Venous Thromboembolism Prophylaxis Research Articles

Gastrointestinal Bleeds Are a Rare Event After Total Hip and Knee Arthroplasty.

The presence of a gastrointestinal (GI) bleed after elective hip and knee arthroplasty (THA and TKA, respectively) is concerning and a potential cause for hospital readmission. This condition can also be life-threatening if not identified and treated appropriately. Many surgeons use multimodal analgesia protocols to limit opioid use and also use venous thromboembolism (VTE) prophylaxis. Aspirin and nonsteroidal anti-inflammatories (NSAIDs), a frequent component of these protocols, reduce prostaglandin production necessary for gastric mucosal protection. The authors hypothesized that the incidence of a GI bleed after TKA and THA in the postoperative setting would be rare. This was a retrospective review of 8,207 patients 18 years or older who had THA or TKA at a single institution between 2015 and 2022. Patients who were evaluated for GI bleed within 90 days postoperatively were identified. Perioperative risks were analyzed based on demographics, procedures, and other risk factors. The incidence of GI bleeding was 0.33%, in which 27 patients sustained a GI bleed in 8,206 THA and TKA cases. There was a higher proportion of TKA cases that had GI bleeds at 15 (57.7%), compared to 11 (42.3%) for THA; however, this difference was not statistically significant, P = 0.69. Additionally, there was no statistically significant difference across primary and revisions for GI bleeds, P = 0.51. The average days from the time of surgery for GI bleed was 18.6 days. There was a difference in the occurrence of GI bleeds by age, with increasing age being positively associated with an increase in the odds of GI bleeds, OR (odds ratio) = 1.15 (95% CI [confidence interval]: 1.09 to 1.21), P < 0.01. The patient population in this study had a low incidence of GI bleed. This institution's perioperative protocol, including the use of NSAIDs and aspirin for TKA and THA, had a low incidence of GI bleeds in the perioperative setting at our community hospital over the course of 2015 to 2022.

Direct oral anticoagulants versus warfarin for venous thromboembolism prophylaxis in nephrotic syndrome patients: a retrospective study

BackgroundNephrotic syndrome (NS) is associated with an increased risk of venous thromboembolism (VTE). Anticoagulants are widely used in the prevention of VTE in NS patients. The use of direct oral anticoagulants (DOACs) has not been studied intensively in NS patients. The aim of this study is to determine the efficacy and safety of DOACs compared to warfarin for prophylactic anticoagulation in patients with nephrotic syndrome.MethodsRetrospective analysis conducted in a tertiary hospital-based ambulatory anticoagulation clinic between 01/07/2016 and 29/11/2021. We aimed to evaluate the incidence of VTE, major bleeding, and non-major bleeding in both the DOACs and warfarin groups.ResultsFifty-seven patients were recruited, 31 patients were prescribed warfarin (54.4%), and 26 were on DOAC (45.6%). Two patients in the DOAC group developed VTE, while no subjects in the warfarin group developed VTE, however, the difference was not statistically significance (p = 0.2). Nine out of 31 patients in the warfarin group developed non-major bleeding compared to three patients in the DOAC group (p = 0.02). One patient developed major bleeding in each group DOAC group 1 (15.4%), warfarin 1 (12.9%) (p = 1.00). There was no statistically significant difference in major bleeding between DOAC and warfarin groups (p = 1.00).ConclusionIn patients with NS, preliminary evidence suggests that DOACs have comparable efficacy as compared to warfarin when used as prophylaxis. Additionally, DOACs result in lower incidences of non-major bleeding. However, further studies are indicated to confirm the superiority of DOACs over warfarin.

Pharmacological prophylaxis of venous thromboembolism in surgical patients

Venous thromboembolism is the third most common cardiovascular disease after myocardial infarction and stroke, affecting a significant percentage of the population. Surgery is a well-known risk factor for venous thromboembolism, and the more serious the surgical procedure, the higher the risk of developing it. This review provides an analysis of the main risk factors for venous thromboembolism in operated patients, the role of optimizing the balance of thromboembolism/bleeding risk in determining the individual risks of surgical patients, and a comparative analysis of therapy for venous thromboembolism using drugs with antiplatelet and anticoagulant activity. A summary of the data available in the scientific literature shows that, despite the existing variety of antiplatelet and anticoagulant drugs, the second-generation low-molecular-weight heparins, with bemiparin as A prominent representative, are currently the first-line drugs for the pharmacoprophylaxis of venous thromboembolism in the context of major surgical interventions, which has been confirmed by numerous clinical trials conducted around the world. Special clinical studies have confirmed the equivalence of efficacy and safety, and in some cases, also certain advantages of second-generation drugs (for example, bemiparin) in comparison with enoxaparin, the most common first-generation drug currently used in clinical practice in surgical/oncological patients. The duration of bleeding prophylaxis with bemiparin and other low-molecular-weight heparins in surgical/oncological patients, according to the data of most clinical trials with an appropriate level of evidence, may range from 1–2 weeks up to 35 days, depending on the individually assessed balance of thromboembolism/bleeding risks.

