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Anticoagulant flavonoid oligomers from the rhizomes of Alpinia platychilus. Fitoterapia 2015; 106:153-7. [DOI: 10.1016/j.fitote.2015.09.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Revised: 09/06/2015] [Accepted: 09/08/2015] [Indexed: 11/22/2022]
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Beer GM, Goldscheider E, Weber A, Lehmann K. Prevention of acute hematoma after face-lifts. Aesthetic Plast Surg 2010; 34:502-7. [PMID: 20333520 DOI: 10.1007/s00266-010-9488-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2009] [Accepted: 02/20/2010] [Indexed: 11/25/2022]
Abstract
Acute hematoma remains one of the most frequently encountered complications after face-lift surgery. Several risk factors inherent to the patient and omission of certain intraoperative regimens are considered to cause hematoma. Significant risk factors include high blood pressure and male gender. Possible intraoperative regimens for the prevention of hematoma include tumescence infiltration without adrenaline, clotting of raw surfaces with fibrin glue, usage of drains, and application of compression bandages. However, little attention has been paid to postoperative measures. To examine whether different regimens in the postoperative phase can influence the incidence of hematoma, all face-lift patients who underwent surgery by a single surgeon in two different clinics (n = 376) with two different postoperative regimens were evaluated over the course of 3 years. In group 1 (n = 308), all postoperative medication was administered on request including medication for pain control, blood pressure stabilization, and prevention of nausea and vomiting as well as postoperative restlessness and agitation. In group 2 (n = 68), this medication was administered prophylactically at the end of the operation before extubation. The hematoma rate was 7% in group 1 and 0% in group 2. This study showed that the prophylactic use of medications (e.g., analgesics, antihypertonics, antiemetics, and sedatives) during the postoperative phase is superior to making drugs available to patients on request and can decrease the occurrence of acute hematoma in face-lift patients.
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Affiliation(s)
- G M Beer
- Clinic of Aesthetic Plastic Surgery, Toblerstrasse 51, Zürich, Switzerland.
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Martin MJ, Blair KS, Curry TK, Singh N. Vena Cava Filters: Current Concepts and Controversies for the Surgeon. Curr Probl Surg 2010; 47:524-618. [DOI: 10.1067/j.cpsurg.2010.03.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Incidence of hematoma complication with heparin venous thrombosis prophylaxis after TRAM flap breast reconstruction. Plast Reconstr Surg 2008; 121:1101-1107. [PMID: 18349626 DOI: 10.1097/01.prs.0000302454.43201.83] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Randomized controlled studies provide ample evidence that heparin is effective in reducing the risk of thromboembolic complications. Nevertheless, plastic surgeons are often reluctant to use heparin chemoprophylaxis for fear of postoperative bleeding. The authors investigated whether heparin chemoprophylaxis was associated with postoperative hematoma that required evacuation in patients who underwent transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. METHODS A multicenter retrospective review of consecutive TRAM flap cases identified 679 patients, 392 in the heparin-treated group and 287 in the control group. The post hoc sample sizes were adequate to detect a 5 percent difference in hematoma rate with 89 percent power at an alpha level of 5 percent (p < 0.05). Outcome measures of reoperative hematoma, deep vein thrombosis, and pulmonary embolism were recorded. RESULTS Reoperative hematoma occurred in 0.5 percent of patients in the heparin-treated group and 1.0 percent of patients in the control group; this difference was not statistically significant (p = 0.66). Thromboembolic events were detected at a low rate (0.8 percent in the heparin-treated group versus 1.4 percent in the untreated group; p = 0.46). CONCLUSIONS The use of heparin for venous thrombotic prophylaxis did not increase the risk of reoperative hematoma after breast reconstruction with abdominal tissue. The authors propose a risk assessment that balances a statistical hematoma rate of 0.5 to 5 percent (clinically observed rate, 0.5 percent) with use of heparin prophylaxis against a rare (clinically observed rate, 1.4 percent) but morbid occurrence of thromboembolic complications when chemoprophylaxis is omitted.
