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Douillet D, Penaloza A, Viglino D, Banihachemi JJ, Abboodi A, Helderlé M, Montassier E, Balen F, Brice C, Laribi S, Duchenoy T, Vives P, Soulat L, Marjanovic N, Moumneh T, Savary D, Riou J, Roy PM. Targeted prophylactic anticoagulation based on the TRiP(cast) score in patients with lower limb immobilisation: a multicentre, stepped wedge, randomised implementation trial. Lancet 2024; 403:1051-1060. [PMID: 38368901 DOI: 10.1016/s0140-6736(23)02369-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/14/2023] [Accepted: 10/20/2023] [Indexed: 02/20/2024]
Abstract
BACKGROUND Prophylactic anticoagulation in emergency department patients with lower limb trauma requiring immobilisation is controversial. The Thrombosis Risk Prediction for Patients with Cast Immobilisation-TRiP(cast)-score could identify a large subgroup of patients at low risk of venous thromboembolism for whom prophylactic anticoagulation can be safely withheld. We aimed to prospectively assess the safety of withholding anticoagulation for patients with lower limb trauma at low risk of venous thromboembolism, defined by a TRiP(cast) score of less than 7. METHODS CASTING was a stepped-wedge, multicentre, cluster-randomised trial with blinded outcome assessment. 15 emergency departments in France and Belgium were selected and randomly assigned staggered start dates for switching from the control phase (ie, anticoagulation prescription according to the physician's usual practice) to the intervention phase (ie, targeted anticoagulation according to TRiP(cast) score: no prescription if score <7 and anticoagulation if score was ≥7). Patients were included if they presented to a participating emergency department with lower limb trauma requiring immobilisation for at least 7 days and were aged 18 years or older. The primary outcome was the 3-month cumulative rate of symptomatic venous thromboembolism during the intervention phase in patients with a TRiP(cast) score of less than 7. The targeted strategy was considered safe if this rate was less than 1% with an upper 95% CI of less than 2%. The primary analysis was performed in the intention-to-treat population. This study is registered at ClinicalTrials.gov (NCT04064489). FINDINGS Between June 16, 2020, and Sept 15, 2021, 15 clusters and 2120 patients were included. Of the 1505 patients analysed in the intervention phase, 1159 (77·0%) had a TRiP(cast) score of less than 7 and did not receive anticoagulant treatment. The symptomatic venous thromboembolism rate was 0·7% (95% CI 0·3-1·4, n=8/1159). There was no difference between the control and the intervention phases in the cumulative rate of symptomatic venous thromboembolism or in bleeding rates. INTERPRETATION Patients with a TRiP(cast) score of less than 7 who are not receiving anticoagulation have a very low risk of venous thromboembolism. A large proportion of patients with lower limb trauma and immobilisation could safely avoid thromboprophylaxis. FUNDING French Ministry of Health.
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Affiliation(s)
- Delphine Douillet
- Emergency Department, Health Faculty, Angers University Hospital, Angers, France; UMR MitoVasc CNRS 6015 - INSERM 1083, Equipe CARME, UNIV Angers, Angers, France; F-CRIN INNOVTE Network, Saint-Etienne, France.
| | - Andrea Penaloza
- F-CRIN INNOVTE Network, Saint-Etienne, France; Emergency Department, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Damien Viglino
- Emergency Department, University Hospital of Grenoble Alpes, University Grenoble-Alpes, Grenoble, France; HP2 Laboratory, Grenoble Alpes University, INSERM U1300, Grenoble, France
| | - Jean-Jacques Banihachemi
- Department of Trauma and Musculo-Skeletal Emergency, University Hospital and Medical Centre of Grenoble-Alpes Hospital South, Grenoble, France
| | - Anmar Abboodi
- Emergency Department, Cholet Hospital, Cholet, France
| | | | - Emmanuel Montassier
- Emergency Department, Nantes University Hospital, Nantes, France; MiHAR Laboratary, EE1701, University of Nantes, Nantes, France
| | - Fréderic Balen
- Department of Emergency Medicine, Toulouse University Hospital, Toulouse, France
| | - Christian Brice
- Emergency Department, Centre Hospitalier de Saint-Brieuc, Saint-Brieuc, France
| | - Saïd Laribi
- Emergency Department, Tours University Hospital, Tours, France
| | | | | | - Louis Soulat
- Emergency Department, Rennes University Hospital, Rennes, France
| | | | - Thomas Moumneh
- Emergency Department, Health Faculty, Angers University Hospital, Angers, France; F-CRIN INNOVTE Network, Saint-Etienne, France
| | - Dominique Savary
- Emergency Department, Health Faculty, Angers University Hospital, Angers, France
| | - Jérémie Riou
- Methodology and Biostatistics Department, Delegation to Clinical Research and Innovation, Angers University Hospital, Angers, France
| | - Pierre-Marie Roy
- Emergency Department, Health Faculty, Angers University Hospital, Angers, France; UMR MitoVasc CNRS 6015 - INSERM 1083, Equipe CARME, UNIV Angers, Angers, France; F-CRIN INNOVTE Network, Saint-Etienne, France
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Douillet D, Barbère T, Peintre M, Moumneh T, Morin F, Savary D, Penaloza A, Roy PM. Risque thromboembolique veineux chez les patients traumatisés d’un membre inférieur nécessitant une immobilisation : vers une approche individualisée. ANNALES FRANCAISES DE MEDECINE D URGENCE 2021. [DOI: 10.3166/afmu-2021-0345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Un traumatisme d’un membre inférieur nécessitant une immobilisation est une situation à risque de développement de maladie thromboembolique veineuse (MTEV). Cependant, les recommandations et les pratiques varient notablement d’un pays à un autre et d’un centre à un autre. Cette revue narrative a pour objectifs de décrire l’épidémiologie, la prévention et les algorithmes de prédiction de la MTEV chez les patients traumatisés d’un membre inférieur nécessitant une immobilisation. L’incidence de la MTEV varie selon les études du fait de la grande hétérogénéité des patients inclus (de l’entorse de cheville à une lésion chirurgicale) et du fait des différents critères d’évaluation utilisés. L’incidence des événements thromboemboliques veineux symptomatiques est estimée à 2,0 % (intervalle de confiance à 95 % : 1,3 à 2,7). L’efficacité de la thromboprophylaxie a été démontrée dans des méta-analyses récentes. Cependant, la confiance à accorder à ces résultats est médiocre, car de nombreux essais présentaient des faiblesses méthodologiques. L’étude la plus importante et la plus récente ne montre pas de bénéfice de la prévention par héparine de bas poids moléculaire sur les événements symptomatiques dans une population non ciblée. Ces résultats suggèrent d’adopter une démarche personnalisée en réservant la prophylaxie aux patients à risque. Plusieurs scores existent pour évaluer le risque thromboembolique individuel. La prise en compte des caractéristiques du patient, du traumatisme et de l’immobilisation permet d’identifier un large sous-groupe de patients chez qui la prévention ne semble pas utile et un sous-groupe de patients à haut risque où la prévention devrait être prescrite, voire renforcée. En conclusion, lors d’un traumatisme d’un membre inférieur nécessitant une immobilisation, l’indication d’une thromboprophylaxie devrait être guidée par l’évaluation individuelle du risque thrombotique.