Incidence of Venous Thromboembolism in Asian Patients With Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis.

Although incidence and prevalence of inflammatory bowel disease (IBD) have been gradually increasing throughout Asia, incidence of venous thromboembolism (VTE) in Asia is relatively lower than that in Western and is not well known. This study aimed to evaluate incidence of VTE in Asian IBD patients using a systematic review and meta-analysis. Studies were identified through literature search of the PubMed, Embase, and Cochrane databases (from inception inclusive April 2024) for English studies. The criteria for selecting participants were as follows: (1) studies including patients with Crohn's disease (CD) and ulcerative colitis in the Asian population; (2) comparisons were specified as with control group of non-IBD patients for comparative incidence; and (3) outcomes were measured by relative risks (RRs) and hazard risk for VTE incidence in nationwide cohort studies. Three independent reviewers extracted published data using standardized procedure in accordance with the reporting guidelines. A fixed-effects model was used to estimate pooled effect sizes. Meta-regression analyses were conducted to identify the potential moderating effects of VTE risk in IBD patients. Five studies met the inclusion criteria. The pooled RR for overall VTE incidence in Asian IBD patients compared with that in non-IBD patients was 2.065 (95% CI: 1.905-2.238). There was no statistical moderating effect of the variables (mean age, female rate, CD proportion, and country) on the outcomes. In our study, VTE incidence in Asian IBD patients was higher than that in non-IBD patients. It seemed reasonable to consider prophylaxis for VTE in hospitalized IBD patients.

P1155 Safety of Venous Thromboembolism Pharmacological Prophylaxis in Hospitalized Patients with Inflammatory Bowel Disease; A Single Center Retrospective Study (VISCOUS)

Abstract Background Hospitalization secondary to inflammatory bowel disease flare is a significant risk factor for venous thromboembolism (VTE). International guidelines recommend the use of pharmacological VTE prophylaxis; however, the risk of bleeding is unknown. We therefore aimed to evaluate the safety of pharmacological thromboprophylaxis in hospitalized patients with IBD. Methods This was a retrospective cohort study. A chart review of patients’ electronic health records with IBD hospitalized between August 2017 to December 2023 was reviewed. Our primary outcome is evaluating the safety of pharmacological VTE prophylaxis. This was investigated by examining increased bleeding risks during admission, which included worsening bloody stool frequency, drop in hemoglobin (&amp;gt;1g/dL from baseline) and development of hemorrhagic shock after starting VTE prophylaxis. Worsening bloody stool frequency was defined as increased bloody stool frequency &amp;gt;1 from baseline before starting VTE prophylaxis. Finally, any major bleeding was also considered. Results Between August 2017 and December 2023, 1045 patient encounters were reviewed. 524 patients met the study inclusion and exclusion criteria, of which 98 had missing information and 73 were duplicates and could not be included. Finally, 353 patients were included in our study. Mean age 34.7 years, 205 (58%) were female males and mean duration of hospitalization was 9 days. Majority of patients were hospitalized with acute severe ulcerative colitis (ASUC) 213 (60.3%), and 140 (39.7%) had Crohn’s disease (CD) flare. Of the total cohort, 264 (75%) patients received enoxaparin 40 mg for VTE prophylaxis, and the 89 (25%) patients received 5000 units of unfractionated heparin twice a day (figure 1). Eighteen (%5) patients had a history of VTE, and 4 female patients had VTE during admission. None of our cohort had any bleeding events including worsening bloody stool frequency, drop in hemoglobin, major bleeding and development of hemorrhagic shock after starting VTE prophylaxis up to the period patients were discharged. Conclusion we found no increased risk of gastrointestinal bleeding in patients admitted with IBD on pharmacological VTE prophylaxis. Therefore, it is important to reassure healthcare providers about the safety of pharmacological VTE prophylaxis in IBD and adopt strategies that guarantee prophylaxis is administered during hospitalization. Although that a balance should be established between the benefits and risks. References -Pleet JL, Vaughn BP, Morris JA, et al. The use of pharmacological prophylaxis against venous thromboembolism in hospitalised patients with severe active ulcerative colitis. Aliment Pharmacol Ther [Internet]. 2014;39(9):940–948. -Dawwas GK, Cuker A, Schaubel DE, et al. Effectiveness and safety of prophylactic anticoagulation among hospitalized patients with inflammatory bowel disease. Blood Adv [Internet]. 2024;8(5):1272–1280. -Kaddourah O, Numan L, Jeepalyam S, et al. Venous thromboembolism prophylaxis in inflammatory bowel disease flare-ups. Ann Gastroenterol. 2019;32(6):578–583.