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Rawat A, Huynh TT, Peden EK, Kougias P, Lin PH. Primary prophylaxis of venous thromboembolism in surgical patients. Vasc Endovascular Surg 2008; 42:205-16. [PMID: 18375602 DOI: 10.1177/1538574408315208] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Venous thromboembolism is a major risk for surgical patients during the perioperative period. Prevention of perioperative venous thromboembolism remains a critical component of surgical patient care. The risk for venous thromboembolism in surgical patients can be stratified by their risk factors and by the type of operation. Pharmacological prophylaxis for venous thromboembolism includes unfractionated heparin, low-molecular weight heparin, fondaparinux, warfarin, antiplatelet therapy, and direct thrombin inhibitors. Mechanical devices such as graduated compression stockings, intermittent pneumatic compressions, and venous foot pumps are also effective modalities for venous thromboembolism prophylaxis. The optimal preventive measure of venous thromboembolism should be based on the degree of risk for venous thromboembolism with the intensity of prophylaxis while balancing potential treatment benefits and risks in each individual patient. The epidemiology of venous thromboembolism, the methods for achieving venous thromboembolism prophylaxis, and the approach to institute venous thromboembolism prophylaxis in surgical patients undergoing various operative interventions are reviewed in this article.
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Affiliation(s)
- Anish Rawat
- Division of Vascular Surgery & Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA
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Hsiao GR, Wolf RE, Kimpel DL. Intravenous immunoglobulin to prevent recurrent thrombosis in the antiphospholipid syndrome. J Clin Rheumatol 2007; 7:336-9. [PMID: 17039166 DOI: 10.1097/00124743-200110000-00017] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The antiphospholipid syndrome (APS) occurs as a primary entity or in association with autoimmune diseases, malignancies, or medications. Conventional treatment for APS-associated thrombosis involves the use of anticoagulants such as aspirin, heparin, and warfarin. Alternative treatment options are limited. We report on a patient with APS who failed conventional therapy but had clinical improvement and a decline in anticardiolipin (aCL) antibody titers during treatment with monthly intravenous immunoglobulin (IVIg). Anticardiolipin antibodies IgG, IgA, and IgM were measured before initiating IVIg and before each subsequent infusion of IVIg. The patient was also evaluated for the presence of thromboses during the treatment period. IgG and IgA aCL levels were elevated initially, and there was a significant decrease in anticardiolipin IgG and IgA levels during treatment without further episodes of thrombosis. IVIg may be an alternative therapy for recurrent thrombosis in the antiphospholipid antibody syndrome.
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Affiliation(s)
- G R Hsiao
- Department of Medicine, Lousiana State University Health Sciences Center, Shreveport, Louisiana 71130, USA
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Abstract
Complex factors, including substances in cancer cells, cancer treatment effects, and venous stasis associated with chronic illness, blood vessel wall injury, and immobility, interact to place patients with cancer at risk for thrombosis. This article describes the etiology, clinical manifestations, diagnostic tests, and treatments for venous and pulmonary emboli associated with cancer. It explores the nurse's role in assessing patients who are at risk, managing symptomatic thrombosis and primary and secondary prevention of emboli, and administering anticoagulant therapy. As growing numbers of patients are treated in outpatient settings, oncology nurses play a critical role in the coordination of care for patients at risk for thrombosis. A nursing care plan summarizes key nursing strategies for assessment and intervention.
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Abstract
Anticoagulation therapy has been identified as an area in which new approaches to treatment and monitoring may allow for significant improvements in healthcare quality and costs. We evaluated the potential benefits of a new approach to anticoagulation therapy, utilizing decision support software, point-of-service testing, and workflow redesign. We performed an intervention study in the setting of a university-affiliated primary care clinic, involving 40 patients receiving chronic anticoagulation therapy. Study measurement included anticoagulation control, complications of therapy and related costs, as well as clinic revenue and overhead costs. After implementation of the new approach, the frequency of international normalized ratio (INR) results within therapeutic range increased from 34% to 67%. During a 1-year follow-up period, complications related to anticoagulation therapy were reduced by 91% (p < 0.01). Labor-related overhead costs decreased from approximately 12,600 to 3,100 US dollars. During the same period, the clinic generated approximately 35,000 US dollars in new revenue. For every dollar spent on clinic implementation and maintenance, over 25 US dollars was returned from cost containment and new revenue production. This approach allows a clinic to show improved anticoagulation control and complication rates while simultaneously improving financial performance.
