Received Venous Thromboembolism Prophylaxis Research Articles

Updated review on malignancy-associated venous thromboembolism: Pathogenesis and comparison between various therapeutic modalities

Venous thromboembolism (VTE) is one of the life-threatening complications in cancer patients, the incidence of which is affected by the patient and malignancy-related variables. Location, type, therapeutic route, stage, grade, and non-supportive treatment of the cancer are the most important VTE risk factors. Patient age, ethnicity, and concomitant genetic or acquired comorbidities or thrombophilias are known risk factors for VTE in cancer. All high-risk cancer patients admitted to hospitals or treated as outpatients should receive VTE prophylaxis. Low molecular weight heparin is the main treatment for active malignant VTE. Vitamin K antagonists and non-Vitamin K-dependent oral anticoagulants are used in stable, non-bleeding cancer patients. Anticoagulation should be continued until the cancer is treated or at least controlled. Over the past two decades, randomized clinical and observational trials have improved the pathogenesis and therapeutic knowledge of VTE, but many challenges remain. The lack of an optimal primary prophylaxis method for inpatients and outpatients in oncology and the care of cancer-associated VTE in standard and high-bleeding risk groups are examples for which more clinical research on cancer-associated thrombosis is necessary to address these issues. In this review, we describe the pathogenesis, factors that increase the risk of VTE, and the comparison between the effectiveness of available anticoagulants in the treatment and prevention of VTE in cancer patients.

Incidence and risk factors of venous thromboembolism in neurosurgical patients after implementing a screening protocol; a retrospective cohort study of a tertiary center

Introduction: Venous thromboembolism (VTE) is a common complication in neurosurgical procedures both before and after surgery. Objective: To examine the incidence of venous thromboembolism (VTE) in neurosurgical patients before surgery and in the postoperative period after implementing a VTE prophylaxis protocol. We also aimed to determine VTE risk factors. Methods: We conducted a retrospective cohort study examining 200 patients admitted to the hospital for cranial and spine neurosurgical procedures between January 2020 and October 2021. All patients were screened for VTE using a protocol combining measurement of D-dimer level and venous duplex ultrasonography. Patients who screened negative for VTE were evaluated for VTE risk using the Caprini risk assessment model; those with Caprini score ≥3 (indicating moderate-to-high risk) received VTE prophylaxis using intermittent pneumatic compression devices. Results: Preoperative screening demonstrated DVT in seven of 200 patients (3.5%). All DVTs were asymptomatic and proximal in location. Univariate logistic regression showed that stroke, neurodegenerative disease, and confinement to bed for more than 72 hours were significant predictors of preoperative DVT. Among the patients without DVT on preoperative screening, 179 (93%) had a Caprini score ≥3; intermittent pneumatic compression was used for prophylaxis in 173 of these (96.6%). Incidence of postoperative VTE was 2.6% (5/193). Extended length of hospital stay, postoperative hydrocephalus, and infection were significant risk factors for VTE. Conclusion: Preoperative VTE screening using D-dimer level and V-DUS and implementation of VTE prophylaxis using IPC can reduce the incidence of VTE and VTE-related mortality in neurosurgical patients.

Bleeding Risk from Anticoagulant Thromboprophylaxis in Patients with Multiple Myeloma