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Venous thromboembolism in trauma patients with lower limb cast immobilization, associated risk reduction and complication using rivaroxaban. Ir J Med Sci 2020; 190:169-175. [PMID: 32642982 DOI: 10.1007/s11845-020-02306-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 07/02/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Several studies have shown a reduction in the rate of thromboembolic events with LMWH thromboprophylaxis in patients immobilised in lower limb cast. However, the literature is limited on the use of rivaroxaban in this setting. Therefore the aim of this study was to assess the associated impact of rivaroxaban on the incidence of venous thromboembolism in trauma patients with lower limb cast immobilisation. METHOD Adult patients treated with lower limb cast immobilisation for different types of lower limb injuries were included in this study. One cohort of patients (n = 518) received rivaroxaban thromboprophylaxis. This was compared with a historical cohort (n = 486), who received no rivaroxaban for thromboprophylaxis. RESULTS The number of patients developing VTEs in the rivaroxaban group was zero, compared with 6 cases (1.2%) in the nonrivaroxaban group p = 0.013. There were no major or minor bleeding incidences; no wound complications reported in the rivaroxaban group. All the side effects reported in association with rivaroxaban use did not require further intervention. CONCLUSION This study has shown that rivaroxaban is associated with a significant reduction in the risk of VTEs in patients with lower limb cast immobilisation without increasing the risk of bleeding or associated untoward effect. Lower limb immobilisation is high risk factor for VTE per se. However, there is still limited data in the literature to make further recommendations.
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Espeit L, Lapole T. Effects of graduated compression stockings, local vibration and their combination on popliteal venous blood velocity. Phlebology 2020; 35:505-512. [DOI: 10.1177/0268355520902000] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Objectives The purpose of this pilot study was to examine and compare the effects of graduated compression stockings, local vibration, and combined graduated compression stockings and local vibration on popliteal venous blood velocity. Method Twenty-four healthy subjects received four 15 min interventions (control, graduated compression stockings alone, local vibration alone, and combined graduated compression stockings and local vibration), while resting inactive in the prone position. Popliteal vein blood velocity was investigated before (PRE) and at the end (POST) of each intervention using Doppler ultrasound. Results At POST, peak velocity was reported to be 26.3 ± 53.5% ( p < 0.05) greater for local vibration than control (CONT). Peak velocity was 46.2 ± 54.6% ( p < 0.001) and 21.1 ± 37.6% ( p < 0.01) higher for graduated compression stockings than CONT and local vibration, respectively. Graduated compression stockings + local vibration presented 64.1 ± 58.0% ( p < 0.001), 38.4 ± 52.4% ( p < 0.001) and 15.0 ± 31.6% ( p < 0.05) greater values than CONT, local vibration and graduated compression stockings, respectively. Conclusions This study demonstrated an increase in popliteal venous blood velocity after graduated compression stockings and local vibration application. Their combination provided the greatest effects.
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Affiliation(s)
| | - Thomas Lapole
- Univ Lyon, UJM Saint-Etienne, Laboratoire Interuniversitaire de Biologie de la Motricité, Saint-Etienne, France
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Pandor A, Horner D, Davis S, Goodacre S, Stevens JW, Clowes M, Hunt BJ, Nokes T, Keenan J, de Wit K. Different strategies for pharmacological thromboprophylaxis for lower-limb immobilisation after injury: systematic review and economic evaluation. Health Technol Assess 2019; 23:1-190. [PMID: 31851608 PMCID: PMC6936165 DOI: 10.3310/hta23630] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Thromboprophylaxis can reduce the risk of venous thromboembolism (VTE) during lower-limb immobilisation, but it is unclear whether or not this translates into meaningful health benefit, justifies the risk of bleeding or is cost-effective. Risk assessment models (RAMs) could select higher-risk individuals for thromboprophylaxis. OBJECTIVES To determine the clinical effectiveness and cost-effectiveness of different strategies for providing thromboprophylaxis to people with lower-limb immobilisation caused by injury and to identify priorities for future research. DATA SOURCES Ten electronic databases and research registers (MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Database of Abstracts of Review of Effects, the Cochrane Central Register of Controlled Trials, Health Technology Assessment database, NHS Economic Evaluation Database, Science Citation Index Expanded, ClinicalTrials.gov and the International Clinical Trials Registry Platform) were searched from inception to May 2017, and this was supplemented by hand-searching reference lists and contacting experts in the field. REVIEW METHODS Systematic reviews were undertaken to determine the effectiveness of pharmacological thromboprophylaxis in lower-limb immobilisation and to identify any study of risk factors or RAMs for VTE in lower-limb immobilisation. Study quality was assessed using appropriate tools. A network meta-analysis was undertaken for each outcome in the effectiveness review and the results of risk-prediction studies were presented descriptively. A modified Delphi survey was undertaken to identify risk predictors supported by expert consensus. Decision-analytic modelling was used to estimate the incremental cost per quality-adjusted life-year (QALY) gained of different thromboprophylaxis strategies from the perspectives of the NHS and Personal Social Services. RESULTS Data from 6857 participants across 13 trials were included in the meta-analysis. Thromboprophylaxis with low-molecular-weight heparin reduced the risk of any VTE [odds ratio (OR) 0.52, 95% credible interval (CrI) 0.37 to 0.71], clinically detected deep-vein thrombosis (DVT) (OR 0.40, 95% CrI 0.12 to 0.99) and pulmonary embolism (PE) (OR 0.17, 95% CrI 0.01 to 0.88). Thromboprophylaxis with fondaparinux (Arixtra®, Aspen Pharma Trading Ltd, Dublin, Ireland) reduced the risk of any VTE (OR 0.13, 95% CrI 0.05 to 0.30) and clinically detected DVT (OR 0.10, 95% CrI 0.01 to 0.94), but the effect on PE was inconclusive (OR 0.47, 95% CrI 0.01 to 9.54). Estimates of the risk of major bleeding with thromboprophylaxis were inconclusive owing to the small numbers of events. Fifteen studies of risk factors were identified, but only age (ORs 1.05 to 3.48), and injury type were consistently associated with VTE. Six studies of RAMs were identified, but only two reported prognostic accuracy data for VTE, based on small numbers of patients. Expert consensus was achieved for 13 risk predictors in lower-limb immobilisation due to injury. Modelling showed that thromboprophylaxis for all is effective (0.015 QALY gain, 95% CrI 0.004 to 0.029 QALYs) with a cost-effectiveness of £13,524 per QALY, compared with thromboprophylaxis for none. If risk-based strategies are included, it is potentially more cost-effective to limit thromboprophylaxis to patients with a Leiden thrombosis risk in plaster (cast) [L-TRiP(cast)] score of ≥ 9 (£20,000 per QALY threshold) or ≥ 8 (£30,000 per QALY threshold). An optimal threshold on the L-TRiP(cast) receiver operating characteristic curve would have sensitivity of 84-89% and specificity of 46-55%. LIMITATIONS Estimates of RAM prognostic accuracy are based on weak evidence. People at risk of bleeding were excluded from trials and, by implication, from modelling. CONCLUSIONS Thromboprophylaxis for lower-limb immobilisation due to injury is clinically effective and cost-effective compared with no thromboprophylaxis. Risk-based thromboprophylaxis is potentially optimal but the prognostic accuracy of existing RAMs is uncertain. FUTURE WORK Research is required to determine whether or not an appropriate RAM can accurately select higher-risk patients for thromboprophylaxis. STUDY REGISTRATION This study is registered as PROSPERO CRD42017058688. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Abdullah Pandor
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Daniel Horner