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Affiliation(s)
- Mark Wurster
- OSU Internal Medicine, Grove City, Ohio 43054, USA.
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Durnig P, Jungwirth W. Low-Molecular-Weight Heparin and Postoperative Bleeding in Rhytidectomy. Plast Reconstr Surg 2006; 118:502-7; discussion 508-9. [PMID: 16874225 DOI: 10.1097/01.prs.0000228180.78071.44] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Postoperative bleeding and hematoma are unwanted complications, especially for face lifts, where the rate of hematoma is reported to be high. The authors investigated the rate of complications. As expected, the major adverse event was postoperative bleeding, requiring surgical evacuation of hematoma in 5.6 percent of cases. Plastic surgeons in Europe are currently under pressure to use low-molecular-weight heparin in every face lift patient because of the guidelines of the European Consensus Conference for Prophylaxis of Thromboembolism. METHODS Over a period of 1.5 years, a total of 126 patients took part in a retrospective, controlled trial on postoperative bleeding, with two comparative groups. Thirty-seven patients had received low-molecular-weight heparin; in 89 patients, no heparin thrombosis prophylaxis was used. The standard for each of the 126 rhytidectomy patients operated on was as follows: one surgeon, use of compression stockings, analgosedation, and mobilization of the patient on the day of operation. RESULTS The authors observed a 16.2 percent rate of postoperative bleeding in the low-molecular-weight heparin-group, compared with 1.1 percent in the group where no low-molecular-weight heparin was used. This was highly significant, especially when the Fisher's exact test was applied (p < 0.003). In 89 patients, when using compression stockings, analgosedation, and mobilization of the patient on the day of operation, the authors observed had no symptomatic thrombosis or pulmonary embolism if not using low-molecular-weight heparin. CONCLUSIONS The authors conclude that the rate of postoperative bleeding in face lifts under the use of low-molecular-weight heparin is higher than generally expected. As no symptomatic thrombosis or embolism without using low-molecular-weight heparin occurred, it seems that the use of low-molecular-weight heparin in face lifts is not categorically necessary in low-risk patients.
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Affiliation(s)
- Peter Durnig
- Department of Plastic, Aesthetic and Reconstructive Surgery, EMCO Private Hospital, Salzburg, Austria.
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Trivalle C, Ongaro G. [Use of low molecular weight heparin for medical prophylaxis by European geriatricians]. Rev Med Interne 2005; 27:10-5. [PMID: 16298021 DOI: 10.1016/j.revmed.2005.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2005] [Accepted: 10/03/2005] [Indexed: 10/25/2022]
Abstract
PURPOSE Many hospitalised elderly patients are at increased risk of venous thromboembolism (VTE). The aim of this study was to assess the rate and duration of medical utilization of low molecular weight heparin (LMWH) for VTE prevention by European geriatricians. METHOD A questionnaire was sent to 94 geriatricians of the European Academy for Medicine of Ageing (EAMA), to be filled out for each patient older than 65 years of their institutions who received LMWH during 1 day of December 2000. RESULTS In the 37 centers that participated (representing 11 different European countries) 2912 patients were present on the day of the study: 857 patients in acute care, 367 in rehabilitation care, 1568 in long-term care and 141 in day hospital. Prophylaxis by LMWH was given to 284 medical patients (9.75%, mean age 82.2 years). Use of LMWH was more frequent in acute and rehabilitation care (22.4% and 9.8%) than in long-term care (3.1%). The main risk factors in patients with LMWH prophylaxis were: bedridden (53%), infectious disease (18%), heart failure (17.6%), venous insufficiency (17.6%), paralysis of lower limbs (16.6%), recent stroke (15%) and malignancy (10%). The duration of the treatment for VTE prophylaxis exceeded 30 days in 51 patients (12%) and one year in 15 patients (3.3%). CONCLUSION In Europe, VTE prophylaxis by LMWH is widely used in elderly medical patients without specific guidelines in this population. Further studies are necessary to evaluate the appropriate duration of prophylaxis in very prolonged immobilization.
