Received Venous Thromboembolism Prophylaxis Research Articles

Venous thromboembolism prophylaxis practice and its association with outcomes in Australia and New Zealand burns patients.

BackgroundPatients with burn injuries are considered to have an increased risk of venous thromboembolism (VTE). While untreated VTEs can be fatal, no studies have examined chemoprophylaxis effectiveness. This study aimed to quantify the variation in prevalence of VTE prophylaxis use in patients in Australian and New Zealand burns units and whether prophylaxis use is associated with in-hospital outcomes following burn injury.MethodsAdmission data for adult burns patients (aged ≥16 years) admitted between 1 July 2016 and 31 December 2018 were extracted from the Burns Registry of Australia and New Zealand. Mixed effects logistic regression modelling investigated whether VTE prophylaxis use was associated with the primary outcome of in-hospital mortality.ResultsThere were 5066 admissions over the study period. Of these patients, 81% (n = 3799) with a valid response to the VTE prophylaxis data field received some form of VTE prophylaxis. Use of VTE prophylaxis ranged from 48.6% to 94.8% of patients between units. In-hospital death was recorded in <1% of patients (n = 33). After adjusting for confounders, receiving VTE prophylaxis was associated with a decrease in the adjusted odds of in-hospital mortality (adjusted odds ratio = 0.21; 95% CI, 0.07–0.63; p = 0.006).ConclusionsVariation in the use of VTE prophylaxis was observed between the units, and prophylaxis use was associated with a decrease in the odds of mortality. These findings provide an opportunity to engage with units to further explore differences in prophylaxis use and develop future best practice guidelines.

Malfunctioning temporary hemodialysis catheters in patients with novel coronavirus disease 2019

ObjectiveThe hypercoagulability seen in patients with novel coronavirus disease 2019 (COVID-19) likely contributes to the high temporary hemodialysis catheter (THDC) malfunction rate. We aim to evaluate prophylactic measures and their association with THDC patency. MethodsA retrospective chart review of our institutions COVID-19 positive patients who required placement of a THDC between February 1 to April 30, 2020, was performed. The association between heparin locking, increased dosing of venous thromboembolism (VTE) prophylaxis and systemic anticoagulation on THDC patency was assessed. Proportional hazards modeling was used to perform a survival analysis to estimate the likelihood and timing of THDC malfunction with the three different prophylactic measures. We also determined the mortality, rate of THDC malfunction and its association with d-dimer levels. ResultsA total of 48 patients with a mortality rate of 71% were identified. THDC malfunction occurred in 31.3% of patients. Thirty-seven patients (77.1%) received heparin locking, 22 (45.8%) received systemic anticoagulation, and 38 (79.1%) received VTE prophylaxis. Overall, the rate of THDC malfunction was lower at a trend level of significance, with heparin vs saline locking (24.3% vs 54.6%; P = .058). The likelihood of THDC malfunction in the heparin locked group is lower than all other groups (hazard ratio [HR], 0.07; 95% confidence interval [CI], 0.01-0.45]; P = .005). The rate of malfunction in patients with subcutaneous heparin (SQH) 7500 U three times daily is significantly lower than of the rate for patients receiving none (HR, 0.03; 95% CI, 0.001-0.74; P = .032). A trend level significant association was found for SQH 5000 U vs none (P = .417) and SQH 7500 vs 5000 U (P = .059). Systemic anticoagulation did not affect the THDC malfunction rate (P = .240). Higher d-dimer levels were related to greater mortality (HR, 3.28; 95% CI, 1.16-9.28; P = .025), but were not significantly associated with THDC malfunction (HR, 1.79; 95% CI, 0.42, 7.71; P = .434). ConclusionsLocking THDCs with heparin is associated with a lower malfunction rate. Prospective randomized studies will be needed to confirm these findings to recommend locking THDC with heparin in patients with COVID-19. Increased VTE prophylaxis suggested a possible association with improved THDC patency, although the comparison lacked sufficient statistical power.

Incidence, Management and Outcomes of Arterial and Venous Thromboembolism after Chimeric Antigen Receptor Modified T Cells for B-Cell Lymphoma and Multiple Myeloma