Introduction: Patients with multiple myeloma (MM) have a high risk of venous thromboembolism (VTE) due to unique disease-related (i.e., vascular inflammation, hyperviscosity) and treatment-related factors (i.e., immunomodulatory drugs [IMiDs], high-dose dexamethasone). Thromboprophylaxis is recommended for most patients starting MM therapy. Anticoagulants are preferred over aspirin except in patients at low risk for VTE. However, compliance with prophylaxis guidelines is low. The risk of bleeding from thromboprophylaxis is not well described in these patients so an excessive perceived risk may influence clinicians' practice. We conducted a real-world analysis of bleeding complications from VTE prophylaxis in MM. Methods: The IBM MarketScan Commercial Claims Database was used to identify MM cases between 2013 and 2021. Cases required MM diagnosis from 1 inpatient or 2 outpatient claims, based on ICD-9 or ICD-10 codes, and MM-specific therapy started between 7 days before and 90 days after index diagnosis code, based on HCPCS codes and prescription records. Those with preexisting VTE, atrial fibrillation or stroke were excluded. Thromboprophylaxis was defined as at least 1 prescription for warfarin, low-molecular weight heparin (LMWH) or direct oral anticoagulants (DOAC) within 30 days of diagnosis. Major bleeding was defined as bleeding requiring hospitalization using inpatient ICD codes previously validated (Cunningham algorithm). Patients were followed from end of prophylaxis exposure window (index MM + 30 days) to first major bleeding event, disenrollment (due to death or other reasons) or December 31, 2021. Descriptive statistics were used to calculate rates of bleeding. Cox regression was used to assess the risk of bleeding from thromboprophylaxis and define risk factors associated with major bleeding. Results: We included 6,656 patients diagnosed and treated for MM, with mean age 62.7 years and 55.3% males. Although over 50% of the population would have had a high thrombotic risk based on consensus guidelines, concurrent anticoagulant prophylaxis was prescribed in only 6.6% (436). Prophylaxis agent of choice was warfarin in 23% (102), LMWH in 39% (169), and DOAC in 38% (165), respectively. There was a trend over time favoring DOAC over other agents (25% increase in DOAC use vs. other agents per year on average, p<0.01). Patients on prophylaxis had a higher rate of IMiD-based therapy (63.8% vs. 46.7%, p<0.01) and lower concomitant anti-platelet use (2.1% vs. 4.7%, p=0.01) than those not receiving prophylaxis. There were no differences in age/sex distribution, Charlson comorbidity index (CCI) or history of bleeding between groups. With a median 1.3 years follow-up, the incidence of major bleeding among MM patients receiving VTE prophylaxis was 1.4% or 7.8 bleeding events per 1,000 person-years. This was numerically but not statistically lower than the incident bleeding rate in patients not receiving prophylaxis: 1.8% or 10.1 events per 1,000 person-years. Table 1 shows risk factors for bleeding in this MM population, adjusting for age and sex, including higher age (per 10-year increase, HR 1.38), higher CCI (per SD increment, HR 1.18), history of bleeding (HR 1.54), hypertension (HR 1.87), and renal disease (HR 1.56). IMiD-based MM therapy was associated with decreased risk of bleeding (HR 0.69). Table 2 shows the estimated bleeding risk associated with prophylaxis across several models. No statistically significant association was identified between major bleeding and anticoagulant prophylaxis. Discussion: In a real-world analysis of commercial claims data, the risk of major bleeding associated with VTE prophylaxis in patients with MM undergoing cancer therapy is low and no significant increase in bleeding risk was identified for concurrent anticoagulant use. The rate of major bleeding events appears to be comparable between patients who receive VTE prophylaxis and those who do not. Nevertheless, underutilization of VTE prophylaxis is frequent. Higher CCI, bleeding history, hypertension, and renal disease were clinical factors associated bleeding risk, which may be included in models to help clinicians assess individual patient's risk and guide clinical decisions.

An Electronic Medical Record Intervention to Increase Pharmacologic Prophylaxis for Venous Thromboembolism in Emergency Department Observation Patients

The role of venous thromboembolism (VTE) prophylaxis among patients receiving emergency department (ED) observation unit care is unclear. We investigated an electronic health record-based clinical decision support tool aimed at increasing pharmacologic VTE prophylaxis use among at-risk patients placed in ED observation units. We conducted an interrupted time-series study of an Epic-based best practice advisory implemented in May 2019 at a health care system comprising 2 academic medical centers and 4 community hospitals with dedicated ED observation units. The best practice advisory alerted staff at 24 hours to conduct a risk assessment and linked to a VTE prophylaxis order set. We used an interrupted time series, Bayesian structured time series, and a multivariable mixed-effect regression model to estimate the intervention effect. Prior to the best practice advisory implementation, there were 8,895 ED observation unit patients with a length of stay more than or equal to 24 hours, and 0.9% received pharmacologic VTE prophylaxis. Afterward, there were 12,664 ED observation unit patients with a length of stay more than or equal to 24 hours, and 4.8% received pharmacologic VTE prophylaxis. The interrupted time series and causal impact analysis showed a statistically significant increase in VTE prophylaxis (eg, absolute percent difference 3.8%, 95% confidence interval 3.5 to 4.1). In a multivariable model, only the intervention was significantly associated with receiving VTE prophylaxis (odds ratio 4.56, 95% confidence interval 2.22 to 9.37). An electronic health record-based alert helped to prompt staff caring for ED observation unit patients at risk for VTE with prolonged visits to order recommended pharmacologic prophylaxis. The best risk assessment model to use and the true incidence of VTE events in this population are unclear.

Efficacy and safety of prophylactic anticoagulation in patients with primary nephrotic syndrome: a systematic review and meta-analysis.

