Prevention of venous thromboembolism in patients admitted to Australian hospitals: summary of National Health and Medical Research Council clinical practice guideline

Evidence-based pharmacological prophylaxis recommendations for venous thromboembolism in hospitalized acutely ill medical patients: a systematic review of clinical practice guidelines

Venous thromboembolism is a complex multifactorial disease considered the most common cause of preventable deaths in hospitalized patients. Recommendations about pharmacological venous thromboembolism prophylaxis in adult hospitalized patients are available in clinical practice guidelines for optimization of healthcare delivery and improvement of patient outcomes. We conducted a systematic review of clinical practice guidelines using ADAPTE to synthesize recommendations for pharmacological prophylaxis of venous thromboembolism in hospitalized medical patients at a medium complexity university hospital. Recommendations for pharmacological prophylaxis were extracted from seven clinical practice guidelines considered of high quality after assessment with the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. These recommendations will support discussion with specialists and implementation of practices in the setting of the hospital studied.

Obesity and the Risk of Venous Thromboembolism after Major Lower Limb Orthopaedic Surgery: A Literature Review

The risk of venous thromboembolism following total joint arthroplasty is significantly greater than those of other types of elective orthopaedic procedures. This risk is increased in obesity due to the associated prothrombotic physiological and hematological changes that predispose to embolic events. The prevalence of obesity is increasing in the aging population, which contributes to a further increase in the risk of postoperative thrombosis in the older patients. There is a lack of clear evidence regarding dosing information for thromboprophylaxis medications in patients with obesity. As a result, the currently available thromboprophylaxis guidelines do not provide specific recommendations for this group. Suboptimal dosing regimens for these medications can place these patients at a risk of bleeding or clotting complications postsurgery. Hence any increase in dosage may require intensive surveillance for the residual anticoagulant effects and careful balancing of risks and benefits on an individual basis. Our review discusses the basis for increased thrombotic risk in obesity, the evidence supporting dosage recommendations, and the implications of the current guidelines for pharmacological thromboprophylaxis in patients with obesity undergoing lower limb arthroplasty.

Prevalence of Venous Thromboembolism in Intensive Care Units: A Meta-Analysis

OBJECTIVE

Venous thromboembolism (VTE) is a life threating complication in intensive care units (ICUs). This study aimed to pool the prevalence of VTE and examined the risk factors of VTE in intensive care patients worldwide.

METHODS

A systematic search in PubMed, EMBASE and Web of Science databases was performed. Studies reported that the data on the prevalence of VTE or relevant information were synthesized using a random-effects model.

RESULTS

A total of 42 studies reporting on 27,344 patients were included. The pooled prevalence of VTE was 10.0% (95% CI: 7.0-14.0%). Subgroup and metaregression analyses found that thromboprophylaxis strategy, simplified acute physiology score (SAPS II), age, study quality, sample size, malignancy, sex, spinal cord injury and injury severity score (ISS) moderated the prevalence of VTE in intensive care patients.

CONCLUSIONS

The present meta-analysis revealed a high prevalence of VTE in critically ill patients. The risk factors of VTE included thromboprophylaxis strategy, SAPS II, age, malignancy, sex, spinal cord injury and ISS. Therefore, we need to pay more attention to high-risk populations of VTE in intensive care patients.

Venous thromboembolism risk screening, training and provider awareness in Australian residential aged care facilities

Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in the geriatric post-surgical population, and its prevention is a public health priority. The aim of this study was to assess the use of VTE risk screening and training protocols, and VTE awareness in the Australian residential aged care sector. A cross-sectional survey was conducted that was directed at facility and policy managers of community aged care facilities with ≥10 residents in two Australian states and territories. Forty-nine of 301 (16.3%) providers responded, representing 249/871 (28.6%) aged care facilities and 20,958/66,121 (31.7%) residents. VTE risk screening protocols were used by 1.2% of facilities (3/249), and 79.5% (198/249) were unaware that VTE is an issue in this population. Only 0.8% (2/249) were aware that risk screening and prophylaxis is required to prevent VTE; none were acting upon this. No facility had specific VTE risk assessment or prevention processes in place. Most residential aged care facilities surveyed do not have VTE risk screening protocols and were unaware of the risk that may be associated with this omission. These results have implications for development and implementation of national and international VTE risk screening guidelines in community care.

Analysis of surgical mortality in rural South Australia: a review of four major rural hospital in South Australia

Background

One‐third of Australia's population reside in rural and remote areas. This audit aims to describe all‐causes of mortality in rural general surgical patients, and identify areas of improvement.

Methods

This is a retrospective multi‐centre study involving four South Australian hospitals (Mt Gambier, Whyalla, Port Augusta, and Port Lincoln). All general surgical inpatients admitted from June 2014 to September 2019 were analysed to identify all‐cause of mortality.

Results

A total of 80 mortalities were recorded out of 26 996 admissions. The overall mortality rate of 0.3% was the same as the 2020 Victorian state‐wide Audit of Surgical Mortality. No mortality was secondary to trauma. Mean age was 79 ± 11 years and ASA was 3.9 ± 1. Malignancy was associated in over a third of cases (41.2%), mostly colorectal and pancreatic. Most cases were related to general surgical subspecialties: colorectal (51.3%), upper gastrointestinal (21.3%), hepatopancreaticobiliary (13.8%); however, there were also vascular (6.3%) and urology (3.8%) cases. The most common causes of mortality were large bowel obstruction (13.4%), ischemic bowel (10.4%), and small bowel obstruction (7.5%). Majority of mortality were beyond the surgeon's control (73.8%). Of the 21 potentially preventable mortalities, 42.9% were attributed to aspiration pneumonia and decompensated heart failure. Only one (1.3%) mortality case was due to pulmonary embolism.

Conclusion

Rural general surgical mortalities occur in older, comorbid patients. Rural surgeons should be equipped to manage basic subspeciality conditions. To further reduce mortalities, clear protocols to prevent aspiration pneumonia and resuscitation associated fluid overload are needed.

Pharmacological venous thromboembolism prophylaxis in elective cranial surgery: a systematic review of time of initiation, regimen and duration

INTRODUCTION

Pharmacological prophylaxis of venous thromboembolism (VTE) requires nuanced decision-making to balance the risk of VTE against haemorrhage. This problem is compounded in neurosurgical patients, in whom postoperative intracranial haemorrhage (ICH) may be catastrophic, compared to non-neuraxial bleeding in other types of surgery. Current major guidelines recommend caution when using pharmacological prophylaxis in elective cranial surgery, but incorporate low-quality evidence and lack precise guidance on timing and duration of anticoagulation.