Introduction: Chimeric antigen receptor modified T Cell (CAR-T) therapy is a rapidly developing treatment for patients with relapsed/refractory (R/R) B-cell non-Hodgkin lymphoma (NHL) or multiple myeloma (MM). Although this population is at high risk for thrombosis, there are few data about rates of venous thromboembolism (VTE) and arterial thromboembolism (ATE) with CAR-T. Additionally, treatment with anticoagulation is complicated because of the prevalence of thrombocytopenia following CAR-T. Our goal was to determine the incidence, associated risk factors, management and outcomes of VTE and ATE in the 60 days following CAR-T therapy. Methods: We performed a single-center, retrospective cohort study of all patients who received inpatient CAR-T cells at UCSF Medical Center between January 2018 and May 2020 for R/R NHL or MM as standard-of-care or on a clinical trial. The outcomes of incident VTE and ATE were identified by ICD-10 codes and medical record review. Patient characteristics, pre-existing thrombosis risk factors, laboratory results, medications, and major or clinically relevant non-major bleeding or recurrent thrombotic complications were obtained through chart review. We used descriptive statistics to delineate risk factors, incidence, management and outcomes of thrombotic events. Results: Ninety-one patients who underwent CAR-T therapy were included in the analysis, 37 with NHL and 54 with MM. For NHL, mean age was 63 (range 38-82), and 41% were women. For MM, mean age was 62 (range 33-77), and 50% were women. Patients with NHL were treated with either investigational or Federal Drug Administration-approved CD19-directed therapies, and patients with MM were treated with a variety of investigational B-cell maturation antigen-directed (BCMA) therapies. For thrombotic risk factors, 13% of patients with NHL had a history of VTE, 3% had a history of ATE, 27% had a BMI ≥30, 59% had a recent procedure including central venous catheter (CVC) placement, 14% had an intensive care unit (ICU) stay, and 22% had an infectious complication in the 30 days pre- or post-CAR-T. Forty-one percent of patients with NHL had neurotoxicity of any grade, and 59% had CRS of any grade. At 30 days, 57% had a complete response, 41% had a partial response, 3% had stable disease. For MM, 6% of patients had a pre-existing history of VTE, 2% had a history of ATE, 19% had a BMI ≥30, 96% had a recent procedure, 11% had an ICU stay and 19% had an infection. Seventeen percent had neurotoxicity, and 85% had CRS. Thirty-two percent of patients with NHL and 48% with MM received pharmacologic VTE prophylaxis while undergoing CAR-T. For those who did not receive VTE prophylaxis, thrombocytopenia was the reason for holding prophylaxis, which occurred in 51% and 50% of NHL and MM patients, respectively. In the 60 days post-CAR-T, 4 (11%) patients with NHL were diagnosed with VTE-3 pulmonary embolism (PE) and 1 lower extremity deep vein thrombosis (DVT) associated with a previously placed inferior vena cava filter. Four (7%) patients with MM were diagnosed with VTE-1 PE and 3 upper extremity DVTs associated with CVCs. Five out of these 8 (63%) patients had symptomatic VTE, while the remainder were incidental on PETCT. Mean time from CAR-T infusion to VTE diagnosis was 20 days (range 6-39 days). There were no documented ATEs. Six out of 8 (75%) were treated with therapeutic anticoagulation. Of those who were anticoagulated, 4 patients received direct oral anticoagulants and 2 received low-molecular-weight-heparin. Duration was 3 months in 3 patients, 11 days in 1, 150 days in 1, and indefinitely in 1 with atrial fibrillation. Among all 8 patients with VTE, there were no bleeding events or recurrent thromboses regardless of whether or not they received anticoagulation. Discussion: In this cohort of patients with R/R NHL or MM who received either CD19- or BCMA-directed therapies, almost 1 in 10 developed VTE in the 60 days post-CAR-T. This occurred in the context of a high prevalence of risk factors for thrombosis and low rates of pharmacologic prophylaxis. Among those who developed VTE, the majority were treated with therapeutic anticoagulation for at least 3 months, without documented bleeding or recurrent VTE. Our findings provide crucial information on a common complication that can inform patients, clinicians and researchers and should be expanded upon in larger, prospective studies to identify optimal preventive and therapeutic strategies. Disclosures Fakhri: University of California San Francisco: Current Employment. Andreadis:Jazz Pharmaceuticals: Honoraria; Karyopharm: Honoraria; Incyte: Consultancy; Merck: Research Funding; Gilead/Kite: Consultancy; Novartis: Research Funding; BMS/Celgene/Juno: Honoraria, Research Funding; Genentech: Consultancy, Current equity holder in publicly-traded company. Wong:Janssen: Research Funding; Amgen: Consultancy; Roche: Research Funding; Fortis: Research Funding; Sanofi: Membership on an entity's Board of Directors or advisory committees; Bristol Myers Squibb: Research Funding; GSK: Research Funding. Shah:BMS, Janssen, Bluebird Bio, Sutro Biopharma, Teneobio, Poseida, Nektar: Research Funding; GSK, Amgen, Indapta Therapeutics, Sanofi, BMS, CareDx, Kite, Karyopharm: Consultancy.

Inflammatory Bowel Disease Therapy and Venous Thromboembolism.