P0871 Textbook Outcomes in Acute Severe Ulcerative Colitis: A Novel Approach to Assessing Patient Quality of Care in Inflammatory Bowel Disease

Abstract Background Textbook outcome (TBO) is a concept of quality performance measurement that has garnered traction in the medical and surgical field. While traditional methods evaluate individual outcome parameters, TBO is a composite measurement of key performance indicators and is only achieved when all individual criteria are met. Studies suggest that a composite TBO provides a superior holistic assessment of patient outcomes, better captures the multidimensional aspects of patient care and sets a comparable benchmark for quality improvement across treatment centres.1,2 To date, a TBO has not been defined or utilised in the setting of acute severe ulcerative colitis (ASUC). We aimed to define a TBO using guideline-based standards of care for ASUC presentations and assessed whether TBO was associated with improved treatment outcomes.3 Methods All ASUC presentations to a Quaternary Sydney hospital over a 10-year period were included. A modified True-love Witts’ Criteria was used to identify ASUC as ≥6 bloody bowel motions daily and presence of at least one systemic feature, including heart rate &amp;gt;90 bpm, temperature &amp;gt;37.8°C, haemoglobin &amp;lt;105 g/L, and C-reactive protein (CRP) ≥30 mg/L.4 We defined achievement of TBO as IV steroids and venous thromboembolism prophylaxis (VTEp) commenced on admission, stool samples to exclude infective pathogens, including C. difficile, abdominal imaging completed within 24 hours from presentation, and flexible sigmoidoscopy completed within 48 hours from presentation. Treatment outcomes measured were rates of rescue therapy, colectomy, length of stay, 30-day and 90-day readmission. Results During the study period, 172 presentations met criteria for ASUC and of these, 14.0% (n=24) admissions achieved a TBO. The number of presentations meeting each TBO criteria is shown Figure 1. Stool sample screening (91.3%), IV steroids (79.1%) and VTEp (73.3%) on admission were the most frequently achieved parameters. The least frequently achieved parameter was timely flexible sigmoidoscopy within 48 hours of presentation (36.0%). A comparison of outcomes for patients achieving TBO compared to those without a TBO is shown in Table 1. Achieving a TBO was associated with significantly shorter length of stay. Conclusion Composite outcome measures, such as TBO, have become a popular metric of comparing and benchmarking standards of care. ASUC patients who achieved a TBO, defined by meeting five guideline-based criteria as part of their initial investigations and management, were found to have a significantly shorter length of stay. There were no differences in need for rescue therapy, colectomy and readmission rate. More research is required to refine the consensus parameters that encompass a TBO in ASUC presentations.

P1285 Incidence of venous thromboembolism in Asian patients with inflammatory bowel disease: a systematic review and meta-analysis

Abstract Background Although the incidence and prevalence of inflammatory bowel disease (IBD) have been gradually increasing throughout Asia, the incidence of venous thromboembolism (VTE) in Asia is relatively lower than that in Western countries and is not well known. This study aimed to evaluate the incidence of VTE in Asian patients with IBD using a systematic review and meta-analysis. Methods Studies were identified through a literature search of the PubMed, Embase, and Cochrane databases (from inception inclusive April 2024) for English studies. The criteria for selecting the participants were as follows: (1) studies including patients with Crohn’s disease (CD) and Ulcerative colitis (UC) in the Asian population; (2) comparisons were specified as with a control group of non-IBD patients for comparative incidence; and (3) outcomes were measured by relative risks (RR) and hazard risk (HR) for VTE incidence in nationwide cohort studies. Three independent reviewers extracted published data using a standardized procedure in accordance with the reporting guidelines. A fixed-effects model was used to estimate pooled effect sizes. Meta-regression analyses were conducted to identify the potential moderating effects of VTE risk in patients with IBD. Results Five studies met the inclusion criteria. The pooled RR for overall VTE incidence in Asian patients with IBD compared to that in non-IBD patients was 2.065 (95% CI: 1.905–2.238). The heterogeneity test resulted in a p-value of 0.418 for the Cochrane Q statistics, and Higgins’ I2 was 0%. There was no statistical moderating effect of the variables (number of patients, mean age, female rate, CD proportion, country, and type of risk) on the outcomes. Conclusion In our systematic review and meta-analysis, the VTE incidence in Asian patients with IBD was higher than that in non-IBD patients (RR 2.065). It seemed reasonable to consider prophylaxis for VTE in hospitalized patients with IBD.