- Emergency Department, Salford Royal NHS Foundation Trust, Salford, UK
| | - Sarah Davis
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - John W Stevens
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Mark Clowes
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Beverley J Hunt
- Haemostasis Research Unit, King's College London, London, UK
| | - Tim Nokes
- Department of Haematology, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Jonathan Keenan
- Department of Haematology, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Kerstin de Wit
- Department of Medicine, Hamilton General Hospital, Hamilton, ON, Canada
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Horner D, Pandor A, Goodacre S, Clowes M, Hunt BJ. Individual risk factors predictive of venous thromboembolism in patients with temporary lower limb immobilization due to injury: a systematic review. J Thromb Haemost 2019; 17:329-344. [PMID: 30580466 PMCID: PMC6392108 DOI: 10.1111/jth.14367] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Indexed: 01/21/2023]
Abstract
Essentials Thromboprophylaxis after lower limb injury is often based on complex risk stratification. Our systematic review identified variables predicting venous thromboembolism (VTE) in this group. Age and injury type were commonly reported to increase the odds of VTE (odds ratio 1.5-3.48). We found limited evidence to support the use of other risk factors within prediction models. SUMMARY: Background Patients immobilized after lower limb injury are at risk of venous thromboembolism (VTE). There is international variation in the use of thromboprophylaxis for such patients. Risk-based strategies have been adopted to aid decision making in many settings. The accuracy of these strategies is unclear. Objectives A systematic review was undertaken to identify all individual patient-identifiable risk factors linked to any VTE outcome following lower limb immobilization. Methods Several electronic databases were searched from inception to May 2017. Any studies that included a measurement of VTE as a patient outcome in adults requiring temporary immobilization (e.g. leg cast or brace in an ambulatory setting) for an isolated lower limb injury and reported risk factor variables were included. Descriptive statistics and thematic analysis were used to synthesize the evidence. Results Our database search returned 4771 citations, of which 15 studies reporting outcome data on 80 678 patients were eligible for analysis. Risk-factor associations were reported through regression analyses, non-parametric tests and descriptive statistics. All studies were assessed as at moderate or serious risk of bias using the ROBINS-I risk of bias tool. Advancing age and injury type were the only individual risk factors demonstrating a reproducible association with increased symptomatic and/or asymptomatic VTE rates. Several risk factors currently used in scoring tools did not appear to be robustly evaluated for subsequent association with VTE within these studies. Conclusions Clinicians should be aware of the limited evidence to support individual risk factors in guiding thromboprophylaxis use for this patient cohort.
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Affiliation(s)
- Daniel Horner
- Emergency DepartmentSalford Royal NHS Foundation TrustSalfordUK
- School for Health and Related ResearchThe University of SheffieldSheffieldUK
- The Royal College of Emergency MedicineLondonUK
| | - Abdullah Pandor
- School for Health and Related ResearchThe University of SheffieldSheffieldUK
| | - Steve Goodacre
- School for Health and Related ResearchThe University of SheffieldSheffieldUK
| | - Mark Clowes
- School for Health and Related ResearchThe University of SheffieldSheffieldUK
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Abstract
Venous thromboembolism (VTE) including pulmonary embolism (PE) and deep vein thrombosis (DVT) is one of the leading causes of preventable cardiovascular disease in the United States (US) and is the number one preventable cause of death following a surgical procedure. Post-operative VTE is associated with multiple short and long-term complications. We will focus on reviewing the many faces of VTE in detail as they represent common challenging scenarios in clinical practice.
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Abstract
BACKGROUND: The knee scooter is a commonly used mobility device in the setting of unilateral below-knee immobilization. The bent-knee posture has been shown to decrease venous flow in a seated position, but the knee scooter differs as the patient is weightbearing through the affected extremity. Our goal was to investigate the effects of knee scooter positioning on popliteal venous flow. METHODS: Duplex ultrasonography was performed to obtain venous diameter and flow velocity of the popliteal vein on healthy subjects over the age of 18 without immobilization. Measurements were performed on the left knee of each subject while standing and with the same knee flexed on the knee scooter, by 2 physicians trained in ultrasound techniques. Mean velocity, peak velocity, vessel diameter, and volumetric flow rate were calculated and t tests were performed for each variable. A power analysis was performed, determining that 9 subjects would provide 80% power with an alpha of 0.05. A total of 13 subjects participated in the study. Mean age was 33 (range 20-56) years, with 6 females and 7 males. RESULTS: Measurements of subjects while standing and on the knee scooter demonstrated a significant decrease in mean velocity (6.5 vs 3.2 cm/s, P < .01) and volumetric flow rate (227.8 vs 106.2 mL/min, P < .01) while subjects were using the scooter. Vessel diameter (0.82 vs 0.78 cm, P = .15) and peak velocities (19.8 vs 14.7 cm/s, P = .19) were not significantly different between standing and kneeling positions. CONCLUSION: Our findings demonstrated a statistically significant decrease in volumetric flow rate in subjects using a knee scooter device with a flexed knee. Although venous stasis is a known risk factor for DVT, flow rate thresholds for increased thrombus formation are not well defined. The duration of scooter use, or flexed knee positioning, may have some effect on the degree of stasis. This finding should caution orthopedists to consider the risk attributed to the knee scooter as part of their overall patient assessment. LEVEL OF EVIDENCE: Level II, therapeutic, comparative study.
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Affiliation(s)
- David J Ciufo
- 1 Department of Orthopaedics, University of Rochester, Rochester, NY, USA
| | | | - Judith F Baumhauer
- 1 Department of Orthopaedics, University of Rochester, Rochester, NY, USA
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Alizadeh RF, Sujatha-Bhaskar S, Li S, Stamos MJ, Nguyen NT. Venous thromboembolism in common laparoscopic abdominal surgical operations. Am J Surg 2017; 214:1127-1132. [DOI: 10.1016/j.amjsurg.2017.08.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Revised: 07/30/2017] [Accepted: 08/05/2017] [Indexed: 11/27/2022]
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The effect of active toe movement (AToM) on calf pump function and deep vein thrombosis in patients with acute foot and ankle trauma treated with cast - A prospective randomized study. Foot Ankle Surg 2017; 23:183-188. [PMID: 28865588 DOI: 10.1016/j.fas.2016.04.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 04/17/2016] [Accepted: 04/18/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Patients with foot and ankle trauma treated with cast are advised to perform toe movements to prevent venous thromboembolism (VTE). Our aim was to determine the effect of active toe movement on asymptomatic deep vein thrombosis (DVT) and venous calf pump function. METHODS Patients aged 18-60 years with acute foot and ankle trauma requiring below knee non weight bearing cast were randomized to intervention (regular active toe movement) or control groups (n=100). Patients had bilateral lower limb venous ultrasound to assess for DVT on discharge from clinic. Patients requiring chemical thromboprophylaxis were excluded. RESULTS 78 completed the study. 27% sustained asymptomatic DVT, with no statistically significant difference in calf pump function or DVT incidence between groups. All DVT's occurred in the injured lower limb. CONCLUSION Active toe movement is not a viable strategy for thromboprophylaxis in patients with acute foot and ankle trauma treated with cast.
