1
|
Berner JE, Geoghegan L, Kyriazidis I, Nanchahal J, Jain A. Alternative physical treatments for deep venous thrombosis prophylaxis in surgical patients: a systematic review. Physiotherapy 2021; 113:73-79. [PMID: 34562667 DOI: 10.1016/j.physio.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Venous thromboembolism (VTE) represents a major cause of morbidity and mortality. A variety of novel physical therapies have been proposed for patients in whom standard prophylaxis, including early mobilisation, is contraindicated. This article presents a systematic literature review of alternative physical treatments for VTE prophylaxis, focusing on surgical and trauma patients. METHODS Following protocol registration in PROSPERO, a systematic review was conducted in accordance with PRISMA. MEDLINE and EMBASE databases were searched for all studies indexed before 27th of July 2019. Two authors independently screened these articles. Data gathering for eligible articles was also undertaken in parallel by two authors. A formal risk of bias assessment was conducted for each study along with an assessment on the quality of the evidence using the GRADE framework. RESULTS A total of 272 abstracts were identified. After exclusion of duplicates and non-eligible articles, 10 publications were reviewed in detail. Two studies involving electrostimulation, another using a portable intermittent compression device and one study using postoperative calf massage reported a statistically significant reduction in the incidence of deep venous thrombosis when used in conjunction with LMWH. The remaining six articles did not show any significant benefits. DISCUSSION All studies reporting significant benefits have methodological flaws, with a high risk of bias. The evidence base informing alternative physical treatments as prophylactic measures in VTE is limited. Our data suggest that the use of these physical modalities can be beneficial in patients who also received LMWH, whilst these alone are of no benefit. LEVEL OF EVIDENCE II - Systematic Review Systematic Review Registration Number PROSPERO CRD42019133684.
Collapse
Affiliation(s)
- Juan Enrique Berner
- Kellogg College, University of Oxford, Oxford, United Kingdom; Queen Victoria Hospital, East Grinstead, United Kingdom.
| | - Luke Geoghegan
- Imperial College NHS Trust, London, United Kingdom; Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom.
| | | | - Jagdeep Nanchahal
- The Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom.
| | - Abhilash Jain
- Imperial College NHS Trust, London, United Kingdom; Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom.
| |
Collapse
|
2
|
Amanatullah DF, Shah HN, Johnson B, Wall J. Mechanical compression augments venous flow equal to intermittent pneumatic compression. J Orthop Res 2020; 38:2390-2395. [PMID: 32175638 DOI: 10.1002/jor.24664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 03/03/2020] [Accepted: 03/12/2020] [Indexed: 02/04/2023]
Abstract
Intermittent pneumatic compression is part of the current standard of care model for preventing venous thromboembolic events (VTE) after total joint arthroplasty. Pneumatic motors limit the rate of inflation resulting in bulky devices with uncomfortable sleeves that inhibited patient compliance and mobility. Nonpneumatic mechanical devices are an alternative for providing mobile, graded, intermittent, sequential, rapid, and monitorable compression posthospitalization. Fifteen healthy volunteers underwent mechanical compression using the Cirvo (Radial Medical, Mountain View, CA) as well as pneumatic compression with four commercially available systems (VenaFlow Elite, Kendall SCD Compression System, ActiveCare DVT, Vasculaire Compression System) and manual calf compression. Peak flow velocity (PFV) was measured by ultrasound of the femoral vein during compression and at baseline. Mechanical compression for 1 second resulted in a significant increase in femoral venous PFV to 107.8 ± 38.2 cm/s from 17.1 ± 4.7 cm/s at baseline (P < .001). The change in femoral venous PFV with mechanical compression for 1 second (90.7 ± 34.9 cm/s) was not statistically different from pneumatic compression from VenaFlow system (106.0 ± 35.6 cm/s, P = .124) and statistically lower than manual calf compression (115.5 ± 26.8 cm/s, P = .015). Pneumatic compression from the VenaFlow system produced the largest change in femoral venous PFV of all commercial pneumatic systems tested. Mechanical compression replicates or exceeds femoral venous PFV available from currently available intermittent pneumatic compression.