METHODS

We aimed to answer the following questions for patients undergoing elective cranial surgery: (1) when is the optimal time to initiate postoperative anticoagulation, and (2) how long should postoperative anticoagulation be continued for? In this systematic review, we screened randomised and non-randomised studies reporting original data on pharmacological VTE prophylaxis in elective cranial surgery. Outcomes of interest were VTE and ICH.

RESULTS

Three retrospective, single-centre observational studies met eligibility criteria, with a total of 923 participants. Meta-analysis was not performed due to a high risk of bias across all studies. Through narrative synthesis, we found that patients who developed VTE were significantly more likely to receive their first postoperative dose at a later time (mean: 144 vs. 29 h, p = .04). Shorter courses of anticoagulation (<7 days) were associated with significantly lower ICH rates (p = .03) compared to longer courses (>21 days).

CONCLUSION

The limited evidence favours earlier initiation and shorter courses of thromboprophylactic anticoagulation. These findings are specific to patients undergoing surgery for meningioma or glioma and may not apply to other populations. Randomised controlled trials or robustly designed observational studies are necessary to establish a clearer evidence base.

Venous Thromboembolism Following Major Abdominal Surgery for Cancer: A Guide for the Surgical Intern

BACKGROUND

Venous thromboembolism (VTE) is a term used to compositely describe deep vein thrombosis (DVT) and pulmonary embolism (PE). Overall, the incidence of VTE after major abdominal and pelvic surgery has been reported to be between 10% and 40%.

OBJECTIVE

To estimate the incidence of post-operative VTE in patients undergoing major abdominal surgery for cancer, to identify risk factors associated with VTE, and to assess available thromboprophylaxis tools.

METHODS

A Medline and Cochrane literature search from database inception until February 1st, 2021 was performed according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines.

RESULTS

Thirty-one studies met our eligibility criteria and were included in the current review. In total, 435,492 patients were identified and the overall incidence of VTE was 2.19%( 95% CI: 1.82-2.38). Τhe following risk factors were associated with VTE: smoking, advanced age (>70 years), a history of diabetes mellitus, American Society of Anesthesiologists' (ASA) classification of Physical Health class III or IV, a history of cardiovascular or pulmonary disease, a history of DVT or PE, elevated plasma fibrinogen level, c-reactive protein (CRP) level, cancer stage III or IV, postoperative acute respiratory distress syndrome (ARDS), prolonged postoperative hospital stay, previous steroid use, history of Inflammatory Bowel Disease (IBD), heart failure and neoadjuvant and adjuvant chemotherapy.

CONCLUSION

VTE remains an important complication after major abdominal surgery for cancer and seems to increase mortality rates.

Feasibility and Safety of a Novel Leg Exercise Apparatus for Venous Thromboembolism Prophylaxis after Total Joint Arthroplasty of the Lower Extremities-A Pilot Study

Venous thromboembolism (VTE) is a severe complication in orthopedic surgeries. Herein, we developed a novel leg exercise apparatus (LEX) to encourage postoperative limb movement in bedridden patients to prevent VTE. We aimed to evaluate its feasibility and safety in individuals at risk of VTE. Twenty patients (four men, 16 women) who underwent total joint arthroplasty in the lower extremity were enrolled in this prospective study. Exercise using the LEX was performed for 5 min at 30 cycles/min, four times/day during postoperative days 1–7. Clinical assessments included the evaluation of vital signs, venous ultrasonography, and blood tests within seven days postoperatively, and adverse events (pulmonary embolism and cerebral hemorrhage) were monitored. Overall, 16/20 (80%) patients completed the 7-day exercise regimen. There were no cases of severe adverse events, changes in vital signs, or lower-extremity deep vein thrombosis in patients who performed exercises with the LEX. Thus, the results of this pilot study show that this novel apparatus may be a safe and feasible tool for VTE prophylaxis after joint arthroplasty of the lower extremities.

Systematic reviews of observational studies of Risk of Thrombosis and Bleeding in General and Gynecologic Surgery (ROTBIGGS): introduction and methodology

BACKGROUND

Venous thromboembolism (VTE) and bleeding are serious and potentially fatal complications of surgical procedures. Pharmacological thromboprophylaxis decreases the risk of VTE but increases the risk of major post-operative bleeding. The decision to use pharmacologic prophylaxis therefore represents a trade-off that critically depends on the incidence of VTE and bleeding in the absence of prophylaxis. These baseline risks vary widely between procedures, but their magnitude is uncertain. Systematic reviews addressing baseline risks are scarce, needed, and require innovations in methodology. Indeed, systematic summaries of these baseline risk estimates exist neither in general nor gynecologic surgery. We will fill this knowledge gap by performing a series of systematic reviews and meta-analyses of the procedure-specific and patient risk factor stratified risk estimates in general and gynecologic surgeries.

METHODS

We will perform comprehensive literature searches for observational studies in general and gynecologic surgery reporting symptomatic VTE or bleeding estimates. Pairs of methodologically trained reviewers will independently assess the studies for eligibility, evaluate the risk of bias by using an instrument developed for this review, and extract data. We will perform meta-analyses and modeling studies to adjust the reported risk estimates for the use of thromboprophylaxis and length of follow up. We will derive the estimates of risk from the median estimates of studies rated at the lowest risk of bias. The primary outcomes are the risk estimates of symptomatic VTE and major bleeding at 4 weeks post-operatively for each procedure stratified by patient risk factors. We will apply the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to rate evidence certainty.

DISCUSSION

This series of systematic reviews, modeling studies, and meta-analyses will inform clinicians and patients regarding the trade-off between VTE prevention and bleeding in general and gynecologic surgeries. Our work advances the standards in systematic reviews of surgical complications, including assessment of risk of bias, criteria for arriving at the best estimates of risk (including modeling of the timing of events and dealing with suboptimal data reporting), dealing with subgroups at higher and lower risk of bias, and use of the GRADE approach.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021234119.

