rate after STC was 10.3% (12/116), with 58.2% (7/12) occurring in hospital and under appropriate thromboprophylaxis. No reoperations or mortality were attributed to thrombotic events. The type and duration of anticoagulant treatment varied considerably. The VTE rate after IPAA for UC was 6.3%, with the majority of events occurring in hospital and under adequate thromboprophylaxis. These findings suggest that routine use of extended VTE prophylaxis in our cohort may not be supported. Further research is needed to clarify the optimal VTE prophylaxis strategy for inflammatory bowel disease surgery.

Patient-Specific Venous Thromboembolic Event Prophylaxis in Total Joint Arthroplasty - Literature-Supported Guidelines.

Following total joint arthroplasty (TJA), venous thromboembolic events (VTE) are a known complication that may result in increased hospitalization cost as well as morbidity. Numerous investigations have documented patient-specific factors that place an individual at increased risk of VTE after TJA. Potential risk factors for VTE include genetic predisposition, history of a prior VTE event, revision surgery and patient comorbidity factors. The American Academy of Orthopedic Surgeons and The American College of Chest Physicians have both provided recommendations for VTE prophylaxis after orthopedic surgery. However, among orthopedic surgeons, there remains a lack of consensus regarding the appropriate agent and time course for prophylactic anticoagulation after TJA. In this study, we review the evidence-supported patient-specific factors that confer an increased risk of VTE in the TJA postoperative period. Furthermore, we describe the VTE prophylaxis regimen used at our home institution after TJA for low- and high-risk patients as well as a recommendation for cessation or continuation of anticoagulation regimens that patients were on preoperatively for comorbid conditions.

328 Incidence and Number of Missed Chemical Venous Thromboembolic Event Prophylactic Doses Predict the Development of Venous Thromboembolic Events in Traumatic Brain Injury Patients

INTRODUCTION: Venous thromboembolic events (VTE) are a major concern in trauma and intensive care, with traumatic brain injury (TBI) patients at an elevated risk. Chemical VTE prophylaxis is used to prevent VTE development. Concerning TBI patients, achieving a fine balance between the risk of worsening hemorrhage and clot development is important. To date, there has been no correlation between the number of missed doses and VTE development in this population. METHODS: Data were retrospectively collected among 818 TBI patients admitted to a level I trauma center between 2015-2020. RESULTS: Overall VTE incidence was 9% (7.6% DVT; 3.2% PE; 1.7% both). Median time to DVT and PE was 7 (IQR: 4-11) and 5 days (IQR: 3-12), respectively. VTE occurred in 37.8% of patients who missed prophylactic doses and 28.4% who did not (p = 0.089). In patients who experienced a VTE, compared to non-VTE patients, missed chemical prophylaxis dosing was primarily due to a pending invasive procedure (44.8% vs. 25.2%, p = 0.02) and the presence of additional bleeding (13.8% vs. 2.8%, p = 0.005). Non-VTE patients missed prophylactic dosing primarily from patient or family refusal (42.1% vs. 3.4%, p &lt; 0.001). VTE incidence was higher in patients receiving invasive neurosurgery (45.9% vs. 30.5%, p = 0.007). Univariate analysis demonstrated 4-6 total missed doses as predicting the highest VTE risk (OR 4.08, 95% CI: 1.53-10.86, p = 0.005). No VTE were seen in &gt;7 missed doses, presumably due to an overall high mortality rate of 13.5%. CONCLUSIONS: This study is novel in showing the incidence and number of missed chemical VTE prophylaxis to predict an increased VTE risk in TBI patients. Our study suggests a threshold of 4 missed doses to be particularly important in this critical patient population.

Timing of venous thromboembolism prophylaxis initiation after injury: Findings from the consensus conference to implement optimal VTE prophylaxis in trauma.

