Venous Thromboembolism Prophylaxis Guidelines Research Articles

Evaluation of Adherence to Venous Thromboembolism Prophylaxis Guidelines Among US Adults After Pancreatic Cancer Surgery

This cohort study evaluates postoperative adherence to venous thromboembolism prophylaxis guidelines among US adults with pancreatic cancer using a national population sample drawn from Surveillance, Epidemiology, and End Results–Medicare data.

Are sequential compression devices routinely necessary following enhanced recovery after thoracic surgery?

OBJECTIVESThe prominence of “enhanced recovery after surgery” (ERAS) protocols being adopted in thoracic surgery requires a re-evaluation of mechanical venous thromboembolism (VTE) prophylaxis guidelines. The goal of this study was to assess the role of sequential compression devices (SCD) in the prevention of VTEs such as deep vein thrombosis and pulmonary embolism (PE) in thoracic surgical patients.METHODSWe identified 200 patients who underwent elective oncological thoracic surgery between December 2018 and December 2020 in 2 cohorts—1 with SCDs and 1 without (i.e. non-SCD). All patients followed a standardized enhanced recovery after surgery (ERAS) protocol. The quality of care provided by SCDs was evaluated by the incidence and severity of postoperative and follow-up VTEs. Cohorts were compared by the Caprini score (CS) and the Charlson Comorbidity Index (CCI) with a two one-sided t-test analysis. Secondary outcomes include perioperative characteristics and follow-up data.RESULTSOnly 2 patients within the SCD group developed a PE with average CS and CCI metrics, both after hospital discharge and treated with anticoagulants, raising concern over the prophylactic nature of SCDs. The CS (6.9 ± 1.3 and 6.9 ± 1.5; P = 0.96) and the CCI (3.8 ± 2.0 and 4.1 ± 2.6; P = 0.33) for non-SCD and SCD, respectively, did not differ. The two one-sided t-test analysis for CS (P < 0.001) and CCI (P < 0.001) demonstrated equivalence.CONCLUSIONSAlthough larger studies are required to confirm these results, routine SCD use may not be required when implementing ERAS protocols because clinically significant VTE rates were minimal.

Adherence to apixaban for extended thromboprophylaxis after major abdominal or pelvic surgery for cancer: A prospective cohort study.

Due to lack of data, direct oral anticoagulants are not considered by guidelines for venous thromboembolism (VTE) prophylaxis after cancer surgery. Adherence to low-molecular-weight heparin injections in this setting is sometimes poor. Analysis of adherence to oral apixaban for extended thromboprophylaxis. Consecutive patients discharged after major surgery for abdominal/pelvic cancer and considered eligible for extended prophylaxis were offered apixaban 2.5 mg twice daily. Primary outcomes were adherence metrics-proportion of prescriptions filled, persistence (not prematurely discontinued), proportion of days covered (PDC) based on apixaban pill counts, and modified Morisky medication adherence scale at Days 28-30. Secondary outcomes were bleeding, VTE, and serious adverse events until Day 90. We included 53 patients, 51 were analyzed. Of 45 patients with prescriptions all had it filled (95% confidence interval [CI], 92%-100%). Persistence was 98% (95% CI, 90%-100%). PDC was ≥80% for 48 patients (94%; 95% CI, 84%-99%). We found good adherence (0/6 answers "yes") in 75% and moderate (1/6 answers "yes") in 25%. No major bleed or VTE occurred while on apixaban. Our results support good adherence with apixaban for VTE prophylaxis up to 28 days after major abdominal or pelvic cancer surgery.

