Use Of Deep Vein Thrombosis Prophylaxis Research Articles

A316 ACUTE NECROTIZING PANCREATITIS COMPLICATED BY PULMONARY EMBOLISM: A CASE REPORT AND REVIEW OF LITERATURE

Abstract Background Acute pancreatitis (AP) is an inflammatory condition associated with local and systemic complications. Severe pancreatitis can include the development of peripancreatic fluid collections and necrotizing pancreatitis (NP). Vascular complications are one of the causes of morbidity and mortality in patients with AP. Splanchnic thrombosis has been well described in AP and can been seen in up to 24% of patients. Extra splanchnic vessel thrombosis, including pulmonary embolism (PE), is rare. Aims Describe a case of acute NP with peripancreatic fluid collection complicated with bilateral PE and review the relevant literature. Methods We performed a literature review for AP complicated by PE. Results Case: A 60-year-old man presented to the hospital with one day of abdominal pain, nausea and vomiting. His medical history was significant for obesity with a BMI of 40. He was not on any medications. He did not drink alcohol. On exam his heart rate was 58, blood pressure 149/94 mmHG, oxygen saturation was 95% on room air, he was afebrile. His abdomen was tender in the epigastric region. His labs revealed a white blood cell count of 14 x 109/L, lipase ampersand:003E 3,000 U/L, Bilirubin 40 umol/ L, AST 613 U/L, ALT 527 U/L, GGT 394 U/L, ALP 94 U/L, Creatinine 159 mmol/L. CT abdomen/pelvis revealed cholelithiasis without choledocholithiasis or biliary dilation. The pancreas was inflammed with necrosis throughout. There were two peripancreatic fluid collections (60mm x 41mm, and 148mm x 89mm). He was diagnosed with acute necrotizing pancreatitis thought secondary to gallstones. He was fluid resuscitated, started on antibiotics and unfractionated heparin (UFH) for deep vein thrombosis (DVT) prophylaxis. His oral intake remained low. Imaging on day 30 showed a large walled off necrotic collection (25cm x15cm). Vascular strucutres were patent. On day 36 he underwent endoscopic ultrasound guided drainage via lumen-apposing metal stent (LAMS). On day 43 he developed new tachycardia. CT chest revealed bilateral pulmonary emboli (Image 1). Doppler ultrasound revealed bilateral occlusive thrombus in the calf veins. He was treated with therapeutic UFH. Literature review: We identified 10 case reports describing AP complicated by PE. The age amonst reports was variable (21 to 68). 4 cases reported additional thrombosis outside of the pulmonary vasculature. No cases which described splanchnic venous thrombosis prior. 3 cases reported pancreatic necrosis. The use of DVT prophylaxis was not reported. There is one case of PE 2 days after LAMS insertion in a patient with known thromboembolic disease. Conclusions PE is a rare complication of AP. Novel to this case was the recent deployment of a LAMS, the significance of which is unknown to date. Improved documentation of variables in future reports is needed to further characterize this event. Image 1: Acute Pulmonary Embolism. Funding Agencies None

The epidemiology of early deep vein thrombosis in kidney transplant recipients.

Because kidney transplant recipients may be at increased risk for deep vein thrombosis (DVT) following transplantation, we investigated the incidence, risk factors, treatments and outcomes of early DVT among kidney transplant recipients. An observational, single-centre cohort study was conducted among adult kidney transplant recipients from Jan. 1, 2005, to Dec. 31, 2016 with 1-year followup. Time to DVT was assessed using the Kaplan-Meier method. Cox proportional hazards and linear regression models were used to analyze risk factors for and outcomes of DVT. The cumulative incidence of DVT was 4.25% at 3 months after transplant. In multivariable analysis, the use of depleting induction agents (hazard ratio [HR] 2.13, 95% confidence interval [CI] 1.05-4.35]), white recipient race (HR 1.84. 95% CI 1.08-3.12), the use of kidneys from expanded criteria donors (HR 2.13, 95% CI 1.05-4.32) and lower recipient body mass index (HR 0.95, 95% CI 0.91-1.00) increased the risk for early DVT. Peritransplant DVT prophylaxis was not associated with early DVT. Early DVT was not associated with reduced graft function, death, graft failure or first hospital readmission. Risk factors for early DVT in our cohort of kidney transplant recipients included white recipient race, use of depleting agents, lower recipient body mass index and use of expanded criteria donors. As practice patterns of donor and recipient selection in kidney transplantation evolve, the results of this study may aid in perioperative risk assessments and decision-making about the use of DVT prophylaxis.