Optimizing prophylaxis against venous thromboembolic events (VTEs) is a critical issue in the care of injured patients. Although these patients are at significant risk of developing VTE, they also present competing concerns related to exacerbation of bleeding from existing injuries. Especially after high-risk trauma, including injuries to the abdominal solid organs, brain, and spine, trauma providers must delineate the time period in which VTE prophylaxis successfully reduces VTE rates without encouraging bleeding. Although existing data are primarily retrospective in nature and further study is required, literature supports early VTE chemoprophylaxis initiation even for severely injured patients. Early initiation is most frequently defined as <48 hours from admission but varies from <24 hours to 72 hours and occasionally refers to time from initial trauma. Prior to chemical VTE prophylaxis initiation in patients at risk for bleeding, an observation period is necessary during which injuries must show themselves to be hemostatic, either clinically or radiographically. In the future, prospective examination of optimal timing of VTE prophylaxis is necessary. Further study of specific subsets of trauma patients will allow for development of effective VTE mitigation strategies based upon collective risks of VTE and hemorrhage progression.

Apixaban vs Enoxaparin for Post-Surgical Extended-Duration Venous Thromboembolic Event Prophylaxis: A Prospective Quality Improvement Study.

Venous thromboembolic events (VTEs) are a major cause of morbidity following abdominopelvic oncologic surgery. Enoxaparin, a subcutaneous injectable low molecular weight heparin, is commonly used for extended-duration VTE prophylaxis (EP), but has been associated with noncompliance. Newer direct oral anticoagulants have not been prospectively studied in the urologic oncology post-discharge setting. We aimed to improve compliance with EP following abdominopelvic oncologic surgery and secondarily test the hypothesis that apixaban is noninferior to enoxaparin for EP. A single-center prospective quality improvement study measuring patient compliance and safety with EP was conducted between August 10, 2020 and September 21, 2021. Baseline data were continuously collected for 6 months, followed by a uniform departmental change from enoxaparin to apixaban. The duration of data collection was determined a priori using a noninferiority sample size estimation (145 per group). The primary outcome was compliance events (real or potential barriers to EP use). The secondary outcome was 30-day post-discharge safety events (symptomatic VTE or major bleed). A total of 161 patients were discharged with enoxaparin (baseline period) and 154 with apixaban (intervention period). Safety events occurred in 3.1% vs 0% of patients receiving enoxaparin and apixaban, respectively. The absolute risk difference of 3.1% (95% CI: 0.043%-5.8%) met the prespecified noninferiority threshold (p=0.028 for apixaban superiority). Compliance events occurred in 33.5% of enoxaparin patients and 14.3% of apixaban patients (p=0.0001). There were fewer compliance events using apixaban for EP than enoxaparin after urologic oncology surgery. Regarding safety, apixaban is noninferior to enoxaparin and may in fact have fewer associated major complications.

Comparison between rivaroxaban versus enoxaparin for venous thromboembolism prophylaxis following spine surgeries, a randomized clinical trial

BackgroundEnoxaparin is currently used for VTE prophylaxis. Rivaroxaban is more cost-effective and is as potent as enoxaparin in VTE prophylaxis. MethodsThe study was held at Al-Zahra and Kashani university hospitals in Isfahan, Iran, from January 2019 to October 2020. Two hundred ninety-six patients requiring instrumented spine surgery were enrolled; 23 were excluded (lack of consent/interfering medical situations). They were randomized into the groups of rivaroxaban (case, n = 137) and enoxaparin receiving (control, n = 136). Medical data were recorded and 244 patients (case = 123, control = 121) were analyzed value < 0.05 was meaningful. Results150 patients were males, and 94 were females. The mean age was 52.09 ± 12.6 years. Postoperative drain volume was higher in rivaroxaban received patients than in enoxaparin (p = 0.02). Post-operation epidural hematoma was detected in 3 patients in the case and 1 in the control group, which was not meaningful(p = 0.622). All of them were evacuated surgically. POH was associated with cervical canal stenosis surgery, existing comorbidities, and new medical events. New medical events were associated with postoperative wound dehiscence (p = 0.001). Short and long-term postoperative outcomes were similar in both groups. The mean follow-up duration was 25.8 ± 7.5 months. ConclusionRivaroxaban is as effective as enoxaparin in venous thromboembolic event prophylaxis. Regarding postoperative epidural hematoma, statistical analysis showed equal safety of both drugs. Still, the authors would like to recommend more discretion in rivaroxaban administration in cervical spine laminectomy until future studies are conducted.

This Month in Adult Urology

This Month in Adult Urology

Thromboembolic events in pelvic and acetabulum fractures: a systematic review of the current literature on incidence, screening, and thromboprophylaxis.

