Venous Thromboembolism Prophylaxis Guidelines Research Articles

Adequacy of Venous Thromboembolism Risk Assessment and Prophylaxis After Gastrointestinal Surgery in a Sudanese Teaching Hospital: A Prospective Audit.

Background Venous thromboembolism (VTE) is a condition that occurs when a blood clot forms in a vein. VTE includes deep vein thrombosis (DVT) and pulmonary embolism (PE). Regular monitoring and risk assessment are crucial for effectively using VTE prevention measures. This study aimed to evaluate the practices related to VTE risk assessment and prophylaxis within our surgical unit in a Sudanese teaching hospital. Methods This study was conducted at Alnao teaching hospital and was comprised of two cycles. It examined adult patients who underwent gastrointestinal operations. Data from medical records including age, sex, type of operation, whetherVTE and bleeding risk assessments were performed, whether pharmacological or mechanical prophylaxis was administered, and any contraindications to VTE prophylaxis. The practice of VTE risk assessment and prophylaxis prescription was compared to the National Institute for Health and Care Excellence(NICE)guidelines for VTE risk assessment and prophylaxis. Following cycle one, regular educational sessions were conducted for medical staff, emphasizing the need for improved practices in assessing the risk of VTE and prophylaxis prescription. Results 32 patients in cycle one and 29 patients in cycle two were included. VTE and bleeding risks were assessed in 0/32 (0.00%)of patients in cycle one compared to 29/29 (100%)in cycle two. In cycle one, 0/32 (0.00%) patients were given VTE prophylaxis according to the guidelines. This practice improved to 17/29 (58.6%)in cycle two. Conclusion The audit highlights the role of organized methods and education in improving adherence to VTE prophylaxis guidelines. Targeted interventions like educational sessions and risk assessment tools led to significant practice improvements, particularly in low-resource settings. Continuous auditing and training are essential for maintaining and enhancing compliance with VTE prophylaxis standards.

Venous Thromboembolism (VTE) Prophylaxis on Discharge Following Major Cancer Surgery in the Abdomen: Improving Compliance With National Guidelines.

Background Venous thromboembolism (VTE) prophylaxis in hospitalized patients, particularly those undergoing abdominal surgery for cancer, is critical to reducing the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE). Despite increased awareness, ensuring appropriate VTE prophylaxis post-discharge remains challenging. The National Institute for Health and Care Excellence (NICE) guidelines recommend prolonged prophylaxis in specific cases, yet compliance on discharge often falls short. Method A retrospective audit was conducted on 60 patients admitted for elective abdominal cancer surgery in a District General Hospital (DGH) from January to December 2023. This assessed compliance with VTE prophylaxis guidelines, both during admission and post-discharge. Following the first audit cycle, educational interventions for junior doctors, posters in relevant departments, and reminders in electronic patient records were implemented to enhance compliance. A second audit cycle was conducted over four months with 30 patients to evaluate the effectiveness of these interventions. Results Initial results showed 100% compliance with VTE assessments and inpatient prophylaxis but only 49.1% compliance with full 28-day post-discharge prophylaxis. Around 24.5% of patients received no further prophylaxis after discharge, while 20.8% exceeded the recommended duration. After the intervention, compliance with recommended VTE prophylaxis improved significantly, with 81.25% of patients completing the prescribed course and only 14.8% receiving inpatient-only prophylaxis. The number of patients exceeding 28 days of prophylaxis decreased from 20.8% to 3.7%. Overall, non-compliance fell from 50.9% to 18.5%. Conclusion Simple, targeted interventions, including education and reminders within electronic records, led to significant improvements in VTE prophylaxis compliance post-abdominal cancer surgery. Continued adherence to these strategies, alongside system-embedded reminders, is expected to sustain these improvements and further reduce VTE-related morbidity and mortality.