416 Venous Thromboembolism Prophylaxis in Emergency Surgical Admission: The Power of a Checkbox in Reducing Errors. a Closed Audit

Abstract Introduction Hospital-acquired venous thromboembolism (VTE) is considered a significant cause of morbidity and mortality in all inpatients. It is potentially preventable with adequate thromboprophylaxis. All surgical patients should be assessed and commenced on an appropriate dose of anticoagulant agent. Drug charts of 40 patients admitted under general surgery teams at Galway University Hospital were reviewed and audited against the Irish VTE prophylaxis guidelines release in 2019. Results A total of 40 (21 M, 19 F) patients were included, 2 out of the 40 patients (30%) were adequately assessed not suitable for chemoprophylaxis, two patients were not missed in the absence of risk factors of bleeding. Of the remaining 36 patients, 29 were adequately treated with chemoprophylaxis and 7 patients were undertreated or overtreated by doses inadequate to their weight and renal clearance. 35 out 40 patients were charted for TED stockings this falls under the 100% standard. Intervention: An educational presentation, along with collaborative agreement with the pharmacy department to add two checkboxes on the prophylactic anticoagulant page of the carder to highlight the renal function and the weight to the prescriber. Re-audit: On re-auditing the data, 40 patients were included, 2 patients have contraindications factors for anti-coagulant. out of 38 patients remaining, 37 of them received weight and renal function-adjusted doses of prophylactic anticoagulants. All 40 patients received TED stockings. Conclusions Check boxes on the prescription sheet act as effective reminders for the busy junior doctor prescriber to highlight the importance of weight and renal function when prescribing anti-coagulants.

The effect of information technology intervention on using appropriate VTE prophylaxis in non-surgical patients: A systematic review and meta-analysis.

IntroductionClinical decision support systems (CDSSs) play an important role in summarizing the best clinical practices, thereby promoting high standards of care in specific medical fields. These systems can serve as tools for gaining knowledge and mediating between clinical guidelines and physicians thereby providing the right information to the right person at the right time.ObjectiveThis review aims to evaluate the effect of CDSSs on adherence to guidelines for venous thromboembolism (VTE) prophylaxis and VTE events compared to routine care without CDSSs in non-surgical patients.MethodsIn order to conduct a systematic literature review, the published studies were identified through screening EMBASE, the international clinical trials registry, OVID, Cochrane database, PubMed, ISI Web of Science, and Scopus databases, from 1982 to March 2021. The included studies were reviewed by two independent reviewers; the proportion of patients that correctly received VTE prophylaxis has been next extracted for further analysis. Additionally, patients were divided into two groups: CDSS-recommended VTE prophylaxis and routine care without using a CDSS.ResultsTwelve articles (three randomized controlled trials, seven prospective cohort trials, and two retrospective cohort trials) were in fine analyzed. The use of CDSSs is found to be associated with a significant increase in the rate of using the appropriate prophylaxis for VTE (p < 0.05) and a significant decrease in the incidence of VTE (p < 0.05).ConclusionImplementation of CDSSs can help improving the appropriate use of VTE prophylaxis in non-surgical patients. Further, evidence-based and interventional studies on the development of CDSSs can provide more in-depth knowledge on both this tool design and efficiency.

EP.FRI.771 National audit on VTE prophylaxis for lower limb injuries treated in a plaster cast

Abstract Aims Audit to assess Orthopaedic departments’ compliance with NICE guidelines on Venous thromboembolism (VTE) prophylaxis published in 2010, specifically looking at VTE practices for patients with lower limb injuries treated in a plaster cast. Methods A telephonic survey was carried out on junior doctors within orthopaedic departments of 66 hospitals across all regions of England. A questionnaire was completed regarding VTE risk assessment, prophylaxis and hospital guidelines etc. Data collected from August 2016 till February 2017. Results 83% (n = 55) of trusts routinely give VTE prophylaxis to these patients. 96% (n = 64) give Chemoprophylaxis of some sort. Formal VTE assessments are performed in 81% (n = 54) and 77% (n = 51) have a local VTE prophylaxis policy. Conclusions We conclude that Orthopaedic departments across England have increased compliance with NICE guidelines for VTE prophylaxis. However there is considerable variation in practice, especially in duration and chemoprophylaxis agent. We attribute this to the lack of specific NICE guidelines for this cohort of patients. We aim that this study can influence NICE to introduce added guidance that will standardise practice.

Evaluation of an Extended-duration Chemoprophylaxis Regimen for Venous Thromboembolism after Microsurgical Breast Reconstruction.