Rates of venous thromboembolic events (VTEs) as high as 41% deep vein thrombosis (DVT) were reported in association with pelvic and acetabular fractures (PAFs). There is no clear consensus on VTE prophylaxis for PAFs. Extracting evidence-based guidelines is key to overcome this challenging complication. The aims of this review are (A) to highlight the incidence of VTEs in PAFs, (B) to examine the screening and prophylaxis methods available in the current literature, and (C) direct future creation of a best practice protocol to reduce the risk of VTE in PAFs. We performed a systematic search of Medline, EMBASE databases, and the Cochrane library. MESH terms were used to identify studies pertinent to VTE in PAFs, including incidence, prophylaxis, and screening. In total, 28 studies were identified and grouped into four categories including incidence, screening, prophylaxis, and the use of inferior vena cava filters (IVCFs). Incidence of VTE ranged from 0.21 to 41% for DVT and 0 to 21.7% for PE. Nine studies screened 1360 patients using different imaging modalities. Ten articles, 2836 patients, examined different thromboprophylaxis protocols. Two out of three studies investigating the use of IVCF showed significant reduction of the rates of PE. Incidence of VTE in PAF varies significantly with different protocols. The current literature shows that screening is still controversial. The combination of chemical and mechanical prophylaxis starting at 24 hours from the injury would provide the best protection. Guidelines were extracted; however, higher level multicenter studies are still required to guide future protocols.

EDITORIAL COMMENT

Post-operative venous thromboembolic events (VTE) are a major source of morbidity among patients undergoing oncologic surgery and a leading cause of post-operative deaths.1 Level 1 evidence supports the use of extended post-operative VTE prophylaxis (EP) following major abdominal or pelvic surgery.2 Most commonly, enoxaparin, a low molecular weight heparin is used; however there are numerous barriers including cost, pain, and difficulty with injections which may reduce compliance.3,4

Incidence of Venous Thromboembolic Events in Patients With Endogenous Cushing Syndrome

Background: Hypercortisolemia is a hypercoagulable state associated with increased risk of venous thromboembolic events (VTE). The reported incidence of VTE in patients with ACTH-dependent or independent Cushing Syndrome (CS) is variable, ranging from 3 to 14%. Our aim was to assess the incidence of clinically significant VTE among patients with endogenous CS and to identify risk factors for the development of VTE. Methods: We conducted a single center retrospective longitudinal study of adult patients diagnosed with endogenous CS between 2010 and 2020. Patients with a known prothrombotic disease (e.g. Factor V Leiden), insufficient data, or non-neoplastic hypercortisolism were excluded. Data collected included patient demographics, presenting symptoms, biochemical and radiological workup, treatment details, and incidence of clinically significant VTE. Results: A total of 114 patients (mean age of 45.55 ± 14.78 years, 79.8% women) followed for mean of 3.26 ± 2.9 years were included. Of the 114 patients, 58 (50.9%) had Cushing disease (CD), 40 (35.1%) had CS due to adrenal adenoma/hyperplasia, 6 (3.5%) had adrenocortical carcinoma (ACC), and 10 (8.8%) had ectopic Cushing syndrome (eCS). The overall incidence of VTE at any time point was 14/114 (12.3%); 11 (79%) VTEs were associated with presence of an additional VTE risk factor (8 surgery and 3 malignancy). Prior to any intervention for CS, 3 of 114 (2.6%) patients had a VTE. Surgery for CS (adrenalectomy, transsphenoidal surgery, tumor resection) was performed in 97 patients (85.1%) whereas 17 were treated medically (n=10), died before treatment (n=1) or observed (n=6). VTE occurred in 2 patients receiving medical therapy for CS. The post-operative incidence of VTE was 9 (9.3%; 4 in CD, 1 in adrenal CS, 3 in ACC, and 1 in eCS). VTE occurred ≤ 3-month post-operative in 4 patients (44.4%). Among the 5 patients in whom VTE occurred >3 months post-operative, 3 had recurrent metastatic ACC with hypercortisolemia and 2 were in remission (1 with CS and 1 with eCS). The median time from surgery to VTE occurrence was 315 days (8-1006). Compared to those who did not develop VTE, those who developed VTE had higher mean 24-hour urine free cortisol (4663.6 vs 558.21 mcg/dL; n = 100, P < 0.0001) and mean 1 mg overnight dexamethasone suppression test (36.3 vs 11.8 mcg/dL; n = 69, P = 0.0003), but similar mean late-night salivary cortisol (0.591 vs 0.790 ng/dL, n = 84, P = 0.71) at diagnosis of CS. Discussion: Among those with CS, the overall incidence of VTE was 12.3% and the majority of VTE were provoked (surgery, malignancy). Moreover, VTE was more likely in those with higher UFC and 1 mg overnight dexamethasone suppression test in our cohort. This suggests that in patients with CS who have an active malignancy, severe CS or those undergoing a surgical procedure may be at increased risk of VTE. Future studies should investigate the optimal type and duration of the VTE prophylaxis.

