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Venous Thromboembolism Prophylaxis in Orthopaedic Trauma Patients: A Survey of OTA Member Practice Patterns and OTA Expert Panel Recommendations. J Orthop Trauma 2015; 29:e355-62. [PMID: 26402304 DOI: 10.1097/bot.0000000000000387] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES First, to provide the readership with a summation of the current practice patterns of North American orthopaedic surgeons for venous thromboembolism prophylaxis after musculoskeletal trauma. Second, to establish a set of guidelines and recommendations based on the most current and best available evidence for venous thromboembolism (VTE) prophylaxis after musculoskeletal trauma. METHODS A 24 item questionnaire titled "OTA VTE Prophylaxis Survey" was sent to active members of the Orthopaedic Trauma Association. PubMed and OVID/MEDLINE were used to search the current published literature regarding VTE prophylaxis in trauma patients using the following search terms: deep venous thrombosis, DVT, pulmonary embolism, PE, venous thromboembolism, VTE, prophylaxis, trauma, fracture, pneumatic compression device, PCD, sequential compression device, SCD, screening, ultrasound, duplex, ultrasonography, DUS, venography, magnetic resonance venography, MRV, inferior vena cava, IVC, filter, and IVCF. Each recommendation was graded using articles that were considered by the subcommittee as "the best available evidence" using the grading system adopted and endorsed by the American Academy of Orthopedic Surgeons' Evidenced Based Quality and Value committee. RESULTS Overall, 185 of 1545 members completed the online survey. The range and variety of prophylaxis and screening methods used among orthopaedic trauma surgeons in North America is large, with a number of agents or methods for which no literature exists to support their use in musculoskeletal trauma. A set of recommendations and guidelines were constructed based on the results of the literature analysis and graded according to guidelines mentioned above. CONCLUSIONS Due to the wide variability in practice patterns, poor scientific support for various therapeutic regimens and important medical-legal implications highlighted by the survey, a standardized set of guidelines and recommendations for VTE prophylaxis after musculoskeletal trauma will be critical in helping to improve patient care and minimize surgeons' exposure to potentially litigious activity. LEVEL OF EVIDENCE Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.
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Liberman AL, Daruwalla VJ, Collins JD, Maas MB, Botelho MPF, Ayache JB, Carr J, Ruff I, Bernstein RA, Alberts MJ, Prabhakaran S. Diagnostic Yield of Pelvic Magnetic Resonance Venography in Patients With Cryptogenic Stroke and Patent Foramen Ovale. Stroke 2014; 45:2324-9. [DOI: 10.1161/strokeaha.114.005539] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ava L. Liberman
- From the Department of Neurology (A.L.L., M.B.M., I.R., R.A.B., S.P.) and Department of Radiology (V.J.D., J.D.C., M.P.F.B., J.B.A., J.C.), Northwestern University-Feinberg School of Medicine, Chicago, IL; and Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas (M.J.A)
| | - Vistasp J. Daruwalla
- From the Department of Neurology (A.L.L., M.B.M., I.R., R.A.B., S.P.) and Department of Radiology (V.J.D., J.D.C., M.P.F.B., J.B.A., J.C.), Northwestern University-Feinberg School of Medicine, Chicago, IL; and Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas (M.J.A)
| | - Jeremy D. Collins
- From the Department of Neurology (A.L.L., M.B.M., I.R., R.A.B., S.P.) and Department of Radiology (V.J.D., J.D.C., M.P.F.B., J.B.A., J.C.), Northwestern University-Feinberg School of Medicine, Chicago, IL; and Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas (M.J.A)
| | - Matthew B. Maas
- From the Department of Neurology (A.L.L., M.B.M., I.R., R.A.B., S.P.) and Department of Radiology (V.J.D., J.D.C., M.P.F.B., J.B.A., J.C.), Northwestern University-Feinberg School of Medicine, Chicago, IL; and Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas (M.J.A)
| | - Marcos Paulo Ferreira Botelho
- From the Department of Neurology (A.L.L., M.B.M., I.R., R.A.B., S.P.) and Department of Radiology (V.J.D., J.D.C., M.P.F.B., J.B.A., J.C.), Northwestern University-Feinberg School of Medicine, Chicago, IL; and Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas (M.J.A)
| | - Jad Bou Ayache
- From the Department of Neurology (A.L.L., M.B.M., I.R., R.A.B., S.P.) and Department of Radiology (V.J.D., J.D.C., M.P.F.B., J.B.A., J.C.), Northwestern University-Feinberg School of Medicine, Chicago, IL; and Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas (M.J.A)
| | - James Carr
- From the Department of Neurology (A.L.L., M.B.M., I.R., R.A.B., S.P.) and Department of Radiology (V.J.D., J.D.C., M.P.F.B., J.B.A., J.C.), Northwestern University-Feinberg School of Medicine, Chicago, IL; and Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas (M.J.A)
| | - Ilana Ruff
- From the Department of Neurology (A.L.L., M.B.M., I.R., R.A.B., S.P.) and Department of Radiology (V.J.D., J.D.C., M.P.F.B., J.B.A., J.C.), Northwestern University-Feinberg School of Medicine, Chicago, IL; and Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas (M.J.A)