Background:Patients undergoing free flap breast reconstruction are at a high risk for venous thromboembolism based upon Caprini scores. Guidelines for venous thromboembolism prophylaxis recommend high-risk groups receive extended chemoprophylaxis for several weeks after gynecological, orthopedic, and surgical oncology cases. Extended prophylaxis has not been studied in free flap breast reconstruction. The purpose of this study was to compare outcomes of free flap breast reconstruction patients who received extended venous thromboembolism (VTE) prophylaxis with those who received standard inpatient-only prophylaxis.METHODS:Patients undergoing microsurgical breast reconstruction were divided into two groups: standard VTE prophylaxis (Group I) and extended prophylaxis (Group II). Both groups received prophylactic subcutaneous heparin or enoxaparin preoperatively and enoxaparin 40 mg daily postoperatively while inpatient. Group II was discharged with a home regimen of enoxaparin 40 mg daily for an additional 14 days.RESULTS:In total, 103 patients met inclusion criteria (36 patients in Group I, 67 patients in Group II). The incidence of VTE was 1.5% in Group II compared with 2.8% in Group I (P = 0.6). There was no difference in reoperative hematoma between Group I (n = 0) and Group II (n = 1) (P = 0.7). Total flap loss was 2.2%.Conclusions:Although this retrospective pilot study did not show statistical significance in VTE between those receiving extended home chemoprophylaxis (1.5% incidence) compared with inpatient-only chemoprophylaxis (2.8%), the risk of bleeding complications was similar. These results indicate that a larger, higher powered study is justified to assess if an extended home chemoprophylaxis protocol should be standard of care post free flap breast reconstruction.

Time for an Update? A Look at Current Guidelines for Venous Thromboembolism Prophylaxis After Hip and Knee Arthroplasty and Hip Fracture.

Venous thromboembolism is a well-established complication of total hip and knee arthroplasty and hip fracture surgery. Clinical practice guidelines have been proposed to help clinicians provide prophylaxis against this risk. However, most guidelines reference data that are becoming outdated because of new advances in perioperative protocols. Recent data would suggest that aspirin may be appropriate for most patients after total hip and knee replacement and a more potent chemoprophylaxis for higher risk patients. Low-molecular-weight heparin remains the recommended choice after hip fracture surgery, although there is a paucity of recent literature in this patient population. There are randomized trials currently underway in the arthroplasty population that may guide clinicians in the appropriate choice of chemoprophylaxis. These studies should inform updates to the current clinical practice guidelines.

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

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

The effect of the transition to Electronic Patient Records on adherence to venous thromboembolism prophylaxis guidelines in general surgical patients

Introduction and objectivesSurgical patients are at risk of hospital-acquired venous thromboembolisms (VTEs), and preventative measures such as thromboembolism deterrent stockings (TEDs) and low molecular weight heparin (LMWH) are proven to be beneficial. The National Quality Requirement in the NHS Standard Contract 2017/19 in England mandates that 95% of inpatients undergo VTE risk assessments. As hospitals transition to Electronic Patient Records (EPR), it is important to observe the impact on vital safety indicators such as VTE risk. The aim of this study is to observe the effect of implementing EPR in a tertiary centre on adherence to national guidelines, including VTE assessment rates and prophylaxis administration in surgical patients. Materials and methodsUsing consecutive sampling, all acute surgical admissions at the hospital from 26/02/2018 to 18/03/2018 (n=154) pre-EPR and 31/10/2018 to 25/11/2018 (n=151) post-EPR were observed for VTE risk assessment, 24-h re-assessment, prophylaxis prescriptions, administration, and patient compliance. Data was compared using a two-tailed Z-test. ResultsPre-EPR, 96% of patients had completed VTE assessments, which increased after EPR implementation to 97% (p=0.39). LWMH prescription rates decreased from 82% to 77% following EPR (p=0.14). Moreover, TED prescriptions decreased from 84% to 64% post-EPR (p<0.01). Administration rates of prophylaxis generally improved post-EPR. The 24-h re-assessment rate decreased from 62% to 54% of patients (p=0.08). ConclusionThe study demonstrated that EPR is non-inferior to paper records. Transitioning to an EPR system did not interfere with the completion of VTE risk assessments, hence did not negatively impact the ability to achieve national targets.