Perioperative medical prophylaxis of venous thromboembolic events in head and neck surgery : Aretrospective study and recommendations

In the authors' department, anewly implemented clinical algorithm for application of perioperative thrombosis prophylaxis in head and neck surgery recommends restrictive handling of anticoagulants. This retrospective study aims to evaluate the algorithm by comparing incidences of venous thromboembolic events (VTE) and surgical revisions due to postoperative hemorrhage. Perioperative incidences of deep vein thrombosis and pulmonary embolism as well as surgical revisions due to postoperative hemorrhage after head and neck surgery were determined based on all patients operated in the department over aperiod of 36months. The incidences before (groupI) and after (groupII) implementation of the restrictive algorithm were compared. Atotal of 9276patients were included. The incidences of VTE (0.12%) and surgical revisions due to postoperative hemorrhage (1.4%) were low. Incidences of VTE were non-significantly higher in groupII (0.16%) than in groupI (0.08%; p > 0.45, chi-square-test). Case analysis revealed that this difference was not due to implementation of the restrictive algorithm. The incidence of surgical revision due to postoperative hemorrhage was identical in the two groups (1.4%). After restricting the indication for thrombosis prophylaxis, the incidence of VTE or surgical revision due to postoperative hemorrhage did not change significantly. The provided clinical algorithm represents a low-risk and low-cost strategy of perioperative risk stratification.

Patient's compliance is a contributor to failure of extended antithrombotic prophylaxis in colorectal surgery: prospective cohort study.

Venous thromboembolic events (VTE) continue to be a major source of morbidity following colorectal surgery. Selective extended VTE prophylaxis for high-risk patients is recommended; however, provider compliance is low. The purpose of this study is to evaluate whether the "global" extended use of enoxaparin in all colorectal patients is feasible and safe. This is a prospective study conducted at a tertiary care center. All Patients undergoing elective colorectal procedures from November 1, 2017 to October 31, 2018 were discharged on 30days of enoxaparin. Safety of use and patient compliance were examined. Total of 270 patients received extended prophylaxis during the study period (100% of intended patients) with five VTE recorded (1.85%). There was no significant difference in rates of VTE or complications when compared to years of selective prophylaxis (1.26% for 2016, 2.32% for 2017). Only 64% of patients reported full compliance. Global use of extended enoxaparin prophylaxis is safe, but does not decrease rates of VTE when compared to selective use. Patient's non-adherence is likely a significant contributing factor.

Effect of Comorbidity Burden on the Risk of Venous Thromboembolic Events After Total Knee Arthroplasty.

BackgroundVenous thromboembolic events (VTEs) are common after total knee arthroplasty (TKA). The rate of VTEs has improved with early mobilization, mechanical prophylaxis, and appropriate chemoprophylaxis. The aim of this study was to analyze the contribution of medical comorbidities to the risk of VTE after TKAMethodMedicare claims from 2005 to 2014 were queried. International Classification of Diseases, Ninth revision (ICD-9), and Current Procedural Terminology codes were used to identify the diagnoses, procedures, and complications. 157,200 primary TKAs were age, sex, and Elixhauser Comorbidity Index (ECI) matched with 157,200 osteoarthritis controls. First instances of deep venous thrombosis (DVT) and pulmonary embolism were tracked at 90 days and 2 years. Odds ratios (ORs), confidence intervals, and P-values (p) were calculated and used to investigate the contribution of comorbidities.Results90 days after TKA or OA diagnosis, comorbidities were associated with 45% of the DVT risk, 38% of the PE risk. 1 in 92 patients would be expected to be diagnosed with VTE after TKA and 1 in 136 patients after only the diagnosis of osteoarthritis. After 90 days, medical comorbidities were associated with 70% of the DVT risk, 68% of the PE risk.ConclusionNearly 50% of DVTs and 40% of PEs within 90 days of TKA may be related to the baseline health of OA patients. Venous thromboembolic events after TKA are a “never” event according to Center of Medicare and services that appropriate VTE prophylaxis likely cannot be neutralized.