COVID-19 venous thromboembolism prophylaxis guidelines in pediatrics

IntroductionSARS-CoV-2 (COVID-19) infection and multisystem inflammatory syndrome in children (MIS-C) are risk factors for venous thromboembolism (VTE). Guidelines for VTE prophylaxis were established at our institution at the beginning of the pandemic. Patients who had any VTE risk factors in addition to COVID-19 met criteria for anticoagulation prophylaxis. Patients who were diagnosed with MIS-C met criteria regardless of additional risk factors. Materials and methodsWe conducted a retrospective review of patients admitted with COVID-19 or MIS-C to determine compliance with VTE prophylaxis guidelines and to evaluate the incidence of VTE and bleeding events in our population. Results and conclusionsAmong a total of 678 patients admitted with COVID-19 or MIS-C, 519 (76 %) patients met criteria for VTE prophylaxis and 348 (65.6 %) started prophylaxis. Logistic regression analysis identified a personal or family history of thrombosis or thrombophilia, diagnosis of MIS-C, admission to the intensive care unit, and presence of a central venous catheter as significantly associated with starting VTE prophylaxis. There were 18 patients who developed VTE. Minor bleeding events occurred in 19 patients (5 %), patient important bleeding, no intervention occurred in 8 patients (2 %), clinically relevant nonmajor bleeding in 8 patients (2 %), and major bleeding in 10 patients (3 %). The incidence of VTE in our patients with COVID-19 and MIS-C is similar to VTE rates at other institutions. We found that universally recognized VTE risk factors were appropriate to include as risk factors for thrombosis in hospitalized children with COVID-19 and MIS-C.

Impact of an updated venous thromboembolism prophylaxis guideline in critically ill trauma patients on rates of venous thromboembolisms

IntroductionThe objective of this analysis was to evaluate differences in incidence of venous thromboembolisms (VTE) in critically ill trauma patients between pre- and post-implementation of updated VTE prophylaxis guidelines. MethodsThis was a pre-post analysis of critically ill trauma patients receiving pharmacologic VTE prophylaxis. Trauma patients were included if they had an intensive care unit admission during their hospitalization. The primary outcome was incidence of detected VTE and was analyzed using a Chi-Squared test. A multivariate analysis assessed the effects of guideline implementation on VTE development when controlling for confounders. ResultsThere were 220 patients included. There was a significant increase in low molecular weight heparin use in initial (p ​= ​0.003) and final (p ​= ​0.004) prophylactic regimens between groups. There was no significant difference in VTE incidence between the pre and post groups (6.3% vs 1.9%, p ​= ​0.10). The multivariate analysis showed guideline implementation was independently associated with an 88% reduced odds of VTE (p ​= ​0.04). ConclusionThis analysis suggests the updated VTE prophylaxis guideline implementation was associated with a trend toward reduced VTE development among critically ill trauma patients.

Guideline-based venous thromboprophylaxis in postpartum women: An in-depth evaluation of ACOG and RCOG recommendations and real-life implementation

ObjectivesVenous thromboembolism is one of the most serious complications of the postpartum period, and international societies have various thromboprophylaxis guidelines for its prevention. This study compares postpartum venous thromboprophylaxis recommendations from the American College of Obstetrics and Gynecology (ACOG) and the Royal College of Obstetricians and Gynecologists (RCOG) with real-life clinical practices. Study DesignData analysis of 1000 postpartum women at a tertiary care center focused on patient demographics, venous thromboembolism risk factors, and clinical thromboprophylaxis practices. Patient-specific risk factors were compared between ACOG and RCOG guidelines, assessing Low-Molecular-Weight-Heparin dosages and durations. Guideline compliance, undertreatment/overtreatment rates, and the required number of prefilled Low-Molecular-Weight-Heparin syringes were evaluated. ResultsSignificant discrepancies were observed between ACOG and RCOG guidelines, particularly in Low Molecular Weight Heparin dosages and durations. Consensus rates with clinical approaches were around 53%, with inconsistencies leaning towards undertreatment (RCOG) and overtreatment (ACOG). The number of required prefilled Low-Molecular-Weight-Heparin syringes was notably higher according to RCOG compared to ACOG guidelines. ConclusionPostpartum Venous thromboembolism prophylaxis guidelines from American College of Obstetrics and Gynecology and Royal College of Obstetricians and Gynecologists exhibit substantial differences, leading to variations in clinical practice. Further research on the significance of Venous thromboembolism risk factors is essential for improving risk assessment tools and refining guideline recommendations for pregnancy-related Venous thromboembolism prevention.