Nephrotic syndrome (NS) is associated with an increased incidence of venous thromboembolism (VTE), approximately 10%. We performed a systematic review to evaluate the efficacy and safety of prophylactic anticoagulation in patients with NS. Studies evaluating prophylactic anticoagulation in NS were identified by an electronic search of MEDLINE and EMBASE databases until December 2021. Weighted mean proportion and 95% confidence intervals (CIs) of thromboembolic and haemorrhagic events were calculated using a fixed-effects and a random-effects model. The differences in the outcomes among groups were estimated as pooled odds ratio (OR) and corresponding 95% CI. Statistical heterogeneity was evaluated using the I2 statistic. Five cohort studies, for a total of 414 adult patients, were included. Only two studies had a control group. The weighted mean incidence of pulmonary embolism (PE) and deep vein thrombosis in patients who received VTE prophylaxis was 1.8% (95% CI: 0.6-3.5%; I2 : 4.4%) and 0.9% (95% CI: 0.2-2.2%; I2 : 43.4%) respectively. The weighted mean incidence of major bleeding in patients who received VTE prophylaxis was 2.3% (95% CI: 1-4.2%; I2 : 25.4%). Patients with NS that received VTE prophylaxis had a non-significant reduced risk of PE (OR: 0.63 (95% CI: 0.03-14.8; I2 : 64.4%)) and an increased risk of major bleeding (OR: 2.08 (95% CI: 0.41-10.45; I2 : 0%)) compared to patients with NS that did not receive VTE prophylaxis. Our findings suggest that prophylactic anticoagulation in adult patients with primary NS may reduce the risk of VTE, even if it may be associated with a not negligible bleeding risk.

1024 Current Adherence to Local Health Board Guidelines for Venous Thromboembolism Risk Assessment in Orthopaedic Trauma Lists

Abstract Aim This audit aims to assess the current adherence to the local health board guidelines for Venous Thromboembolism (VTE) risk assessment in Orthopaedic Trauma lists. Method Data was collected for all patients who underwent operation on trauma lists between 1st June 2022 and 31st June 2022. Data collected included the operation type, if VTE risk assessment was completed on admission and pre-operatively. Plan post-operatively and on discharge was also noted as well as the length of VTE prophylaxis prescribed. Results There were 172 patients in total, 117 lower limb procedures and 55 upper limb procedures. Of these procedures 42 lower limb patients and two upper limb patients had risk assessments on admission. 110 patients with lower limb injuries received VTE prophylaxis on admission compared to eight of the non-day case upper limb. Seven lower limb patients and five upper limb did not have a VTE plan post-operatively. There was variation in length of prophylaxis prescribed post-operatively in relation to procedure and guidelines ranging from nine days to six weeks. Conclusions As per local health board guidelines all patients that are admitted or undergo operation as part of the Orthopaedic Department should have VTE assessment carried out. This audit concludes that approximately 25% of VTE assessments on admission are clearly documented. Despite the lack of formal assessment most patients receive VTE prophylaxis but questions whether prescription is appropriate. We also conclude that most patients have a well-documented post-operative VTE plan. Re-audit with intervention is due to end 4th January 2023.

Evaluation of venous thromboembolism prophylaxis protocol in hematopoietic cell transplant patients

Hematopoietic cell transplant (HCT) recipients are at risk for thromboembolic and bleeding complications. There is limited evidence regarding the optimal approach to managing venous thromboembolism (VTE) prophylaxis in hospitalized patients undergoing HCT. In this retrospective cohort study, we evaluated the incidence of bleeding and VTE events in hospitalized HCT patients who received VTE prophylaxis per our institution’s VTE Prophylaxis Protocol (VPP), with either enoxaparin 40 mg subcutaneously daily or heparin 5 000 units subcutaneously twice daily, compared to historical controls who did not receive VTE prophylaxis. The primary outcome was a composite of major bleeding events, clinically relevant non-major bleeding (CRNMB), and minor bleeding. The secondary outcome was a composite of VTE events. A total of 614 patients were evaluated, including 278 prior to and 336 after implementation of VPP. VTE prophylaxis resulted in no difference in bleeding events (15.1% in the pre-VPP group vs. 14.6% in the post-VPP group, p = 0.86) or composite of major and CRNMB events (0.72% vs. 0.30%, p = 0.59). There was a trend toward lower incidence of VTE events in the post-VPP group which did not reach statistical significance (8.6% vs. 6.0%, p = 0.20). We conclude that VTE prophylaxis does not pose additional bleeding risk in HCT patients.

Body Mass Index and Pharmacologic Venous Thromboembolism Prophylaxis in Traumatic Brain Injury