Collapse
Affiliation(s)
- Derek F Amanatullah
- Department of Orthopaedic Surgery, Stanford Hospital and Clinics, Palo Alto, California
| | - Harsh N Shah
- Department of Orthopaedic Surgery, Stanford Hospital and Clinics, Palo Alto, California
| | - Bonnie Johnson
- Fogarty Institute for Innovation, Mountain View, California
| | - James Wall
- Department of Surgery, Division of Pediatrics, Lucile Packard Children's Hospital, Palo Alto, California
| |
Collapse
|
3
|
Greenall R, Davis RE. Intermittent pneumatic compression for venous thromboembolism prevention: a systematic review on factors affecting adherence. BMJ Open 2020; 10:e037036. [PMID: 32883726 PMCID: PMC7473613 DOI: 10.1136/bmjopen-2020-037036] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Venous thromboembolism (VTE) is a potentially fatal complication of hospitalisation. Intermittent pneumatic compression (IPC) is one approach to reducing the likelihood of a VTE. Adherence to IPC is known to be inadequate though the reasons for this remain unclear. This systematic review explores factors that affect adherence to IPC in the inpatient context. METHODS Information sources-EMBASE, MEDLINE and PsycINFO were searched for literature between January 1960 and May 2019. Eligibility criteria-studies were included if they focused on inpatient care and examined factors affecting adherence to IPC devices. RESULTS Included studies-a total of 20 out of 1476 studies were included. Synthesis of results-eight factors were identified that affected adherence: patient discomfort (n=8), healthcare professionals' knowledge and behaviours (n=6), mobilisation (n=6), equipment supply and demand (n=3), the use of guidelines (n=3), intensive care context (n=2), computer-assisted prescribing (n=2) and patients' knowledge of IPC (n=1). CONCLUSION Overall while the evidence base is quite limited, a number of factors were shown to affect adherence to IPC. These findings could be used to inform future research and quality improvement efforts to increase adherence in this very important, but currently under-researched area.
Collapse
Affiliation(s)
- Richard Greenall
- Executive Offices, Princess Royal University Hospital, King's College Hospital NHS Foundation Trust, Farnborough, UK
| | - Rachel E Davis
- Centre for Implementation Science, Health Services and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| |
Collapse
|
4
|
Comparative efficacy and safety of pharmacological prophylaxis and intermittent pneumatic compression for prevention of venous thromboembolism in adult undergoing neurosurgery: a systematic review and network meta-analysis. Neurosurg Rev 2020; 44:721-729. [PMID: 32300889 DOI: 10.1007/s10143-020-01297-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 03/22/2020] [Accepted: 03/30/2020] [Indexed: 02/05/2023]
Abstract
Whether intermittent pneumatic compression (IPC) is a more effective form of thromboprophylaxis than anticoagulants in individuals undergoing neurosurgery remains controversial. Relevant studies are sparse and inconsistent. Therefore, direct comparisons are difficult to perform and impractical. Hence, we summarized and compared the efficacy and safety of IPC and anticoagulants for the prevention of venous thromboembolism (VTE) in adults undergoing cranial or spinal procedures. Several electronic databases were searched for randomized controlled trials on the use of IPC and anticoagulants for thromboembolism prevention in neurosurgical patients, from inception to August 6, 2019. Studies reporting the selected endpoints were included in direct and Bayesian network meta-analyses to estimate the relative effects of the interventions. Overall, our analysis included 18 trials comprising 2474 patients. Both IPC (RR, 0.41; 95% CrI, 0.26-0.60) and chemical prophylaxis (RR, 0.48; 95% CrI, 0.28-0.68) were found to be more efficacious than the placebo in reducing the risk of deep vein thrombosis (DVT). In addition, our analysis also demonstrated that both IPC (RR, 0.10; 95% CrI, 0.01-0.60) and chemical prophylaxis (RR, 0.31; 95% CrI, 0.05-1.00) reduced the risk of pulmonary embolism (PE) significantly more than the placebo. Based on the available evidence of moderate-to-good quality, IPC is equivalent to anticoagulants for thromboprophylaxis in terms of efficacy. Evidence to support or negate the use of pharmacological prophylaxis in terms of safety is lacking. The results of ongoing and future large randomized clinical trials are needed.
Collapse
|
5
|
Mejzlik J, Skoloudik L, Cerny M, Ryska A, Radochova V, Pellantova V, Chrobok V. Use of a new pneumatic system to support capillary microperfusion in surgical wound healing: an animal model. J Wound Care 2019; 28:229-237. [PMID: 30975053 DOI: 10.12968/jowc.2019.28.4.229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To test the efficacy of the a developed medical device, based on the principle of mechanical support of capillary microperfusion. METHOD In this pilot study involving experimental animals, each pig had two standardised surgical wounds. A cuff that delivered pneumatic three-second micropulses was applied to the wound designated as the 'experimental wound'. The pressure inside the cuff was kept at a level <10mmHg so that during the pulse, the pressure would decrease by one third of the established value. The second wound, designated as the 'control wound', was covered with a standard dressing. Over the course of five days, the pressure inside the cuff was monitored. After the five days, the experimental animal was euthanised and two specimens were collected for histological analysis (one sample from each wound site). Wound healing parameters for the experimental and control wounds were examined by a pathologist. The level of statistical significance was set at 0.05. RESULTS In this study, 10 experimental animals were used. The average pressure in the cuffs was 8.46mmHg (standard deviation: 3.86). No disparities in wound healing were observed in cases of different average pressures in the experimental wound. With respect to wound healing parameters, a statistically significant difference (p<0.05) was found in favour of the experimental wound. The occurrence of histological signs of poor healing was identical in both study wounds. CONCLUSION The study shows that a device for the support of capillary microperfusion of the surgical wound had a positive effect. It was confirmed that the mechanical support system of capillary microperfusion was safe and reliable.