To explore the relationship between IBD (inflammatory bowel diseases) therapy and VTE (venous thromboembolism) risk, as well as the safety, barriers, and utility of VTE prophylaxis. In 2019, the Food and Drug Administration (FDA) issued a black box warning concerning the use of tofacitinib among ulcerative colitis (UC) patients with a post hoc analysis revealing that all patients had additional risk factors for VTE. Additionally, although IBD patients experiencing a disease flare often present with hematochezia, these patients are less likely to receive VTE prophylaxis, despite data showing that pharmacologic prophylaxis has not been associated with clinically significant signs of bleeding. Among IBD patients, corticosteroid use has been associated with an increased risk of VTE, whereas anti-TNF therapy does not appear to increase this risk. High-dose tofacitinib has also been shown to increase the likelihood of VTE in patients with additional risk factors. In order to prevent future VTE events, pharmacologic thromboprophylaxis should be emphasized, particularly in hospitalized IBD patients, with recent data suggesting that a select population at risk may benefit from continued prophylaxis.

Trends in venous thromboembolism prophylaxis in gynecologic surgery for benign and malignant indications.

Venous thromboembolism (VTE) is a leading cause of perioperative morbidity and mortality. We analyzed the trends in use of VTE prophylaxis over time in women undergoing hysterectomy for both benign and malignant indications. The Premier Database was used to identify women who underwent hysterectomy from 2011 to 2017. Women were stratified by indication for surgery (benign or malignant) and route of hysterectomy. VTE prophylaxis was classified as none, mechanical, pharmacologic, or combination (mechanical and pharmacologic). Trends in use of prophylaxis over time were analyzed. Multivariate models were developed to examine predictors of use of prophylaxis. Among 920,477 patients identified, 579,824 (63.0%) received VTE prophylaxis, including 15.4% who received pharmacologic, 34.5% who received mechanical, and 13.1% who received combination prophylaxis. Overall use of prophylaxis declined annually from 68.1% in 2011 to 56.7% in 2017 (P < 0.001). Among patients with cancer, the use of prophylaxis declined from 84.5% in 2011 to 78.6% in 2017 (P < 0.001). A similar trend was noted among women with benign conditions, with rates of prophylaxis declining from 66.2 to 53.3% (P < 0.001). Additionally, use of prophylaxis declined for patients undergoing MIS hysterectomy from 65.4% in 2011 to 53.3% in 2017, and from 73.1 to 66.7% in patients who underwent abdominal hysterectomy. Among patients with cancer, rates of pharmacologic and combined prophylaxis was 70.9% in 2011 and 69.7% in 2017. However, among women with benign conditions, the rates of pharmacologic and combined prophylaxis rose from 19.4% in 2011 to 25.6% in 2017 (P < 0.001). Despite these changes in prophylaxis rates and methods, there was no significant change in the rate of VTE between 2011 and 2017 (P = 0.06). Despite the lack of change in guidelines for VTE prophylaxis in gynecologic surgery, the overall rates of prophylaxis decreased over time independent of the indication or route of surgery. The rates of thromboembolic events did not significantly increase in response to the decreased use of VTE prophylaxis.

Early Chemoprophylaxis in Severely Injured Trauma Patients Reduces Risk of Venous Thromboembolism.

Venous thromboembolism (VTE) remains a serious complication for trauma patients. While early VTE prophylaxis has gained traction, the timing of prophylaxis remains uncertain. We hypothesized that VTE prophylaxis within 24 hours of admission would have lower VTE rates and similar rates of adverse events in seriously injured patients. Trauma patients were included from 32 American College of Surgeons verified Level 1 and 2 trauma centers over a 10-year period. Patients with injury severity score (ISS) <15, death or discharge within 48 hours of arrival, or who received no prophylaxis were excluded. 14 096 patients received VTE prophylaxis with an ISS of ≥15. Patients given prophylaxis at <24 hours had fewer VTE events and trended toward fewer serious in-hospital complications. Mortality and return to the operating room were similar across groups. Hospital and intensive care unit length of stay in the <24 hours prophylaxis group was significantly shorter when VTE prophylaxis was initiated earlier. In severely injured trauma patients with ISS >15, early VTE prophylaxis within 24 hours significantly reduced the risk of VTE as compared with delayed prophylaxis. Early chemoprophylaxis was found to be efficacious in reducing the incidence of VTE; however, the safety of this practice should be evaluated by future prospective studies.

Venous thromboembolism (VTE) risk stratification in general medical patients at an academic medical center.

Hospital-acquired venous thromboembolism (VTE) is still a concern for general medical patients. Pharmacologic prophylaxis can reduce VTE incidence, but there is the potential for adverse effects. Therefore, determining which patients should receive VTE prophylaxis via risk scoring tools is essential. Limited evidence exists for the ideal venous thromboembolism risk assessment model (RAM) in hospitalized medical patients, as compared to other hospitalized patient subgroups such as surgical patients. The primary objective was to investigate the utilization and appropriateness of our institution-based VTE RAM and comparison to the Padua Prediction Score (PPS). This would allow for a gauge of provider risk assessment accuracy as well as appropriate predictive potential of the PPS or whether an alternative to the PPS should be considered. A total of 330 adult general medicine patients were included in this retrospective chart review. When compared to our institution-based VTE RAM, providers predominately stratified patients at a higher VTE risk than the institution-based VTE RAM. VTE incidence was 0.3%, which was lower than predicted. Significant discordance exists between providers' VTE risk assessment and that predicted by RAMs. Our institution-based VTE RAM appears comparable to PPS; however, it was not being utilized by providers, resulting in potentially unnecessary use of pharmacologic prophylaxis. The most appropriate venous thromboembolism risk assessment model for general medicine patients is undetermined. Our providers generally assess patients as moderate or high VTE risk, despite our institution-based RAM which typically recommends a lower risk category than provider selection. Because of provider risk assessment, more patients received pharmacologic VTE prophylaxis than would have been recommended by the RAM, which might correlate to the low incidence of VTE which was<0.5%, although bleeding complications were not assessed in this study. A prospective study utilizing the Padua Prediction Score (or similar RAM) in general medicine patients is warranted in order to decipher the best method of predicting VTE risk.