The rational use of thromboprophylaxis therapy in hospitalized patients and the perspectives of health care providers in Northern Cyprus

Despite the presence of effective strategies and standard guidelines for the prevention of deep vein thrombosis (DVT), a considerable proportion of patients at risk of developing thromboembolism did not receive prophylaxis during hospitalization, while others received it irrationally, thus led to unwanted side effects. This study aimed to evaluate the current thromboprophylaxis practice and management of hospitalized patients at risk of developing DVT, along with the assessment of health care providers (HCPs) knowledge, and attitudes regarding DVT prevention. An observational study was conducted in the general wards of two leading tertiary university hospitals in Northern Cyprus in which patients from multiple clinics were enrolled to investigate the rational use of DVT prophylaxis using the Caprini risk assessment tool. Patients were also followed for possible complications two weeks post-hospitalization. A cross-sectional study followed to assess the knowledge and attitude of HCPs regarding DVT risks and prophylaxis. Of the 180 patients enrolled, 47.7% were identified as irrationally managed, 52.3% were identified as rationally managed, 77.8% of patients were identified as having a high level of risk. Notably, Four of thirteen patients who received more thromboprophylaxis developed minor complications. Additionally, 73.3% of nurses had not received DVT education. Furthermore, more than 50% of physicians and nurses achieved a low knowledge score for DVT risks and prophylaxis. A high degree of irrationality in the administration of thromboprophylaxis therapy to hospitalized patients was observed. The overall scores for HCPs indicated insufficient knowledge of DVT risk assessments and prophylaxis.

Current Delivery of Hyperthermic Intraperitoneal Chemotherapy with Cytoreductive Surgery (CS/HIPEC) and Perioperative Practices: An International Survey of High-Volume Surgeons.

Cytoreductive surgery and heated intraperitoneal chemotherapy (CS/HIPEC) is performed for selected indications at a limited number of specialized centers worldwide. Currently there is no standardized approach to the perioperative care process. We sought to capture current practices in the perioperative management of patients who undergo CS/HIPEC at high-volume centers. Surgeon members of the American Society of Peritoneal Surface Malignancies working at high-volume CS/HIPEC centers (>10 cases/year) were invited to complete an online survey. The survey included questions relating to preoperative preparation of patients, intraoperative practices, and postoperative care. Ninety-seven surgeons from five continents completed the survey (response rate 55%). The majority (80%) practiced in academic environments. Most respondents (68%) indicated that a formal preoperative preparatory pathway for CS/HIPEC surgery existed at their centers, but few (26%) had used enhanced recovery protocols in this group of patients. Whereas the intraoperative technical practices of the CS/HIPEC procedure were relatively consistent across respondents, there was little agreement on pre- and postoperative care practices, including use of mechanical bowel preparation, nutritional supplementation, methods of perioperative analgesia, timing of physical therapy and ambulation, nasogastric tube and Foley removal, intravenous fluids, blood transfusion parameters, and postoperative use of deep-vein thrombosis prophylaxis and antibiotics. Perioperative care practices for CS/HIPEC are widely variable nationally and internationally. Standardization of such practices offers an opportunity to incorporate evidence-based interventions and may enhance patient outcomes and improve care standards across all centers that offer this procedure.