Development of a risk-oriented algorithm for the combined use of hemostatics and anticoagulants to prevent thrombosis and bleeding cases after total arthroplasty of knee or hip joints

Introduction: The goal of our study was to develop a risk-oriented algorithm for the combined use of hemostatics and anticoagulants in patients after total arthroplasty of the knee or hip joints to reduce the risk of thrombohemorrhagic complications.

Materials and methods: We performed a retrospective study (n=253). In group (Gr.) 1, the time interval (TI) between the administration of hemostatic and anticoagulant prophylaxis was ≤17 hours (n=145; 57.31%), and in Gr. 2 – 18-24 hours (n=108; 42.68%). We analyzed the influence of different factors on the development of thrombosis and bleeding cases after the operation.

Results and discussion: Thrombohemorrhagic complications were observed in 27 (10.67%) patients. Thrombosis in Gr. 1 was associated with the use of tranexamic acid, and were recorded 2.2 times more often than in Gr. 2 (p&lt;0.05). The development of thrombosis in Gr. 1 was influenced by: class II obesity, type 2 diabetes mellitus, myocardial infarction, venous pathology, age of patients &gt;75 years, for women – an initially low level of international normalized ratio, and activated partial thromboplastin time (APTT) (p&lt;0.05). The development of bleeding in Gr. 1 was influenced by: age &gt;75 years, among men and women – an increased preoperative level of APTT, for women – a decreased level of fibrinogen and platelets (p&lt;0.05).

Conclusion: To prevent thrombosis and bleeding after arthroplasty of large joints, the TI between the use of hemostatics and anticoagulants should be at least 18 hours, especially in patients with the above risk factors, in particular, when using tranexamic acid and low molecular weight heparins.

Chinese orthopaedic nurses' knowledge, attitude and venous thromboembolic prophylactic practices: A multicentric cross-sectional survey

BACKGROUND

Venous thromboembolism is a severe preventable complication among orthopaedic surgical patients. Integrating therapeutic guidelines into clinical practice can help improve patient safety and reduce the burden of this pathology. Improving the quality of patient care is important for bridging the gap between the prophylaxis for venous thromboembolism and therapeutic guidelines.

OBJECTIVES

This study aimed at evaluating the knowledge, attitude, and venous thromboembolism and prophylaxis practices of Chinese orthopaedic nurses to guide quality care improvements.

METHODS

The data used in this study are secondary data obtained from a multicentric survey. An anonymous questionnaire was used to measure the attitude and knowledge of venous thromboembolic prophylaxis among orthopaedic nurses. VTE prophylactic practices were extracted from medical records within the electronic case report form immediately after the nurses' investigations. The STROBE statement for observational studies was applied.

RESULTS

Results indicated that although 94.0% of the responding nurses had attended training courses in their wards, a majority of them (68.9%) achieved a median knowledge score of 7 points or below (range 0-9). Knowledge regarding the proper use of prophylaxis, identification of risk factors, signs and symptoms for pulmonary embolism was limited. Self-reported attitudes underestimate the relationships between venous thromboembolism and low-quality nursing care. Pharmacological prophylaxis was highly used (90.9%), while the utilisation of mechanical prophylaxis and its proper use was relatively low.

CONCLUSIONS

Chinese orthopaedic nurses demonstrated enthusiasm for venous thromboembolism and prophylaxis. Their knowledge needs to be improved, including the proper use of prophylaxis, identification of risk factors, signs and symptoms. Mechanical prophylaxis practice for VTE prevention after THA and TKA surgical procedures is not optimistic. Further studies should analyse the causes from multiple perspectives, including the availability of resources, the knowledge and attitude of doctors, nurses and patients.

RELEVANCE TO CLINICAL PRACTICE

The findings from this study can be used to develop and implement interventions for venous thromboembolism after orthopaedic surgery.

Prophylactic Enoxaparin Dosing in Obese Orthopedic Patients: A Literature Search

Objective: The objective of the study was to review the current literature for prophylactic enoxaparin dosing in obese orthopedic patients. Method: A literature search was undertaken using OVID Medline, OVID Embase, and Cochrane Central databases, accessed through hospital library websites. Key search terms (in UK and US spelling) included orthopaedics, low-molecular-weight heparin, enoxaparin, venous thromboembolism prophylaxis, weight, obese, morbid obesity. Possible related subheadings, such as bone, fractures, anticoagulants, overweight, body mass index, deep vein thrombosis, pulmonary embolism, were also included in the database search to optimize the search strategies. The search was restricted to human subjects and limited to articles published from 1998 to the present. Results: The search identified 429 potentially relevant articles. Once duplicates were removed, 345 were screened for inclusion in this review. Only 3 articles (a case-control study, an observational prospective study, and a case report) met both the inclusion and exclusion criteria. The findings from this review need to be interpreted cautiously due to limitations in study designs and the potential for confounding bias. Conclusion: The results of a multiple database search draw one to the conclusion that there is very limited evidence in the literature with regard to prophylactic enoxaparin dosing in obese orthopedic-specific patients. Orthopedic patients are among the highest risk of all surgical specialties for venous thromboembolism. There is strong evidence to support an increased prophylactic low-molecular-weight heparin doses in obese patients; thus, the authors recommend higher prophylactic enoxaparin dosing in obese orthopedic patients.

Cancer-associated thromboembolism: antithrombotic management of hospitalized patients

Cancer increases risk for venous thromboembolism. Incident thrombocytopenia increases hemorrhagic risk. Hospitalized adults with a cancer diagnosis who received subcutaneous dalteparin in doses adjusted according to platelet count were retrospectively evaluated. Outcomes of interest included nadir platelet counts, transfusions, thromboembolism, and hemorrhage. During a 2-year period of observation, 1854 cancer patients received individualized inpatient treatment with dalteparin. Transfusion was required in 38 of 77 (49.4%) patients with nadir platelet counts < 25 × 10⁹ cells/L as compared with 16 of 75 (21.3%) patients whose nadir platelet counts were 25-50 × 10⁹ cells/L [risk ratio (RR) 2.31; 95% CI 1.42 to 3.78, p < 0.001] and 45 of 1657 (2.7%) patients with platelet counts > 50 × 10⁹ cells/L (RR - 8.07; 95% CI - 4.79 to - 13.59, p < 0.001). Transfusions were administered primarily as supportive therapy. Among transfusion recipients, new or recurrent venous thromboembolism was documented in 2.6%, 0%, and 2.2% of patients with nadir platelet counts of < 25, 25-50, or > 50 × 10⁹ cells/L, respectively (p > 0.9 for all comparisons). Acute blood loss or major bleeding was documented in 10.5%, 12.5%, and 15.6% of patients with platelet counts of < 25, 25-50, or > 50 × 10⁹ cells/L, respectively (p > 0.9 for all comparisons). Among hospitalized cancer patients who received individualized dalteparin treatment, transfusion requirements varied inversely with platelet count. Irrespective of platelet counts, occurrence rates for venous thromboembolism and acute hemorrhage were similar across all treatment groups. Individualized dalteparin treatment provided a consistent pattern of safety and effectiveness.