VTE prophylaxis for major abdominal surgery: A hospital audit and nurses' survey for quality improvement

Objective: The objective of this study is to assess and improve VTE prophylaxis practices in major abdominal surgery through a hospital audit and nurses' survey. Primary aims: Evaluate adherence to VTE prophylaxis guidelines in abdominal surgery, identify improvement opportunities in VTE prevention and assess the effectiveness of current prophylactic measures. Nurses’ survey: Evaluate surgical nurses' knowledge and implementation of VTE prophylaxis and identify educational gaps to improve VTE prevention. Secondary aims: Integrate audit and survey insights: Gain insight into VTE management practices, to develop quality improvement programs for better prophylaxis and outcomes. Background: Guidelines for the prevention of venous thromboembolism (VTE) in surgical patients involve risk assessment, followed by chemical and mechanical prophylaxis. Often, VTE risk assessments are not completed which leads to inappropriate or inadequate prophylaxis. The current guidelines suggest that a healthcare provider, such as a nurse or physician, should conduct the VTE risk assessment for each patient. Study design and methods: Initially, a prospective audit was conducted to examine VTE prophylaxis practices at a tertiary hospital. This VTE audit was conducted alongside a nurses' survey to assess current VTE prophylaxis practices. Both measures were taken to review the quality of care provided to surgical patients. Results: The practice of VTE prophylaxis shows high utilisation of all three prophylactic modalities but a lack of risk assessment documentation in the medical records. Nurses, although perceiving it as their responsibility, do not conduct assessments for venous thromboembolism risk. Conclusion: Based on the audit and survey results, the hospital has not fully adopted the guidelines for venous thromboembolism prophylaxis in major abdominal surgery cases. There is a lack of proper risk assessment documentation, and nurses are not consistently engaged in conducting these. Implications for research, policy, and practice: This paper presents valuable insights into the current prescribing practices for VTE prophylaxis after major abdominal surgery, as gleaned from a clinical audit and a survey of nurses. The hospital audit indicates that overall, all three are being used, instead of two. While this approach does not contravene current guidelines, the use of both stockings and compression devices is not needed, instead adding new risks, unnecessary nursing workload and financial cost to health services. Further, this approach may prolong recovery with patients unable to mobilise while wearing compression devices to take part in rehabilitation programs. What this paper adds: This paper adds to the existing literature by highlighting the gap between recommended guidelines and the actual implementation of VTE prophylaxis practices in the context of major abdominal surgery. These results provide meaningful clinical relevance about VTE prophylaxis practice for nurses and surgeons involved major abdominal surgery. The continuing education of Australian nurses should include an emphasis on VTE risk assessment and prevention.

A retrospective review of recurrent venous thromboembolism in patients with cancer with direct factor Xa inhibitors.

e24136 Background: Venous thromboembolism (VTE) in cancer patients is a significant cause of morbidity and mortality. People with malignancies are at an increased risk of thrombosis compared to the normal population. Regimens that include platinum-based agents and vascular endothelial growth factor (VEGF) inhibitors have a higher risk of thromboembolism1. The recent ASCO 2023 guidelines for VTE prophylaxis and treatment have advised that direct factor Xa inhibitors are a suitable option for initial and long-term treatment for VTE, given patient preference of oral over subcutaneous administration of anti coagulation2. In our retrospective review of a single centre in Western Australia, we have identified twelve patients who have developed thromboembolic events whilst on direct oral anticoagulation. Methods: Electronic patient records were reviewed for oncology patients attending between 2016 and 2023 at a single centre in Western Australia.Diagnosis of VTE and subsequent treatment was confirmed from radiology and medication records. Twelve patients were identified, and data was recorded and analysed. Results: 12 patients were identified with recurrent VTE whilst on direct factor Xa inhibitors. The median age was 59.5 years (range 50-71). The most common associated malignancies were pancreatic, ovarian and lung cancer. Others include breast, vulval, colon and gastroesophageal cancer. Two thirds of patients were metastatic at diagnosis (n = 8). Common sites of thrombosis include the lower limbs at both initial [n = 6] and recurrent [n = 4] presentation. All patients were treated with therapeutic doses of rivaroxaban (n = 8) or apixaban (n = 4) at the time of of initial or recurrent thrombotic event. Median time to initial thrombotic event was 4.5 months from diagnosis compared to recurrent VTE [5 months]. All patients were changed to either LMWH (n = 10) or unfractionated heparin (n = 2). Ten patients [83.3%] did not have further thrombosis post switching to heparin. One patient had recurrent pulmonary emboli on imaging despite heparin administration, and the other had an IVC filter insertion. Conclusions: VTE is a common complication for oncology patients. Given our results, clinicians should be suspicious for recurrent VTE for patients on direct factor Xa inhibitors. There is an argument for enoxaparin or dalteparin to be better options, particularly in those high risk. Whilst patient preference for an oral option is desirable, further investigation is needed to directly compare the differing direct factor Xa inhibitors and the rates of VTE recurrence.