IntroductionPatients with traumatic brain injury (TBI) are at risk for developing venous thromboembolic complications. Previous work suggests venous thromboembolism (VTE) prophylaxis with low molecular weight heparin (LMWH) is protective compared to unfractionated heparin (UH) in trauma patients. The purpose of this study was to evaluate the role of body mass index (BMI) and type of pharmacological VTE prophylaxis in patients who develop VTE with severe TBI. MethodsPatients with a severe TBI who received VTE prophylaxis were queried from the 2019 American College of Surgeons Trauma Quality Improvement Program database. Demographics, injury characteristics, timing of VTE prophylaxis, and BMI were collected. Outcome measures include VTE, mortality, and neurosurgical interventions. ResultsOf the 39,520 patients with severe TBI included in the study, 25,671 received LMWH and 13,849 received UH. Multivariable logistic regression found patients with a BMI 25-29.9 kg/m2 (odds ratio [OR] 1.375; 95% confidence interval [CI] 1.180-1.603; P < 0.0001) and a BMI>30 kg/m2 (OR 1.831; 95% CI 1.570-2.137; P < 0.0001) were independent predictors of VTE. Patients with BMI of 25-29.9 kg/m2 (OR 1.145; 95% CI 1.016-1.289; P = 0.0265) have a higher risk of mortality. For every hour delay in initiation to VTE prophylaxis, patients were 0.2% more likely to develop VTE (OR 1.002; 95% CI 1.002-1.003; P < 0.0001). Patients treated with UH were more likely to develop VTE complications (OR 1.085; 95% CI 1.058-1.112; P < 0.0001) and have increased mortality (OR 1.116; 95% CI 1.094-1.139; P < 0.0001), regardless of BMI and time to initiation of prophylaxis, compared to patients treated with LMWH. ConclusionsIn patients with severe TBI, higher BMI was associated with an increased risk of VTE and death. Delay in VTE prophylaxis initiation was associated with an increased risk of VTE. LMWH had a protective association with VTE.

Risk factors for thromboembolic complications in isolated severe head injury

PurposePatients with traumatic brain injury (TBI) are at high risk for venous thromboembolism (VTE). The aim of the present study is to identify factors independently associated with VTE events. Specifically, we hypothesized that the mechanism of penetrating head trauma might be an independent factor associated with increased VTE events when compared with blunt head trauma.MethodsThe ACS-TQIP database (2013–2019) was queried for all patients with isolated severe head injuries (AIS 3–5) who received VTE prophylaxis with either unfractionated heparin or low-molecular-weight heparin. Transfers, patients who died within 72 h and those with a hospital length of stay < 48 h were excluded. Multivariable analysis was used as the primary analysis to identify independent risk factors for VTE in isolated severe TBI.ResultsA total of 75,570 patients were included in the study, 71,593 (94.7%) with blunt and 3977 (5.3%) with penetrating isolated TBI. Penetrating trauma mechanism (OR 1.49, CI 95% 1.26–1.77), increasing age (age 16–45: reference; age > 45–65: OR 1.65, CI 95% 1.48–1.85; age > 65–75: OR 1.71, CI 95% 1.45–2.02; age > 75: OR 1.73, CI 95% 1.44–2.07), male gender (OR 1.53, CI 95% 1.36–1.72), obesity (OR 1.35, CI 95% 1.22–1.51), tachycardia (OR 1.31, CI 95% 1.13–1.51), increasing head AIS (AIS 3: reference; AIS 4: OR 1.52, CI 95% 1.35–1.72; AIS 5: OR 1.76, CI 95% 1.54–2.01), associated moderate injuries (AIS = 2) of the abdomen (OR 1.31, CI 95% 1.04–1.66), spine (OR 1.35, CI 95% 1.19–1.53), upper extremity (OR 1.16, CI 95% 1.02–1.31), lower extremity (OR 1.46, CI 95% 1.26–1.68), craniectomy/craniotomy or ICP monitoring (OR 2.96, CI 95% 2.65–3.31) and pre-existing hypertension (OR 1.18, CI 95% 1.05–1.32) were identified as independent risk factors for VTE complications in isolated severe head injury. Increasing GCS (OR 0.93, CI 95% 0.92–0.94), early VTE prophylaxis (OR 0.48, CI 95% 0.39–0.60) and LMWH compared to heparin (OR 0.74, CI 95% 0.68–0.82) were identified as protective factors for VTE complications.ConclusionThe identified factors independently associated with VTE events in isolated severe TBI need to be considered in VTE prevention measures. In penetrating TBI, an even more aggressive VTE prophylaxis management may be justified as compared to that in blunt.

An Audit of Inpatient Management of Acute Decompensated Heart Failure With Reduced Ejection Fraction in General Medicine

This audit aimed to describe the use of guideline-directed medical therapies (GDMT) in patients with heart failure with reduced ejection fraction who have been hospitalised with decompensated heart failure in a tertiary hospital. Patients not on GDMT due to medical contraindications are termed to be on “rationalised medical therapy” (RMT). The primary objective was to assess the percentage of patients discharged on GDMT, RMT, or suboptimal therapy. Secondary outcomes were the prevalence of sodium-glucose transport protein 2 inhibitors (SGLT2I) use and inpatient venous thromboembolism (VTE) prophylaxis. Patients aged ≥18 years, with a left ventricular ejection fraction of <40% and admitted under General Medicine at Middlemore with an ICD-10 diagnosis of acute decompensated heart failure between 30 September 2021 and 30 March 2022 were identified. Sixty-two patients were randomly selected from an eligible population of 339 patients. Data collection was performed using the Electronic-Prescribing and Electronic Discharge Summary applications. Twenty-seven patients (44%) were discharged on GDMT, 17 (27%) were discharged on RMT, and 18 (29%) were discharged on suboptimal therapy; 8% of patients were discharged on SGLT2I, while 80% did not meet PHARMAC Special Authority criteria. A total of 69% of patients received VTE prophylaxis. Eighteen patients (29%) were on suboptimal heart failure therapy at discharge and almost 31% did not have VTE prophylaxis. This may lead to suboptimal outcomes in mortality and morbidity. A total of 80% of patients could benefit from SGLT2I therapy but did not meet special authority criteria.