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AlHajri L, Jabbari S, AlEmad H, AlMahri K, AlMahri M, AlKitbi N. The Efficacy and Safety of Edoxaban for VTE Prophylaxis Post-Orthopedic Surgery: A Systematic Review. J Cardiovasc Pharmacol Ther 2016; 22:230-238. [PMID: 27811198 DOI: 10.1177/1074248416675732] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a common complication that manifests during and/or after hospitalization, as well as postsurgeries including orthopedic surgeries. Edoxaban is a new oral direct factor Xa inhibitor that has been recently approved for treating VTE in patients who have already been treated with a parenteral anticoagulant and for the prevention of stroke and non-central nervous system systemic embolism in patients with nonvalvular atrial fibrillation. OBJECTIVES The purpose of this systematic review was to evaluate the safety and efficacy of edoxaban for VTE prophylaxis after lower limb orthopedic surgery. MATERIALS AND METHODS A comprehensive search was conducted in Google Scholar, PubMed, MEDLINE, and ScienceDirect to identify potential records, then titles, abstracts, and full texts were screened using the inclusion criteria to filter out irrelevant studies. Moreover, the data extraction and quality assessment were undertaken using standardized tools, and the results were narratively synthesized and presented in tables. RESULTS Six studies were included in this systematic review after screening 2989 records. The majority of studies demonstrated a statistically significant reduction in VTE events in the edoxaban group(s) compared to the dalteparin, placebo, or enoxaparin groups (P < .05). The differences in VTE cases in some studies reached to approximately 50% favoring edoxaban 30 mg over the comparator (P < .05). However, other studies uncovered a statistically insignificant difference between edoxaban and the comparator "enoxaparin" when used for VTE prophylaxis (P > .05). On the other hand, although edoxaban found to cause more bleeding, the differences between edoxaban and the comparator are statistically insignificant (P > .05). CONCLUSION This study helped to amalgamate evidence with regard to the use of edoxaban for VTE prophylaxis post-lower limb orthopedic surgery. In line with the results of the reviewed studies, edoxaban seems to be highly effective in reducing VTE post-lower limb orthopedic surgery.
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Affiliation(s)
- Lamia AlHajri
- 1 Higher Colleges of Technology, Dubai, United Arab Emirates
| | - Sima Jabbari
- 1 Higher Colleges of Technology, Dubai, United Arab Emirates
| | - Hind AlEmad
- 1 Higher Colleges of Technology, Dubai, United Arab Emirates
| | - Khawla AlMahri
- 1 Higher Colleges of Technology, Dubai, United Arab Emirates
| | - Maryam AlMahri
- 1 Higher Colleges of Technology, Dubai, United Arab Emirates
| | - Noora AlKitbi
- 1 Higher Colleges of Technology, Dubai, United Arab Emirates
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Watson U, Hickey BA, Jones HM, Perera A. A critical evaluation of venous thromboembolism risk assessment models used in patients with lower limb cast immobilisation. Foot Ankle Surg 2016; 22:191-195. [PMID: 27502229 DOI: 10.1016/j.fas.2015.08.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 08/09/2015] [Accepted: 08/15/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND There is a recognised link between lower limb cast immobilisation and the development of venous thromboembolism (VTE). Our aim was to assess the diagnostic accuracy of risk assessment models (RAMs) applicable to this patient group. This has not been done before. METHODS A literature and guideline review identified five RAMs. They were used to retrospectively risk assess a consecutive series of patients who were diagnosed with symptomatic VTE following lower limb injury treated with a cast (Group I). A case-matched cohort who did not suffer symptomatic VTE (Group II) was also retrospectively risk assessed. The RAMs' diagnostic performance indicators were calculated. RESULTS Groups I and II consisted of 21 patients each. There was no significant difference in the mean age or total number of VTE risk factors between Groups I and II (p=.957 and p=.878 respectively). The Plymouth (2010) RAM achieved the highest accuracy (54.8%). CONCLUSIONS Each RAM demonstrated significant limitations. Two displayed very limited clinical utility. Three recommended chemical thromboprophylaxis to all patients because they weighted lower limb immobilisation as an absolute risk factor for the development of VTE. Cast immobilisation should not be considered an absolute risk factor when risk assessing patients who all have casts. Prospective evaluation with a larger patient cohort is required.
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Affiliation(s)
- Ultan Watson
- Cardiff University Medical School, United Kingdom.
| | - Ben A Hickey
- University Hospital Wales, Cardiff and Vale University Health Board, United Kingdom
| | - Huw M Jones
- University Hospital Wales, Cardiff and Vale University Health Board, United Kingdom
| | - Anthony Perera
- University Hospital Wales, Cardiff and Vale University Health Board, United Kingdom
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Effects of intermittent pneumatic compression of the thigh on blood flow velocity in the femoral and popliteal veins: developing a new physical prophylaxis for deep vein thrombosis in patients with plaster-cast immobilization of the leg. J Thromb Thrombolysis 2016; 42:579-84. [DOI: 10.1007/s11239-016-1403-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Yamada SM, Tomita Y, Murakami H, Nakane M. Deep Vein Thrombosis in the Lower Extremities in Comatose Elderly Patients with Acute Neurological Diseases. Yonsei Med J 2016; 57:388-92. [PMID: 26847291 PMCID: PMC4740531 DOI: 10.3349/ymj.2016.57.2.388] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 07/16/2015] [Accepted: 07/28/2015] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
- Shoko Merrit Yamada
- Department of Neurosurgery, Teikyo University Mizonokuchi Hospital, Kawasaki, Japan.
| | - Yusuke Tomita
- Department of Neurosurgery, Teikyo University Mizonokuchi Hospital, Kawasaki, Japan
| | - Hideki Murakami
- Department of Neurosurgery, Teikyo University Mizonokuchi Hospital, Kawasaki, Japan
| | - Makoto Nakane
- Department of Neurosurgery, Teikyo University Mizonokuchi Hospital, Kawasaki, Japan
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15
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Domeij-Arverud E, Ackermann PW. Deep Venous Thrombosis and Tendon Healing. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 920:221-8. [PMID: 27535264 DOI: 10.1007/978-3-319-33943-6_21] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Tendon metabolism after acute Achilles tendon rupture (ATR) is associated with major complications related to immobilization, which results in reduced circulation, high risk of deep venous thrombosis (DVT), impaired healing and functional deficits.DVT has been demonstrated to occur in up to 50 % of the patients with ATR. Suffering from a DVT during tendon healing has been demonstrated as an independent predictive factor for impaired patient outcome at 1 year after ATR, suggesting that specific interventions are warranted to prevent DVT. Since pharmacological DVT prophylaxis has low or no effect during lower leg immobilization it is speculated whether adjuvant treatment with intermittent pneumatic compression (IPC) applied during lower limb immobilization can reduce the incidence of DVT.IPC, which acts through mechanical, chemical and molecular mechanisms, has been demonstrated to enhance neuro-vascular ingrowth in a tendon repair model and stimulate collagen production leading to improved maximum force during healing.Recently, a prospective randomized trial compared adjuvant IPC applied under an orthosis versus plaster cast only in ATR patients. The study found at 2 weeks post-operatively 21 % DVTs in the IPC-group compared to 37 % in the control group. Patients that received no IPC treatment exhibited an almost threefold increased odds for DVT, independently of age. Furthermore, using microdialysis technique, adjuvant IPC treatment was shown to increase the metabolic healing activity at 2 weeks post-ATR.Tendon healing is impaired by reduced circulation and DVT. The demonstration that adjuvant IPC effectively reduced DVT incidence, and also is capable of enhancing the metabolic response suggests that IPC treatment may not only be a viable means of prophylaxis against DVT, but possibly also a method of promoting healing.
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Affiliation(s)
- Erica Domeij-Arverud
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-17176, Stockholm, Sweden.