Evaluation of thromboprophylaxis in medium-sized general hospital

CONTEXT: Deep vein thrombosis (DVT) is a serious, common disease whose complications include pulmonary thromboembolism (PTE) and postthrombotic syndrome. The importance and benefits of correct and effective pharmacological prophylaxis for DVT are well documented. OBJECTIVES: The aims of this study were to evaluate adequacy of prophylaxis for DVT and PTE at the Santa Casa de Misericórdia de Ponta Grossa (SCMPG), Paraná, Brazil, and determine risk stratification for patients hospitalized in this institution. METHODS: A cohort study was conducted to assess DVT prophylaxis of patients hospitalized on May 15th, 2009. The study population consisted of a sample of 104 patients, subdivided into clinical and surgical groups and stratified into different specialties. Correct use of DVT prophylaxis was evaluated according to recommendations published by The Brazilian Society for Angiology and Vascular Surgery and took into account prophylactic methods specified explicitly in information found in each patient's medical chart. RESULTS: Of the 104 patients interviewed, 51 (49.04%) were clinical patients and 53 (50.96%) surgical. Based on risk stratification, 17 (16.35%) were classified as low risk, 37 (35.58%) as moderate risk, 46 (44.23%) as high risk and 4 (3.85%) as extremely high risk for DVT/PTE. A total of 68 patients (65.38%) received prophylaxis, but of these only 56 (53.85%) received the correct prophylaxis, and 36 (34.62%) did not receive any prophylaxis. CONCLUSION: The rates of prophylaxis use for DVT and PTE in this service are higher than rates published in the literature.

Prophylactic Dose Low Molecular Weight Heparin (dalteparin) For Treatment Of Vaso-Occlusive Pain Crisis In Patients With Sickle Cell Disease

The most common cause for hospitalization and the hallmark of sickle cell disease (SCD) is painful vaso-occlusive crisis (VOC). Several studies including our own have documented a hypercoagulable state in patients with SCD, which becomes further accentuated during pain crisis. Therefore, there has been increasing interest in the use of anticoagulation in patients with SCD to prevent and treat VOC. For patients admitted for VOC, deep vein thrombosis (DVT) prophylaxis with low molecular weight heparin (LWMH) is currently used at the discretion of the treating physician. No formal guidelines in the United States advocate universal use of DVT prophylaxis for patients with SCD and DVT risk assessment tools such as the Padua risk assessment model do not include SCD as a thrombophilic condition. We hypothesized that the daily use of prophylactic dose LMWH would decrease markers of hypercoagulability and daily pain scores for patients admitted for VOC.We performed a double blind placebo controlled trial using prophylactic dose dalteparin for patients with SCD admitted for VOC. Adult patients >18 years of age were enrolled at Duke University and included sickle cell type SS, SC, and Sβ0. Patients were treated for the initial 7 days of hospitalization, had pain scores (visual analog scale) recorded twice daily, and had hypercoagulable markers drawn on days 1, 3 and 5. Hypercoagulable markers tested included D-dimer, thombin-antithrombin (TAT), and calibrated automated thrombography (CAT). Analysis was performed to compare the amount of change in hypercoagulable markers and pain scores for each patient treated with either dalteparin or placebo.We enrolled 34 patients (median 27 years old, range 20-56) over 18 months, including 29 patients who were randomized and administered study drug. Ten patients treated with dalteparin and ten treated with placebo had blood drawn on day 1 and 3. Mean age, clinical history, and baseline laboratory values were not significantly different between dalteparin and placebo groups except for LDH, which was lower in the dalteparin group (303.9 U/L ± 120.9 vs. 432.6 ± 188, p=0.03). There was no significant difference between dalteparin and placebo treated patients for hypercoagulable markers on day 1 and 3 including: D-dimer (167.4 ng/mL ± 262.6 vs. 814 ± 621.8, p=0.19), TAT, and each phase of thrombin generation by CAT including endogenous thrombin potential (59.1 nM ± 26.8 vs. -24.3 ± 60.6, p=0.13). There also was no significant decrease between all hypercoagulable markers on day 1 when compared to day 5. Pain scores were found to significantly decrease each day during hospitalization from enrollment (day 0) to day 3 for each treatment group. Importantly, when comparing patients treated with dalteparin versus placebo, there was a greater decrease in pain scores from day 0 to 1 (-1.6 vs. -0.3, p=0.06) and from day 0 to 3 (-2.4 vs. -0.9, p=0.07).No studies to date have evaluated the use of prophylactic dose LMWH for the treatment of inpatient pain crisis. We found that prophylactic dose dalteparin did not seem to significantly affect hypercoagulable markers including D-dimer and CAT. Interestingly, there was also no significant decrease in markers through hospitalization from day 1 to day 5. This may be due to the underlying accentuated hypercoagulable state in SCD and the prophylactic dosing of dalteparin. We did find, however, a greater decrease in pain scores from day 0 to 1 as well as day 0 to 3 for patients treated with prophylactic dose dalteparin as compared to patients treated by placebo. This decrease in pain seems promising for larger multi-center studies to evaluate the use of prophylactic dose anticoagulation for VOC. Disclosures:Shah:Eisai: Research Funding. Telen:GlycoMimetics, Inc.: Research Funding; Dilaforette, NA: Research Funding; Pfizer, Inc.: Consultancy.