COVID‐19 associated coagulopathy and thromboembolic disease: Commentary on an interim expert guidance

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) is the causative pathogen of a new infectious disease, COVID-19, that first occurred in late December 2019 in the city of Wuhan in Hubei Province, China. It has since spread globally, resulting in a WHO declared pandemic, with as yet (17/4/20) more than two million confirmed cases and about 150.000 confirmed deaths. As for every new disease, clinicians, hospitals and governments struggle to find optimal clinical and public health measures to contain its spread and burden. For this, information from scientific research is crucial and fortunately we see a rapidly accumulating output of studies.

Effect of prophylactic anticoagulation on incidence of venous thromboembolism in testicular germ cell tumor patients.

422 Background: Testicular germ cell tumors (GCTs) are among the most common solid tumors in young males. With the availability of highly effective treatment, improving patients’ quality of life has gained more focus in recent years. Venous thromboembolism (VTE), commonly occurring in GCT patients, is associated with increased morbidity and mortality. Prophylactic anticoagulation has been shown to decrease the risk of VTE in cancer patients. In this retrospective study we evaluated the effect of low molecular weight heparin (LMWH) prophylaxis during hospitalization on incidence of VTE and outcome in GCT patients treated with first-line chemotherapy. Methods: Study population included 394 chemotherapy-naive GCT patients treated with first-line chemotherapy at the National Cancer Institute, Bratislava, Slovakia from January 2000 to December 2017. VTE was defined as any venous thrombosis or pulmonary embolism, confirmed by imaging, occurring during first-line chemotherapy. No visceral thromboses were observed. Results: Forty-one out of 394 patients (10.4%) were diagnosed with VTE on initial staging and were excluded from the analysis. Final cohort included 353 patients. LMWH prophylaxis was administered to 104 patients (29.5%), 249 patients (70.5%) did not receive prophylaxis. We observed 14 (4.0%) VTE events. The difference in VTE incidence between patients with and without prophylaxis was not statistically significant (5.8% vs. 3.2% p = 0.37). We have observed a trend to longer overall survival in patients without prophylaxis (HR = 0.61, 95%CI = 0.32-1.13, p = 0.08). Patients with extragonadal GCT receiving VTE prophylaxis had significantly shorter survival compared to patients without prophylaxis (HR = 0.29, 95%CI = 0.08-1.12, p = 0.04). Conclusions: LMWH prophylaxis was not associated with decreased VTE incidence. Moreover, it was associated with shorter survival in extragonadal GCTs. Taking into account these data, LMWH prophylaxis during hospitalization should not be used in GCT patients receiving chemotherapy.

Prophylaxis for Pediatric Venous Thromboembolism: Current Status and Changes Across Pediatric Orthopaedic Society of North America From 2011.

Pediatric venous thromboembolism (VTE) is a concern for orthopaedic surgeons. We sought to query the Pediatric Orthopaedic Society of North America (POSNA) members on current VTE prophylaxis practice and compare those results with those of a previous survey (2011). A 35-question survey was emailed to all active and candidate POSNA members. The survey consisted of questions on personal and practice demographics; knowledge and implementation of various VTE prophylaxis protocols, mechanical and chemical VTE prophylaxis agents, and risk factors; and utilization of scenarios VTE prophylaxis agents for various clinical scenarios. One- and two-way frequency tables were constructed comparing results from the current survey and those of the 2011 survey. Two hundred thirty-nine surveys were completed (18% respondent rate), with most respondents from an academic/university practice reporting one or two partners (>60%). Half were in practice ≥15 years, and >90% reported an almost exclusive pediatric practice. One-third of the respondents reported familiarity with their institution-defined VTE prophylaxis protocol, and 20% were aware of an institutionally driven age at which all patients receive VTE prophylaxis. The most frequently recognized risk factors to guide VTE prophylaxis were oral contraceptive use, positive family history, and obesity. Respondents indicated a similar frequency of use of a VTE prophylaxis agent (either mechanical or chemical) for spinal fusion, hip reconstruction, and trauma (60% to 65%), with lower frequency for neuromuscular surgery (34%) (P < 0.001). One hundred thirty-seven respondents had a patient sustain a deep vein thrombosis, and 66 had a patient sustain a pulmonary embolism. Compared with responses from 2011, only 20 more respondents reported familiarity with their institution VTE prophylaxis protocol (75 versus 55). In 2018, aspirin was used more frequently than in 2011 (52% versus 19%; P < 0.0001) and enoxaparin was used less frequently (20% versus 41%; P < 0.0001). Over the past 7 years since the first POSNA survey on VTE prophylaxis, most POSNA members are still unaware of their institution specific VTE prophylaxis protocol. Most respondents agree that either mechanical or chemical VTE prophylaxis should be used for spinal fusion, hip reconstruction, and trauma. The use of aspirin as an agent of chemical VTE prophylaxis has increased since 2011. Level IV. Type of evidence: therapeutic.