Collapse
Affiliation(s)
- Jan Mejzlik
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Czech Republic
| | - Lukas Skoloudik
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Czech Republic
| | - Michal Cerny
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Czech Republic
| | - Ales Ryska
- Fingerland's institute of Pathology, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Czech Republic
| | - Vera Radochova
- Vivarium, Faculty of Military Health Sciences, University of Defence, Brno, Czech Republic
| | - Vera Pellantova
- Department of Infectious Diseases, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Czech Republic
| | - Viktor Chrobok
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Czech Republic
| |
Collapse
|
6
|
Anderson DR, Morgano GP, Bennett C, Dentali F, Francis CW, Garcia DA, Kahn SR, Rahman M, Rajasekhar A, Rogers FB, Smythe MA, Tikkinen KAO, Yates AJ, Baldeh T, Balduzzi S, Brożek JL, Ikobaltzeta IE, Johal H, Neumann I, Wiercioch W, Yepes-Nuñez JJ, Schünemann HJ, Dahm P. American Society of Hematology 2019 guidelines for management of venous thromboembolism: prevention of venous thromboembolism in surgical hospitalized patients. Blood Adv 2019; 3:3898-3944. [PMID: 31794602 PMCID: PMC6963238 DOI: 10.1182/bloodadvances.2019000975] [Citation(s) in RCA: 281] [Impact Index Per Article: 56.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 10/22/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a common source of perioperative morbidity and mortality. OBJECTIVE These evidence-based guidelines from the American Society of Hematology (ASH) intend to support decision making about preventing VTE in patients undergoing surgery. METHODS ASH formed a multidisciplinary guideline panel balanced to minimize bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline-development process, including performing systematic reviews. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 30 recommendations, including for major surgery in general (n = 8), orthopedic surgery (n = 7), major general surgery (n = 3), major neurosurgical procedures (n = 2), urological surgery (n = 4), cardiac surgery and major vascular surgery (n = 2), major trauma (n = 2), and major gynecological surgery (n = 2). CONCLUSIONS For patients undergoing major surgery in general, the panel made conditional recommendations for mechanical prophylaxis over no prophylaxis, for pneumatic compression prophylaxis over graduated compression stockings, and against inferior vena cava filters. In patients undergoing total hip or total knee arthroplasty, conditional recommendations included using either aspirin or anticoagulants, as well as for a direct oral anticoagulant over low-molecular-weight heparin (LMWH). For major general surgery, the panel suggested pharmacological prophylaxis over no prophylaxis, using LMWH or unfractionated heparin. For major neurosurgery, transurethral resection of the prostate, or radical prostatectomy, the panel suggested against pharmacological prophylaxis. For major trauma surgery or major gynecological surgery, the panel suggested pharmacological prophylaxis over no prophylaxis.