P0446 Increased risk of venous thromboembolism post hospital discharge in patients with Inflammatory Bowel Disease: a systematic review and meta-analysis

Abstract Background Inflammatory bowel disease (IBD) increases the risk of venous thromboembolism (VTE). During acute hospitalisation, the risk increases up to six-fold, but is mitigated with pharmacological VTE prophylaxis. The European Crohn’s Colitis Organisation (ECCO) recommends extended prophylaxis for atleast 3 weeks for IBD patients undergoing major surgery. However, it is currently unknown whether this also applies for non-surgical hospitalisations for IBD patients. We performed an updated systematic review and meta-analysis to evaluate this risk. The primary outcome was evaluating the risk of post-hospitalisation VTE within 30 days after an IBD-related surgical or non-surgical hospitalisation. Methods PubMed, MEDLINE, EMBASE, CENTRAL and Web of Science was searched up until 1st June 2024 for observational cohort studies evaluating rates of VTE in IBD hospitalisations. Odds ratios were calculated using a random-effects model. Subgroup and sensitivity analysis were conducted in order to explore sources of heterogeneity. Results Seven eligible studies were included (973,267 IBD patients). 52.9% were female and mean age was 45.3 +/- 3.2 years. Average follow up was 43.2 +/- 5.6 months. Patients with IBD were associated with an increased risk of VTE within 30 days post-discharge in the adjusted analysis (OR 1.58; 95% CI 1.41-1.78) with moderate heterogeneity observed (I² = 67%, p = 0.005). Subgroup analysis based on hospitalisation type (surgical vs. non-surgical) revealed an increased risk amongst surgical hospitalisation for post discharge VTE (OR 1.34; 95% CI 1.09–1.64) with moderate heterogeneity (I² = 35%, p = 0.21). In contrast, non-surgical hospitalisation demonstrated a higher risk of post-discharge VTE (OR 1.70; 95% CI 1.52–1.90) with no significant heterogeneity (I² = 0%, p = 0.37). The overall effect size across both subgroups suggested a significant association between IBD and post-discharge VTE, with an odds ratio of 1.61 (95% CI 1.46–1.78), and moderate heterogeneity (I² = 45%, p = 0.10). Conclusion There is an independently increased risk of VTE within 30 days of a flare of IBD in both surgical and non-surgical hospitalisations. Extended VTE prophylaxis for all hospitalisations should be considered. Further prospective studies are required to identify specific patient risks.

P1029 Janus Kinase Inhibitors for the Management of Acute Severe Ulcerative Colitis: A Multicentre Study

Abstract Background Acute Severe Ulcerative Colitis (ASUC) is a medical emergency, with limited therapeutic options available for medical management. Tofacitinib and Upadacitinib are novel Janus Kinase inhibitors (JAKi), with proven efficacy for ulcerative colitis (UC). This study aimed to examine the outcomes of patients treated with JAKi for ASUC in a real-world population. Methods A retrospective multi-centre study was conducted including patients (≥18 years) with ASUC commenced on Tofacitinib or Upadacitinib from April 2021 to April 2024. ASUC was defined according to Truelove and Witt’s criteria. Demographic and clinical data were recorded at admission, JAK induction, discharge, week 8, week 16 and 1 year post-induction. The primary outcome was need for colectomy. We further evaluated adverse events and drug-specific response. Results A total of 124 patients were included from 11 Australian Inflammatory Bowel Disease (IBD) centers. Tofacitinib was used in 49%, while Upadacitnib was used in the remainder. 58% of patients received JAKi as first line salvage therapy, while the remainder received JAKi sequentially after failure of first line infliximab therapy. The rate of colectomy during admission was 17% and 40% by 1 year. There was no significant difference between rate of colectomy during index admission (p=0.38), or 1 year post induction (p=0.24) between Tofacitinib and Upadacitinib. There was a significantly increased risk of inpatient colectomy for those receiving sequential salvage compared to initial JAKi salvage (p=&amp;lt;0.01). However, there was no significant difference in the rate of colectomy in either cohort up to 1 year post induction (p=0.19). Clinical response was observed in 45% of patients by day 3 of induction and 65% by day 7. Clinical remission rates were 40% by week 8 and 65% by week 16. Biochemical remission was achieved in 51% by week 16. Mucosal healing was achieved in 47% of patients who underwent repeat endoscopy within 16 weeks of induction. Adverse events occurred in 16% of patients, all of which were minor and did not require hospitalisation. The most common events noted were acne (7%) and nasopharyngitis (6%). Conclusion Jaki demonstrate effectiveness and safety for the management of ASUC. There was no significant difference in the inpatient colectomy rate between Tofacitinib and Upadacitinib. There was a significantly higher rate of inpatient colectomy for patients requiring sequential salvage therapy, but no significance when patients were followed up to 1 year. There is variability in prescribing practice between dosage of Tofacitinib and Upadacitinib, duration and dosage of corticosteroid wean, and the use of prophylactic PJP and VTE prophylaxis.