Overuse of venous thromboembolism prophylaxis among hospitalized patients with liver disease.

Patients with liver disease are at risk of venous thromboembolism (VTE); however, little is understood regarding the safety and efficacy of VTE prophylaxis in patients with cirrhosis. We examined the application of a VTE risk assessment model in VTE prophylaxis decision-making in a closed cohort of hospitalized patients with liver disease. Sequential patients admitted to an inpatient hepatology service at a tertiary care center were evaluated for need for VTE prophylaxis. Risk assessment by IMPROVE was compared with current practice patterns of VTE prophylaxis. Rates of bleeding and clotting events were noted. 98 patient encounters were included in our analysis. 76% of patients received VTE prophylaxis in practice. IMPROVE recommended use of VTE prophylaxis in 19% of patients. Patients who received VTE prophylaxis that was not warranted had significantly lower risk of clotting compared with patients in whom VTE prophylaxis was warranted per IMPROVE. Application of IMPROVE risk assessment would significantly reduce VTE prophylaxis use among hospitalized patients with liver disease. Our findings challenge the "one-size-fits-all" current practice pattern of VTE prophylaxis. Future studies are needed in large cohorts of hospitalized patients with liver disease that include clinical outcomes of bleeding and clotting risk.

Venous thromboembolism prophylaxis and the impact of a thrombosis service at a Canadian level 1 trauma centre

Venous thromboembolism (VTE) is a common and serious complication seen in patients with trauma. Guidelines recommend the routine use of pharmacologic prophylaxis; however, compliance rates vary widely. The aim of this study was to describe the clinical practice related to VTE prophylaxis in the first 24 hours after injury at our level 1 Canadian trauma centre and the impact of a thrombosis consultation service. We performed a retrospective review of the health records of adult patients with trauma admitted between Jan. 1, 2012, and June 30, 2013. The rate of VTE was ascertained. The use of an initial prophylactic regimen, potential contraindications to prophylaxis and involvement of the thrombosis service were determined. A total of 633 patients were included, 459 men and 174 women with a mean age of 47.4 years. The mean Injury Severity Score was 15.8. The overall VTE rate was 2.8%. A total of 514 patients (81.2%) received VTE prophylaxis, mechanical in 302 (47.7%) and pharmacologic in 231 (36.5%) (19 patients received both types). The thrombosis service was involved in the care of 164 patients (25.9%). Patients seen by the thrombosis service were more likely to receive VTE prophylaxis than those not seen by the service (145 [88.4%] v. 369 [78.7%], p < 0.01). Compliance with VTE prophylaxis administration was suboptimal, and opportunities for improvement exist. The involvement of a thrombosis consultation service appears to improve compliance with VTE prophylaxis, and augmented use of this service may improve clinical outcomes.

A Retrospective Review of Hospital-Acquired Venous Thromboembolism at a Large Pediatric Tertiary Care Center