Real-world Analysis of Deep Vein Thrombosis Prevention in Patients With Severe Lung Disease

PURPOSE: Acute and chronic lung diseases are recognized to be high risk factors for the development of deep vein thrombosis (DVT). In the current analysis, the real-world use of DVT prophylaxis and rates of DVT and pulmonary embolism (PE) were assessed in-hospital and then followed post-discharge in US patients with severe lung diseases.

Estudo comparativo entre protocolos para profilaxia da trombose venosa profunda: uma nova proposta

INTRODUCAO: O artigo compara os protocolos Davison-Caprini (americano) e Sandri (brasileiro) para profilaxia da trombose venosa profunda (TVP), buscando a elaboracao de um novo protocolo, mais abrangente e aplicavel. METODO: Foi realizado um estudo prospectivo, durante um ano, abrangendo 212 pacientes, comparando os protocolos quanto a estratificacao de risco de TVP, e ao tipo de profilaxia indicado. Um novo protocolo foi proposto, aplicado e comparado aos anteriores. RESULTADOS: Obteve-se um novo protocolo, denominado Sandri modificado, que restringe a heparina a um grupo seleto de pacientes, semelhante ao americano, mantendo-se adequado tanto para cirurgias esteticas quanto reparadoras. CONCLUSOES: A baixa adesao, por parte dos cirurgioes plasticos, ao uso rotineiro da profilaxia de TVP, espelha a escassez de informacao sobre o tema. O protocolo Sandri modificado busca melhorar a compreensao e a aplicabilidade da profilaxia da TVP na cirurgia plastica.

Use of deep vein thrombosis prophylaxis in hospitalized cancer patients

Venous thromboembolism is a common complication and a major cause of morbidity and mortality in cancer patients. Patients with malignancies have a four-fold greater risk of venous thromboembolism compared with patients without malignancies. Underuse of deep vein thrombosis (DVT) prophylaxis persists, despite guidelines supporting its use in hospitalized cancer patients. This study was conducted to evaluate the use of DVT prophylaxis and its appropriateness in hospitalized cancer patients. This retrospective study included cancer patients admitted to Rafik Hariri University Hospital, a tertiary referral center in Beirut, Lebanon, over 2-month period, who were hospitalized for at least 2 days. We evaluated the use of anticoagulants for DVT prophylaxis in the absence of contraindications for their use. The risk factor profiles of the patients were reported in addition to the choice of the anticoagulant and the use of mechanical prophylaxis in patients with contraindications to anticoagulation. One hundred and thirty patients were studied out of which 34 (26.2%) had contraindications to anticoagulation use. In addition, 21 patients out of 95 (22.1%) who qualified for DVT prophylaxis received pharmacologic DVT prophylaxis. Enoxaparin was the most frequently prescribed anticoagulant (76.2% of the patients). Of those who received anticoagulation, only 47.6% received appropriate agent and dose. Among patients with contraindications to anticoagulation, only three (8.8%) received mechanical devices as nonpharmacologic DVT prophylaxis. DVT prophylaxis in hospitalized cancer patients is significantly underutilized. Several options are available to increase physicians' awareness of the problem.