- Department of Orthopedic Surgery, Danderyd Hospital, Stockholm, SE-17176, Sweden.
| | - Paul W Ackermann
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-17176, Stockholm, Sweden
- Department of Orthopedic Surgery, Karolinska University Hospital, SE-17176, Stockholm, Sweden
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16
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Nemeth B, van Adrichem RA, van Hylckama Vlieg A, Bucciarelli P, Martinelli I, Baglin T, Rosendaal FR, le Cessie S, Cannegieter SC. Venous Thrombosis Risk after Cast Immobilization of the Lower Extremity: Derivation and Validation of a Clinical Prediction Score, L-TRiP(cast), in Three Population-Based Case-Control Studies. PLoS Med 2015; 12:e1001899; discussion e1001899. [PMID: 26554832 PMCID: PMC4640574 DOI: 10.1371/journal.pmed.1001899] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 09/28/2015] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Guidelines and clinical practice vary considerably with respect to thrombosis prophylaxis during plaster cast immobilization of the lower extremity. Identifying patients at high risk for the development of venous thromboembolism (VTE) would provide a basis for considering individual thromboprophylaxis use and planning treatment studies. The aims of this study were (1) to investigate the predictive value of genetic and environmental risk factors, levels of coagulation factors, and other biomarkers for the occurrence of VTE after cast immobilization of the lower extremity and (2) to develop a clinical prediction tool for the prediction of VTE in plaster cast patients. METHODS AND FINDINGS We used data from a large population-based case-control study (MEGA study, 4,446 cases with VTE, 6,118 controls without) designed to identify risk factors for a first VTE. Cases were recruited from six anticoagulation clinics in the Netherlands between 1999 and 2004; controls were their partners or individuals identified via random digit dialing. Identification of predictor variables to be included in the model was based on reported associations in the literature or on a relative risk (odds ratio) > 1.2 and p ≤ 0.25 in the univariate analysis of all participants. Using multivariate logistic regression, a full prediction model was created. In addition to the full model (all variables), a restricted model (minimum number of predictors with a maximum predictive value) and a clinical model (environmental risk factors only, no blood draw or assays required) were created. To determine the discriminatory power in patients with cast immobilization (n = 230), the area under the curve (AUC) was calculated by means of a receiver operating characteristic. Validation was performed in two other case-control studies of the etiology of VTE: (1) the THE-VTE study, a two-center, population-based case-control study (conducted in Leiden, the Netherlands, and Cambridge, United Kingdom) with 784 cases and 523 controls included between March 2003 and December 2008 and (2) the Milan study, a population-based case-control study with 2,117 cases and 2,088 controls selected between December 1993 and December 2010 at the Thrombosis Center, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy. The full model consisted of 32 predictors, including three genetic factors and six biomarkers. For this model, an AUC of 0.85 (95% CI 0.77-0.92) was found in individuals with plaster cast immobilization of the lower extremity. The AUC for the restricted model (containing 11 predictors, including two genetic factors and one biomarker) was 0.84 (95% CI 0.77-0.92). The clinical model (consisting of 14 environmental predictors) resulted in an AUC of 0.77 (95% CI 0.66-0.87). The clinical model was converted into a risk score, the L-TRiP(cast) score (Leiden-Thrombosis Risk Prediction for patients with cast immobilization score), which showed an AUC of 0.76 (95% CI 0.66-0.86). Validation in the THE-VTE study data resulted in an AUC of 0.77 (95% CI 0.58-0.96) for the L-TRiP(cast) score. Validation in the Milan study resulted in an AUC of 0.93 (95% CI 0.86-1.00) for the full model, an AUC of 0.92 (95% CI 0.76-0.87) for the restricted model, and an AUC of 0.96 (95% CI 0.92-0.99) for the clinical model. The L-TRiP(cast) score resulted in an AUC of 0.95 (95% CI 0.91-0.99). Major limitations of this study were that information on thromboprophylaxis was not available for patients who had plaster cast immobilization of the lower extremity and that blood was drawn 3 mo after the thrombotic event. CONCLUSIONS These results show that information on environmental risk factors, coagulation factors, and genetic determinants in patients with plaster casts leads to high accuracy in the prediction of VTE risk. In daily practice, the clinical model may be the preferred model as its factors are most easy to determine, while the model still has good predictive performance. These results may provide guidance for thromboprophylaxis and form the basis for a management study.
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Affiliation(s)
- Banne Nemeth
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Raymond A. van Adrichem
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Paolo Bucciarelli
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca’ Granda–Ospedale Maggiore Policlinico, Milan, Italy
| | - Ida Martinelli
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca’ Granda–Ospedale Maggiore Policlinico, Milan, Italy
| | - Trevor Baglin
- Department of Haematology, Addenbrook’s Hospital, Cambridge, United Kingdom
| | - Frits R. Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Saskia le Cessie
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, the Netherlands
| | - Suzanne C. Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- * E-mail:
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Menakaya CU, Khan AS, Nunn T, Pennington N, Ward M, Malhotra R, Muthukumar N, Mohsen A. Patient evaluation of outpatient venous thromboembolism prophylaxis service following lower limb injuries using a developed validated questionnaire. J Perioper Pract 2015; 25:72-7. [PMID: 26012185 DOI: 10.1177/175045891502500403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This paper explores patients' perceptions of a new service and protocol for managing outpatient venous thromboembolism (VTE) prophylaxis, using either subcutaneous Dalteparin or oral off-license Dabigatran in patients with lower limb injury requiring immobilisation. Establishing a patient's perspective is part of good practice as, when this is positive, it aids patient compliance and protocol dissemination. A questionnaire consisting of fifty questions was given at random to one hundred patients over a six month period when they attended the trauma clinic. Each question was scored on a five point Likert scale (1 = poor, 5 = excellent) by the patient. The internal consistency of the questionnaire (Cronbach's alpha reliability coefficient) was more than 0.9 in all domains. Qualitative analysis was done for open-ended questions. One hundred respondents completed the questionnaire, two were void due to significant amounts of incomplete data. The gender split was 54 females, 43 males, and one did not answer the question. The average age was 43 (range 18-72). Sixty seven respondents were first-time attenders, 22 were follow-up patients and nine did not complete this section. The overall average score was 4.26 (range 1-5), with 90% of the patients recommending the service. The overall patient satisfaction for a VTE prophylaxis service is high although there is room for improvement as demonstrated by the range of the scores.
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18
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Domeij-Arverud E, Labruto F, Latifi A, Nilsson G, Edman G, Ackermann PW. Intermittent pneumatic compression reduces the risk of deep vein thrombosis during post-operative lower limb immobilisation. Bone Joint J 2015; 97-B:675-80. [DOI: 10.1302/0301-620x.97b5.34581] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Deep vein thrombosis is a common complication of immobilising the lower limb after surgery. We hypothesised that intermittent pneumatic compression (IPC) therapy in outpatients who had undergone surgical repair of acute ruptures of the Achilles tendon could reduce the incidence of this problem. A total of 150 patients who had undergone surgical repair of the Achilles tendon were randomised to either treatment with IPC for six hours per day (n = 74) under an orthosis or treatment as usual (n = 74) in a plaster cast without IPC. At two weeks post-operatively, the incidence of deep vein thrombosis was assessed using blinded, double-reported compression duplex ultrasound. At this point, IPC was discontinued and all patients were immobilised in an orthosis for a further four weeks. At six weeks post-operatively, a second compression duplex ultrasound scan was performed. At two weeks, the incidence of deep vein thrombosis was 21% in the treated group and 37% in the control group (p = 0.042). Age over 39 years was found to be a strong risk factor for deep vein thrombosis (odds ratio (OR) = 4.84, 95% confidence interval (CI) 2.14 to 10.96). Treatment with IPC, corrected for age differences between groups, reduced the risk of deep vein thrombosis at the two-week point (OR = 2.60; 95% CI 1.15 to 5.91; p =0.022). At six weeks, the incidence of deep vein thrombosis was 52% in the treated group and 48% in the control group (OR 0.94, 95% CI 0.49 to 1.83). IPC appears to be an effective method of reducing the risk of deep vein thrombosis in the early stages of post-operative immobilisation of outpatients. Further research is necessary to elucidate whether it can confer similar benefits over longer periods of immobilisation and in a more heterogeneous group of patients. Cite this article: Bone Joint J 2015;97-B:675–80.