Introduction: The incidence of venous thromboembolism (VTE) in hospitalized pediatric patients is increasing secondary to the growing medical complexity of pediatric patients and the increasing use of central venous catheters. Pediatric patients diagnosed with VTE have up to 2% mortality associated directly with their thromboses. While incidence, risk factor identification and preventive strategies are well established in hospitalized adults, this information is limited in the pediatric population. There are currently no standardized VTE risk screening tools or thromboprophylaxis guidelines for children at Duke Children's Hospital. The incidence of hospital acquired VTE (HA-VTE), as well as their associated risk factors were investigated in a retrospective review. Methods: Medical records of pediatric patients hospitalized at Duke Children's Hospital during June 2018 through November 2018 were reviewed. The EPIC SlicerDicer tool was used to identify patients with ICD-10 diagnoses codes related to thrombosis or treated with anticoagulants. Included patients were diagnosed with HA-VTE during their hospitalization or within 14 days of discharge. Data collected included demographics, thrombosis characteristics, family history, mobility, and acute or chronic co-morbid conditions. The characteristics of the study population were described by median (with 25th and 75th percentiles) for continuous variables and frequencies (with percentages) for binary or categorical variables. Results: Out of 4,176 total pediatric admissions to all units of Duke Children's Hospital (ages 0-18.99 years) during the inclusion timeframe, 33 VTE events were identified. The incidence of VTE events per 1000 patient days was 0.98. The complete patient and VTE event characteristics are listed in Tables 1 and 2. The median age of patients with VTE events was 0.4 years. Of the identified cohort, 73% had an associated central venous line (CVL). Neonates with congenital cardiac disease comprised the majority of the cohort. Other common patient characteristics observed in this cohort included impaired mobility, recent major surgery, and recent mechanical ventilation. Of the 33 VTE diagnoses, 70% received therapeutic anticoagulation with enoxaparin or unfractionated heparin. Only 2 patients (8%) received prophylactic anticoagulation prior to their diagnosis of VTE. Conclusions: The retrospective review of HA-VTE events at Duke Children's Hospital identified that the majority of the events occurred in neonates with congenital cardiac disease and the presence of CVLs. It was also noted that there was no standardization among the use of anticoagulation agents that were initiated for treatment of VTE. Furthermore, few patients received VTE prophylaxis during the hospitalization. A limitation of this review was that it was retrospective and the documentation of family history of thrombosis was inconsistent. It is also possible that several VTE events were missed due to inadequate ICD-10 coding. Based on the results of this review, there is a need to implement a risk stratification tool and develop standardized recommendations of VTE prophylaxis and treatments for pediatric patients admitted to Duke Children's Hospital. There is an additional quality improvement phase of this project and the goal is to implement a risk calculator that is based on information learned from the retrospective review. Ultimately, this risk calculator will help to decrease the incidence of VTE events at Duke Children's Hospital. Disclosures Rothman: Agios: Honoraria, Research Funding; Pfizer: Consultancy, Honoraria, Research Funding; Novartis: Honoraria, Research Funding.

A Survey of Venous Thromboembolism (VTE) Prophylaxis in Obstetrics Patients in Iran

Objective: The purpose of the present study was a survey of venous thromboembolism (VTE) prophylaxis in obstetrics patients in Iran. Materials and methods: A national, multicenter, non-interventional, prospective study was performed on 1000 women at 11 different parts of Iran. Primary outcome was to assess the situation of VTE prophylaxis in pregnant and postpartum women and the secondary outcome was risk stratification in obstetrics patients and to evaluate the guideline adherence in physician's practice of VTE prophylaxis. Results: 1,036 women entered the final analysis. The three main VTE risk factors before hospitalization were BMI > 30 kg/m2, history of oral contraceptive (OCP) use, and the age over 35.VTE risk factors upon enrollment were detected in 780 (75.28%) patients. 219 women (28.07%) were deemed eligible for drug prophylaxis, however, only 37 women (17%) received it. A total of 113 (10.9%) patients received VTE prophylaxis, of which 76 (67.25%) women had no clear indications. Concordance between theory and practice was detected with a Cohen's Kappa coefficient to be 0.74 (p < 0.001), which fell within "good agreement". Multivariate analysis for association between VTE prophylaxis and VTE risk factors showed that history of VTE [OR = 9.06 (CI 95% 1.16 - 70.8) p = 0.036] was the most frequent risk factor for receiving VTE prophylaxis followed by obesity (BMI > 30 Kg/m2); [OR = 3.74 (CI 95% 1.79 - 5.69), p = <0.001], multiple pregnancy [OR= 2.81 (CI 95% 1.70 - 4.64), p = < 0.001] and age > 35 years; [OR =1.09 (CI 95% 0.82 - 1.21), p = 0.026]. Varicose Veins [OR= 0.22 (CI 95% 0.56 - 0.87), p = 0.031], PROM / PPROM [OR= 0.33 (CI 95% 0.12 - 0.91), p = 0.032] and history of using OCP [OR= 0.36 (CI 95% 0.24 - 0.53), p = < 0.001] were the most missed risk factors for receiving VTE prophylaxis respectively. Conclusion: History of VTE, obesity, multiple pregnancy and age > 35 years were the most frequent risk factors for receiving VTE prophylaxis and varicose veins, PROM / PPROM and history of using OCP were the most missed risk factors for receiving VTE prophylaxis.

992 Venous Thromboembolism Prophylaxis in Hospitalized Patients With Chronic Liver Disease and the Bleeding and Thrombosis Risk: A Systematic Review and Meta-Analysis

