Prevention of Venous Thromboembolism in the Geriatric Patient

Deep Vein Thrombosis in the Lower Extremities in Comatose Elderly Patients with Acute Neurological Diseases

PURPOSE

Comatose elderly patients with acute neurological illness have a great risk of deep vein thrombosis (DVT). In this study, the incidence of DVT and the effectiveness of early initiation of treatment were evaluated in those patients.

MATERIALS AND METHODS

Total 323 patients were admitted to our ward due to neurological diseases in one year, and 43 patients, whose Glasgow Coma Scale was ≤ 11 and who was older than ≥ 60 years, were included in this study. D-dimer was measured on admission and day 7, and lower-extremity ultrasonography was performed on day 7. When DVT was positive, heparin treatment was initiated, and further evaluation of pulmonary embolism (PE) was conducted. Vena cava filter protection was inserted in PE-positive patients. Incidence of DVT and PE, alteration of D-dimer value, and effect of heparin treatment were analyzed.

RESULTS

DVT was positive in 19 (44.2%) patients, and PE was in 4 (9.3%). D-dimer was significantly higher in DVT-positive group on day 7 (p<0.01). No DVT were identified in patients with ischemic disease, while 66.7% of intracerebral hemorrhage and 53.3% of brain contusion patients were DVT positive. Surgery was a definite risk factor for DVT, with an odds ratio of 5.25. DVT and PE disappeared by treatment in all cases, and no patients were succumbed to the thrombosis.

CONCLUSION

Patients with hemorrhagic diseases or who undergo operation possess high risk of DVT, and initiation of heparin treatment in 7 days after admission is an effective prophylaxis for DVT in comatose elderly patients without causing bleeding.

Age-Related Morbidity and Mortality with Cytoreductive Surgery

INTRODUCTION

Cytoreduction and intraperitoneal chemotherapy (IPC) are increasingly considered in older patients. We sought to better characterize the influence of age on 30-day outcomes following this procedure.

METHODS

The ACS NSQIP database was queried for patients who underwent IPC and a concurrent intra-abdominal operation (2005-2012). Thirty-day death and serious morbidity (DSM) was the primary outcome. Trends in DSM by age were defined using Joinpoint regression. Univariate and multivariate logistic regression identified factors associated with DSM.

RESULTS

In 1085 patients, DSM increased at a significant rate after age 50 (0.6 %/year, p = 0.001). Patients ≥60 (n = 376) represented 35 % of the study population. Age ≥60 years was independently associated with DSM (odds ratio [OR] 1.6, p = 0.001). The older patient population (≥60 years) experienced 44 % morbidity and 3.2 % mortality. In these patients, preoperative weight loss, low preoperative albumin, splenectomy, intraoperative transfusion, contaminated or dirty wound classification, and prolonged operative time were all independently significantly associated with increased DSM. In the absence of these factors (n = 45), the DSM rate was 11 %. Rates of DSM increased to 33, 63, and 100 % in patients with 1 factor, 2-3 factors, and 4 or more factors (n = 14; p < 0.001), respectively. Venous thromboembolism, sepsis, postoperative bleeding, and respiratory complications were significantly more common among those aged 60 years and older (p < 0.05 each).

CONCLUSIONS

The risk of DSM increases with age in patients undergoing cytoreduction and IPC. Risk can be stratified using a limited number of patient and operative characteristics.

Medical management of hip fracture

The United States population at the greatest risk for hip fracture, those aged 65 years and older, is steadily increasing in size. Today, the incidence of hip fracture is approximately 250,000 per year and it is expected to double in the next 30 years. Hip fracture patients are comorbid at baseline, and there are complications inherent to hip fractures that can occur in almost a predictable fashion. Overall, one in four hip fracture patients will die within one year of injury. Medical comanagement of hip fracture patients offers the best chance for successful outcome.