P0655 VTE thromboprophylaxis in patients with inflammatory bowel disease admitted to hospital; can we increase adherence with guidelines?

Abstract Background Incidence of venous thromboembolism (VTE) increases two to three folds in patients with inflammatory bowel disease (IBD), with hospitalisation, active disease and surgery as the major risk factors. VTE risk assessment and low molecular weight Heparin (LMWH) is recommended in all patients with IBD admitted to hospital1,2. The aim of the quality improvement project was to look at our practice, audit our adherence with guidance and where possible improve practice. Methods A tertiary centre audit was conducted from 1 September 2023 to 30 November 2023, to include all IBD patients ≥ 18 years, admitted for one day or more. Relevant data on VTE risk assessment, prescribing VTE prophylaxis, any missed doses and reasons were collected from electronic patient records. Patient identifiable details were omitted, and the audit was registered with institutional audit department. Audit outcomes were identified, interventions were implemented and a re-audit was conducted from 1 June 2024 to 30 June 2024. Results Out of 107 patients, VTE risk assessment was done in 61(57%) and LMWH was started in 79 (74%). Among 45 patients admitted with IBD flare, LMWH was started in 36 (80%). Among 28 patients where LMWH was not started, rectal bleeding(n=6) and ‘declined by patients’ (n=5) were the most common reasons. Other reasons highlighted included subdural haematoma (2), fall and suspected brain haemorrhage (1), major trauma (1), razor blade ingestion (1), diverticular bleed (1), lymphoma and low platelets (1), metastatic cancer and end of life (1). In patients started on LMWH (n=79), 76 (96%) received the first dose on Day 1, while 47 (59%) received all the recommended doses. ‘Declined by the patient’ was the most common reason for any missed dose (47%). The findings were disseminated with the relevant medical teams at team education sessions with opportunities to discuss the guidelines, wider issues including importance of giving LMWH despite rectal bleeding, and any concerns explored. After these initiatives, a re-audit was conducted. Out of 51 admissions, 45 (88.2%) had VTE risk assessments, and 44 (86.25%) started on LMWH, showing improvement in practice. Among 16 patients admitted with IBD flare, all had VTE risk assessment and started on LMWH. No thromboembolic events were identified during either of the audit periods. Conclusion Low compliance with thromboprophylaxis in IBD inpatients is commonly driven by fear of aggravating rectal bleeding and patient’s declining administration. Communication and raising awareness by education with relevant medical &amp; nursing teams and patients can improve practice and thus prevent thromboembolic events.

Effects of Continuous Graduated Pneumatic Compression and Intermittent Pneumatic Compression on Lower Limb Hemodynamics for VTE Prophylaxis in Arthroplasty.

Intermittent pneumatic compression (IPC) is considered the standard of care for preventing venous thromboembolism (VTE) in the hospital setting. However, its widespread adoption after hospitalization has been limited due to its shortcomings in obstruction of venous valves and blood reflux. The objective of this study is to compare the effects of continuous graduated pneumatic compression (CGPC), a new device with a novel mechanism, and IPC on lower hemodynamics and the incidence of VTE in patients undergoing arthroplasty. We randomized 123 participants undergoing knee arthroplasty to receive either IPC or CGPC from June 2022 through August 2023. An experienced sonographer used a Doppler ultrasound scanner to obtain hemodynamic indicators of venous blood. The primary outcome was the blood velocity of the femoral vein measured by a Doppler scanner. Secondary outcomes included the hemodynamic of the femoral vein and popliteal vein, quality of life at discharge and 30 days after surgery, symptomatic and asymptomatic VTE up to 30 days, and adverse events related to the IPC and CGPC device. For statistical analyses, Student's t-test, analysis of covariance, and the Mann-Whitney U test were used. Statistical significance was indicated with p < 0.05. There was no significant difference in femoral vein velocity between the IPC and CGPC groups. However, CGPC demonstrated a significant increase in femoral vein flow compared to the IPC group, with a median (interquartile) increasing from 158.9 (122.9, 204.3) to 265.6 (203.3, 326.8) mL/min in the CGPC group and from 139.0 (103.3, 175.9) to 189.6 (161.4, 270.8) mL/min in the IPC group (p < 0.001). Similar trends were observed in popliteal vein measurements. The differences between the two groups were similar in terms of quality of life, incidence of VTE, and adverse events. The CGPC device provides a substantial increase in blood flow compared to the IPC device. Its safety and effectiveness have been preliminarily validated. The CGPC device presents a promising alternative for VTE prophylaxis in arthroplasty. Chinese Clinical Trial Registry (registration number: ChiCTR2300078201).