Collapse
Affiliation(s)
- David R Anderson
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Gian Paolo Morgano
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Francesco Dentali
- Department of Medicine and Surgery, Insubria University, Varese, Italy
| | - Charles W Francis
- Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY
| | - David A Garcia
- Division of Hematology, Department of Medicine, University of Washington Medical Center, University of Washington School of Medicine, Seattle, WA
| | - Susan R Kahn
- Department of Medicine, McGill University and Lady Davis Institute, Montreal, QC, Canada
| | | | - Anita Rajasekhar
- Division of Hematology and Oncology, Department of Medicine, University of Florida, Gainesville, FL
| | - Frederick B Rogers
- Trauma and Acute Care Surgery, Penn Medicine Lancaster General Health, Lancaster, PA
| | - Maureen A Smythe
- Department of Pharmaceutical Services, Beaumont Hospital, Royal Oak, MI
- Department of Pharmacy Practice, Wayne State University, Detroit, MI
| | - Kari A O Tikkinen
- Department of Urology and
- Department of Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Adolph J Yates
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Tejan Baldeh
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Sara Balduzzi
- Department of Diagnostic, Clinical, and Public Health Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Jan L Brożek
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine and
| | | | - Herman Johal
- Center for Evidence-Based Orthopaedics, Division of Orthopaedic Surgery, McMaster University, Hamilton, ON, Canada
| | - Ignacio Neumann
- Department of Internal Medicine, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Holger J Schünemann
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine and
| | - Philipp Dahm
- Urology Section, Minneapolis VA Health Care System, Minneapolis, MN; and
- Department of Urology, University of Minnesota, Minneapolis, MN
| |
Collapse
|
7
|
Abstract
BACKGROUND Hospitalised patients are at increased risk of developing deep vein thrombosis (DVT) in the lower limb and pelvic veins, on a background of prolonged immobilisation associated with their medical or surgical illness. Patients with DVT are at increased risk of developing a pulmonary embolism (PE). The use of graduated compression stockings (GCS) in hospitalised patients has been proposed to decrease the risk of DVT. This is an update of a Cochrane Review first published in 2000, and last updated in 2014. OBJECTIVES To evaluate the effectiveness and safety of graduated compression stockings in preventing deep vein thrombosis in various groups of hospitalised patients. SEARCH METHODS For this review the Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), and trials registries on 21 March 2017; and the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE Ovid, Embase Ovid, CINAHL Ebsco, AMED Ovid , and trials registries on 12 June 2018. SELECTION CRITERIA Randomised controlled trials (RCTs) involving GCS alone, or GCS used on a background of any other DVT prophylactic method. We combined results from both of these groups of trials. DATA COLLECTION AND ANALYSIS Two review authors (AS, MD) assessed potentially eligible trials for inclusion. One review author (AS) extracted the data, which a second review author (MD) cross-checked and authenticated. Two review authors (AS, MD) assessed the methodological quality of trials with the Cochrane 'Risk of bias' tool. Any disagreements were resolved by discussion with the senior review author (TL). For dichotomous outcomes, we calculated the Peto odds ratio and corresponding 95% confidence interval. We pooled data using a fixed-effect model. We used the GRADE system to evaluate the overall quality of the evidence supporting the outcomes assessed in this review. MAIN RESULTS We included 20 RCTs involving a total of 1681 individual participants and 1172 individual legs (2853 analytic units). Of these 20 trials, 10 included patients undergoing general surgery; six included patients undergoing orthopaedic surgery; three individual trials included patients undergoing neurosurgery, cardiac surgery, and gynaecological surgery, respectively; and only one trial included medical patients. Graduated compression stockings were applied on the day before surgery or on the day of surgery and were worn up until discharge or until the participants were fully mobile. In the majority of the included studies DVT was identified by the radioactive I125 uptake test. Duration of follow-up ranged from seven to 14 days. The included studies were at an overall low risk of bias.We were able to pool the data from 20 studies reporting the incidence of DVT. In the GCS group, 134 of 1445 units developed DVT (9%) in comparison to the control group (without GCS), in which 290 of 1408 units developed DVT (21%). The Peto odds ratio (OR) was 0.35 (95% confidence interval (CI) 0.28 to 0.43; 20 studies; 2853 units; high-quality evidence), showing an overall effect favouring treatment with GCS (P < 0.001).Based on results from eight included studies, the incidence of proximal DVT was 7 of 517 (1%) units in the GCS group and 28 of 518 (5%) units in the control group. The Peto OR was 0.26 (95% CI 0.13 to 0.53; 8 studies; 1035 units; moderate-quality evidence) with an overall effect favouring treatment with GCS (P < 0.001). Combining results from five studies, all based on surgical patients, the incidence of PE was 5 of 283 (2%) participants in the GCS group and 14 of 286 (5%) in the control group. The Peto OR was 0.38 (95% CI 0.15 to 0.96; 5 studies; 569 participants; low-quality evidence) with an overall effect favouring treatment with GCS (P = 0.04). We downgraded the quality of the evidence for proximal DVT and PE due to low event rate (imprecision) and lack of routine screening for PE (inconsistency).We carried out subgroup analysis by speciality (surgical or medical patients). Combining results from 19 trials focusing on surgical patients, 134 of 1365 (9.8%) units developed DVT in the GCS group compared to 282 of 1328 (21.2%) units in the control group. The Peto OR was 0.35 (95% CI 0.28 to 0.44; high-quality evidence), with an overall effect favouring treatment with GCS (P < 0.001). Based on results from seven included studies, the incidence of proximal DVT was 7 of 437 units (1.6%) in the GCS group and 28 of 438 (6.4%) in the control group. The Peto OR was 0.26 (95% CI 0.13 to 0.53; 875 units; moderate-quality evidence) with an overall effect favouring treatment with GCS (P < 0.001). We downgraded the evidence for proximal DVT due to low event rate (imprecision).Based on the results from one trial focusing on medical patients admitted following acute myocardial infarction, 0 of 80 (0%) legs developed DVT in the GCS group and 8 of 80 (10%) legs developed DVT in the control group. The Peto OR was 0.12 (95% CI 0.03 to 0.51; low-quality evidence) with an overall effect favouring treatment with GCS (P = 0.004). None of the medical patients in either group developed a proximal DVT, and the incidence of PE was not reported.Limited data were available to accurately assess the incidence of adverse effects and complications with the use of GCS as these were not routinely quantitatively reported in the included studies. AUTHORS' CONCLUSIONS There is high-quality evidence that GCS are effective in reducing the risk of DVT in hospitalised patients who have undergone general and orthopaedic surgery, with or without other methods of background thromboprophylaxis, where clinically appropriate. There is moderate-quality evidence that GCS probably reduce the risk of proximal DVT, and low-quality evidence that GCS may reduce the risk of PE. However, there remains a paucity of evidence to assess the effectiveness of GCS in diminishing the risk of DVT in medical patients.