Venous Thromboembolism Prophylaxis and Thrombotic Risk Stratification in the Varicose Veins Surgery-Prospective Observational Study.

Background: An invasive phlebological treatment is still not free from complications such as thrombosis. As in other surgical populations, not only the treatment modality, but also patient condition-related venous thromboembolism (VTE) risk factors matter. The current protocols used in varicose vein surgery centers are based mostly on individual risk assessment as well as on an implementation and extrapolation of general surgery VTE prophylaxis guidelines. In the presented study, the efficacy of routine VTE pharmacological thromboprophylaxis in patients undergoing saphenous varicose vein surgery was prospectively evaluated. In the result assessment, VTE risk factor evaluation and Caprini score results were included; however, due to the limited size of the projected study group, as well as expected limited deep vein thrombosis (DVT) prevalence in this clinical scenario, it was not possible to perform the validation of the Caprini model efficacy in the projected study model. Methods: In the study, 141 patients undergoing saphenous vein stripping and miniphlebectomy in spinal anesthesia were included. In all of the patients, VTE risk factors (including Caprini score evaluation) were assessed, and the routine thromboprophylaxis with enoxaparin 40 mg for 10 days was used. The venous ultrasounds were undertaken before the surgery and on the 10th and 30th day after surgery. The study endpoint was the presence of symptomatic or asymptomatic DVT confirmed in the imaging study. The study safety endpoint was major bleeding occurrence intraoperatively or within 30 days after surgery. Results: The presence of a postoperative DVT was diagnosed in five cases (3.5%) In all of these cases, only distal DVT was confirmed. Despite extensive saphenous varicose vein surgery with stripping and miniphlebectomy performed in nontumescent but spinal anesthesia, no proximal lower leg episode was diagnosed. Three out of five DVT cases were diagnosed on day 10 postoperative control, while a further two were confirmed in the ultrasound examination performed 30 days after procedure. No clinically documented pulmonaly embolism (PE) as well as no bleeding episodes were noticed. Among the factors related to the statistically significant higher DVT occurrence, the results of the Caprini score were identified with odds ratio (OR) = 2.04 (95% CI = (0.998; 4.18)). Another factor that became statistically significant in terms of the higher postoperative DVT prevalence was the reported Venous Clinical Severity Score (VCSS) results (OR = 1.98; 95% CI (1.19; 3.26)). In the multiple logistic regression analysis, the patient age (OR = 0.86; 95% CI (0.75–0.99)), Caprini score evaluation results (OR = 4.04; 95% CI (1.26–12.9)) and VCSS results (OR = 2.4; 95% CI (1.23–4.7)) were of statistical significance as predictors for postoperative DVT occurrence, with a p value of 0.029 for age, and p = 0.017 and p = 0.009 for Caprini score results and VCSS results, respectively. Due to the confirmed limited number of the DVT events in our study cohort, as well as the descriptive and explorative nature of the achieved results, the final clinical potential and significance of the identified parameters, including Caprini score rate and VCSS rate, should be interpreted with caution and studied in the further trials in these clinical settings. Conclusion: All the patients undergoing varicose vein surgery should undergo VTE risk evaluation based on the individual assessment. In VTE risk evaluation, patient and surgical procedure characteristics based on the factors included into the Caprini score but also on specific chronic venous disease-related factors should be taken into consideration. Further studies are needed to propose an objective and validated VTE risk assessment model, as well as a validated antithrombotic prophylaxis protocol in this particular patient group.

Quality appraisal of clinical guidelines for venous thromboembolism prophylaxis in patients undergoing hip and knee arthroplasty: a systematic review

IntroductionVenous thromboembolism (VTE) occurs in up to 40%–80% of patients after hip and knee arthroplasty. Clinical decision-making aided by guidelines is the most effective strategy to reduce the burden of...