Aspirin Is as Effective and Safe as Oral Anticoagulants for Venous Thromboembolism Prophylaxis After Joint Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Clinical Trials.

Joint arthroplasty effectively treats osteoarthritis, providing pain relief and improving function, but postoperative venous thromboembolism (VTE) remains a common complication. This study therefore assessed the effectiveness and safety of aspirin compared with oral anticoagulants (OACs) for VTE prophylaxis after joint arthroplasty. A systematic review and meta-analysis was performed by searching PubMed, Embase, the Web of Science, and the Cochrane Library for randomized controlled trials (RCTs) up to May 14, 2024, that compared the effect of aspirin versus OACs on VTE prophylaxis in adults undergoing joint arthroplasty. Data extraction followed the PRISMA guidelines. Two independent researchers conducted the literature searches and data extraction. A random-effects model was used to estimate effects. The primary outcome was the incidence of VTE, including deep vein thrombosis (DVT) and pulmonary embolism (PE); secondary outcomes included bleeding, wound complications, and mortality. The meta-analysis included 11 RCTs with a total of 4,717 participants (55.1% female) from several continents. The relative risk (RR) of VTE following joint arthroplasty was 1.11 (95% confidence interval [CI], 0.93 to 1.32) for aspirin compared with OACs. Similar results were observed for DVT (RR, 1.12; 95% CI, 0.90 to 1.40) and PE (RR, 1.18; 95% CI, 0.51 to 2.71). There were no significant differences in the risks of bleeding, wound complications, or mortality between patients receiving aspirin and those receiving OACs. Subgroup analyses considering factors such as study region, type of joint surgery, type of VTE detection, year of publication, use of mechanical VTE prophylaxis, aspirin dose, type of OAC comparator, study quality, and funding also found no significant differences in VTE incidence between aspirin and OACs. The overall quality of evidence for VTE and DVT outcomes was high. Based on high-quality evidence from RCTs, aspirin is as effective and safe as OACs in preventing VTE, including DVT and PE, after joint arthroplasty, without increasing complications. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Enoxaparin Venous Thromboembolism Prophylaxis Dosing in Critically Ill Underweight Patients.

Purpose: Optimal dosing of VTE prophylaxis for specific patient populations remains an area of concern as insufficient evidence exists regarding dosing for underweight patients. The purpose of this study is to compare the incidence of major bleeding events in underweight patients given different prophylactic doses of enoxaparin. Methods: This is a retrospective analysis performed at multiple hospitals within a single health care system. Patients with a BMI < 18.5 kg/m2 were divided into 2 groups depending on whether they received at least 1 prophylactic dose of enoxaparin 30 mg subcutaneously once daily or enoxaparin 40 mg subcutaneously once daily. Underweight adult patients were included if they were admitted to an ICU for at least 48 hours and received at least 1 dose of enoxaparin for VTE prophylaxis during their ICU admission. The primary aim was to compare the incidence of clinically significant bleeding between dosing strategies. Secondary aims included the incidence of VTE during admission, ICU length of stay, overall hospital length of stay, and all-cause mortality 30 days post-discharge. Results: A total of 310 patients met inclusion criteria for this study, with 80 patients in the 30 mg group and 230 patients in the 40 mg group. There was no significant difference in major bleeding events between the 2 groups (P = .61). No significant differences in incidence of VTE (P = .455 ), ICU length of stay (P = .466), overall hospital stay (P = .502), or all-cause mortality (P = .925) were found between groups. Conclusions: No difference was found in clinically significant bleeding between underweight critically ill patients receiving VTE prophylaxis with enoxaparin 30 mg once daily or 40 mg once daily. Further studies are needed to evaluate the optimal dosing of VTE prophylaxis with enoxaparin in underweight patients.

Three-Month Incidence of Venous Thromboembolism in Patients Who Underwent Neurological Surgeries.

Background/Objectives: The incidences of venous thromboembolism (VTE) in patients undergoing neurological surgeries vary. The objectives were to assess the incidence and risk factors of VTE, bleeding and all-cause mortality in patients undergoing neurological surgery. Methods: This retrospective cohort study was conducted at a single center, a university-based hospital in Thailand. Inclusion criteria comprised patients aged 15 years or older who were admitted for elective or emergency neurosurgery. Patients with preoperative VTE diagnosed within three months or a history of anticoagulant use were excluded. Outcomes measured included the 90-day incidences of VTE, any bleeding, major bleeding, and mortality. Results: Between January 2021 and December 2022, a total of 626 patients were included. The mean age was 50.21 ± 17.37 years, and 55.27% were males. Thromboprophylaxis was administered to 86 patients (13.74%, 95% CI 11.14-16.69). Fourteen patients were confirmed to have symptomatic VTE, resulting in an incidence of 2.24%, with a 95% confidence interval (CI) of 1.23-3.72. Patients aged ≥75 years (HR 4.53; 95% CI 1.25-16.38; p = 0.021), those with cancer (HR 8.51; 95% CI 2.95-24.60, p <0.001), and those experiencing postoperative paraparesis/paralysis (HR 3.26; 95% CI 1.12-9.45; p = 0.030) were associated with an increased risk of postoperative VTE. Fifty-three patients (8.47%, 95% CI 6.41-10.93) experienced any bleeding, with 23 patients (3.67%, 95% CI 2.34-5.46) having major bleeding. The incidence of postoperative mortality was 6.55%, with a 95% CI of 4.74-8.78. Conclusions: This study revealed that elderly patients, those with cancer or those experiencing postoperative paraparesis/paralysis were at higher risk of VTE. These patients were likely to benefit from VTE prophylaxis.