Collapse
Affiliation(s)
- Ashwin Sachdeva
- Newcastle UniversityWellcome Centre for Mitochondrial Research4th floor, Cookson Building, Medical SchoolFramlington PlaceNewcastle upon TyneUKNE2 4HH
| | - Mark Dalton
- Royal Victoria InfirmaryDepartment of AnaestheticsQueen Victoria RoadNewcastle upon TyneTyne and WearUKNE1 4LP
| | - Timothy Lees
- NMC Royal HospitalKhalifa CityAbu DhabiUnited Arab Emirates
| | | |
Collapse
|
8
|
Ebeling M, Lüdemann W, Frisius J, Karst M, Schedel I, Gerganov V, Samii A, Fahlbusch R. Venous thromboembolic complications with and without intermittent intraoperative and postoperative pneumatic compression in patients with glioblastoma multiforme using intraoperative magnetic resonance imaging. A retrospective study. Neurochirurgie 2018; 64:161-165. [PMID: 29859696 DOI: 10.1016/j.neuchi.2018.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 02/14/2018] [Accepted: 04/13/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of intraoperative and postoperative intermittent pneumatic compression (IPC) as a method used to decrease the incidence of deep venous thrombosis (DVT), in comparison to the standard use of graduated compression stockings, low-molecular weight heparin (LMWH) and physiotherapy during the hospital stay. All patients in this study underwent intracranial surgery for glioblastoma multiforme (GBM) using intraoperative magnetic resonance imaging (MRI) guidance. PATIENTS AND METHODS We performed a single center retrospective study of a cohort of 153 patients who underwent surgery for GBM aided by intraoperative MRI from October of 2009 to January of 2015 at the International Neuroscience Institute (INI), Hannover, Germany. Out of all patients, 75 in comparison to 78 were operated with and without the additional use of IPC, respectively. Both groups received graduated compression stockings, LMWH and physiotherapy postoperatively as a basic thromboprophylaxis. Postoperatively the patients were screened for DVT by Doppler ultrasonography of the limbs and pulmonary embolism (PE) by CT-scan of the chest. RESULTS DVTs were found in 6 patients with IPC and in 3 patients without IPC. The incidence of developing DVTs was therefore not significantly increased with the application of IPC from 3.9% to 8% (P-value: 0.33). No statistically significant differences were found in the probability of occurrence of pulmonary embolism (PE) with a reduction from 2.6% to 1.3% (P-value: 0.59). CONCLUSION Our results demonstrate, that the surgical intervention and the subsequent patient immobilization, as well as the thromboprophylactic techniques used have a relatively low influence on the occurrence of thromboembolic complications than we expected. Our findings might be attributed to the overall low number of these complications in a glioblastoma multiforme patient population expected to be at a high risk for coagulopathy. In other words, in order to produce statistically significant results, we would need to increase the patient cohort. By doing so we may better detect a positive therapeutic effect. Alternatively, because of the multitude of possible complex risk-factors leading to coagulopathy in a glioblastoma patient population it might be the case that IPC has little or no effect and that there is a different underlying mechanism responsible for the observed coagulopathy.