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Affiliation(s)
| | - F. Labruto
- Karolinska Institutet, Stockholm, 171
76, Sweden
| | - A. Latifi
- Karolinska Institutet, Stockholm, 171
76, Sweden
| | - G. Nilsson
- Karolinska Institutet, Stockholm, 171
76, Sweden
| | - G. Edman
- Tiohundra Hospital, SE-761
29, Norrtälje, Sweden
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19
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Imbalzano E, Creazzo M, Trapani G, Lizio G, Saitta A. Ineffective Treatment of Low-Molecular-Weight Heparin in Obese Subject with Traumatic Fractures of the Leg. Int J Angiol 2015; 25:e16-e18. [PMID: 28031644 DOI: 10.1055/s-0034-1396899] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
American College of Chest Physicians Evidence-Based Clinical Practice Guidelines, 9th edition, 2012, suggest no prophylaxis rather than pharmacological thromboprophylaxis in management of venous thromboembolism (VTE) risk of isolated lower leg injuries distal to knee requiring leg immobilization. Low-molecular-weight heparin (LMWH) is a class of drugs commonly used as antithrombotics in surgery and in case of prolonged bed rest and hypomobility. A 35-year-old obese man with no history of health disease (height, 170 cm; weight, 95 kg; and body mass index, 32.9 kg/m2) was involved in a car accident, and as a result of the trauma he suffered the compound fracture of left tibia and fibula. Tibial intramedullary nailing was performed. The injury was near the knee, and the patient was advised long-term bed rest. For these reasons, he was treated with enoxaparin 40 mg once daily subcutaneously. On the 7th day of hospitalization, the leg became edematous and reddish. A Doppler ultrasonography evaluation was performed which showed a massive deep vein thrombosis of left leg and then a pulmonary angiotomography showed a massive pulmonary embolism. In this clinical case, there was a pharmacological treatment failure to prevent VTE after orthopedic surgery and related long-term rest using enoxaparin at prophylaxis dosage in a patient without history of health disease but at high risk of VTE for obesity, trauma, orthopedic surgery, and immobilization. Enoxaparin dosage to prevent VTE in patients with high risk should be reconsidered and especially in obese a weight-adjusted dosage can be better than a fixed dosage.
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Affiliation(s)
- Egidio Imbalzano
- Department of Internal Medicine and Medical Therapy, University of Messina, Messina, Sicily, Italy
| | - Michele Creazzo
- Department of Internal Medicine and Medical Therapy, University of Messina, Messina, Sicily, Italy
| | - Giovanni Trapani
- Department of Internal Medicine and Medical Therapy, University of Messina, Messina, Sicily, Italy
| | - Giuseppina Lizio
- Department of Internal Medicine and Medical Therapy, University of Messina, Messina, Sicily, Italy
| | - Antonino Saitta
- Department of Internal Medicine and Medical Therapy, University of Messina, Messina, Sicily, Italy
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20
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Craik JD, Clark A, Hendry J, Sott AH, Hamilton PD. The effect of ankle joint immobilization on lower limb venous flow. Foot Ankle Int 2015; 36:18-23. [PMID: 25249319 DOI: 10.1177/1071100714552823] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Below-knee cast immobilization is associated with an increased risk of developing deep vein thrombosis secondary to venous stasis. We investigated the effect of weight-bearing in a below-knee cast or pneumatic walking boot on lower limb venous blood flow. METHODS Duplex ultrasonography was used to measure venous blood flow in the popliteal vein of 10 healthy volunteers. Venous blood flow was measured while at rest, ambulating non-weight-bearing, partial weight-bearing, and full weight-bearing. Measurements were performed without ankle joint immobilization, with the ankle immobilized in a neutral cast, and with the ankle immobilized in a pneumatic walking boot in both neutral and equinus. RESULTS There was no significant reduction in venous blood flow measurements between full weight-bearing without ankle joint immobilization and full weight-bearing in a neutral cast or neutral pneumatic walking boot. However, venous blood flow was reduced when partial weight-bearing (50%) and when full weight-bearing in a pneumatic walking boot in equinus. CONCLUSION These results demonstrate that venous blood flow returned to normal levels when the subjects were permitted to fully bear weight in below-knee casts or walking boots, provided that the ankle joint was not in equinus. CLINICAL RELEVANCE Weight-bearing status and ankle joint position should be appreciated during decisions for the provision of chemical thromboprophylaxis.
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Affiliation(s)
| | - Amanda Clark
- Department of Orthopaedics, Epsom General Hospital, Surrey, UK
| | - James Hendry
- Department of Orthopaedics, Epsom General Hospital, Surrey, UK
| | - Andrea H Sott
- Department of Orthopaedics, Epsom General Hospital, Surrey, UK
| | - Paul D Hamilton
- Department of Orthopaedics, Epsom General Hospital, Surrey, UK
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21
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Hickey BA, Morgan A, Pugh N, Perera A. The effect of lower limb cast immobilization on calf muscle pump function: a simple strategy of exercises can maintain flow. Foot Ankle Int 2014; 35:429-33. [PMID: 24719402 DOI: 10.1177/1071100714530884] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND We have investigated the role of the calf muscle pump in casted patients. An audit of venous thromboembolism (VTE) in casted patients showed that the thrombosis occurred in the casted leg; this has not been previously assessed. We postulated that local factors play a major role, and we set out to assess the calf muscle pump in casted patients and to determine whether this can be optimized despite below-knee cast immobilization. METHODS We measured the flow in the popliteal vein using a validated method of Doppler ultrasound measurement of peak velocity with and without a below-knee plaster cast. RESULTS We demonstrated that a simple strategy of toe and ankle exercises can maintain venous return despite below-knee cast immobilization. CONCLUSION This is the first study to examine the effect of the calf muscle pump in the presence of a plaster cast. Major muscle groups such as the flexor hallucis longus and gastrocsoleus extend beyond the field of control of the cast and can still be recruited. CLINICAL RELEVANCE We recommend that all patients treated with a below-knee cast be given a program of exercises that can be comfortably performed with the cast; this could provide a useful, inexpensive, and safe thromboprophylaxis strategy acting at the site of greatest risk and targeting a major cause of VTE.