Is it time for a large trial to evaluate aspirin for obstetric venous thromboembolism prophylaxis?

Is it time for a large trial to evaluate aspirin for obstetric venous thromboembolism prophylaxis?

A clinical decision support tool for improving venous thromboembolism risk assessment and thromboprophylaxis prescribing compliance within an electronic medication management system: a retrospective observational study.

Despite various interventions to improve best-practice venous thromboembolism (VTE) prevention measures within hospitals, compliance remains poor. For health services utilising electronic medication management systems (eMMS), implementation of clinical decision support (CDS) tools could address this gap. To evaluate whether local implementation of an integrated electronic alert system linked with a computerised physician order entry (CPOE)-based order set for VTE risk assessment within an eMMS improves the rates of timely VTE risk assessment and guideline-compliant VTE prophylaxis prescribing among hospitalised patients. A retrospective observational study conducted among hospitalised patients pre- and post-implementation of an electronic alert system combined with a CPOE-based order set to prompt VTE risk assessment documentation and VTE prophylaxis prescribing within a single tertiary hospital. Admissions were consecutively screened over 7-day periods before and after implementation for inclusion and assessed for compliance with a local VTE prevention protocol. Eight hundred and fifty patients (458 pre-intervention, 392 post-intervention) were included for evaluation. Rates of VTE risk assessment documentation within 24h of admission increased by 29.9% (p < 0.001). Guideline-compliant VTE prophylaxis improved by 10.4% (p < 0.001). Patients with completed VTE risk assessments were significantly more likely to receive guideline-compliant VTE prophylaxis, compared to patients without documented VTE risk assessments (19.3% difference, p < 0.001). After adjusting for demographic differences, the odds of achieving positive outcomes significantly increased across all measures, with adjusted odds ratios ranging from 1.95 to 4.89 (p < 0.001). Local implementation of CDS featuring CPOE within the eMMS improved rates of VTE risk assessment documentation and guideline-compliant VTE prophylaxis prescribing.

Racial disparities in extended venous thromboembolism prophylaxis after hysterectomy.

Venous thromboembolism (VTE) is a significant preventable cause of postoperative morbidity and mortality after major abdominopelvic surgery that calls for extended VTE prophylaxis (eVTEp). Literature suggests that significant racial disparities may exist in post-operative care. The study sought to examine if racial disparities exist in the administration of eVTEp after hysterectomy in a statewide collaborative. We conducted a retrospective cohort study of post-hysterectomy patients across 69 hospitals in the Michigan Surgical Quality Collaborative from January 2016 to February 2020. The variable of interest was race (Black/African or White American). The primary outcome was administration or absence of eVTEp. Descriptive statistics and mixed effects logistic regression were performed for risk adjustment with covariates such as age, cancer occurrence, inflammatory bowel disease, American Society of Anesthesiologists physical status classification, perioperative VTE prophylaxis, postoperative VTE prophylaxis, surgical approach, and surgical duration, among other variables. In total, 24,513 patients underwent hysterectomy. Of these patients, 1,107 (4.45%) received eVTEp, 153 (13.24%) of which were Black and 954 (82.53%) of which were White. Mixed effects logistic regression analysis suggested that Black patients were significantly less likely to receive eVTEp than White patients (odds ratio = 0.776; 95% CI: 0.615-0.979; P = 0.039). Additionally, tobacco use, coronary artery disease, bleeding disorder, cancer occurrence, functional status, perioperative VTE prophylaxis, surgical duration, length of stay, and surgical approach were associated with a higher likelihood of receiving eVTEp. eVTEp is recommended for the prevention of post-discharge VTE in select patients after hysterectomy. Regression analysis showed that, compared to their White counterparts, Black females were significantly less likely to receive eVTEp. The underlying reasons for this disparity require further investigation into possible socioeconomic influences and inherent biases.

Pre-induction and post-discharge venous thromboembolism chemoprophylaxis should be considered in patients after major vascular open abdominal procedures.