Identification of prophylaxis and treatment for hospitalized patients associated with venous thromboembolism.

Identification of prophylaxis and treatment for hospitalized patients associated with venous thromboembolism.

Caprini assessment utilization and impact on patient safety in gynecologic surgery.

Postoperative venous thromboembolism (VTE) can potentially be associated with significant morbidity, mortality, and healthcare costs. The aim of this study was to determine the utilization of Caprini guideline indicated VTE in elective gynecologic surgery patients and its impact on postoperative VTE and bleeding complications. This was a retrospective cohort study of elective gynecologic surgical procedures performed between January 1, 2016, and May 31, 2021. Two study cohorts were generated: (1) those who received and (2) those who did not receive VTE prophylaxis based on Caprini score risk stratification. Outcome measures were then compared between the study cohorts and included the development of a VTE up to 90-days postoperatively. Secondary outcome measures included postoperative bleeding events. A total of 5471 patients met inclusion criteria and the incidence of VTE up to 90days postoperatively was 1.04%. Overall, 29.6% of gynecologic surgery patients received Caprini score-based guideline VTE prophylaxis. 39.2% of patients that met high-risk VTE criteria (Caprini > 5) received appropriate Caprini score-based prophylaxis. In multivariate regression analysis, the American Society of Anesthesiologists (ASA) score (OR 2.37, CI 1.27-4.45, p < 0.0001) and Caprini score (OR 1.13, CI 1.03-1.24, p = 0.008) predicted postoperatively VTE occurrence. Increasing Charlson comorbidity score (OR 1.39, CI 1.31-1.47, P < 0.001) ASA score (OR 1.36, CI 1.19-1.55, P < 0.001) and Caprini score (OR 1.10, CI 1.08-1.13, P < 0.001) were associated with increased odds of receiving appropriate inpatient VTE prophylaxis. While the overall incidence of VTE was low in this cohort, enhanced adherence to risk-based practice guidelines may provide more patient benefit than harm to postoperative gynecologic patients.

The impact of Charlson Comorbidity Index on surgical complications and reoperations following simultaneous bilateral total knee arthroplasty

Simultaneous bilateral total knee arthroplasty (TKA) might be associated with higher postoperative morbidity and mortality rates compared with staged bilateral TKA. However, risk factors for surgical complications and reoperations following simultaneous bilateral TKA remain elusive. We conducted this retrospective, single-surgeon case series from 2010 through 2019. A total of 1561 patients who underwent simultaneous bilateral TKA procedures were included. The outcome domains included 30-day and 90-day readmission events for medical or surgical complications and 1-year reoperation events. We performed logistic regression analysis and backward stepwise selection to identify possible risk factors, including age, sex, body mass index, diabetes mellitus (DM), rheumatoid arthritis, American Society of Anesthesiologist (ASA) classification, Charlson Comorbidity Index (CCI), receiving venous thromboembolism (VTE) prophylaxis, or blood transfusion. The overall 30-day, 90-day readmission, and 1-year reoperation rates were 2.11%, 2.88%, and 1.41%, respectively. Higher CCI score (CCI = 4+) was a risk factor for 90-day readmission (aOR: 2.783; 95% CI 0.621–12.465), 90 day readmission for surgical complications (aOR: 10.779; 95% CI 1.444–80.458), and 1 year reoperation (aOR: 4.890; 95% CI 0.846–28.260). Other risk factors included older age, higher ASA level, DM, and receiving VTE prophylaxis. In conclusion, high CCI scores were associated with increased risks of surgical complications and reoperations following simultaneous bilateral TKA procedures.

COMPLIANCE WITH STANDARD THROMBOPROPHYLAXIS GUIDELINES AGAINST VENOUS THROMBOEMBOLISM IN ACUTE MEDICAL WARDS —A SINGLE CENTRE EXPERIENCE