Development of a clinical prediction tool for cancer-associated venous thromboembolism (CAT): the MD Anderson Cancer Center CAT model

INTRODUCTION

Cancer-associated venous thromboembolism (CAT) is a major complication of malignancy. Our goal was to develop a prediction model for VTE that better represented to the population seen at large referral cancer centers.

MATERIALS AND METHODS

This study was nested in a prospective cohort study at the University of Texas MD Anderson Cancer Center that evaluated adult patients during outpatient cancer-staging computed tomography to estimate the prevalence of incidental VTE. Data from patients in whom incidental VTE was not found on initial CT were collected until 24 months ± 7 days from the study inclusion date to determine the occurrence of new VTE events. Demographics, clinical data, current cancer treatment information, and the use of erythropoietin stimulating agents (ESAs) along with hematologic variables were collected in all patients and analyzed to determine differences between those who developed VTE versus those who did not. All candidate variables with significance p value (≤ 0.1) under univariate analysis were considered to enter the final multivariate model.

RESULTS

Data of 548 patients were analyzed. The presence of metastatic disease and the use of platinum-based chemotherapy were strongly associated with CAT occurrence. The use of ESAs and specific malignancies showed trends of association with CAT, while associations were not statistically significant.Those characteristics were utilized to develop a clinical prediction model for CAT readily available and effective (c-index = 0.74).

CONCLUSION

Our model is effective and easy to incorporate in busy clinical settings and it does not depend on esoteric or difficult-to-obtain laboratory testing. Future external validation studies may provide further evidence for the applicability of our results.

Critical appraisal of international guidelines for the prevention and treatment of pregnancy-associated venous thromboembolism: a systematic review

Background

Pregnancy-associated Venous thromboembolism (VTE) is one of the most common causes of maternal morbidity and mortality in developed countries. In this study, we aimed to systematically review and critical appraisal of guidelines to compare the recommendations in pregnancy-associated VTE.

Methods

Guidelines in English between January 1, 2009 and November 31, 2018 were searched using Medline via PubMed, as well as the guidelines’ website. The guidelines containing the recommendations on pregnancy-associated VTE were included. Through the Appraisal of Guidelines Research and Evaluation II (AGREE II) instrument, three reviewers appraised the quality of the included guidelines. The recommendations were also summarized and compared to analyze the consistency.

Results

Fifteen guidelines from 13 organizations were included. Ten guidelines from nine organizations, namely, ACCP, ANZJOG, ASH, Australia, ESC, Korea, RCOG, SASTH, SOCC, were regarded as “strongly recommended for use in practice”. Most of the included guidelines scored low in lower scores in domain 3 (Rigor of development) and domain 6 (Editorial independence). Recommendations on prevention are contained in ten guidelines while treatment are included in seven. The main conflicting recommendations were mainly at the anticoagulant choice for prevention on pregnant women and prevention after cesarean section. The duration of VTE treatment in pregnant women was also controversial.

Conclusions

In summary, the quality of pregnancy-associated VTE guidelines varied widely, especially in Rigor of development and Editorial independence. Recommendations were inconsistent both in prevention and treatment across guidelines. Increased efforts are required to provide high-quality evidence specific to the pregnancy population. Guideline developers should also pay more attention to methodological quality.

Electronic supplementary material

The online version of this article (10.1186/s12872-019-1183-3) contains supplementary material, which is available to authorized users.

Concurrent presentation of a hemorrhagic pericardial effusion and venous thromboembolism in malignancy: a systematic review of case studies

The concurrent presentation of symptomatic malignant pericardial hemorrhage and venous thromboembolism is a rare event that poses a clinical dilemma. Existing VTE guidelines do not indicate when, or if, anticoagulation therapy should be started after the treatment of the pericardial bleed. We performed a systematic review to compile the published clinical evidence on the occurrence of coexisting pericardial hemorrhage and VTE in cancer patients and to describe the clinical presentations and bleeding and thrombosis outcomes before and after anticoagulation therapy. We studied published case reports on patients with cancer who presented to the hospital with pericardial hemorrhage and VTE through April 11, 2019. We found seven published case reports. All patients had suffered from a pulmonary embolism and had pericardiocentesis during hospitalization. Five patients (71%) had lung cancer. Four patients (57%) were started on anticoagulation after pericardial drainage and survived the index event. Two patients (29%) were not started on anticoagulation after pericardiocentesis; only one of these patients survived the hospitalization. Pericardial bleeding risk in cancer may be inherent to malignancy, and it is unclear if anticoagulation use increases the risk of recurrent pericardial bleeding. The management of pericardial bleeding typically requires pericardiocentesis, and clinical registries, prospective collaboration projects, and case adjudication are needed to establish the safety of initiation of antithrombotic therapy in such patients.

Evaluation of a nurse-led intervention to improve adherence to recommended guidelines for prevention of venous thromboembolism for hip and knee arthroplasty patients: A quasi-experimental study

AIMS AND OBJECTIVES

To measure adherence to a nurse-led evidence-based venous thromboembolism prevention programme (intervention) compared to usual care in hip and knee arthroplasty patients and associated clinical outcomes.

BACKGROUND

Venous thromboembolism morbidity and mortality of hospitalised patients is a major concern for health professionals. Venous thromboembolism prevention guidelines have been developed; however, adherence to guidelines is variable.

PARTICIPANTS

There were 410 potential participants who were adult patients that were booked for elective hip or knee arthroplasty at the two study sites during a 2-year period (2011-2013). Of these, 27 did not meet the inclusion criteria, and the remainder were eligible for inclusion in the study (intervention site n = 196 and control site n = 187, total population n = 383).