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Affiliation(s)
- Ben A Hickey
- University Hospital of Wales, Cardiff, Wales, UK
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22
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Samama CM, Lecoules N, Kierzek G, Claessens YE, Riou B, Rosencher N, Mismetti P, Sautet A, Barrellier MT, Apartsin K, Jonas M, Caeiro JR, Van der veen AH, Roy PM. Étude comparant le fondaparinux à une héparine de bas poids moléculaire dans la prévention de la maladie thromboembolique veineuse en cas d’immobilisation rigide ou semi-rigide après traumatisme isolé non chirurgical du membre inférieur au-dessous du genou. ANNALES FRANCAISES DE MEDECINE D URGENCE 2014. [DOI: 10.1007/s13341-014-0405-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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23
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Domeij-Arverud E, Latifi A, Labruto F, Nilsson G, Ackermann PW. Can foot compression under a plaster cast prevent deep-vein thrombosis during lower limb immobilisation? Bone Joint J 2013; 95-B:1227-31. [PMID: 23997137 DOI: 10.1302/0301-620x.95b9.31162] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We hypothesised that adjuvant intermittent pneumatic compression (IPC) beneath a plaster cast would reduce the risk of deep-vein thrombosis (DVT) during post-operative immobilisation of the lower limb. Of 87 patients with acute tendo Achillis (TA) rupture, 26 were prospectively randomised post-operatively after open TA repair. The treatment group (n = 14) received two weeks of IPC of the foot for at least six hours daily under a plaster cast. The control group (n = 12) had no additional treatment. At two weeks post-operatively all patients received an orthosis until follow-up at six weeks. At two and six weeks the incidence of DVT was assessed using colour duplex sonography by two ultrasonographers blinded to the treatment. Two patients withdrew from the study due to inability to tolerate IPC treatment. An interim analysis demonstrated a high incidence of DVT in both the IPC group (9 of 12, 75%) and the controls (6 of 12, 50%) (p = 0.18). No significant differences in incidence were detected at two (p = 0.33) or six weeks (p = 0.08) post-operatively. Malfunction of the IPC leading to a second plaster cast was found to correlate with an increased DVT risk at two weeks (ϕ = 0.71; p = 0.019), leading to a premature abandonment of the study. We cannot recommend adjuvant treatment with foot IPC under a plaster cast for outpatient DVT prevention during post-operative immobilisation, owing to a high incidence of DVT related to malfunctioning of this type of IPC application.
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Affiliation(s)
- E Domeij-Arverud
- Institution of Molecular Medicine and Surgery, Karolinska Institutet, 171 77, Stockholm, Sweden.
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24
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Samama CM, Lecoules N, Kierzek G, Claessens YE, Riou B, Rosencher N, Mismetti P, Sautet A, Barrellier MT, Apartsin K, Jonas M, Caeiro JR, van der Veen AH, Roy PM. Comparison of fondaparinux with low molecular weight heparin for venous thromboembolism prevention in patients requiring rigid or semi-rigid immobilization for isolated non-surgical below-knee injury. J Thromb Haemost 2013; 11:1833-43. [PMID: 23965181 DOI: 10.1111/jth.12395] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2013] [Indexed: 01/19/2023]
Abstract
BACKGROUND In several small studies, anticoagulant therapy reduced the incidence of venous thromboembolism (VTE) in patients with isolated lower-limb injuries. OBJECTIVES To compare the efficacy and safety of fondaparinux 2.5 mg (1.5 mg in patients with a creatinine clearance between 30 and 50 mL min(-1) ) over nadroparin 2850 anti-factor Xa IU. PATIENTS AND METHODS In this international, multicenter, randomized, open-label study, patients with an isolated non-surgical unilateral below-knee injury having at least one additional major risk factor for VTE and requiring, in the Investigator's opinion, rigid or semi-rigid immobilization for 21-45 days with thromboprophylaxis up to complete mobilization received subcutaneously once-daily either fondaparinux or nadroparin. The primary efficacy outcome was the composite of VTE (symptomatic or ultrasonographically detected asymptomatic deep vein thrombosis of the lower limb or symptomatic pulmonary embolism) and death up to complete mobilization. The main safety outcome was major bleeding. RESULTS We randomized 1349 patients (mean age 46 years): 88.7% had a bone fracture, and 83.8% had a plaster cast fitted (mean duration of immobilization, 34 days). The primary efficacy outcome occurred in 15 of 584 patients (2.6%) in the fondaparinux group and 48 of 586 patients (8.2%) in the nadroparin group (odds ratio, 0.30; 95% confidence interval [CI], 0.15-0.54; P < 0.001). A single major bleed was experienced by fondaparinux-treated patients and none by nadroparin-treated patients. These results were maintained up to the end of follow-up. CONCLUSIONS Fondaparinux 2.5 mg day(-1) may be a valuable therapeutic option over nadroparin 2850 anti-FXa IU day(-1) for preventing VTE after below-knee injury requiring prolonged immobilization in patients with additional risk factors.
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Affiliation(s)
- C M Samama
- Department of Anesthesia and Intensive Care Medicine, Hôtel Dieu and Cochin University Hospitals, Assistance Publique- Hôpitaux de Paris (AP-HP), Paris Descartes University, Paris, France
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25
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Menakaya CU, Pennington N, Muthukumar N, Joel J, Ramirez Jimenez AJ, Shaw CJ, Mohsen A. The cost of outpatient venous thromboembolism prophylaxis following lower limb injuries. Bone Joint J 2013; 95-B:673-7. [PMID: 23632680 DOI: 10.1302/0301-620x.95b5.30555] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This paper reports the cost of outpatient venous thromboembolism (VTE) prophylaxis following 388 injuries of the lower limb requiring immobilisation in our institution, from a total of 7408 new patients presenting between May and November 2011. Prophylaxis was by either self-administered subcutaneous dalteparin (n = 128) or oral dabigatran (n = 260). The mean duration of prophylaxis per patient was 46 days (6 to 168). The total cost (pay and non-pay) for prophylaxis with dalteparin was £107.54 and with dabigatran was £143.99. However, five patients in the dalteparin group required nurse administration (£23 per home visit), increasing the cost of dalteparin to £1142.54 per patient. The annual cost of VTE prophylaxis in a busy trauma clinic treating 12 700 new patients (2010/11), would be £92 526.33 in the context of an income for trauma of £1.82 million, which represents 5.3% of the outpatient tariff. Outpatient prophylaxis in a busy trauma clinic is achievable and affordable in the context of the clinical and financial risks involved.
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Affiliation(s)
- C U Menakaya
- Hull and East Yorkshire Hospitals NHS Trust, Hull, United Kingdom.
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Randelli F, Romanini E, Biggi F, Danelli G, Della Rocca G, Laurora NR, Imberti D, Palareti G, Prisco D. II Italian intersociety consensus statement on antithrombotic prophylaxis in orthopaedics and traumatology: arthroscopy, traumatology, leg immobilization, minor orthopaedic procedures and spine surgery. J Orthop Traumatol 2013; 14:1-13. [PMID: 23224149 PMCID: PMC3585990 DOI: 10.1007/s10195-012-0214-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 11/03/2012] [Indexed: 11/28/2022] Open
Abstract
Pharmacological prophylaxis for preventing venous thromboembolism (VTE) is a worldwide established procedure in hip and knee replacement surgery, as well as in the treatment of femoral neck fractures, but few data exist in other fields of orthopaedics and traumatology. Thus, no guidelines or recommendations are available in the literature except for a limited number of weak statements about knee arthroscopy and lower limb fractures. In any case, none of them are a multidisciplinary effort as the one here presented. The Italian Society for Studies on Haemostasis and Thrombosis (SISET), the Italian Society of Orthopaedics and Traumatology (SIOT), the Association of Orthopaedic Traumatology of Italian Hospitals (OTODI), together with the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) and the Italian Society of General Medicine (SIMG) have set down easy and quick suggestions for VTE prophylaxis in a number of surgical conditions for which only scarce evidence is available. This inter-society consensus statement aims at simplifying the approach to VTE prophylaxis in the single patient with the goal to improve its clinical application.