114 Burn Specific VTE Prophylaxis: Higher Enoxaparin Dose and Anti-Xa Adjustments Is Safe and Potentially Beneficial

Abstract Introduction Burn and trauma patients are at high risk of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolus (PE). VTE prophylaxis guidelines for trauma patients recommends a higher standard dose of enoxaparin and anti-Xa level adjustments in select patients; however, no guidelines specific to burn patients exist. We hypothesize that higher standard doses of enoxaparin and anti-Xa level adjustments will be safe and effective at reducing VTE complications in burn patients. Methods This retrospective review included patients admitted to a regional burn center six months prior to and after the initiation of a VTE prophylaxis quality improvement protocol. The protocol doubled the standard dose of enoxaparin, 40 mg daily to 40 mg twice a day, for all burn patients who were > 50 kg and had creatinine clearance > 60mg/dl. Peak anti-Xa level monitoring was indicated if a high-risk factor (TBSA ≥20%, inhalation injury, burn shock, BMI ≥40) was present. Patients on therapeutic anticoagulation or anti-platelet therapy, had a history of chronic kidney disease, decompensated cirrhosis, coagulation disorder, heparin induced thrombocytopenia (HIT), or were admitted for polytrauma were excluded. Efficacy was evaluated by rates of VTE within 31 days of discharge. Safety was evaluated by bleeding complications, including estimated blood loss (EBL), number of transfusions and gastrointestinal (GI) bleeding events. Differences between groups were compared using a two-sample t-test or Wilcoxon rank-sum test. A p-value of < 0.05 signified statistical significance. Results The pre-protocol group included 217 patients and the post-protocol group included 207 patients. There were no significant differences in age (45 vs 44 years), BMI (27 vs 26.4 kg/m2), TBSA (5.9 vs 5.3%), IHI (4.6 vs 7%), number of procedures (3 vs 3), mortality (4.1 vs 3%), or ICU length of stay (1.9 vs 1.6 days) between groups. No significant difference in EBL (50 vs 25 cc), number of transfusions (3.3 vs 2.4 units), or GI bleeding events (1 vs 1) was noted between groups, and no patient developed thrombocytopenia or HIT. There were 5 patients (2.3%) with a VTE within 31 days of discharge in the pre-protocol group compared to 1 patient (0.4%) in the post-protocol group (p=0.19). There was not enough power to determine statistically significant VTE prevention. Conclusions A lack of VTE prophylaxis recommendations for burn patients leads to variability in protocols among burn centers. These protocols are infrequently studied. This protocol, which doubled the standard dose of enoxaparin and adjusted based on anti-Xa levels for high-risk patients, was safe. Efficacy and applicability to other centers needs further elucidation. Applicability of Research to Practice Enoxaparin 40mg twice a day with anti-Xa level adjustments is safe and a promising strategy to reduce the rates of VTE in the burn population without increasing bleeding complications.

American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma clinical protocol for postdischarge venous thromboembolism prophylaxis after trauma.