Collapse
Affiliation(s)
- M Ebeling
- Hanover Medical School, Hanover, Carl-Neuberg-Straße 1, 30625 Hanover, Germany.
| | - W Lüdemann
- Department of Neurosurgery, Helios Klinik, Hildesheim, Senator-Braun-Allee 33, 31135 Hildesheim, Germany.
| | - J Frisius
- Department of Anesthesiology, International Neuroscience Institute, Hanover, Rudolf-Pichlmayr-Straße 4, 30625 Hanover, Germany
| | - M Karst
- Department of Anesthesiology, Hanover Medical School, Hanover, Carl-Neuberg-Straße 1, 30625 Hanover, Germany.
| | - I Schedel
- Department of Internal Medicine, Hanover Medical School, Hanover, Germany, Carl-Neuberg-Straße 1, 30625 Hanover, Germany
| | - V Gerganov
- Department of Neurosurgery, International Neuroscience Institute, Hanover, Rudolf-Pichlmayr-Straße 4, 30625 Hanover, Germany
| | - A Samii
- Department of Neurosurgery, International Neuroscience Institute, Hanover, Rudolf-Pichlmayr-Straße 4, 30625 Hanover, Germany
| | - R Fahlbusch
- Department of Neurosurgery, International Neuroscience Institute, Hanover, Rudolf-Pichlmayr-Straße 4, 30625 Hanover, Germany
| |
Collapse
|
9
|
|
10
|
George AJ, Nair S, Karthic JC, Joseph M. The incidence of deep venous thrombosis in high-risk Indian neurosurgical patients: Need for early chemoprophylaxis? Indian J Crit Care Med 2016; 20:412-6. [PMID: 27555696 PMCID: PMC4968064 DOI: 10.4103/0972-5229.186223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Deep venous thrombosis (DVT) is thought to be less common in Asians than in Caucasian population. The incidence of DVT in high-risk groups, especially the neurosurgical (NS) patients, has not been well studied. This leaves no firm basis for the start of early prophylactic anticoagulation within first 5 postoperative days in Indian NS patients. This is a prospective observational study to determine the early occurrence of DVT in the NS patients. PATIENTS AND METHODS We screened 137 consecutive high-risk NS patients based on inclusion and exclusion criteria. The femoral veins were screened using Doppler ultrasound on day 1, 3, and 5 of admission into the NS Intensive Care Unit (ICU) at tertiary center from South India. RESULTS Among 2887 admissions to NICU 147 patients met inclusion criteria. One hundred thirty seven were screened for DVT. There was a 4.3% (6/137) incidence of DVT with none of the six patients having signs or symptoms of pulmonary embolism. Among the risk factors studied, there was a significant association with femoral catheterization and a probable association with weakness/paraparesis/paraplegia. The mortality in the study group was 10.8% with none attributable to DVT or pulmonary embolism. CONCLUSION There is a low incidence of DVT among the high risk neurosurgical population evaluated within the first 5 days of admission to NICU, limiting the need for early chemical thrombo-prophylaxis in these patients. With strict protocols for mechanical prophylaxis with passive leg exercise, early mobilization and serial femoral Doppler screening, heparin anticoagulation can be restricted within the first 5 days of ICU admission in high risk patients.
Collapse
Affiliation(s)
- Ajith John George
- Department of General Surgery, Christian Medical College, Vellore, Tamil Nadu, India
| | - Shalini Nair
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Mathew Joseph
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| |
Collapse
|
11
|
The Use of Intermittent Pneumatic Compression in Orthopedic and Neurosurgical Postoperative Patients: A Systematic Review and Meta-analysis. Ann Surg 2016; 263:888-9. [PMID: 26720432 DOI: 10.1097/sla.0000000000001530] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this systematic review and meta-analysis was to carry out an up-to-date evaluation on the use of compression devices as deep vein thrombosis (DVT) prophylaxis methods in orthopedic and neurological patients. SUMMARY OF BACKGROUND DATA There is an increased risk of DVT with surgery, particularly in patients who are not expected to mobilize soon after their procedures, such as orthopedic and neurosurgical patients. Compression devices are often employed for DVT prophylaxis in these patients. However, the true efficacy of these devices and the standardization of use with these devices are yet to be established. METHODS Medline, CINAHL, Embase, Google Scholar, and the Cochrane library electronic databases were searched to identify randomized controlled trials and observational studies reporting on the use of compression devices for DVT prevention. RESULTS Nine studies were included for review and meta-analysis. Use of an intermittent pneumatic compression device alone is neither superior nor inferior to chemoprophylaxis. CONCLUSIONS In the absence of large randomized multicenter trials comparing the use of intermittent pneumatic compression or chemoprophylaxis alone to a combination of both treatments, the current evidence supports the use of a combined approach in high-risk surgical patients.