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Affiliation(s)
- C Trivalle
- Service de gérontologie et de soins palliatifs, hôpital Paul-Brousse, 14, avenue Paul-Vaillant-Couturier 94800 Villejuif cedex, France.
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Koya MP, Manoharan M, Kim SS, Soloway MS. Venous thromboembolism in radical prostatectomy: is heparinoid prophylaxis warranted? BJU Int 2005; 96:1019-21. [PMID: 16225520 DOI: 10.1111/j.1464-410x.2005.05783.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To review the incidence of venous thromboembolism (VTE) after radical retropubic prostatectomy (RRP) and evaluate the need for heparinoid prophylaxis as opposed to mechanical compression devices after RRP. PATIENTS AND METHODS RRP is classified as a category 1 (high risk) procedure for VTE by the American College of Chest Physicians and several international guidelines recommend subcutaneous heparinoids as the preferred prophylaxis. However, this regimen may be associated with a greater risk of bleeding. We have not used heparinoid prophylaxis but place a mechanical compression device for prophylaxis of VTE, and report our clinical experience over a 12-year period. Between 1992 and 2004, all RRPs carried out by one surgeon (M.S.S.) at our centre were retrospectively reviewed after obtaining institutional review board approval. The protocol for prophylaxis of VTE consisted of compression stockings and a sequential compression device from the time of entry into the operating room until complete ambulation (we encourage early ambulation). Patients were evaluated for VTE if they developed any clinical signs or symptoms. Patients were followed at 7 days, 6 weeks and 3 months after RRP in the first year and 6-monthly thereafter. All relevant clinical data and complications were entered in a database. RESULTS In all there were 1364 RRPs; the mean (sd) age of the patients was 61 (7) years and the mean follow-up 44 (38) months. All patients had a mechanical compression device and ambulated on the first day after surgery. None received heparinoid prophylaxis. Three VTE events were identified (0.21%); two patients had a lower limb VTE and one an upper limb VTE. All were successfully treated with anticoagulation. No patient had a documented pulmonary embolus and none died from VTE. There was one death after RRP, from myocardial infarction. CONCLUSION The incidence of VTE after RRP is low, possibly related to the use of a mechanical compression device and early aggressive mobilization. Despite the recommendations by some, we feel that routine heparinoid prophylaxis is questionable.
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Affiliation(s)
- Madhusudan P Koya
- Department of Urology, University of Miami School of Medicine, Miami, FL 33101, USA
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Macdonald RL, Amidei C, Baron J, Weir B, Brown F, Erickson RK, Hekmatpanah J, Frim D. Randomized, pilot study of intermittent pneumatic compression devices plus dalteparin versus intermittent pneumatic compression devices plus heparin for prevention of venous thromboembolism in patients undergoing craniotomy. SURGICAL NEUROLOGY 2003; 59:363-72; discussion 372-4. [PMID: 12765806 DOI: 10.1016/s0090-3019(03)00111-3] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Unfractionated heparin and the low molecular weight heparin, dalteparin, are used for prophylaxis against venous thromboembolism in patients undergoing craniotomy. These drugs were compared in a randomized, prospective pilot study comparing intermittent pneumatic compression devices plus dalteparin to intermittent pneumatic compression devices plus heparin. METHODS One hundred patients undergoing craniotomy were randomly allocated to receive perioperative prophylaxis with subcutaneous (SC heparin, 5000 units every 12 hours, or dalteparin, 2,500 units once a day, begun at induction of anesthesia and continued for 7 days or until the patient was ambulating. Entry criteria were age over 18 years, no deep vein thrombosis (DVT) preoperatively as judged by lower limb duplex ultrasound and no clinical evidence of pulmonary embolism preoperatively. Patients with hypersensitivity to heparin, penetrating head injury or who refused informed consent were excluded. Patients underwent a duplex study 1 week after surgery and 1 month clinical follow-up. All patients were treated with lower limb intermittent pneumatic compression devices. RESULTS There were no differences between groups in age, gender, and risk factors for venous thromboembolism. There were no differences between groups in intraoperative blood loss, transfusion requirements or postoperative platelet counts. Two patients receiving dalteparin developed DVT (one symptomatic and one asymptomatic). No patient treated with heparin developed DVT and no patient in either group developed pulmonary embolism. There were two hemorrhages that did not require repeat craniotomy in patients receiving dalteparin and one that did require surgical evacuation in a patient treated with heparin. Drug was stopped in two patients treated with dalteparin because of thrombocytopenia. None of these differences were statistically significant. CONCLUSION There was no significant difference in postoperative hemorrhage, venous thromboembolism or thrombocytopenia between heparin and dalteparin. The results suggest that, given the small sample size of this trial, both drugs appear to be safe and the incidence of venous thromboembolism by postoperative screening duplex ultrasound appears to be low when these agents are used in combination with intermittent pneumatic compression devices.