The Choice of Anticoagulation Among Internal Medicine Residents to Treat/Prevent Venous Thromboembolism in Cancer Patients

Introduction: Venous thromboembolism (VTE) is the second most common cause of death in cancer patients next to disease progression. The patients with cancer are not only at increased risk to develop VTE but are also at increased risk of recurrence and bleeding complications from treatment. Hence, anticoagulation is of utmost importance in this population. The International Society of Thrombosis and Hemostasis (ISTH) and American Society of clinical oncology (ASCO) propose guidelines for treatment and prophylaxis of VTE in cancer patients frequently. We aimed to assess the choice and ease among internal medicine residents at different levels of postgraduate training in a teaching community hospital regarding the use of anticoagulation for the prevention and treatment of VTE in medical cancer patients. This study also determines the awareness of the 2019 guidelines of ISTH and ASCO among these residents. Methods: A Cross-sectional study including a web-based survey of five clinical scenarios was designed to determine the anticoagulation of choice as per the 2019 ASCO and ISTH guidelines. The scenarios consisted of non-gastrointestinal cancer patients with a diagnosis of VTE with and without normal kidney function, upper gastrointestinal cancer patents with recent VTE, and VTE prophylaxis in hospitalized and ambulatory cancer patients. Also, four questions were included to determine the ease of residents to start anticoagulation in cancer patients and to assess the difference in choices based on their postgraduate year (PGY) level making a total of nine questions. Results: 58 (77%) of the total residents (75) responded to the questionnaire who included, 18 PGY-1, 18 PGY-2, and 22 PGY-3. The average correct answers were 1.9 (Mean 39%; SD 21%) out of the five questions that were scored i.e the clinical scenario questions based on guidelines. In the scenario of VTE in non-gastrointestinal cancer, the majority of residents chose Lower Molecular Weight Heparin (LMWH) (60.34%), followed by rivaroxaban (24.14%). For a patient with impaired renal function, although a majority of residents preferred warfarin (41.38%), quite a few picked LMWH (29.31%). For upper gastrointestinal cancer, LMWH was the favored option (41.38%) and apixaban was second (31.03%). For VTE prophylaxis, LMWH had 63.16% of preference vs 35.09% of other options. In an ambulatory, fully functional patient with cancer, only 26% of residents believed anticoagulation is not required. 87.72% of the residents said they were unaware of the current guidelines and a total of 65.38% PGY-3 residents did not feel very comfortable starting anticoagulants on their patients without guidance. For the individual answers based on the PGY level see Figure 1. Conclusion: Most of the internal medicine residents preferred LMWH for cancer patients over direct oral anticoagulants. However, they picked the wrong choices in other common scenarios; such as one third preferred to start apixaban in a gastrointestinal cancer patient, or the majority would give prophylactic anticoagulation to ambulatory patients, which is not required per guidelines. These mistakes were supported by the majority of them saying that they were unaware of the treatment recommendations for VTE in cancer patients. Also more than half of the PGY-3 residents are not very comfortable initiating anticoagulants on their own. Based on the above study, we concluded that all residents should be educated on current VTE guidelines on cancer patients, and emphasis should be on including them in the Internal Medicine curriculum. This action will help the residents be more confident and highlight the importance of keeping up with new guidelines. Disclosures No relevant conflicts of interest to declare.

Incidence of venous thromboembolism and bleeding after pulmonary lobectomy: evaluating the timing for thromboprophylaxis

Venous thromboembolism (VTE) is an important postoperative complication after major lung cancer resective surgery, such as lobectomy. It is recommended to start chemical thromboprophylaxis within the first 12 h following the procedure. Postoperative bleeding is also a relevant complication in patients with predisposing conditions. However, the criterion for classifying a patient as "high risk of bleeding" is not standardized and is left to the expertise of the attending physician or surgeon. We aim to describe the incidence and risk factors for postoperative VTE and hemorrhage after pulmonary lobectomy; and to assess the impact of the timing of thromboprophylaxis on the incidence of postoperative thrombotic or hemorrhagic events. A retrospective observational study of 358 lobectomies performed in a single center was performed, analyzing the rates of postoperative thrombotic and hemorrhagic events and predisposing factors, including postoperative thromboprophylaxis management. Cumulative incidence of VTE was 3.07% (95% CI 1.54-5.43), and early postoperative bleeding was 10.05% (95% CI 7.14-13.64). Underlying pulmonary disease was associated with VTE (p = 0.001) and open approach was associated with hemorrhagic events (p = 0.01). The use of thromboprophylaxis and timing of its initiation were not associated with a higher incidence of events. VTE and postoperative hemorrhage are relevant complications following pulmonary lobectomy. Compliance with VTE prophylaxis guidelines is essential. Even so, a case-by-case risk evaluation of VTE and bleeding remains preferable and safe in order to decide on the most suitable timing of thromboprophylaxis.