Background: Venous thromboembolism (VTE) prevention in hospitalized patients is primarily based on adequate risk stratification, but the recommended prophylaxis for associated risk factors are not adequately utilized. Objective was to estimate the implementation of the standard international VTE prophylaxis guidelines in acutely ill patients in medical wards of Hayatabad Medical Complex (HMC), Peshawar. Methods: This study was conducted in HMC (1st April to 31st December, 202), to determine the proportion of patients receiving appropriate VTE prophylaxis according to ANZ WP recommendations, based on their risk profiles. The modalities employed for prevention were Compression Stockings alone, Anticoagulation alone or use of both. Random sampling technique allowed inclusion of 600 patients from medicine department, HMC. Results: Out of the 600 patients, 336 were female while 264 were male. Patients stratified as High Risk were 72% while 28% as Low Risk group. Risk factors observed were age &gt;60 years (43.05), past history of stroke with neurological deficits (64.12%), admission with lung disorders (18.05%) and those with active cancers 6.01%. A total of 57.6% were found to be receiving VTE prophylaxis with 54.2% in High Risk group while 45.8% in low risk group. Amongst the patients receiving VTE prophylaxis, 20.80% patients were receiving both modalities, 49.30 were having TED Stockings alone, while 29.90% were receiving anticoagulation alone. Conclusion: The international standard guidelines for thromboprophylaxis were observed to be poorly followed in our hospital which calls for strategies to identify high risk individuals and initiation of appropriate prophylaxis. Pak J Physiol 2023;19(1):29–32

Venous Thromboembolism Prophylaxis in Plastic Surgery Patients Undergoing Facelift

Objective: In 2005 the ASPS approved the VTE Task Force Report, which recommended use of the Caprini scoring system for plastic surgery patients; this system has been adopted for venous thromboembolism (VTE) prophylaxis by most surgical societies in the United States. The aim of this study is to investigate the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing facelifts at our institution, who were not chemoprophylaxed based on the Caprini scoring system. Methods: A retrospective chart review was conducted of patients that underwent facelift at a single institution. Patients were included if they were operated on between 2016-2021 by the lead surgeon and excluded if they received VTE prophylaxis. Comorbidities, rate of VTE, and other relevant data was collected. Descriptive statistics were then conducted to analyze the collected date. Results: 136 patients were isolated after chart review, and no patients were found to have had DVT or VTE. The average Caprini score was 5.625 and ranged from 3 to 10. There was 1 patient with evidence of post-operative hematoma (Caprini score=7). Overall hematoma percentage was 0.735%. Conclusion: Based on the average Caprini score for our patients, all should have received chemoprophylaxis for VTE. We found no VTE-related events in our patients without chemoprophylaxis. This is consistent with a previous study of 1,453 patients receiving a variety of cosmetic procedures without chemoprophylaxis that had no VTE related events. Our study suggests that Caprini Scoring system might not be optimal in predicting VTE in aesthetic patients. Corresponding Author: Kenneth Shaheen, 3555 W 13 Mile Rd #120, Royal Oak, MI, 48073, [email protected], 248-890-2515

Chemical versus Mechanical and Chemical Venous Thromboembolism Prophylaxis in Neurocritically Ill Patients: A Cohort Study.

Patients admitted with neurocritical illness are presumed to be at high risk for venous thromboembolism (VTE). The administration of chemical and/or mechanical VTE prophylaxis is a common practice in critically ill patients. Recent data did not show a significant difference in the incidence of VTE between chemical compared to a combined chemical and mechanical VTE prophylaxis in critically ill patients with limited data in neurocritically ill population. The objective of this study is to investigate the incidence of VTE between chemical alone compared to chemical and mechanical VTE prophylaxis in neurocritically ill patients. This was a retrospective cohort study at a tertiary teaching hospital. Data were obtained from electronic medical records for all patients admitted with neurocritical illness from January 1, 2016, to December 31, 2020. Patients were excluded if they did not receive VTE prophylaxis during admission or were younger than 18 YO. Major outcomes were symptomatic VTE based on clinical and radiological findings, intensive care unit (ICU) length of stay (LOS), and hospital LOS. Minor outcomes included severe or life-threatening bleeding based on GUSTO criteria, and mortality at 28-days. Two hundred and twelve patients were included in this study. Patients did not have any significant differences in their baseline characteristics. The incidence of VTE was similar in the chemical only group compared to the combined VTE prophylaxis group (19/166 (11.3%) vs 7/46 (15.2%)); P = 0.49. No difference between groups in their ICU LOS 6 [3-16.2] vs 6.5 [3-19]; P = 0.52, nor their mortality (18/166 (10.7%) vs 3/46 (6.5%)); P = 0.38, respectively. Less bleeding events were seen in the chemical prophylaxis group compared to the combined VTE prophylaxis group (19/166 (11.3%) vs 12/46 (26.1%); P = 0.01). Our findings observed no difference between the administration of chemical VTE prophylaxis alone compared to the combined VTE prophylaxis strategy. More data are needed to confirm this finding with more robust methodology.