Collapse
|
12
|
Vázquez-Alonso E, Iturri Clavero F, Valencia Sola L, Fábregas N, Ingelmo Ingelmo I, Valero R, Cassinello C, Rama-Maceiras P, Jorques A. Clinical practice guideline on thromboprophylaxis and management of anticoagulant and antiplatelet drugs in neurosurgical and neurocritical patients. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2016; 63:406-418. [PMID: 26965554 DOI: 10.1016/j.redar.2016.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 01/18/2016] [Indexed: 06/05/2023]
Affiliation(s)
- E Vázquez-Alonso
- Servicio de Anestesiología, Complejo Hospitalario Universitario Granada, Granada, España.
| | - F Iturri Clavero
- Servicio de Anestesiología, Hospital Universitario Cruces, , Bilbao, Vizcaya, España
| | - L Valencia Sola
- Servicio de Anestesiología, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas, España
| | - N Fábregas
- Servicio de Anestesiología, Hospital Clinic, Universitat de Barcelona, Barcelona, España
| | - I Ingelmo Ingelmo
- Servicio de Anestesiología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - R Valero
- Servicio de Anestesiología, Hospital Clinic, Universitat de Barcelona, Barcelona, España
| | - C Cassinello
- Servicio de Anestesiología, Hospital Universitario Miguel Servet, Zaragoza, España
| | - P Rama-Maceiras
- Servicio de Anestesiología, Complejo Hospitalario Universitario Juan Canalejo, A Coruña, España
| | - A Jorques
- Servicio de Neurocirugía, Complejo Hospitalario Universitario Granada, Granada, España
| |
Collapse
|
13
|
Sadaghianloo N, Dardik A. The efficacy of intermittent pneumatic compression in the prevention of lower extremity deep venous thrombosis. J Vasc Surg Venous Lymphat Disord 2015; 4:248-56. [PMID: 26993875 DOI: 10.1016/j.jvsv.2015.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 07/24/2015] [Indexed: 01/18/2023]
Abstract
Intermittent pneumatic compression (IPC) has been used to prevent lower extremity deep venous thrombosis for more than 30 years and is a popular choice for prophylaxis among both physicians and patients because of its efficacy and reduced risk of bleeding compared with pharmacologic prophylaxis. However, the efficacy of IPC may depend on the clinical situation as well as on several variables associated with the devices. To determine the efficacy of IPC, recent guidelines and literature were reviewed. IPC is efficacious as a sole prophylactic agent in low- or moderate-risk surgical patients and in patients with high risk of bleeding with pharmacologic prophylaxis. In high-risk surgical and medical patients, IPC is recommended as a synergistic tool in combination with pharmacologic agents, if pharmacologic agents are not contraindicated. No specific compression modality proved its superiority, although newer portable battery-powered devices seem to allow better patient compliance and satisfaction.
Collapse
Affiliation(s)
- Nirvana Sadaghianloo
- University of Nice Sophia Antipolis, Nice, France; Department of Vascular Surgery, University Hospital of Nice, Nice, France
| | - Alan Dardik
- Department of Surgery, Yale University School of Medicine, New Haven, Conn; Veterans Affairs Connecticut Healthcare Systems, West Haven, Conn.
| |
Collapse
|
14
|
Meier KA, Clark E, Tarango C, Chima RS, Shaughnessy E. Venous thromboembolism in hospitalized adolescents: an approach to risk assessment and prophylaxis. Hosp Pediatr 2015; 5:44-51. [PMID: 25554759 DOI: 10.1542/hpeds.2014-0044] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pediatric hospital-acquired venous thromboembolism (VTE) is an increasingly prevalent and morbid disease. A multidisciplinary team at a tertiary children's hospital sought to answer the following clinical question: "Among hospitalized adolescents, does risk assessment and stratified VTE prophylaxis compared with no prophylaxis reduce VTE occurrence without an increase in significant adverse effects?" METHODS Serial literature searches using key terms were performed in the following databases: Medline, Cochrane Database, CINAHL (Cumulative Index to Nursing and Allied Health), Scopus, EBMR (Evidence Based Medicine Reviews). Pediatric studies were sought preferentially; when pediatric evidence was sparse, adult studies were included. Abstracts and titles were screened, and relevant full articles were reviewed. Studies were rated for quality using a standard rating system. RESULTS Moderate evidence exists to support VTE risk assessment in adolescents. This evidence comes from pediatric studies that are primarily retrospective in design. The results of the studies are consistent and cite prominent factors such as immobilization and central venous access. There is insufficient evidence to support specific prophylactic strategies in pediatric patients because available pediatric evidence for thromboprophylaxis efficacy and safety is minimal. There is, however, high-quality, consistent evidence demonstrating efficacy and safety of thromboprophylaxis in adults. CONCLUSIONS On the basis of the best available evidence, we propose a strategy for risk assessment and stratified VTE prophylaxis for hospitalized adolescents. This strategy involves assessing risk factors and considering prophylactic measures based on level of risk. We believe this strategy may reduce risk of VTE and appropriately balances the adverse effect profile of mechanical and pharmacologic prophylactic methods.