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Affiliation(s)
- F. Randelli
- Dipartimento di Ortopedia e Traumatologia V, I.R.C.C.S. Policlinico San Donato, S. Donato Milanese, MI Italy
| | - E. Romanini
- Divisione di Ortopedia e Traumatologia, Casa di Cura San Feliciano, Rome, Italy
| | - F. Biggi
- UOA Ortopedia e Traumatologia, Ospedale S. Martino, Belluno, Italy
| | - G. Danelli
- UO Anestesia Analgesia e Medicina Perioperatoria, Azienda Istituti Ospitalieri di Cremona, Cremona, Italy
| | - G. Della Rocca
- Anestesia e Rianimazione, Università degli Studi di Udine, Udine, Italy
| | | | - D. Imberti
- UO di Medicina Interna, Centro Emostasi e Trombosi, Ospedale Civile di Piacenza, Piacenza, Italy
| | - G. Palareti
- UO Angiologia e Malattie della Coagulazione, Azienda Ospedaliera Universitaria S. Orsola-Malpighi, Bologna, Italy
| | - D. Prisco
- SOD Patologia Medica, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
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Garrastazu R, Fernández-Fonfria JR. [Thromboprophylaxis during immobilization of non-surgical traumatic injury in the lower limb. An outpatient perspective]. Semergen 2012; 38:408-13. [PMID: 22935839 DOI: 10.1016/j.semerg.2011.09.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Revised: 09/22/2011] [Accepted: 09/29/2011] [Indexed: 11/29/2022]
Abstract
Thromboprophylaxis with low molecular weight heparin is efficient, effective and generates savings in health costs in hospitals. However, outside hospitals, there are situations of apparent risk of thrombosis, where there seems to be no such consensus. This occurs in traumatic lower limb injuries which are not undergoing surgery and need a period of immobilization. These are processes with multidisciplinary interventions (Emergency, Family Physicians and Traumatology), although during outpatient follow up it is not easy to find criteria for using thromboprophylaxis. We report a case of a pulmonary embolism, with unusual symptoms, in an ambulatory patient with a fractured fibula and metatarsal, who was being treated with Bemiparin. As we shall see, this is a rare complication, but it shows the importance of proper risk assessment of thromboembolic disease in these patients. We emphasize the accompanying tomographic images for their clarity and eloquence.
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Affiliation(s)
- R Garrastazu
- Servicio de Urgencias de Atención Primaria, Centro de Salud de Gama, Bárcena de Cicero, España.
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Iqbal HJ, Dahab R, Barnes S. UK national survey of venous thromboembolism prophylaxis in ankle fracture patients treated with plaster casts. Foot Ankle Surg 2012; 18:157-9. [PMID: 22857956 DOI: 10.1016/j.fas.2011.05.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2011] [Revised: 04/24/2011] [Accepted: 05/20/2011] [Indexed: 02/04/2023]
Abstract
BACKGROUND Ankle fractures are one of the commonest orthopaedic injuries. A substantial proportion of these are treated non-operatively at outpatient clinics with cast immobilization. We conducted this survey to assess the current practice in UK regarding thromboembolism prophylaxis in these patients. METHODS A telephonic survey was carried out on junior doctors within orthopaedic departments of 56 hospitals across the UK. A questionnaire was completed regarding venous thromboembolism risk assessment, prophylaxis, hospital guidelines, etc. RESULTS 84% (n=47) hospitals did not routinely use any prophylaxis for these patients, while 7% (n=4) hospitals used chemo-prophylaxis. Only 5.3% (n=3) hospitals had DVT prophylaxis guidelines regarding these patients while other 9% (n=5) hospitals were in process of developing such guidelines. In 64% (n=36) hospitals, no formal DVT risk assessment was carried out. CONCLUSION A large variation exists across NHS hospitals and a poor risk assessment is being carried out in these patients. Development of local guidelines and extension of national guidelines to include high risk outpatients may improve the situation.
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Affiliation(s)
- Hafiz Javaid Iqbal
- Mid Cheshire Hospitals NHS Foundation Trust, Leighton Hospital, Crewe, CW1 4QJ, UK.
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Meek R, Tong RLK. Venous thromboembolism in emergency department patients with rigid immobilization for lower leg injury: Incidence and risk factors. Emerg Med Australas 2012; 24:277-84. [PMID: 22672168 DOI: 10.1111/j.1742-6723.2012.01539.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To determine the incidence and risk factors for symptomatic venous thromboembolism (VTE) in adults who are discharged from the ED with rigid immobilization for lower limb injury. METHODS Eligible patients presenting between 1 December 2008 and 31 December 2010 were identified retrospectively from the Southern Health ED (Monash Medical Centre, Dandenong Hospital, Casey Hospital, all located in Melbourne, Australia) information system. Age, sex, diagnosis, type of splint and other defined potential VTE risk factors were recorded. VTE was confirmed from archived diagnostic imaging or hospital re-attendance records. Patients presenting between 1 October 2010 and 31 December 2010 were contacted to detect VTE diagnosed and treated outside of Southern Health. VTE incidence is reported, and comparison of risk factors performed. RESULTS VTE was initially confirmed in 33 of 1231 patients (2.7%, 95% confidence interval 1.9-3.7). VTE was reported by 3 of 174 in the contacted subgroup (1.7%, 0.4-4.6). Applying this 'missed rate' to the whole sample, the estimated VTE incidence is between 3.1% and 7.1%. Multivariate risk factor analysis found VTE risk to increase with age and a diagnosis of Achilles tendon rupture. CONCLUSION The estimated VTE incidence was between 3% and 7% in this ED population with age and diagnosis of Achilles tendon rupture increasing risk. Prospective research to more accurately determine incidence, severity and risk stratification is required before firm recommendations on the likely risk versus benefit profile of thromboprophylaxis can be made for this population.
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Affiliation(s)
- Robert Meek
- Department of Medicine, Monash University, Melbourne, Victoria, Australia.
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Healy B, Beasley R, Weatherall M. Venous thromboembolism following prolonged cast immobilisation for injury to the tendo Achillis. ACTA ACUST UNITED AC 2010; 92:646-50. [PMID: 20436000 DOI: 10.1302/0301-620x.92b5.23241] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report an audit of 208 patients with a mean age of 39 years (16 to 65) attending the Orthopaedic Assessment Unit at the Wellington Hospital between January 2006 and December 2007 with an injury of the tendo Achillis requiring immobilisation in a cast. Information on assessment of venous thromboembolism (VTE) risk, prophylactic measures and VTE events for all patients was obtained from the medical records. A VTE risk factor was documented in the records of three (1%) patients. One of the 208 patients received aspirin prophylaxis; none received low molecular weight heparin. In all, 13 patients (6.3%, 95% confidence interval 3.4 to 10.5) developed symptomatic VTE during immobilisation in a cast, including six with a distal deep-vein thrombosis (DVT), four with a proximal DVT, and three with a confirmed pulmonary embolus. This incidence of symptomatic VTE is similar to that reported following elective hip replacement. We propose that consideration is given to VTE prophylaxis during prolonged immobilisation of the lower limbs in a cast, to ensure that the same level of protection is provided as for patients undergoing elective hip replacement.
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Affiliation(s)
- B Healy
- Medical Research Institute of New Zealand, P. O. Box 10055, Wellington 6143, New Zealand.
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