Angioembolization in Severe Pelvic Trauma is Associated with Venous Thromboembolism

IntroductionManagement of hemorrhage from pelvic fractures is complex and requires multidisciplinary attention. Pelvic angioembolization (AE) has become a key intervention to aid in obtaining definitive hemorrhage control. We hypothesized that pelvic AE would be associated with an increased risk of venous thromboembolism (VTE). MethodsAll adults (age >16) with a severe pelvic fracture (Abbreviated Injury Scale ≥ 4) secondary to a blunt traumatic mechanism in the 2017-2019 American College of Surgeons Trauma Quality Improvement Program database were included. Patients who did not receive VTE prophylaxis during their admission were excluded. Patients who underwent pelvic AE during the first 24 h of admission were compared to those who did not using propensity score matching. Matching was performed based on patient demographics, admission physiology, comorbidities, injury severity, associated injuries, other hemorrhage control procedures, and VTE prophylaxis type, and time to initiation of VTE prophylaxis. The rates of VTE (deep vein thrombosis and pulmonary embolism) were compared between the matched groups. ResultsOf 72,985 patients with a severe blunt pelvic fracture, 1887 (2.6%) underwent pelvic AE during the first 24 h of admission versus 71,098 (97.4%) who did not. Pelvic AE patients had a higher median Injury Severity Score and more often required other hemorrhage control procedures, with laparotomy being most common (24.7%). The median time to initiation of VTE prophylaxis in pelvic AE versus no pelvic AE patients was 60.1 h (interquartile range = 36.6-98.6) versus 27.7 h (interquartile range = 13.9-52.4), respectively. After propensity score matching, pelvic AE patients were more likely to develop VTE compared to no pelvic AE patients (11.8% versus 9.5%, P = 0.03). ConclusionsPelvic AE for control of hemorrhage from severe pelvic fractures is associated with an increased risk of in-hospital VTE. Patients who undergo pelvic AE are especially high risk for VTE and should be started as early as safely possible on VTE prophylaxis.

The Pattern of Heparin Dosing as Venous Thromboembolism Prophylaxis in Adult Underweight Patients Admitted to Critical Care Units at a Tertiary Hospital.

Venous thromboembolism (VTE) is one of thecauses of hospital-related deaths in critically ill patients. Guidelines recommended VTE prophylaxis with standardized, fixed doses for most patients. The underweight population has limited data to guide the appropriate drug and dosing regimen. The aim of this study was to describe the pattern of VTE prophylaxis dose regimens for underweighted critically ill adult patients and the prevalence of associated VTE and bleeding. This study is a retrospective cohort study, conducted at the King Abdulaziz Medical City, Riyadh, Saudi Arabia. It included all critical patients admitted to the intensive care units (ICUs) and were above 14 years old with weight less than 50 kg or body mass index (BMI) of 18.5 kg/m2 or less, and were on heparin as VTE prophylaxis for more than 72 h from January 2016 until January 2020. After screening 270 patients, only 40 patients were included in this study according to our inclusion and exclusion criteria. Only six patients (15%) received VTE prophylaxis as an adjusted dose of heparin 2500 U Q12, while the rest of the patients were taking standard dosing of heparin; 5000 U Q12 was given to 21 (52.50%) patients, and 5000 U Q8 was given to 13 (32.50%) patients. None of the adjusted doses developed any complications such as VTE or bleeding. There was no significant difference compared with the standard dose group. In this study, we described the pattern of heparin doses as VTE prophylaxis in underweight patients. We also compared the standard dosing and adjusted dosage of VTE prophylaxis on underweight patients and any complications. There was no significant difference in the complications outcome or benefits between the two groups.

Anticoagulation Use for Secondary Prophylaxis Against Recurrent Venous Thromboembolism in Hospitalized Children: A Report from the Children's Hospital-Acquired Thrombosis (CHAT) Consortium