METHODS

This study adopted a quasi-experimental design, using an intervention and control study site, conducted in two private hospitals in a regional area in Australia.

RESULTS

The intervention group had a mean compliance score of 11.09, higher than the control group score of 7.19. This is equivalent to a compliance rate of 85% and 55%, respectively, and indicates that adherence at the study site was significantly higher. Patient adherence and outcomes in the postdischarge period were not significantly different between the study sites.

CONCLUSION

This study demonstrated a nurse-led intervention achieved high adherence with translating evidence-based guidelines into routine patient care for hip and knee arthroplasty patients. Nurses can be critical to implementing clinical practice guidelines and adopting preventive programmes in acute care to improve patient outcomes and reduce postoperative venous thromboembolism in arthroplasty patients.

RELEVANCE TO CLINICAL PRACTICE

This research demonstrates the capacity of nurses to lead the translation of evidence-based practice guidelines for prevention of venous thromboembolism into routine patient care.

Postoperative D-dimer predicts venous thromboembolism in patients undergoing urologic tumor surgery

PURPOSE

We examined the incidence of pulmonary thromboembolism (PE) and deep venous thromboembolism (DVT) in patients who underwent urologic tumor surgery. The aim of this study was to investigate the postoperative D-dimer for prediction of venous thromboembolism events (VTE), as well as to identify other risk factors associated with the occurrence of thromboembolisms.

PATIENTS AND METHODS

This was a prospective observational cohort study, which included 1,269 patients who underwent major urologic tumor surgery, from August 2015 to February 2017, at our center. Data comprising age, sex, body mass index, Charlson comorbidity index, type of surgery, Caprini score, postoperative D-dimer levels, and other laboratory tests were collected for analyses. Lower limb venous ultrasound was performed before surgery and the day before hospital discharge to measure DVT. Computerized tomography or ventilation/perfusion lung scan was applied to detect PE.

RESULTS

The overall incidence of VTE was 2.4% (31 cases) in 1,269 patients, consisting of 23 PE events and 9 DVT events. Patients undergoing radical cystectomy were most likely to suffer VTE (4.3%). The optimal cutoff value for postoperative D-dimer was 0.98μg/ml, according to the receiver operating characteristic curve analysis, with a sensitivity of 83.9%, and a specificity of 80.0%. On multivariate analysis, hypertension (odds ratio, OR = 2.5, 95% CI: 1.1-5.7; P = 0.026), Charlson comorbidity index ≥ 2 (OR = 5.6, 95% CI: 2.2-14.6; P<0.001), and D-dimer lever ≥ 1μg/ml on postoperative day 1 (OR = 12.52, 95% CI: 4.6-35.2; P<0.001) were independently associated with VTE after urologic tumor surgery.

CONCLUSIONS

The overall incidence of urologic-tumor-surgery-associated VTE in an Asian population is similar to those reported in European and North American series. Elevated D-dimer early after operation is an independent predictor of VTE in patients undergoing urologic tumor surgery. In addition, hypertension and the Charlson comorbidity index are both important clinical risk factors. The Caprini score recommended by the guideline is inadequate in this study population. The postoperative D-dimer plasma level is a more reliable marker for identifying patients at high-risk of developing venous thromboembolisms.

Variables associated with pulmonary thromboembolism in injured patients: A systematic review

BACKGROUND

Pulmonary thromboembolism (PTE) is a dangerous complication of traumatic injury, with varied risk profiles and treatment options. This review aims to describe reported incidence and variables associated with PTE among severely injured patients.

METHODS

Searches were conducted using PubMed, Cochrane and MEDLINE. Relevant studies were identified by two independent reviewers based on predetermined inclusion criteria. Incidence of PTE was the primary outcome measure. Variables associated with PTE was the secondary outcome measure. The Newcastle-Ottawa Scale was used to assess quality of included studies.

RESULTS

There were eight studies that satisfied inclusion criteria. The diagnosed incidence of PTE in these populations ranged from 0.35 to 24%. The most common variables associated with PTE were pelvic or lower limb injury, chest injury, higher total Injury Severity Score, male sex and age. Variables that were less commonly associated with PTE were previous warfarin use, head injury, high serum lactate, soft tissue injury, more than one operation, more than three days on a ventilator, presence of a subclavian central venous catheter, need for a blood transfusion, systolic blood pressure <90mmHg, abdominal injury, presence of a deep venous thrombosis, inferior vena cava filter placement and isolated liver spleen or spinal injuries.

CONCLUSIONS

The reported incidence of PTE after major trauma is variable and dependent on inclusion criteria, diagnostic criteria and study design. Identified variables differed to those reported for venous thromboembolism in other populations. It is difficult to predict populations at risk of clinically significant PTE following injury using available evidence. Further studies linked to patient-specific variables will assist in more precise risk-stratification and interventions.

The role of direct oral anticoagulants in cancer-related venous thromboembolism: a perspective beyond the guidelines

Cancer-related venous thromboembolism (Wickham et al., Intern Med J 42(6):698-708, 2012) is an important source of morbidity and mortality in that population. The standard of care for the treatment of cancer-related venous thromboembolism (VTE) is a low molecular weight heparin (LMWH) for long periods of time. The favorable clinical trial results for efficacy and safety and availability of direct oral anticoagulants (DOAC) have remodeled the care and options for treatment of venous thromboembolism in the adult population. The data of cancer population-subgroup analysis of those studies have shown that DOAC are as effective and safe as conventional long-term oral anticoagulation with vitamin K antagonists (VKA). Additionally, non-controlled retrospective and prospective cohort data have been published describing efficacy and safety outcomes for the use of DOAC in cancer-related VTE. Altogether, the results from clinical studies have shown that direct oral anticoagulants may represent a treatment option for cancer-related VTE and an alternative to anticoagulation with VKA. Little is known about the patient-centered and system-based variables that determine the use of DOAC outside consensus guidelines, neither is known the impact of different anticoagulant modalities in adherence and quality of life in cancer patients. The objectives of this manuscript are to summarize the clinical trial-based and cohort data of cancer patients treated with DOAC for VTE and to highlight the aspects that may influence adherent to therapy, effectiveness, and safety outcomes in the treatment of cancer-related VTE.