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Affiliation(s)
- R Loch Macdonald
- Department of Surgery, Section of Neurosurgery, Pritzker School of Medicine, University of Chicago Medical Center, Chicago, Illinois, USA
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Bick RL, Haas S. Thromboprophylaxis and thrombosis in medical, surgical, trauma, and obstetric/gynecologic patients. Hematol Oncol Clin North Am 2003; 17:217-58. [PMID: 12627670 DOI: 10.1016/s0889-8588(02)00100-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The International Consensus and the ACCP Sixth Consensus had a great impact on the clinical acceptance of LMWHs. These recommendations have been instrumental in initiating further clinical trial to answer key questions regarding thromboprophylaxis and in setting a new standard for patient care. Also, the key to cost containment in management of DVT/PE is to (1) define the etiology (blood coagulation protein or platelet defect), institute appropriate long-term therapy as indicated, and assess appropriate family members as indicated if a hereditary defect is found and (2) use LMWH as inpatient management. saving a minimum of 210,000.00 dollars per 1000 patients simply from cost savings of recurrence, saving 17 lives per 1000 patients, and saving exorbitant costs of care for patients with recurrence and development of chronic venous insufficiency. The use of outpatient LMWH will save 4,900,000.00 dollars per 1000 patients if applied to the 70% of patients with DVT who fit the criteria of no comorbid condition requiring hospitalization and who arrive early enough to allow a diagnosis to be sent home or hospitalized for 24 hours or less. The simple defining of defects leading to unexplained thrombosis will add another 3,000,000.00 dollars in savings per 1000 patients with DVT and approximately 350,000.00 dollars per 100 patients with thrombotic stroke. In those with transient ischemic attacks, defining the defect and instituting appropriate antithrombotic therapy, thereby potentially saving approximately 30% from developing a thrombotic stroke, amounts to approximately 350,500.00 dollars (= 30% of 1,168,500.00 dollars) in savings per 100 patients.
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Affiliation(s)
- Rodger L Bick
- Department of Medicine and Pathology, University of Texas Southwestern Medical Center, 10455 North Central Expressway, Suite 109-PMB320, Dallas, TX 75231, USA.
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Garrote García M, Iglesias Piñeiro MJ, López Gil A, Martín Alvarez R. [Profile of patients under treatment with heparin of low molecular weight]. Aten Primaria 2002; 30:256-7. [PMID: 12237032 PMCID: PMC7668977 DOI: 10.1016/s0212-6567(02)79018-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Abstract
From the information presented in this article, it can be concluded that clinical suspicion of VTE should be increased in patients with a history of VTE, recent surgery, spinal cord injury, trauma, or malignancy. A variety of medical illnesses also increase the risk of venous thrombosis, including congestive heart failure, myocardial infarction, stroke with paresis, nephrotic syndrome, cigarette smoking, and obesity. Hypercoagulable states, such as antithrombin III deficiency, protein C deficiency, protein S deficiency, or factor V Leiden mutation should be considered in those patients who develop VTE in the absence of known risk factors. Additionally, the presence of vena caval filters does not exclude the possibility of PE or recurrent DVT. With a careful assessment of risk, physicians can hope to increase the diagnostic yield of VTE and decrease the significant morbidity and mortality of caused by this disease.