Trauma patients are at an elevated risk for developing venous thromboembolism (VTE), which includes pulmonary embolism and deep vein thrombosis. In the inpatient setting, prompt pharmacologic prophylaxis is utilized to prevent VTE. For patients with lower extremity fractures or limited mobility, VTE risk does not return to baseline levels postdischarge. Currently, there are limited data to guide postdischarge VTE prophylaxis in trauma patients. The goal of these postdischarge VTE prophylaxis guidelines are to identify patients at the highest risk of developing VTE after discharge and to offer pharmacologic prophylaxis strategies to limit this risk.

Compliance with Australian Orthopaedic Association guidelines does not reduce the risk of venous thromboembolism after total hip and knee arthroplasty.

Preventing avoidable venous-thrombo-embolism (VTE) is a priority to improve patient and service outcomes after total hip and total knee arthroplasty (THA, TKA), but compliance with relevant clinical guidelines varies. This study aims to determine the degree to which prophylaxis was compliant with Australian Orthopaedic Association (AOA) VTE prophylaxis guidelines and whether non-compliance is associated with increased risk of VTE. A prospective multi-centre cohort study of adults with osteoarthritis undergoing primary TKA/THA was completed at 19 high-volume public and private hospitals. Data were collected prior to surgery and for one-year post-surgery. Logistic regression was undertaken to explore associations between non-compliance with AOA VTE prophylaxis guidelines and symptomatic 90-day VTE outcomes. Data were analysed for 1838 participants from 19 sites. The rate of non-compliance with all clinical guideline recommendations was 20.1% (N = 369), with 14.1% (N = 259) non-compliance for risk-stratified prophylaxis, 35.8% (N = 658) for duration, and 67.8% (N = 1246) for other general recommendations. Symptomatic VTE was experienced up to 90-days post-surgery by 48 people (2.6%). Overall guideline non-compliance (AOR = 0.93, 95%CI = 0.4 to 1.3, p = 0.86) was not associated with a lower risk of symptomatic 90-day VTE. Results were consistent when people with high bleeding risk were excluded (AOR = 0.94, 95%CI = 0.44 to 2.34, p = 0.89). Non-compliance with the AOA VTE prophylaxis guidelines was not associated with risk of 90-day VTE after arthroplasty. This counterintuitive finding is concerning and necessitates a rigorous review of the AOA VTE prevention clinical guideline.

High Rates of Thrombotic Events in Newly Diagnosed Multiple Myeloma Patients Enrolled on the Maia Trial