Introduction: Most venous thromboembolism (VTE) in children are provoked and have an overall low risk for recurrence, especially if the original provoking factor is mitigated. Nonetheless, certain factors heighten VTE recurrence risk, including hospitalization. In fact, the rate of VTE in hospitalized children has increased more than 200% since 20011. This staggering discovery emphasizes the dire need for more effective tactics aimed at VTE prevention. Historically, pediatric providers have been hesitant to initiate pharmacologic (i.e. anticoagulant) measures in children for a number of reasons. In our recent survey of practice patterns of secondary prevention against recurrent VTE in pediatrics, we found low use (<25%) of pharmacologic prophylaxis in high-risk children2. Additionally, most respondents did not feel comfortable initiating secondary pharmacologic prophylaxis in younger children2. In the wake of the COVID-19 pandemic, numerous trials have been conducted to evaluate anticoagulation for VTE prevention in affected individuals. The recently published COVID-19 Anticoagulation in Children- Thromboprophylaxis trial showed safety of low-dose enoxaparin in children hospitalized with COVID-19 or multisystem inflammatory syndrome in children (MIS-C)3. Furthermore, trials of direct oral anticoagulants have also shown safety and efficacy in secondary VTE prevention in children4. Importantly, these studies have consistently demonstrated low rates of bleeding. Methods: The CHAT Registry is an IRB-approved registry that captures clinical data on hospital-acquired VTE in children <21 years of age and non-VTE controls. Subjects were enrolled from 2012-2021 across 8 participating pediatric hospitals. Using this REDCap database, we performed a retrospective study of enrolled subjects to explore trends for secondary anticoagulation prophylaxis use in hospitalized children. Subjects (cases and controls) were included if they had a history of VTE. Descriptive statistics were used to analyze demographics/characteristics and VTE prophylaxis measures. Results: Fifty-two subjects (%) out of 2219 total CHAT subjects (1273 cases, 946 controls) reviewed had a prior history of VTE. Characteristics of these subjects are presented in Table 1. The mean age was 9.6 years with a slight male predominance (54%). Regarding VTE prophylaxis (Figure 1), 18 (35%) received VTE prophylaxis (mechanical and/or pharmacologic) during hospitalization. Of these, 11 subjects (61%) were prescribed pharmacologic prophylaxis either alone (8) or in combination with mechanical prophylaxis (3). The remaining seven (39%) received only mechanical prophylaxis. Four subjects were already on anticoagulation at the time of admission. Forty-four (85%) subjects experienced a hospital-acquired VTE recurrence. Only 16 (36%) of these had received some method of VTE prophylaxis. Of those who did not receive pharmacologic prophylaxis, only 3 had a documented contraindication. The most commonly documented contraindications to pharmacologic prophylaxis pertained to risk of bleeding, and included uncorrected coagulopathy, ongoing/uncontrolled hemorrhage and thrombocytopenia. The median time between admission and VTE event was 9 days. Conclusion: There is a high rate of recurrent VTE in hospitalized children with a history of prior VTE. These results underscore the significance of implementing consistent pharmacologic prophylaxis in high-risk children where appropriate. As the landscape is actively changing in terms of available anticoagulant formulations available for children, providers may feel more confident in initiating secondary pharmacologic prophylaxis particularly as new data confirm the safety. Nevertheless, ongoing definitive studies are required to better understand which particular factors yield the highest rates of VTE and hence warrant pharmacologic prophylaxis above standard mechanical measures. We want to acknowledge the CHAT Consortium sites who contributed to the CHAT Registry. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

S937 Venous Thromboembolism in the Setting of Inflammatory Bowel Disease: A Multi-Centric Retrospective Analysis

Introduction: Inflammatory bowel disease (IBD) is a systemic inflammatory condition with an increased risk of venous thromboembolism (VTE). The most common sites include deep veins of lower extremities and pulmonary vasculature, and rarely cerebrovascular veins which can significantly increase morbidity and mortality. While the higher incidence of VTE in IBD has been well established, standardized risk assessment models for VTE do not consider the presence of IBD as a high-risk factor. Methods: A retrospective chart review of 261 randomly selected patients with IBD over the last 5 years was performed. Patients with an incidence of VTE in the last 5 years (2017-2022) were identified. Baseline characteristics, site of VTE, use of anticoagulation for VTE prophylaxis, and anticoagulant used were collected. Descriptive statistics were used to analyze the incidence of VTE and the percentage of patients on anticoagulation. Results: The 5-year incidence of VTE in the studied 259 patients was 13.51% (35) of which 11.2% (29) had DVT, 3.5% (9) had both DVT and PE, and 2.3% (6) had only PE. The average age of the patients with VTE was 57.4 ± 12.3 years; 37% (13) were men and 63% (22) were women; 66% (23) were Caucasian, 31% (11) were African American, and 3% (1) were Pacific-islander. Of the 259 patients, 133 (51.4%) received VTE prophylaxis during hospitalizations, while 126 (48.6%) did not. Of the patients who received prophylaxis, the incidence of VTE was 4.5% (6 of 133) whereas the incidence was 23% (29 of 126) in those who did not receive VTE prophylaxis. Of the 133 patients who were on anticoagulation, 11 were on NOACs (8.3%), 38 were on heparin (28.6%), 81 were on LMWH (60.9%), and 3 were on warfarin (2.2%). Of the 6 patients who had an incidence of VTE on anticoagulation, 3 were on NOACs, 1 was on heparin, 1 was on LMWH, and 1 was on warfarin. Conclusion: Being a chronic inflammatory state, IBD is associated with a 2-3 times higher incidence of VTE. However, multiple factors exist in both the pathophysiology and treatment of the disease that may contribute to the development of VTE. Numerous factors such as surgeries, use of steroids, and gender have been implicated in increasing the risk for VTE. There is a wide scope for further research regarding the same. Despite conclusive evidence, at most centers, the presence of IBD is not considered to be a high-risk factor for VTE warranting anticoagulation. Awareness and education are the cornerstones to cause a momentous change in practice patterns.Figure 1.: Proportion of IBD patients on different anticoagulants and the incidence of VTE while on them