Venous thromboembolism in primary central nervous system lymphoma during frontline chemoimmunotherapy

BackgroundIn primary central nervous system lymphoma (PCNSL), venous thromboembolism (VTE) can cause significant morbidity and hinder chemotherapy delivery. ObjectivesTo assess VTE incidence, timing and adequacy of inpatient and outpatient VTE prophylaxis in patients with PCNSL receiving chemoimmunotherapy with curative intent. Patients/MethodsWe reviewed patients diagnosed with PCNSL between 1997 and 2018 who received methotrexate, procarbazine, and vincristine ± Rituximab. Patient demographics, VTE prophylaxis and incidence, adverse events of anticoagulation, and survival outcomes were collected. ResultsFifty‐one PCNSL patients were included (median 67 years [range, 32‐87], 30 males [59%]). Thirteen patients (25%, 95% confidence interval [CI], 14‐40) developed VTE at a median of 1.6 months from diagnosis (range, 0‐4). Patients with Khorana Risk Score ≥2 were more likely to have VTE than those with a KRS < 2 (60% vs 15%; P = .01). Eighty‐five percent had deviations from inpatient VTE prophylaxis guidelines, and outpatient prophylaxis was not routinely administered. Three patients required inferior vena cava filters. Hemorrhagic complications of anticoagulation included an intracranial hemorrhage from therapeutic anticoagulation and three cases of major bleeding from prophylactic anticoagulation. No patients died from VTE or its treatment. ConclusionsPatients with newly diagnosed PCNSL are at high risk of VTE. Further research is required into optimal VTE prophylaxis in PCNSL.

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.

Low levels of salicylic acid and salicyluric acid are present in synovial fluid of patients taking aspirin at the time of knee arthroplasty surgery

Low doses of acetylsalicylic acid (aspirin) are recommended in some venous thromboembolism prophylaxis guidelines for total knee replacement arthroplasty surgery. As salicylic acid has antimicrobial activity it would be advantageous if aspirin's use reduced the risk of prosthetic joint infection. We measured salicylate levels in the synovial fluid of patients taking long term low dose aspirin who were having knee arthroplasty surgery. Low levels of salicylic and salicyluric acids were present in synovial fluid immediately pre surgery. Acetylsalicylic acid was not measurable in synovial fluid. The measured salicylic acid levels were lower than those previously shown to have antibacterial activity against any of the bacteria that typically cause prosthetic joint infection.

Head and Neck Microsurgeon Practice Patterns and Perceptions Regarding Venous Thromboembolism Prophylaxis.

Patients undergoing head and neck (H&N) microvascular reconstruction comprise a population at high risk for venous thromboembolism (VTE). Free flap and VTE thromboprophylaxis may coincide but tend to vary from surgeon to surgeon. This study identifies VTE prophylaxis patterns and perceptions among H&N microsurgeons in the United States. An online survey on VTE prophylaxis practice patterns and perceptions was emailed to 172 H&N microsurgeons in the United States using an anonymous link. There were 74 respondents (43% response rate). These surgeons completed residencies in otolaryngology (59%), plastic surgery (31%), and oral maxillofacial surgery (7%). Most underwent fellowship training (95%) and have practiced at an academic center (97%) for at least 6 years (58%), performing an average of 42 ± 31 H&N free flap cases per year (range = 1-190). Most adhered to general VTE prophylaxis guidelines (69%) while 11% did not and 20% were unsure. Nearly all surgeons (99%) would provide prophylactic anticoagulation, mostly in the form of subcutaneous heparin (51%) or enoxaparin (44%); 64% additionally used aspirin, while 4% used aspirin alone. The majority of surgeons (68%) reported having postoperative VTE complications, with six surgeons (8%) reporting patient deaths due to pulmonary embolism. A third of the surgeons have encountered VTE prophylaxis-related adverse bleeding events, but most still believe that chemoprophylaxis is important for VTE prevention (92%). While 35% of surgeons were satisfied with their current practice, most would find it helpful to have official prophylactic anticoagulation guidelines specific to H&N free flap cases. The majority of microsurgeons experienced postoperative VTE complications after H&N free flap reconstruction despite the routine use of prophylactic anticoagulation. Though bleeding events are a concern, most surgeons believe chemoprophylaxis is important for VTE prevention and would welcome official guidelines specific to this high-risk population.