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Affiliation(s)
- V Kim
- Department of Internal Medicine, Jefferson Medical College, Philadelphia, Pennsylvania, USA
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May CR. Management of venous thromboembolic disease in the lower limb. EMERGENCY MEDICINE (FREMANTLE, W.A.) 2001; 13:211-23. [PMID: 11482861 DOI: 10.1046/j.1442-2026.2001.00214.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Thromboembolic disease continues to cause significant morbidity and mortality in our community, despite extensive research into the aetiological factors and significant resources invested in the development of pharmacological agents for treating this condition. Development of more sensitive and specific modalities for identifying venous thromboses has improved their early detection, particularly in the commonest site, the lower limb. A rational evidence-based management pathway has not been formulated as debate continues over the most appropriate method of treatment. This review outlines the pathophysiology of the disease, provides a clinical pathway for the management of lower limb thromboembolic disease using reliable available evidence and briefly discusses the efficacy of drug therapy.
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Affiliation(s)
- C R May
- Department of Emergency Medicine, Royal Brisbane Hospital, Queensland, Australia.
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McLeod RS, Geerts WH, Sniderman KW, Greenwood C, Gregoire RC, Taylor BM, Silverman RE, Atkinson KG, Burnstein M, Marshall JC, Burul CJ, Anderson DR, Ross T, Wilson SR, Barton P. Subcutaneous heparin versus low-molecular-weight heparin as thromboprophylaxis in patients undergoing colorectal surgery: results of the canadian colorectal DVT prophylaxis trial: a randomized, double-blind trial. Ann Surg 2001; 233:438-44. [PMID: 11224634 PMCID: PMC1421263 DOI: 10.1097/00000658-200103000-00020] [Citation(s) in RCA: 182] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To compare the effectiveness and safety of low-dose unfractionated heparin and a low-molecular-weight heparin as prophylaxis against venous thromboembolism after colorectal surgery. METHODS In a multicenter, double-blind trial, patients undergoing resection of part or all of the colon or rectum were randomized to receive, by subcutaneous injection, either calcium heparin 5,000 units every 8 hours or enoxaparin 40 mg once daily (plus two additional saline injections). Deep vein thrombosis was assessed by routine bilateral contrast venography performed between postoperative day 5 and 9, or earlier if clinically suspected. RESULTS Nine hundred thirty-six randomized patients completed the protocol and had an adequate outcome assessment. The venous thromboembolism rates were the same in both groups. There were no deaths from pulmonary embolism or bleeding complications. Although the proportion of all bleeding events in the enoxaparin group was significantly greater than in the low-dose heparin group, the rates of major bleeding and reoperation for bleeding were not significantly different. CONCLUSIONS Both heparin 5,000 units subcutaneously every 8 hours and enoxaparin 40 mg subcutaneously once daily provide highly effective and safe prophylaxis for patients undergoing colorectal surgery. However, given the current differences in cost, prophylaxis with low-dose heparin remains the preferred method at present.