Background. Patients with newly diagnosed multiple myeloma (NDMM) have a nine-fold increased risk of developing venous thromboembolism (VTE). Despite the availability of the IMWG and NCCN VTE prophylaxis guidelines and updated risk stratification models such as SAVED and IMPEDE, the optimal thromboprophylaxis strategy is unknown, especially in the age of modern daratumumab-containing regimens. To continue highlighting the importance of appropriate thromboprophylaxis for patients with NDMM, we performed a post-hoc analysis of the randomized phase 3 MAIA trial to identify rates of venous and arterial thromboembolism. Methods. This retrospective study, carried out under YODA Project #2021-4663, used data from the randomized phase 3 MAIA trial that investigated lenalidomide and dexamethasone (Rd) with or without daratumumab (DRd) in 733 transplant ineligible (TIE) patients obtained from the Yale University Open Data Access (YODA) Project, which has an agreement with JANSSEN RESEARCH & DEVELOPMENT, L.L.C.. Thrombotic events (TE), including both venous and arterial events (V/ATE) were examined with VTE events including deep vein thrombosis (DVT), pulmonary embolism (PE), and superficial thrombophlebitis (SVT). Arterial events (ATE) included cerebrovascular accidents (CVA) defined as hemorrhagic, ischemic, or verebrobasilar strokes. The incidence and time to event of V/ATE were calculated and graded using the CTCAE v4, with Grade 1 representing nonactionable venous thrombosis, Grades 2-4 representing TEs requiring increasing higher levels of medical intervention, and Grade 5 indicating death was a result of the TE. Rates and time to events were compared between the DRd and Rd arms. Results. Of the included patients, median age was 72 years (range 64-72) and 48% were female. There was no signficant difference between baseline characteristics of sex, race, myeloma subtype, presence of high-risk cytogenetics, or ISS staging between patients that experienced a V/ATE event and those that did not. All grade V/ATE events were 18% (66/363) and 19% (70/365) in the DRd and Rd arms, respectively. Of these, most were VTE events in both arms (16%), with G2-4 actionable VTE event rate of 14.9% vs 14.8% for the DRd and Rd arms, respectively. G5 VTE events were 0.2% in both arms (no G5 ATEs). ATE were 2.2% and 2.7% in the DRd and Rd group, respectively, overall constituting a minority of events. The overall PE rate was higher in the DRd than Rd arm, 6.3% vs 4.7%, DVT was more frequent in the Rd arm, 9.6% vs 7.7%, and rates of SVT rates were similar between both arms at 1.9% and 2.2% for the DRd vs Rd arms, respectively (Table 1). Median time to onset of cumulative TEs was longer in DRd vs Rd arm, 7.15 (0.27 - 63.0) vs 4.65 (0.03 - 58.0) months, respectively. Among these, median time to onset of VTE was similar among the groups [6.57 (0.27 - 63.0) vs 4.48 (0.03 - 52.9) months, respectively] while the median time to onset of ATEs was longer in DRd vs Rd arm, 19.8 (1.70 - 26.6) vs 8.3 (0.67 - 58.5) months. The incidence of VTE events persisted past 24 months and incidence of ATE events increased over time (Figure 1). Analysis regarding prophylactic anticoagulation use and rates of TE based on prophylactic regimen are ongoing. Conclusion. This retrospective study reveals the highest reported rates of VTE in any modern therapy dataset. In patients with transplant ineligible NDMM, we show that the TE risk persists past 24 months of treatment in patients on DRd or Rd therapy. Similar to observations in the GRIFFIN trial, the addition of daratumumab did not increase the risk of TE. Our report highlights the critical need for further investigation of optimal prophylactic strategies and their duration for patients with NDMM.

Venous thromboembolism in orthopedic surgery: Global guidelines.

Venous thromboembolism (VTE) is a severe complication that can occur after major orthopedic procedures. As VTE-related morbidity and mortality are a significant concern for both medical professionals and patients, and preventative measures are typically employed. Multiple organizations, including the American College of Chest Physicians (ACCP) and the American Academy of Orthopedic Surgeons (AAOS), have developed guidelines for VTE prophylaxis specifically in patients undergoing joint replacement procedures. However, recently, the International Consensus Meeting (ICM) was convened, which brought together over 600 experts from 68 countries and 135 international societies. These experts, spanning a range of medical disciplines including orthopedic surgery, anesthesia, cardiology, hematology, vascular, and internal medicine, conducted a comprehensive review of the literature using a strict Delphi process to generate practical recommendations for VTE prophylaxis across all types of orthopedic procedures. This review article summarizes some of the recommendations of the ICM. Level of Evidence: Level V, Expert opinion.

AB125. SOH23ABS_089. Adherence to VTE prophylaxis guidelines on a surgical ward in Midlands Regional Hospital Tullamore

Background: Risk factors associated with venous thromboembolism (VTE) include immobilisation, recent surgery, malignancy, and infection. Surgical patients in particular often have several risk factors for VTE. As per National Institute for Health and Care Excellence (NICE) guidelines, all patients at risk of VTE over 16 years should start pharmacological prophylaxis within 14 h of admission. Antiembolism stockings (AES) are also recommended. The aim of this audit was to assess adherence to VTE prophylaxis guidelines on the surgical ward.

Safety of the Trauma Quality Improvement Program Guideline for Venous Thromboembolism Prophylaxis in Traumatic Brain Injury.