Validation of a Patient-Completed Caprini Risk Score for Venous Thromboembolism Risk Assessment

Introduction  Individualized risk assessment for venous thromboembolism (VTE) using the Caprini risk score (CRS), coupled with targeted prophylaxis based on the score, is effective in reducing postoperative VTE. Critics contend that using this tool is time consuming for health care providers. We decided to create a patient-completed CRS and conducted a prospective study to compare the scores calculated by a patient with those calculated by a blinded physician for the same patient.

Methods  In phase 1, we interviewed patients in our deep vein thrombosis (DVT) support group who had a history of thrombosis and included their family members to determine areas of misunderstanding in the original CRS. We created a patient-completed form based on these interviews. In phase 2, we further optimized the questions after a CRS-trained, blinded physician scored 20 hospitalized patients during the pilot study. In the final (third) phase, we measured the agreement level between the new form filled out by the trained physicians and those filled out by the patients. The study was approved by our local institutional review board. Using PASS version 11, we determined that a sample size of 37 individuals achieves a power of 80%, to detect a 0.1 difference between the null hypothesis correlation of 0.5 and the alternative hypothesis correlation of 0.7 using a two-sided hypothesis test with a significance level of 0.05. We tabulated the individuals' answers and categorized the scores by using SPSS version 23 to estimate the kappa value, linear correlation, and the Bland–Altman test. A kappa value greater than 0.8 indicated an “almost perfect agreement.”

Results  We tested the first patient-completed CRS version (phase 2) in a 20-patient pilot study. A poor agreement was observed with the body mass index (BMI) responses in multiple iterations, and so we excluded the BMI calculation from the final patient-completed CRS form. We recruited 42 patients with an average age of 55, mostly female (45%), who completed less than college education (62%) to fill out the updated CRS form (phase 3). An almost perfect agreement was found for both the individual questions and the overall score comparing physician and patient answers, resulting in a high correlation ( r  = 0.95). In Bland–Altman, we did not find any trend for extreme values.

Conclusion  We created and validated a patient-completed CRS form that has an excellent agreement level with the physician-completed form. From the results, the physician only needs to calculate the BMI. The average time for a patient to complete the form was 5 minutes. The average time for the physician to finalize the score was approximately 6 minutes. Implementation studies are needed to assess the correlation of the aggregated score, derived from this form, with the occurrence of perioperative VTE.

Venous thromboembolism prophylaxis in urology: A review

Venous thromboembolism is potentially a lethal problem, and is associated with chronic morbidity. Venous thromboembolism is frequently diagnosed after urological surgery, yet the role of perioperative venous thromboembolism prophylaxis is not clearly defined. Any current recommendations are largely based on evidence derived from other surgical specialties. Even within different guidelines, there remains significant variation, suggesting a consensus is required. The present review aims to define the problem of venous thromboembolism within the urological population, and identifies patients at risk. It evaluates the role of various types of mechanical and pharmacological prophylaxis, along with its timing and duration of administration in common urological operations. The current guidelines are summarized and compared in order to give the reader a better perspective of this vital condition.

Thromboprophylaxis and mortality among patients who developed venous thromboembolism in seven major hospitals in Saudi Arabia

INTRODUCTION

Venous thromboembolism (VTE) during hospitalization is a serious and potentially fatal condition. Despite its effectiveness, evidence-based thromboprophylaxis is still underutilized in many countries including Saudi Arabia.

OBJECTIVE OF THE STUDY

Our objectives were to determine how often hospital-acquired VTE patients received appropriate thromboprophylaxis, VTE-associated mortality, and the percentage of patients given anticoagulant therapy and adherence to it after discharged.

METHODS

This study was conducted in seven major hospitals in Saudi Arabia. From July 1, 2009, till June 30, 2010, all recorded deep vein thrombosis (DVT) and pulmonary embolism (PE) cases were noted. Only patients with confirmed VTE diagnosis were included in the analysis.

RESULTS

A total of 1241 confirmed VTE cases occurred during the 12-month period. Most (58.3%) of them were DVT only, 21.7% were PE, and 20% were both DVT and PE. 21.4% and 78.6% of confirmed VTE occurred in surgical and medical patients, respectively. Only 40.9% of VTE cases received appropriate prophylaxis (63.2% for surgical patients and 34.8% for medical patients; P < 0.001). The mortality rate was 14.3% which represented 1.6% of total hospital deaths. Mortality was 13.5% for surgical patients and 14.5% for medical patients (P > 0.05). Appropriate thromboprophylaxis was associated with 4.11% absolute risk reduction in mortality (95% confidence interval: 0.24%-7.97%). Most (89.4%) of the survived patients received anticoagulation therapy at discharge and 71.7% of them were adherent to it on follow-up.

CONCLUSION

Thromboprophylaxis was underutilized in major Saudi hospitals denoting a gap between guideline and practice. This gap was more marked in medical than surgical patients. Hospital-acquired VTE was associated with significant mortality. Efforts to improve thromboprophylaxis utilization are warranted.

Venous thromboembolism in medical patients during hospitalisation and 3 months after hospitalisation: a prospective observational study

OBJECTIVES

This study was conducted to assess the incidence and risk factors for venous thromboembolism (VTE) in a cohort of medical patients both during the period of hospitalisation and following discharge.

DESIGN

This was a prospective observational study to document the risk profile and incidence of VTE posthospitalisation among all medical patients admitted to our institution during the trial period.

SETTINGS

Primary healthcare. Single tertiary referral centre, Tasmania, Australia.

PARTICIPANTS

A total of 986 patients admitted to the medical ward between January 2012 and September 2012 were included in the study with male to female ratio of 497:489. The mean age of patients was 68 years (range 17-112, SD 16).

RESULTS

Overall, 54/986 patients (5.5%) had a VTE during the study period. Of these, 40/54 (74.1%) occurred during hospitalisation and 14/54 (25.9%) occurred following discharge. VTE risk factors revealed in multivariate analysis to be associated with a previous diagnosis of VTE (p<0.001, OR=6.63, 95% CI 3.3 to 13.36), the occurrence of surgery within the past 30 days (p<0.001, OR=2.52, 95% CI 1.33 to 4.79) and an admission diagnosis of pulmonary disease (p<0.01, OR 3.61, 95% CI 1.49 to 8.76). Mobility within 24 hours of admission was not associated with an increased risk. There was risk of VTE when the length of stay prolonged (p=0.046, OR=1.01, 95% CI 1.00 to 1.03), however it was not sustained with multivariate modelling. VTE-specific prophylaxis was used in 53% of the studied patients. Anticoagulation including antiplatelet agents were administered in 63% of patients who developed VTE.