| | - Richard A. Bernstein
- From the Department of Neurology (A.L.L., M.B.M., I.R., R.A.B., S.P.) and Department of Radiology (V.J.D., J.D.C., M.P.F.B., J.B.A., J.C.), Northwestern University-Feinberg School of Medicine, Chicago, IL; and Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas (M.J.A)
| | - Marc J. Alberts
- From the Department of Neurology (A.L.L., M.B.M., I.R., R.A.B., S.P.) and Department of Radiology (V.J.D., J.D.C., M.P.F.B., J.B.A., J.C.), Northwestern University-Feinberg School of Medicine, Chicago, IL; and Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas (M.J.A)
| | - Shyam Prabhakaran
- From the Department of Neurology (A.L.L., M.B.M., I.R., R.A.B., S.P.) and Department of Radiology (V.J.D., J.D.C., M.P.F.B., J.B.A., J.C.), Northwestern University-Feinberg School of Medicine, Chicago, IL; and Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas (M.J.A)
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The Impact of Pelvic and Lower Extremity Fractures on the Incidence of Lower Extremity Deep Vein Thrombosis in High-Risk Trauma Patients. Am Surg 2003. [DOI: 10.1177/000313480306900602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Lower extremity fractures (LEFx) and pelvic fractures (PFx) are believed to increase the risk of lower extremity deep vein thrombosis (LEDVT). We studied trauma patients at high risk for LEDVT to determine whether an increased incidence of LEDVT was associated with LEFx and/or PFx. From January 1995 through December 1997 4163 trauma patients were admitted to our Level I trauma center. One thousand ninety-three patients at high risk for LEDVT were screened with serial lower extremity venous duplex ultrasound. Their medical records were retrospectively reviewed for demographics, mechanism of injury, and fracture data. The occurrence of LEDVT, pulmonary embolus, and LEDVT prophylaxis and treatment were noted. The incidence of LEDVT in the fracture group (Fx) was compared with that in the nonfracture group (NFx) using chi-square analysis and logistic regression. Statistical significance was set at ≤0.05. Complete data were available for 1059 of 1093 patients. Five hundred sixty-nine (53.73%) patients had PFx and/or LEFx, 151 (14.26%) patients had PFx only, 317 (29.3%) patients had LEFx only, and 101 (9.54%) patients had both PFx and LEFx. Four hundred ninety (46.27%) patients had NFx. In 1059 patients LEDVT was detected in 125 (11.8%). Sixty-three patients in the Fx groups developed LEDVT (50.4%): 19 (15.2%) PFx patients, 15 (12.0%) PFx/LEFx patients, and 29 (23.2%) LEFx patients. Sixty-two (49.6%) NFx patients developed LEDVT. LEDVT incidence was not significantly different between the Fx and NFx groups or among the PFx, LEFx, and PFx/LEFx groups ( P = 0.317). Nine patients developed pulmonary embolism: four NFx patients, two LEFx patients, two PFx patients, and one PFx/LEFx patient. Significant predictors of LEDVT were age and hospital length of stay. Mean age in patients with LEDVT was 47.58 years and in patients without LEDVT it was 40.89 years ( P < 0.001). Mean hospital length of stay in patients with LEDVT was 29.81 days and in patients without LEDVT it was 16.84 days. The power of this study to detect differences representing medium effect sizes was greater than 90 per cent. We conclude that LEFx and/or PFx was not associated with an increased incidence of LEDVT in trauma patients at high risk for LEDVT. Lower extremity venous duplex ultrasound needs to be performed in both Fx and NFx groups to detect LEDVTs.
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Ryu JH, Swensen SJ, Olson EJ, Pellikka PA. Diagnosis of pulmonary embolism with use of computed tomographic angiography. Mayo Clin Proc 2001; 76:59-65. [PMID: 11155414 DOI: 10.4065/76.1.59] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Pulmonary embolism (PE) is a common diagnostic problem, particularly in hospitalized patients. It remains a frequent cause of unexpected deaths. Traditionally, the diagnostic work-up for suspected PE has centered on the use of ventilation-perfusion (V-P) radionuclide lung scanning. However, V-P scanning does not provide adequate confirmation or exclusion of the diagnosis in the majority of patients who undergo this test. Although published guidelines advise further diagnostic testing after nondiagnostic V-P scans, clinicians infrequently perform such testing, and management decisions are commonly based on clinical judgment. In recent years, there has been an increasing interest in the use of computed tomographic (CT) angiography in the diagnostic evaluation of patients with suspected PE. Although there are unresolved issues regarding its sensitivity in detecting small peripheral emboli, CT angiography is more accurate than V-P scanning in the diagnosis of PE and yields other intrathoracic diagnoses. Herein we summarize the problems with the traditional approach centered on the use of V-P scanning in the diagnosis of PE and propose an alternative diagnostic strategy based primarily on the use of CT angiography.
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Affiliation(s)
- J H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
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