The American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) provides a guideline for when to initiate pharmacologic venous thromboembolism (VTE) prophylaxis in traumatic brain injury (TBI) patients. We hypothesized that implementation of the guideline would not result in progression in intracranial hemorrhage. The TBI TQIP guideline was implemented at a Level I Trauma Center. Patients with a stable Computerized tomography (CT) of the brain were started on chemical prophylaxis per the Modified Berne-Norwood Criteria. CT scans before and after initiation of treatment were retrospectively reviewed by one board-certified radiologist to determine if there was progression of hemorrhage. Patients without a follow-up CT scan were evaluated for progression of bleed/neurologic deterioration by review of physician notes, nursing documentation, and Glasgow coma scale (GCS). From July 2017 to December 2020, 12,922 patients were admitted to the trauma service. A total of 552 of these patients had TBI and 269 met inclusion criteria. 55 patients had at least one CT of the brain after initiation of prophylaxis. None of these 55 patients had progression of hemorrhage. 214 patients did not have a CT of the brain after prophylaxis. Chart review showed that none of these patients had a clinical decline. Overall, there was no progression of hemorrhage in the 269 patients that met inclusion criteria. Initiation of the TQIP TBI VTE prophylaxis guideline was found to be safe with no progression of intracranial hemorrhage.

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

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

Joint 2022 European Society of Thoracic Surgeons and The American Association for Thoracic Surgery guidelines for the prevention of cancer-associated venous thromboembolism in thoracic surgery.

Venous thromboembolism (VTE), which includes deep vein thrombosis and pulmonary embolism, is a potentially fatal but preventable postoperative complication. Thoracic oncology patients undergoing surgical resection, often after multimodality induction therapy, represent among the highest risk groups for postoperative VTE. Currently there are no VTE prophylaxis guidelines specific to these thoracic surgery patients. Evidenced-based recommendations will help clinicians manage and mitigate risk of VTE in the postoperative period and inform best practice. These joint evidence-based guidelines from The American Association for Thoracic Surgery and the European Society of Thoracic Surgeons aim to inform clinicians and patients in decisions about prophylaxis to prevent VTE in patients undergoing surgical resection for lung or esophageal cancer. The American Association for Thoracic Surgery and the European Society of Thoracic Surgeons formed a multidisciplinary guideline panel that included broad membership to minimize potential bias when formulating recommendations. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used, including GRADE Evidence-to-Decision frameworks, which were subject to public comment. The panel agreed on 24 recommendations focused on pharmacological and mechanical methods for prophylaxis in patients undergoing lobectomy and segmentectomy, pneumonectomy, and esophagectomy, as well as extended resections for lung cancer. The certainty of the supporting evidence for the majority of recommendations was judged as low or very low, largely due to a lack of direct evidence for thoracic surgery. The panel made conditional recommendations for use of parenteral anticoagulation for VTE prevention, in combination with mechanical methods, over no prophylaxis for cancer patients undergoing anatomic lung resection or esophagectomy. Other key recommendations include: conditional recommendations for using parenteral anticoagulants over direct oral anticoagulants, with use of direct oral anticoagulants suggested only in the context of clinical trials; conditional recommendation for using extended prophylaxis for 28 to 35days over in-hospital prophylaxis only for patients at moderate or high risk of thrombosis; and conditional recommendations for VTE screening in patients undergoing pneumonectomy and esophagectomy. Future research priorities include the role of preoperative thromboprophylaxis and the role of risk stratification to guide use of extended prophylaxis.

Impact of clinical pharmacist services on physicians' guideline compliance and prognosis of patients for venous thromboembolism prophylaxis in ICU.

Whether the clinical pharmacist services (CPS) improve ICU physicians' compliance with venous thromboembolism (VTE) prophylaxis guidelines remains unclear, and the impact of CPS on VTE incidence and mortality in ICU patients should also be investigated. ICU patients were assigned to a CPS group or a control group according to the medical arrangements of the day of patient admission, without any intervention. The impact of CPS on guideline compliance, VTE incidence, and mortality was assessed. A total of 338 patients were included. With CPS, ICU physicians' compliance with VTE prophylaxis guideline was improved by 7-25% (p<0.001). The incidences of VTE (9 vs. 17%, p = 0.037) and bleeding events (5 vs. 11%, p= 0.042) were both lower in the CPS group than in the control group. Multivariate Cox regression model showed that CPS was an independent risk factor for VTE events (HR = 0.438, 95% CI = 0.224-0.857, p = 0.016) and 14-day mortality (HR = 0.416, 95%CI = 0.25-0.692, p = 0.001). CPS could significantly improve ICU physician compliance with VTE prophylaxis guidelines and reduce the incidence of VTE events and mortality in ICU patients. A clinical pharmacist should be involved in the daily management of ICU patients as an important member of the clinical team.