Deep Vein Thrombosis Following Hip Fracture and Prevalence of Hyperhomocysteinaemia in the Elderly

Introduction: The prevalence of deep vein thrombosis (DVT) in the West is reported to be as high as 50% after hip surgery. A study performed 14 years ago showed the incidence in Singapore to be <10%. Lately, some case-control and cross-sectional studies have suggested hyperhomocysteinaemia as an independent risk factor for DVT. This study investigates the local incidence of DVT and plasma hyperhomocysteinaemia in elderly patients presenting with proximal hip fracture. Materials and Methods: We recruited 104 consecutive patients from April 2001 to November 2001 who satisfy certain criteria. Firstly, patients of both genders who were >55 years old with radiological diagnosis of neck of femur fracture, intertrochanteric or subtrochanteric fracture. Secondly, these patients must not have any haemorrhagic or thrombogenic disease. Thirdly, patients were not given folate and B complex pre- or postoperation. Duplex ultrasound was then done for these patients on the 5th to 7th postoperative day. Results: The incidence of DVT above the trifurcation was 7.7 %, no incidence of pulmonary embolism (PE) was detected. The incidence of hyperhomocysteinaemia was 52.3%. Conclusions: The incidence of DVT in the local population after proximal hip fracture is much lower than in the West. The use of DVT prophylaxis in Asians should be selective to avoid incurring extra cost and its associated morbidity. Case-control studies and cross-sectional studies clearly indicate that hyperhomocysteinaemia is an independent risk factor for venous thrombosis. Given the high incidence of hyperhomocysteinaemia in our elderly with hip fracture, the prophylactic correction of hyperhomocysteinaemia with folate and vitamin B supplements is justified.

Is deep vein thrombosis surveillance warranted in high'risk trauma patients?

Deep vein thrombosis (DVT) has been reported to occur in 20% to 40% of high-risk trauma patients if no prophylaxis is used. The purpose of this study was to determine the incidence of DVT and utility of a screening program in a high-risk group of trauma patients for whom routine DVT prophylaxis was utilized. Of 3,154 trauma admissions over a 20-month period, 343 patients (10.9%) identified as high risk based on established criteria (prolonged bed rest, Glasgow coma score (GCS) of 7, spinal injury, lower extremity or pelvic fracture) were placed on a prospective surveillance protocol using color-flow duplex scanning and received thromboembolic prophylaxis. Twenty-three thromboembolic complications occurred, including 20 DVTs (5.8%) and 3 pulmonary emboli ([PE] 1%). Univariate analysis showed that the risk of DVT was related to age (52.6 + 19.9 years versus 38.1 + 18.5; P = 0.001), a longer hospital stay (31.4 versus 17.8 days; P = 0.001), or the presence of spinal fracture (12.6% versus 3.5%; P = 0.01). Discriminant function analysis revealed that length of stay, intensive care unit days, age, and GCS allowed correct classification of those who did not develop DVT in 97% of cases but was only correct in 15% of cases in predicting those who would develop DVT. Injury severity score (ISS) was not predictive in this multivariate analysis. Seventeen (85%) DVTs were unsuspected clinically. Study patients received an average of 3.5 studies at an overall charge of $313,330 to detect 17 clinically unsuspected DVTs (5%). This represents about 5% of the total bed charges for these patients, or $18,000 per DVT. These results suggest that standard use of DVT prophylaxis in a high-risk trauma population leads to a low incidence of DVT and that a screening protocol is effective in detecting unsuspected DVTs. Use of a surveillance protocol, however, may reduce but will not eliminate the incidence of pulmonary emboli in this patient population.