CONCLUSIONS

This prospective observational study found that 5.5% of the studied patients developed VTE. Among those, 25.9% (14/54) of patients had a detected VTE posthospitalisation with this risk being increased if there was a history of VTE, recent surgery and pulmonary conditions. Thromboprophylaxis may be worth considering in these cohorts. Further study to confirm these findings are warranted.

TRIAL REGISTRATION NUMBER

ACTRN12611001255976.

Muscle activity in the lower limbs during push-down movement with a new active-exercise apparatus for the leg

[Purpose] Lower-limb deep vein thrombosis is a complication of orthopedic surgery. A leg-exercise apparatus named “LEX” was developed as a novel active-exercise apparatus for deep vein thrombosis prevention. Muscle activity was evaluated to assess the effectiveness of exercise with LEX in the prevention. [Subjects] Eight healthy volunteers participated in this study. [Methods] Muscle activities were determined through electromyography during exercise with LEX [LEX (+)] and during active ankle movements [LEX (−)]. The end points were peak % maximum voluntary contraction and % integrated electromyogram of rectus femoris, vastus lateralis, biceps femoris, tibialis anterior, gastrocnemius, and soleus. [Results] LEX (+) resulted in higher average values in all muscles except the tibialis anterior. Significant differences were noted in the peak of the biceps femoris and gastrocnemius and in the integrated electromyogram of the rectus femoris, vastus lateralis, gastrocnemius, and soleus. The LEX (+)/LEX (−) ratio of the peak was 2.2 for the biceps femoris and 2.0 for the gastrocnemius . The integrated electromyogram was 1.8 for the gastrocnemius, 1.5 for the rectus femoris, 1.4 for the vastus lateralis, and 1.2 for the soleus. [Conclusion] Higher muscle activity was observed with LEX (+). LEX might be a good tool for increasing lower-limb blood flow and deep vein thrombosis prevention.

Primary prevention and treatment of venous thromboembolic events in patients with gastrointestinal cancers - Review

Venous thromboembolism event (VTE) is a common and morbid complication in cancer patients. Patients with gastrointestinal cancers often suffer from symptomatic or incidental splanchnic vein thrombosis, impaired liver function and/or thrombocytopenia. These characteristics require a thorough risk/benefit evaluation for individual patients. Considering the risk factors for the development of VTE and bleeding events in addition to recent study results may be helpful for correct initiation of primary pharmacological prevention and treatment of cancer-associated thrombosis (CAT), preferably with low molecular weight heparins (LMWH). Whereas thromboprophylaxis is most often recommended in hospitalized surgical and non-surgical patients with malignancy, there is less agreement as to its duration. With regard to ambulatory cancer patients, the lack of robust data results in low grade recommendations against routine use of anticoagulant drugs. Anticoagulation with LMWH for the first months is the evidence-based treatment for acute CAT, but duration of secondary prevention and the drug of choice are unclear. Based on published guidelines and literature, this review will focus on prevention and treatment strategies of VTE in patients with gastrointestinal cancers.

Incidence and risk factors of venous thromboembolism after pelvic uro-oncologic surgery--a single center experience

OBJECTIVE

To determine the incidence and assess risk factors for the development of VTE among patients undergoing major pelvic surgery for prostate and bladder cancer in an Australian tertiary referral center.

PATIENTS AND METHODS

Consecutive patients undergoing major pelvic uro-oncologic surgery, namely radical cystectomy and radical prostatectomy over a five-year period (2009-2013) were identified. Patient variables and types of thromboprophylaxis (pharmacological and/or mechanical) used in this patient cohort were collected for analyses as predictive factors.

RESULTS

The overall incidence of VTE was 1.8%. Patients undergoing radical cystectomy were more likely to suffer a VTE event compared to patients having radical prostatectomy. In this cohort, the risk factors for VTE include, prolonged operative time of greater than 4 hours (h), lymph node dissection (LND) and patients requiring blood transfusions.

CONCLUSION

Patients undergoing major pelvic uro-oncologic surgery have an approximately 1.8% risk of developing VTE. Risk factors identified in this study should be used to guide the use of early and prolonged thromboprophylaxis.

Warfarin treatment complications do not correlate to cTTR when above 70

BACKGROUND

The mean time in target range for each centre, cTTR, has previously been shown to correlate to the rate of complications in poorly managed warfarin treatment. However less is known about the correlation when warfarin treatment is well managed.

OBJECTIVES

The aim of this study was to examine the correlation between cTTR and the rate of complications in a real life setting with cTTR above 70%, with focus on patients with warfarin due to atrial fibrillation or secondary prevention of a VTE.

PATIENTS/METHODS

In total 66,605 patients with 89,293 treatment periods, corresponding to 179,624 treatment years, with warfarin treatment due to VTE or AF between January 1st 2006 and December 31th 2011, was retrieved from the national quality register AuriculA. The cohort was matched with the National Patient Register in Sweden for complications and background characteristics.

RESULTS

We found 172 centres and 68,797 treatment periods for AF and 166 centres and 20,496 treatment periods for VTE. Over 90% of the patients had a target range between INR 2-3. We found no correlation between increasing cTTR and reduction in the rate of complications for the AF patients. However, for VTE patients we saw a correlation between increasing cTTR and a reduced complication rate.

CONCLUSIONS

Our results show that at very high cTTR levels, above 70%, further improvements in cTTR do not correlate to less treatment complications at least for patients with AF.

Antithrombotic Therapy in Patients With Thrombocytopenic Cancer

Background:

Guidelines are discordant concerning management of patients having thrombocytopenia with cancer-associated thrombosis (CAT).

Methods:

Hospitalized adults with CAT and platelets ≤50 × 109 cells/L were managed with dalteparin 100 units/kg subcutaneously once daily. Comparator patients with CAT and platelets >50 × 109 cells/L were managed with dalteparin 200 units/kg/d.