INTRODUCTION: Patients with chronic liver disease, especially cirrhosis have an increased risk in both venous thromboembolism (VTE) and bleeding. Most of hospitalized chronic liver disease patients, however, were not given the VTE prophylaxis during admission. METHODS: A systematic search was conducted for studies published up to May 2019 using MEDLINE, EMBASE, and Cochrane Library. We included cohort studies of patients with chronic liver disease who were hospitalized for ≥48 hours which compared patients with and without VTE prophylaxis. Study quality was assessed using Newcastle-Ottawa scale (NOS). A random-effects model was used to determine relative risk (RR) with 95% confidence interval (CI) for bleeding and thrombotic events. RESULTS: After screening 2462 abstracts, 188 potentially studies were assessed. Seven retrospective cohorts met the criteria and were included in this meta-analysis. Only one study matched intervention group and controls and was done with propensity score. In total, there were 1,855 patients who received VTE prophylaxis and 2,915 patients who did not receive VTE prophylaxis. Regarding bleeding events, there were 76 patients (4.0%) and 231 patients (7.9%) in prophylaxis and no prophylaxis group, respectively. There was no increase of bleeding event in the VTE prophylaxis compared to the no-VTE prophylaxis group with pulled RR of 0.70 (0.30–1.64, I2 = 87%). Regarding thrombosis risk, there were 34 patients (1.8%) and 68 patients (2.3%) in prophylaxis and no prophylaxis group, respectively. There was no increase of thrombosis event in the VTE prophylaxis compared to the no-VTE prophylaxis group with pulled RR of 0.76 (0.44-1.31, I2 = 17%). When included only patients with INR ≥ 1.4 or with cirrhosis, the RR of patients with VTE prophylaxis for bleeding was 0.73 (0.31–1.69, I2 = 74%) and thrombosis was 1.13 (0.67–1.92, I2 = 0%). CONCLUSION: This meta-analysis found no difference of bleeding and thrombosis events between chronic liver disease patients with and without VTE prophylaxis. The similar results were seen with subgroup analysis of patients with elevated INR or cirrhosis. However, with limitation of retrospective study, the patients who received prophylaxis tended to have less advanced liver disease, which potentially had less risk of bleeding and risk of thrombosis. Further study with liver disease staging and coagulopathy risk matched for intervention and control groups is warranted.

A 10-year Retrospective Case-Series of Venous Thrombo-Embolism frequency in Patients Treated with Total Contact Casts

Category:DiabetesIntroduction/Purpose:Venous Thrombo-Embolism (VTE) is a recognized complication of lower limb immobilization. In the neuropathic patient total contact casting (TCC) is used in the management of acute charcot neuroathropathy and/or to off-load neuropathic ulcers. To our knowledge, there is currently no literature stating the prevalence of VTE in patients, despite the possibility of prolonged lower limb immobilization. There are also no recommendations regarding VTE prophylaxis in the setting of TCCs. We report a retrospective case series assessing the frequency of symptomatic VTE in the patients treated with TCCs. Given that diabetic foot disease manifests as one of many co-morbidities in this medically complex group of patients we hypothesize that the rate of occurrence of VTE should be higher than that of the general population.Methods:Patients undergoing TCC between 2006 and 2018 were identified using plaster room records. These patients subsequently had electronic clinical letters and radiological reports assessed for details around the TCC episode, past medical history and any VTE events.Results:There were 143 TCC episodes in 105 patients. Average age at cast application was 55 years. The mean time in a cast was 45 days (range from 5 days to 8 months). 3 out of 4 patients had neuropathy as a consequence of diabetes. One TCC related VTE (0.7% of casting episodes) was documented. This was a proximal DVT confirmed on USS 9 days following cast removal. Only 3 patients received VTE prophylaxis while in TCC.Conclusion:Despite these complex patients having a multitude of co-morbidities the frequency of VTE in the TCC setting remains similar to that of the general population. This may be due to the fact that TCCs permit weight bearing or that Charcot arthropathy leads to a high outflow state, potentially turning Virchow’s triad in the patient’s favour. This case series suggests that, while all patients should be individually VTE risk assessed as for any lower limb immobilization, chemical thromboprophylaxis is not routinely indicated in the context of TCCs.

Use of Prophylaxis for Prevention of Venous Thromboembolism in Patients with Isolated Foot or Ankle Surgery: A Systematic Review and Meta-Analysis.

Although prophylaxis for venous thromboembolism (VTE) is recommended after many surgeries, evidence base for use of VTE prophylaxis after foot or ankle surgery has been elusive, leading into varying guidelines recommendations and notable practice variations. We conducted a systematic review of the literature to determine if use of VTE prophylaxis decreased the frequency of subsequent VTE, including deep vein thrombosis (DVT) or pulmonary embolism (PE), compared with control. We searched PubMed, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov through May 2018, for randomized controlled trials (RCTs) or prospective controlled observational studies of VTE prophylaxis in patients undergoing foot and ankle surgery. Our search retrieved 263 studies, of which 6 were finally included comprising 1,600 patients. Patients receiving VTE prophylaxis had lower risk for subsequent DVT (risk ratio [RR]: 0.72; 95% confidence interval [CI]: 0.55-0.94) and subsequent VTE (RR: 0.72; 95% CI: 0.55-0.94). There was only one case of nonfatal PE, no cases of fatal PE, and no change in all-cause mortality (RR: 3.51; 95% CI: 0.14-84.84). There was no significant difference in the risk for bleeding (RR: 2.12; 95% CI: 0.53-8.56). Very few RCTs exist regarding the efficacy and safety of VTE prophylaxis in foot and ankle surgery. Prophylaxis appears to reduce the risk of subsequent VTE, but the event rates are low and symptomatic events are rare. Future studies should determine the subgroups of patients undergoing foot or ankle surgery in whom prophylaxis may be most useful.