Venous Thromboembolism Prophylaxis After Pelvic and Acetabular Fractures: A Survey of Orthopaedic Surgeons' Current Practices.

The goal of this study was to identify the current practices and rationale of orthopaedic surgeons regarding venous thromboembolism (VTE) prophylaxis for pelvic and acetabular (P&A) fractures. A 25-item web-based questionnaire was made available to all Orthopaedic Trauma Association (OTA) members on the OTA website. Analysis of data was performed after the three-month study period. One hundred three active OTA members completed the survey. Most respondents practiced at an academic level I trauma centers. The most important factor in selecting a VTE regimen was its effectiveness, whereas cost was the least important. Low-molecular-weight heparin (LMWH) remains the preferred agent for VTE prophylaxis after P&A trauma. Factors such as surgical intervention and weight-bearing had a variable effect on surgeons' opinions regarding the type and duration of VTE prophylaxis. Most surgeons treating P&A fractures use LMWH for VTE prophylaxis, but the decision on which agent to use and duration of treatment is multifactorial. Published VTE prophylaxis literature and guidelines provide some guidance, but there is no consensus. Overall, LMWH appears to be the VTE prophylaxis agent of choice for most orthopaedic trauma surgeons, irrespective of nonsurgical or surgical management of these fractures.

Evaluation of the use of low-molecular-weight heparin for venous thromboembolism prophylaxis in medical patients.

Venous thromboembolism (VTE) complicates a significant proportion of medical admissions. As well as increasing patient morbidity, pulmonary embolism is one of the commonest preventable causes of in-hospital death. An increase in the use of pharmacological preventive measures has been advocated in recent years. South African (SA) and international guidelines have been published in an effort to promote the safe use of VTE prophylaxis. To describe adherence to both local and international recommendations for VTE prophylaxis in an SA hospital with regard to appropriateness of the decision to prescribe or withhold low-molecular-weight heparin (LMWH), and to observe the practice of dose adjustment in special population groups. This was a prospective, observational study, and data were collected from consenting adults admitted to the medical wards. We assessed the patients' VTE risk, bleeding risk and the presence of contraindications at the time of LMWH prescription as well as the dose prescribed, specifically taking into consideration adjustment for renal dysfunction and obesity. Three hundred and fifty-two patients were enrolled, of whom 51.4% were male and 58.5% received LMWH. Primary outcomes. The appropriate overall decision according to both SA and international guidelines was made in 254 cases (72.2%). The inappropriate decision according to both guidelines was made in 79 cases (22.4%) and the appropriate decision according to one guideline only was made in 18cases (5.1%), while 1 case (0.3%) was not categorised. Contraindications to VTE prophylaxis were present in 35 patients (9.9%), but 9 of these patients nevertheless received LMWH. An incorrect dose was prescribed in 36 cases (17.5%), the most common reason being an inappropriate reduction in the dose in mild renal dysfunction. Other medications that may have increased bleeding risk were prescribed in 46 patients who received LMWH (22.3%). Mechanical prophylaxis was indicated in 25 (7.1%) of the total sample; however, none received this. Overall adherence to published guidelines for VTE prophylaxis has improved compared with other published reviews on the topic, but documentation of patients' VTE risk in files is poor. Overuse in low-risk patients may be an unintended consequence of the widespread advocacy of LMWH use in hospital, highlighting the importance of adequate VTE risk stratification. Incorrect dosing in special population groups is an issue that needs to be addressed, as is non-utilisation of mechanical prophylaxis methods.