Venous thromboembolism (VTE) is a significant morbidity following major open abdominal surgery. While there are clear recommendations for perioperative and post-discharge VTE chemoprophylaxis in general surgery, guidance for vascular patients is unclear. We compared the incidence of VTE in vascular versus general surgery cases and then investigated the timing of VTE in vascular patients. Two cohorts of major open abdominal surgery, vascular (open abdominal aortic aneurysm and aortoiliac reconstruction) and general, were compared in ACS-NSQIP database. There were significant preoperative differences between cohorts that were corrected using 1:1 propensity matching and logistic regression. Thirty-day outcomes included incidence and timing of VTE (in-hospital and post-discharge), mortality, and major morbidities. After propensity matching, there were 14,983 and 15,075 patients had vascular and general surgery, respectively. VTE rate was significantly lower in vascular. The distribution of in-hospital and post-discharge VTE was similar in both groups. Over the last 10 years, the overall incidence of VTE has decreased for both general and vascular surgery, with a corresponding decrease in in-hospital VTE but no change in post-discharge VTE. VTE occurrence showed a bimodal distribution with 76.92% of VTE occurring in early period (<14 days) and 23.08% occurring in late period (>14 days), which coincided with in-hospital (77.91%) and post-discharge (22.09%), respectively. Although VTE incidence after vascular procedures has decreased, in-hospital VTE may be further reduced if pre-induction subcutaneous heparin is given. Furthermore, 22% VTE developed post-discharge in vascular patients, which suggests post-discharge VTE prophylaxis should be considered in selected high-risk patients.

Risk of venous thromboembolic complications in pregnant trauma patients: A matched cohort study.

Trauma and pregnancy are both risk factors for venous thromboembolism (VTE). We hypothesized that pregnant blunt trauma patients would have a higher incidence of VTE complications compared with matched nonpregnant females. We conducted a retrospective cohort study using National Trauma Data Bank data from 2017 to 2022. Female patients with blunt mechanism, age between 15 and 50years old, were eligible for inclusion. Patients who presented as transfers, hospitalized for less than 72h, discharged against medical advice, injury severity score <9, or abbreviated injury scale=6 of any region were excluded. Pregnant patients were matched 1:2 with nonpregnant female patients by age, injury characteristics, comorbidities, and type and timing of chemical VTE prophylaxis. The primary outcomes were the incidences of VTE, deep vein thrombosis (DVT), and pulmonary embolism (PE). Secondary outcomes included other complications and length of stay. We included 735 pregnant and 1470 matched nonpregnant controls. The median time to initiate chemical VTE prophylaxis was 33h in pregnant and 34h in nonpregnant patients (p=0.42). The incidence of VTE in pregnant blunt trauma patients was 27 (3.7%) versus 45 (3.1%) in matched controls (p=0.446). There were no significant differences in DVT, PE, or any other complication or mortality or in ICU or hospital length of stay. Unplanned admissions to the ICU were significantly more frequent in pregnant patients (3.8% vs. 2.2% and p=0.026). The incidence of VTE complications was similar in pregnant and matched nonpregnant female blunt trauma patients in this retrospective cohort study, supporting the safety of current VTE prophylaxis practices in pregnant patients.

Efficacy and safety of aspirin in preventing venous thromboembolism after hip arthroplasty for femoral neck fracture: a noninferiority prospective cohort study

BackgroundVenous thromboembolism (VTE) is a common complication after hip arthroplasty. Here, we investigated the clinical efficacy and safety of prophylactic aspirin vs. conventional therapy in hip arthroplasty for femoral neck fracture.MethodsPatients who underwent total hip arthroplasty and hemiarthroplasty for femoral neck fractures between April 2021 and April 2024 were prospectively enrolled. Group A received oral aspirin (100 mg, once daily) as VTE prophylaxis; Group LR received low-molecular-weight heparin (4,250 U, once daily) sequentially followed by rivaroxaban (10 mg, once daily). The patients were followed up for 90 days postoperatively. Safety and efficacy were comprehensively evaluated based on postoperative VTE incidence, laboratory blood tests, bleeding events, and other complications.ResultsGroup A was noninferior to Group LR in preventing VTE (incidence rates of 11.6% and 10.1%, respectively, with a rate difference of 1.5%, 95% CI: 0.7–2.3%, P for non-inferiority test = 0.017). There was no significant difference between the groups in the incidence of bleeding events (3.3 vs. 8.4%; P = 0.092). Furthermore, the rates of other complications did not differ significantly between groups.ConclusionIn patients undergoing hip arthroplasty for femoral neck fractures, the efficacy and safety of oral aspirin for preventing VTE was similar to that of low-molecular-weight heparin followed by rivaroxaban.