Bleeding risk in patients with venous thromboembolic events treated with new oral anticoagulants

New oral anticoagulants (NOACs) is the preferred treatment in secondary prophylaxis of venous thromboembolic events (VTE). The aim of this study was to investigate possible risk factors associated with major bleeding in VTE-patients treated with NOACs. In this retrospective register-based study we screened the Swedish anticoagulation register Auricula (during 2012.01.01–2017.12.31) to find patients and used other national registers for outcomes. Primary endpoint was major bleeding defined as bleeding leading to hospital care. Multivariate Cox-regression analysis was used to reveal risk factors. 18 219 patients with NOAC due to VTE were included. 85.6% had their first VTE, mean age was 69.4 years and median follow-up time was 183 days. The most common NOAC was rivaroxaban (54.8%), followed by apixaban (42.0%), dabigatran (3.2%) and edoxaban (0.1%). The rate of major bleeding was 6.62 (95% CI 6.19–7.06) per 100 treatment years in all patients and 11.27 (CI 9.96–12.57) in patients above 80 years of age. Statistically independent risk factors associated with major bleeding were age (normalized HR 1.38, CI 1.27–1.50), earlier major bleeding (HR 1.58, Cl 1.09–2.30), COPD (HR 1.28, CI 1.04–1.60) and previous stroke (HR 1.28, Cl 1.03–1.58) or transient ischemic attack (TIA) (HR 1.33, Cl 1.01–1.76). Prior warfarin treatment was protective (HR 0.67, CI 0.58–0.78). This real world cohort shows a high bleeding rate especially among the elderly and in patients with previous major bleeding, COPD and previous stroke or TIA. This should be considered when deciding on treatment duration and NOAC dose in these patients.

Thromboinflammation and the hypercoagulability of COVID‐19

Thromboinflammation and the hypercoagulability of COVID‐19

1776P - High incidence of venous thromboembolic events (VTE) in patients with diffuse large b-cell lymphoma

BackgroundIncidence of venous thromboembolic events (VTE) is higher among cancer patients, especially while on chemotherapy. Diffuse large B-cell lymphoma (DLBL) is the most common lymphoma. Studies that specifically evaluated the risk of VTE in patients with different kinds of lymphomas reported a risk ranged from 1.5% to 14.6%. In this study, we specifically address VTE in a unified lymphoma population. MethodsMedical records and hospital databases were searched for patients with a diagnosis of DLBL and VTE. All patients were diagnosed, treated and followed up at our institution. The Khorana and “Throly” risk assessment models (RAM) were applied on all patients and known risk factors for VTE were studied. ResultsA total of 393 patients (52.4% males), median age: 49 (range: 18-90) years were included. At diagnosis, 163 (41.5%) were stage IV, 116 (29.5%) had bulky disease and 197 (50.1%) had high LDH. All patients were treated on a unified guidelines using R-CHOP chemotherapy; 285 (72.5%) achieved CR while 72 (18.3) had salvage chemotherapy. Venous thromboembolic events were reported in 57 (14.5%) patients. Pulmonary embolism (PE) with or without deep venous thrombosis (DVT) was reported in 24 (42.1%), 8 of them (33.3%) were incidental. Upper extremity DVT were seen in 18 (31.6%); only 4 (22.2%) were associated with a vascular device. Thrombosis was diagnosed in ambulatory sitting in 30 (52.6%) and majority of the VTE occurred while on active chemotherapy; 20 (35.1%) while on initial induction and 15 (26.3%) while on salvage chemotherapy, however, 19 (33.3%) occurred before the initiation of any chemotherapy. Among the 35 patients on active chemotherapy, only 6 (17.1%) had high Khorana risk score. In a multivariate analysis, significantly higher rates of thrombosis were associated with stage-IV disease, high LDH and high International Prognostic Index (IPI). Sex, age, BMI, and the Khorana risk score were not. ConclusionsIncidence of VTE in patients with DLBL is high and majority of such events occurred in ambulatory setting were VTE prophylaxis is not offered. Upper extremity DVT and incidental PE were exceptionally high. Stage at diagnosis, IPI score and LDH are important in predicting the risk for thrombosis. Legal entity responsible for the studyThe authors. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

Weight-based enoxaparin with anti-factor Xa assay-based dose adjustment for venous thromboembolic event prophylaxis in adult trauma patients results in improved prophylactic range targeting.