Implementation science approaches to optimizing venous thromboembolism prevention in patients with traumatic injuries: Findings from the 2022 Consensus Conference to Implement Optimal Venous Thromboembolism Prophylaxis in Trauma.

Disease burden of venous thromboembolism (VTE) without pharmacologic prophylaxis is high in trauma patients. Although VTE prophylaxis guidelines exist, studies on real-world use of VTE prophylaxis in trauma shows limited uptake of guideline recommendations. Despite existing guidelines, reports indicate that VTE prophylaxis implementation across trauma centers is lagging. Implementation barriers of VTE prophylaxis in trauma are multifactorial, and VTE prescribing practices require further optimization. Implementation science methods can help standardize and improve care; well-established approaches in medical and surgical hospitalized patients and their effects on clinical outcomes such as VTE and bleeding complications must be investigated because they apply to trauma patients. Nonadministration of VTE prophylaxis medications in hospitalized patients is associated with VTE events and remains a barrier to providing optimal defect-free care. Further investigations are required for VTE prophylaxis implementation across all trauma populations.

Association between VTE and antibiotic prophylaxis guideline compliance and patient-reported outcomes after total hip and knee arthroplasty: an observational study

BackgroundSurgical site infection (SSI) and venous thromboembolism (VTE) are associated with high burden and cost and are considered largely preventable following total knee or hip arthroplasty (TKA, THA). The risk of developing VTE and SSI is reduced when prophylaxis is compliant with evidence-based clinical guidelines. However, the association between VTE and antibiotic prophylaxis clinical guideline compliance and patient-reported outcome measures (PROMs) after THA/TKA is unknown. This study aims to explore whether care that is non-compliant with VTE and antibiotic guideline recommendations is associated with PROMs (Oxford Hip/Knee Score and EQ-5D Index scores) at 90- and 365-days after surgery.MethodsThis prospective observational study included high-volume arthroplasty public and private sites and consenting eligible participants undergoing elective primary THA/TKA. We conducted multiple linear regression and linear mixed-effects modelling to explore the associations between non-compliance with VTE and antibiotic guidelines, and PROMs.ResultsThe sample included 1838 participants. Compliance with VTE and antibiotic guidelines was 35% and 13.2% respectively. In adjusted modelling, non-compliance with VTE guidelines was not associated with 90-day Oxford score (β = − 0.54, standard error [SE] = 0.34, p = 0.112) but was significantly associated with lower (worse) 365-day Oxford score (β = − 0.76, SE = 0.29, p = 0.009), lower EQ-5D Index scores at 90- (β = − 0.02 SE = 0.008, p = 0.011) and 365-days (β = − 0.03, SE = 0.008, p = 0.002).. The changes in Oxford and EQ-5D Index scores were not clinically important. Noncompliance with antibiotic guidelines was not associated with either PROM at 90- (Oxford: β = − 0.45, standard error [SE] = 0.47, p = 0.341; EQ-5D: β = − 0.001, SE = 0.011, p = 0.891) or 365-days (Oxford score: β = − 0.06, SE = 0.41, p = 0.880 EQ-5D: β = − 0.010, SE = 0.012, p = 0.383). Results were consistent when complications were included in the model and in linear mixed-effects modelling with the insurance sector as a random effect.ConclusionsNon-compliance with VTE prophylaxis guidelines, but not antibiotic guidelines, is associated with statistically significant but not clinically meaningful differences in Oxford scores and EQ-5D Index scores at 365 days.

Improving compliance with venous thromboembolism prophylaxis guidelines in obese inpatients.

Obesity is a well-recognised risk factor for venous thromboembolism, and increased dosing of pharmacological prophylaxis is recommended in obese inpatients. We performed a clinical decision support intervention by adjusting order sentences of prophylactic enoxaparin within our electronic medical records, which significantly improved appropriate dosing for thromboprophylaxis in obese inpatients at our institution.