Results:

Outcomes of 35 patients with thrombocytopenia (mean platelet count 26 ± 8.3 × 109 cells/L) and 58 comparator patients (mean platelet count 155 ± 75 × 109 cells/L) were evaluated. In all, 2 (5.7%) patients in the thrombocytopenia group and 1 patient (1.9%) in the comparator group experienced new-onset venous thromboembolism (odds ratio 3.31, 95% confidence interval [CI] 0.29-37.90, P = .556). The incidence of bleeding in patients with thrombocytopenia (8.6%) was similar to that in comparator patients (9.4%; risk ratio 0.94, 95% CI 0.37-2.39, P = .607).

Conclusion:

In hospitalized patients having thrombocytopenia with CAT, reduced-dose low-molecular-weight heparin was generally efficacious.

Quality assessment of guidelines on thromboprophylaxis in orthopaedic surgery

We evaluated the quality of guidelines on thromboprophylaxis in orthopaedic surgery by examining how they adhere to validated methodological standards in their development. A structured review was performed for guidelines that were published between January 2005 and April 2013 in medical journals or on the Internet. A pre-defined computerised search was used in MEDLINE, Scopus and Google to identify the guidelines. The AGREE II assessment tool was used to evaluate the quality of the guidelines in the study. Seven international and national guidelines were identified. The overall methodological quality of the individual guidelines was good. 'Scope and Purpose' (median score 98% interquartile range (IQR)) 86% to 98%) and 'Clarity of Presentation' (median score 90%, IQR 90% to 95%) were the two domains that received the highest scores. 'Applicability' (median score 68%, IQR 45% to 75%) and 'Editorial Independence' (median score 71%, IQR 68% to 75%) had the lowest scores. These findings reveal that although the overall methodological quality of guidelines on thromboprophylaxis in orthopaedic surgery is good, domains within their development, such as 'Applicability' and 'Editorial Independence', need to be improved. Application of the AGREE II instrument by the authors of guidelines may improve the quality of future guidelines and provide increased focus on aspects of methodology used in their development that are not robust.

Prevention of venous thromboembolism, 2nd edition: Korean Society of Thrombosis and Hemostasis Evidence-based Clinical Practice Guidelines

In 2010, we proposed the first Korean Guidelines for the Prevention of Venous Thromboembolism (VTE). It was applicable to Korean patients, by modifying the contents of the second edition of the Japanese guidelines for the prevention of VTE and the 8th edition of the American College of Chest Physicians (ACCP) evidence-based clinical practice guidelines. From 2007 to 2011, we conducted a nationwide study regarding the incidence of VTE after major surgery using the Health Insurance Review and Assessment Service (HIRA) database. In addition, we have considered the 9th edition of the ACCP Evidenced-Based Clinical Practice Guidelines, published in 2012. It emphasized the importance of clinically relevant events as opposed to asymptomatic outcomes with preferences for both thrombotic and bleeding outcomes. Thus, in the development of the new Korean guidelines, three major points were addressed: 1) the new guidelines stratify patients into 4 risk groups (very low, low, moderate, and high) according to the actual incidence of symptomatic VTE from the HIRA databases; 2) the recommended optimal VTE prophylaxis for each group was modified according to condition-specific thrombotic and bleeding risks; 3) guidelines are intended for general information only, are not medical advice, and do not replace professional medical care and/or physician advice.

Venous thromboembolism prevention in patients undergoing colorectal surgery for cancer

INTRODUCTION

Patients undergoing surgery for colorectal cancer are at high risk of post-operative venous thromboembolism (VTE). Thromboprophylaxis has been shown to have significant risk reduction, although there remains some controversy surrounding the optimal duration of pharmacological prophylaxis. Our institution does not routinely practise extended prophylaxis. The aim of this study was to retrospectively review the rate of post-operative thromboprophylaxis in colorectal cancer patients, and incidence of symptomatic VTE.

METHODS

We conducted a retrospective audit of 200 consecutive patients who underwent colorectal surgery for cancer. Data to 90 days post-operatively were collected from medical records and imaging and phone calls to patients and family practitioners.

RESULTS

Of the patients, 98% received pharmacological prophylaxis, with a median duration of eight days. Eight (4%) symptomatic VTEs were diagnosed within the 90-day follow-up period: two deep vein thrombosis (DVTs), five pulmonary emboli (PE) and one patient with both PE and DVT. A higher proportion of patients developed DVT/PE if they received prophylaxis other than low molecular weight heparin and similarly there was a trend in increased risk of DVT in the presence of metastatic disease. However, using univariate analysis, these results were not statistically significant (P = 0.18 and 0.11, respectively).

DISCUSSION

The use of thromboprophylaxis was high in our centre, and the incidence of VTE was low when patients received a median of 8 days pharmacological prophylaxis combined with mechanical prophylaxis. The VTE incidence of 4% is similar to previous studies using extended prophylaxis. Our study findings do not support changing local protocol to extended prophylaxis.

Evidence-based review for patients undergoing elective hip and knee replacement

BACKGROUND

The objective of this study was to evaluate the evidence for different interventions in the preoperative, perioperative and post-operative care for people undergoing elective total hip (THR) and knee (TKR) replacement surgery.

METHOD

A multidisciplinary working group comprising consumers, managers and clinicians from the areas of orthopaedics, rheumatology, aged care and rehabilitation evaluated randomized controlled trials (RCTs) and systematic reviews/meta-analyses concerning aspects of preoperative, perioperative and post-operative clinical care periods for THR/TKR through systematic searching of Medline, Embase, CENTRAL and the Cochrane Database of Systematic Reviews from May 2007 to April 2011. Multiple reviewers determined study eligibility and one or more members extracted primary study findings. The body of evidence were assessed and specific recommendations made according to NHMRC guidelines.

RESULTS

Twenty-five aspects were identified for review. Recommendations for 16 of 25 areas of care were made: impact of waiting, multidisciplinary preparation, preoperative exercise, smoking cessation, interventions for comorbid conditions, predictors of outcome, clinical pathways, implementation of a blood management programme, antibiotic prophylaxis, regional anaesthesia and analgesia, use of a tourniquet in knee replacement, venous thromboembolism prophylaxis, early post-operative cryotherapy, early mobilization and continuous passive motion. In the post-operative period, study heterogeneity across all aspects of care precluded specific recommendations.

CONCLUSIONS

There was a deficiency in the quality of the evidence supporting key aspects of the continuum of care for primary THR/TKR surgery. Consequently, recommendations were limited. Prioritization and funding for research into areas likely to impact clinical practice and patient outcomes after elective joint replacement surgery are the next important steps.