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Affiliation(s)
- R S McLeod
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
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Mackenzie AR, Laing RB, Douglas JG, Greaves M, Smith CC. High prevalence of iliofemoral venous thrombosis with severe groin infection among injecting drug users in North East Scotland: successful use of low molecular weight heparin with antibiotics. Postgrad Med J 2000; 76:561-5. [PMID: 10964121 PMCID: PMC1741719 DOI: 10.1136/pmj.76.899.561] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Injecting drug use, mainly of heroin, currently represents a major public health issue in the North East of Scotland. The recent tendency of the committed injecting drug user to inject into the groin has created novel problems for the Infection Unit. Data are presented on 20 consecutive patients admitted between 1994 and 1999 with iliofemoral venous thromboses, often complicated by severe soft tissue infections and bacteraemia as a result of heroin injection into the femoral vein. Nine had coexistent groin abscesses, four had severe streptococcal soft tissue infection of the right thigh, groin and lower abdomen, and two had coincidental soft tissue infections of the upper limb. Nine were bacteraemic on admission. All of the patients were chronic injecting drug users with a median injection duration of 6.5 years. The 18 patients tested for hepatitis C virus were all seropositive. None of the 14 patients tested was positive for HIV. Seventeen patients were treated with subcutaneous low molecular weight heparin (tinzaparin), three having received intravenous unfractionated heparin initially. The tinzaparin was self administered and given for a median duration of seven weeks. One patient declined to have any treatment. Three months after presentation eight patients were asymptomatic, seven had a persistently swollen leg, and five were lost to follow up. None developed clinically apparent pulmonary embolism after institution of anticoagulant therapy. The management of iliofemoral venous thrombosis in injection drug users is problematic because of poor venous access, non-compliance with prescribed treatment, ongoing injecting behaviour, and coexistent sepsis. It is unlikely that a randomised trial of standard treatment with heparin and warfarin versus low molecular weight heparin alone would be practical in this patient group. These retrospective data indicate that the use of tinzaparin in injecting drug users is feasible and appears to result in satisfactory clinical responses. The possibility of concomitant infection in injecting drug users with venous thrombosis should always be addressed, as it appears to be a common phenomenon. Early drainage of abscesses and antimicrobial chemotherapy, often administered intramuscularly or orally because of lack of peripheral venous access, is central to the appropriate care of these patients.
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Affiliation(s)
- A R Mackenzie
- Aberdeen Royal Infirmary, Foresterhill, Aberdeen, Scotland.
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Bick RL. Proficient and cost-effective approaches for the prevention and treatment of venous thrombosis and thromboembolism. Drugs 2000; 60:575-95. [PMID: 11030468 DOI: 10.2165/00003495-200060030-00005] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Thrombosis is clearly a common cause of death in the US. It is obviously of major importance to define the aetiology of deep vein thrombosis (DVT) as (i) many of these events are preventable if appropriate therapy, dependent upon the risk factors known is utilised; (ii) appropriate antithrombotic therapy will decrease risks of recurrence; (iii) the type of defect(s) and risk(s) will determine length of time the patient should remain on therapy for secondary prevention and (iv) if the defect is hereditary appropriate family members can be assessed. Aside from mortality, significant additional morbidity occurs from DVT including, but not limited to, stasis ulcers and other sequelae of post-phlebitic syndrome. Numerous studies have provided evidence that medical patients and patients undergoing surgery or trauma are at significant risk for developing DVT, including pulmonary embolism (PE). Thus, an important task for the clinician is to prevent DVT and its complications. It is important to define risk groups where prophylaxis must be considered. The attitudes and beliefs towards prophylaxis show great regional variations. This is true for the definition of risk groups, the proportion of patients receiving prophylaxis and prophylactic modalities used. For this reason, various 'consensus conference' groups have attempted to alleviate these problems; the primary mission of consensus guidelines is to provide optimal direction to the clinician in the setting of clinical practice. If the practice guidelines generated are successful they will assist clinicians in decision-making for their patients, and they will also provide protection against unjustified malpractice actions. Therapy may be complex, as clinical studies continue to identify more effective treatments. This review includes currently accepted approaches to the treatment of DVT. The clinical course of DVT is highly dynamic. When the response to therapy is not as expected, more than one cause of DVT may be present in a patient. Treatment must address the primary coagulopathy as well as any precipitating factors. The risk of pharmacological intervention must be balanced against potential benefit. If the incidence of DVT in a given disorder is low and if the mortality rate is similarly low, therapy with an agent known to be associated with a high risk for complications, such as warfarin, would not be indicated. If DVT is seen primarily after surgery or in other high-risk situations, therapy might be limited to a fixed time period. However, if the ongoing risk of DVT remains high or if a history of recurrent DVT dictates, lifelong therapy might be indicated. The recommendations presented are based upon published controlled trials; however, indications for therapy and therapeutic agents of choice will continually evolve. By applying the principles outlined in this review, substantial cost savings, reduction in morbidity and reductions in mortality should occur.