Venous thromboembolism (VTE) is a common morbidity in trauma patients. Standard VTE chemoprophylaxis is often inadequate. We hypothesized that weight-based dosing would result in appropriate prophylaxis more reliably than fixed dosing. All patients admitted to a Level 1 trauma center over a 6-month period were included unless contra-indications for VTE prophylaxis existed. A prospective adjusted-dosing group was compared to a retrospective uniform-dosing group. The adjusted-dosing approach consisted of initial weight-based dosing of 0.5mg/kg subcutaneously (subQ) every 12h (q12h). Peak anti-factor Xa was measured. Patients outside of the prophylactic range had their dose adjusted by ± 10mg. The uniform-dosing group received 30mg subQ q12h, without adjustments. Eighty-four patients were included: 44 in the retrospective control cohort and 40 in the prospective experimental cohort. More patients were sub-prophylactically dosed in the uniform-dosing group relative to the adjusted-dosing group (25% vs 5%, p = 0.03). There was no difference in overall prophylactic range targeting, because the supra-prophylactically dosed patients in the adjusted-dosing group eliminated the effect (p = 0.173). However, after a single dose adjustment, zero patients were outside of prophylactic range (25% versus 0%, RR = infinite, p = 0.003). In the uniform-dosing group, anti-Xa level correlated with body surface area (BSA; R2 = 0.33, p < 0.0001) and weight (R2 = 0.26, p = 0.0005). Weight-based dosing both pre- and post-readjustment normalized the correlation of anti-Xa with BSA (R2 = 0.07, p = 0.1) and weight (R2 = 0.07, p = 0.1). Weight-based VTE prophylaxis with anti-Xa-based dose adjustment improves prophylactic range targeting relative to uniform dosing and eliminates variances secondary to BSA and weight in trauma patients.

Lower Mortality and Morbidity With Low Molecular Weight Heparin for Venous Thromboembolic Event Prophylaxis in Spine Trauma

Abstract INTRODUCTION Up to 80% of spine trauma patients who do not receive thromboprophylaxis have a venous thromboembolic event (VTE) and pulmonary embolism (PE) is a major cause of death, yet national consensus on prophylactic regimens has not been reached. We compared the efficacy of low molecular weight heparin (LMWH) versus unfractionated heparin (UH) in decreasing poor outcomes in spine trauma patients. METHODS Isolated spine trauma cases in the American College of Surgeons Trauma Quality Improvement Program (TQIP) were queried using the Abbreviated Injury Scale (AIS). Patients who received LMWH were compared to UH on adjusted rates of in-hospital mortality, thromboembolic complications (DVT and PE), and total in-hospital complications. RESULTS UH patients had higher rates of spinal cord injury (32.26% vs 25.32%; P &lt; .0001), altered mental status (6.26% vs 5.18%; P = .0005), hypotension on arrival (4.70% vs 4.11%; P = .03) and spinal fusions (29.52% vs 22.94%; P &lt; .0001). LMWH patients had lower rates of mortality (OR: 0.74; 95% CI: 0.62-0.88; P = .0008), thromboembolic complications (OR: 0.75; 95% CI: 0.64-0.88; P = .0003), and total complications (OR: 0.89; 95% CI: 0.83-0.94; P = .0001). While nonfused patients had lower odds of death (OR: 0.35; 95% CI: 0.29-0.43; P &lt; .0001), thromboembolic (OR: 0.71; 95% CI: 0.58-0.87; P = .001), and any complications (OR: 0.84; 95% CI: 0.78-0.91; P &lt; .0001) when given LMWH, fused on LMWH had no improvement in these outcomes. CONCLUSION Spinal trauma patients who received LMWH were less likely to die, have thromboembolic complications and any complication compared to those who received UH. Further research, including randomized clinical trials, is necessary to investigate this potential benefit.