Description of anti-Xa monitoring practices during low molecular weight heparin use.

Certain patient populations (pregnancy, cancer, renal impairment, and obesity) may be at higher risk of adverse events during low molecular weight heparin (LMWH) therapy and may benefit from anti-Xa monitoring. Yet, evidence supporting a standardized approach to anti-Xa monitoring correlated to clinical outcomes is lacking. Patients with at least one documented anti-Xa level and receiving LMWH within a 6-month period were identified. In a 6-month period, 224 adult LMWH patients with 359 anti-Xa levels were identified. Anti-Xa monitoring was most commonly performed in patients with active cancer receiving venous thromboembolism (VTE) treatment doses (57.4%) or obese patients receiving VTE prophylaxis (48.1%). Anti-Xa monitoring during renal impairment and pregnancy were infrequent (0.9% and 1.8%, respectively). Most (71.9%) anti-Xa levels were therapeutic, but only 45% were drawn correctly in relation to LMWH administration time. Compared to those with therapeutic anti-Xa levels, patients with out-of-range levels were four times as likely to receive a LMWH therapy change (odds ratio, 4.16; 95% confidence interval, 2.53-6.84). However, when levels were supratherapeutic or subtherapeutic, the LMWH doses remained unchanged in one-third to one-half of patients, respectively. Anti-Xa monitoring was most commonly performed in patients with cancer or obesity and was more common with VTE prophylaxis dosing. The majority of levels were therapeutic, indicating that anti-Xa monitoring may be unnecessary even in high-risk patient populations. Many out-of-range anti-Xa levels did not prompt a change in LMWH therapy. Further research is still needed to determine if anti-Xa- guided LMWH dosing improves clinical outcomes.

Reassessment of venous thromboembolism and bleeding risk in medical patients receiving VTE prophylaxis

The majority of hospitalized nonsurgical medical patients receive pharmacological prophylaxis for venous thromboembolism (VTE), and reassessment of changes in thrombosis and bleeding risk factors during hospital admission may represent an opportunity to discontinue unnecessary or unsafe therapy. The use of validated, clinically derived risk assessment models (RAMs) represents a shift towards an individualized, patient-centred approach to VTE prophylaxis. We are interested in using these tools to assess whether risk categories for VTE and bleeding change during admission and to assess whether such changes result in discontinuation of prophylaxis. Our primary objective was to determine whether VTE and bleed risk categories changed during the course of admission to warrant discontinuation of VTE prophylaxis, using the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) VTE and Bleed RAMs, respectively. Secondary objectives were to determine the number of patients whose risk categorizations for VTE and bleeding warranted discontinuation of VTE prophylaxis and to survey whether prophylaxis was continued or discontinued. A retrospective review was undertaken for a cross-sectional, randomly selected sample of patients who received VTE prophylaxis while admitted to medical wards in a collection of regional hospitals. Of the 351 medical records reviewed, only eight patients (2.3%) changed their VTE risk category and six (1.7%) changed their bleed risk category to warrant discontinuation of VTE prophylaxis. Ninety patients (26%) were at high risk of VTE and low risk of bleed throughout admission, warranting continued VTE prophylaxis. The majority of patients remained at low risk of VTE throughout admission but remained on VTE prophylaxis until discharge. Risk categories for VTE and bleeding for medical patients did not appreciably change throughout hospital admission. Use of VTE RAMs at admission and prior to initiation of therapy should reduce unnecessary prophylaxis in the majority of medical patients who are at low risk of VTE.

Reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism in medical inpatients

Venous thromboembolism (VTE), consisting of deep venous thrombosis (DVT) and pulmonary embolism (PE), is a common, potentially preventable and sometimes fatal illness complicating hospitalisation. Although the case incidence rate is higher in surgical patients, medical patients are probably responsible for up to 75% of hospital-acquired VTE defined as VTE occurring within 90 days of a period of hospitalisation. The Department of Health in 2010 mandated VTE risk assessment for all hospital admissions, and the implementation of this was initially assisted through a national CQUIN (Commissioning for Quality and Innovation). As a consequence, it is likely that many more medical admissions now receive prophylaxis than in the past, although data on the outcome of risk assessment and the use of chemical thromboprophylaxis in general medical inpatients in the NHS is not collected or published. The treatment of clinically diagnosed VTE is well established, with increasing use of outpatient management.1 By contrast, there is uncertainty around which medical patients should receive VTE prophylaxis, with which agent, at what dosage and for how long. The recent National Institute for Health and Care Excellence (NICE) guideline update NG892 reviewed the evidence and made recommendations for all inpatients over 16. This concise guideline focuses on recommendations relevant to medical inpatients.