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Affiliation(s)
- R L Bick
- Department of Medicine and Pathology, University of Texas Southwestern Medical Center, Dallas, USA.
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22
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Peetz D, Hafner G, Hansen M, Mayer A, Rippin G, Rommens PM, Prellwitz W. Dose-adjusted thrombosis prophylaxis in trauma surgery according to levels of D-Dimer. Thromb Res 2000; 98:473-83. [PMID: 10899346 DOI: 10.1016/s0049-3848(00)00208-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
In 234 trauma surgery patients, thrombosis prophylaxis with Nadroparin-Calcium low-molecular-weight heparin (LMWH) was adjusted according to levels of D-Dimer. Basic prophylaxis was 2,850 IU per day. If D-Dimer concentrations rose above 2 mg/L after the fourth postoperative (p.o.) day, LMWH was administered twice a day. Color Doppler ultrasound was performed between the fifth and seventh p.o. days. Patients were divided into a high-risk (group 1: hip, femur, or knee replacement surgery, n=102) and a moderate-risk group (group 2: other surgery of the knee, tibia, fibula, or foot, n=132). Group 1 showed significantly higher D-Dimer levels than group 2 (p<0.001). Measurement of D-Dimer on days 2 and 4 p.o. showed a sensitivity of 100% and a specificity of 72.8% in identifying patients at risk (i.e., D-Dimer>2 mg/L after day 4 p.o.). The overall deep vein thrombosis (DVT) rate in group 1 was 3.9%, and the rate of proximal DVT was 1.96%. In group 2, one distal DVT (0.8%) occurred. The results show that D-Dimer is a useful marker to monitor p.o. coagulation activation and to manage LMWH prophylaxis in trauma surgery patients.
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Affiliation(s)
- D Peetz
- Institute of Clinical Chemistry and Laboratory Medicine, University of Mainz, Germany.
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23
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McDevitt NB. Deep vein thrombosis prophylaxis. American Society of Plastic and Reconstructive Surgeons. Plast Reconstr Surg 1999; 104:1923-8. [PMID: 10541199 DOI: 10.1097/00006534-199911000-00052] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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24
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Heras M, Fernández Ortiz A, Gómez Guindal JA, Iriarte JA, Lidón RM, Pérez Gómez F, Roldán I. [Practice guidelines of the Spanish Society of Cardiology. Recommendations for the use of antithrombotic treatment in cardiology]. Rev Esp Cardiol 1999; 52:801-20. [PMID: 10563156 DOI: 10.1016/s0300-8932(99)75009-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The indications for the use of antithrombotic therapy are evolving as new drugs become available or new indications or dosages are recommended for drugs already in use. This document reviews and updates the former one published in 1994. To that end, an exhaustive revision of the literature published in the last 15 years has been undertaken. Following the evidence based medicine dictates, and aiming to select all the relevant publications for each pathology, all studies were selected through MEDLINE, using the specified key words for each subject, and were filtered using the following steps: a) only randomized, controlled studies, meta-analysis, guidelines and review articles were chosen; b) then, the Best-Evidence and Cochrane Collaboration databases were consulted; c) finally, the evidence based medicine validation, relevance and applicability criteria were assessed for each publication. The use of antiaggregants and anticoagulants are given for the following conditions: a) prevention of deep vein thrombosis and pulmonary embolism; b) prevention of systemic emboli in patients with lone atrial fibrillation, atrial fibrillation associated or not with rheumatic heart disease, in patients with biological or mechanical cardiac valvular prostheses and in dilated cardiomyopathy; c) antithrombotic therapy in coronary heart disease and in coronary intervention; d) the interactions with oral anticoagulants and how to control these therapies are also discussed.
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Affiliation(s)
- M Heras
- Institut de Malalties Cardiovasculars, Hospital Clínic, Barcelona.
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25
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Bick RL. Therapy for venous thrombosis: guidelines for a competent and cost-effective approach. Clin Appl Thromb Hemost 1999; 5:2-9. [PMID: 10725975 DOI: 10.1177/107602969900500102] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- R L Bick
- University of Texas Southwestern Medical Center, Dallas, USA
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