Collapse
Affiliation(s)
- Katie A Meier
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Eloise Clark
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Cristina Tarango
- Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and
| | - Ranjit S Chima
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Erin Shaughnessy
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio;
| |
Collapse
|
15
|
Frisius J, Ebeling M, Karst M, Fahlbusch R, Schedel I, Gerganov V, Samii A, Lüdemann W. Prevention of venous thromboembolic complications with and without intermittent pneumatic compression in neurosurgical cranial procedures using intraoperative magnetic resonance imaging. A retrospective analysis. Clin Neurol Neurosurg 2015; 133:46-54. [DOI: 10.1016/j.clineuro.2015.03.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 02/27/2015] [Accepted: 03/05/2015] [Indexed: 11/16/2022]
|
16
|
Summers JA, Clinch J, Radhakrishnan M, Healy A, McMillan V, Morris E, Rua T, Ofuya M, Wang Y, Dimmock PW, Lewis C, Peacock JL, Keevil SF. The geko™ electro-stimulation device for venous thromboembolism prophylaxis: a NICE medical technology guidance. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2015; 13:135-147. [PMID: 25403719 PMCID: PMC4376951 DOI: 10.1007/s40258-014-0139-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The geko™ device is a single-use, battery-powered, neuromuscular electrostimulation device that aims to reduce the risk of venous thromboembolism (VTE). The National Institute for Health and Care Excellence (NICE) selected the geko™ device for evaluation, and invited the manufacturer, Firstkind Ltd, to submit clinical and economic evidence. King's Technology Evaluation Centre, an External Assessment Centre (EAC) commissioned by the NICE, independently assessed the evidence submitted. The sponsor submitted evidence related to the geko™ device and, in addition, included studies of other related devices as further clinical evidence to support a link between increased blood flow and VTE prophylaxis. The EAC assessed this evidence, conducted its own systematic review and concluded that there is currently limited direct evidence that geko™ prevents VTE. The sponsor's cost model is based on the assumption that patients with an underlying VTE risk and subsequently treated with geko™ will experience a reduction in their baseline risk. The EAC assessed this cost model but questioned the validity of some model assumptions. Using the EACs revised cost model, the cost savings for geko™ prophylaxis against a 'no prophylaxis' strategy were estimated as £197 per patient. Following a second public consultation, taking into account a change in the original draft recommendations, the NICE medical technologies guidance MTG19 was issued in June 2014. This recommended the adoption of the geko™ for use in people with a high risk of VTE and when other mechanical/pharmacological methods of prophylaxis are impractical or contraindicated in selected patients within the National Health Service in England.
Collapse
|
17
|
Sachdeva A, Dalton M, Amaragiri SV, Lees T. Graduated compression stockings for prevention of deep vein thrombosis. Cochrane Database Syst Rev 2014:CD001484. [PMID: 25517473 DOI: 10.1002/14651858.cd001484.pub3] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND One of the settings where deep vein thrombosis (DVT) in the lower limb and pelvic veins occurs is in hospital with prolonged immobilisation of patients for various surgical and medical illnesses. Using graduated compression stockings (GCS) in these patients has been proposed to decrease the risk of DVT. This is an update of a Cochrane review first published in 2000 and updated in 2010. OBJECTIVES To evaluate the effectiveness and safety of graduated compression stockings in preventing DVT in various groups of hospitalised patients. SEARCH METHODS For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched March 2014) and CENTRAL (2014, Issue 2). SELECTION CRITERIA Randomised controlled trials (RCTs) involving GCS alone; or GCS used on a background of any other DVT prophylactic method. Results from both these groups of trials were combined in this update. DATA COLLECTION AND ANALYSIS For this update one review author (AS) extracted the data. These were cross-checked and authenticated by a second author (MJD). Two review authors (AS and MJD) assessed the quality of trials. Disagreements were resolved by discussion. MAIN RESULTS Nineteen RCTs were identified involving 1681 individual patients and 1064 individual legs (2745 analytic units). Of these 19 trials, nine included patients undergoing general surgery, six included patients undergoing orthopaedic surgery, and only one trial included medical patients. Graduated compression stockings were applied on the day before surgery or on the day of surgery and were worn up until discharge or until the patients were fully mobile. In the majority of the included studies DVT was identified by the radioactive I(125) uptake test. Overall, included studies were of good quality.In the treatment group (GCS) of 1391 units 126 developed DVT (9%) in comparison to the control group (without GCS) of 1354 units where 282 (21%) developed DVT. The Peto odds ratio (OR) was 0.33 (95% confidence interval (CI) 0.26 to 0.41) with an overall effect favouring treatment with GCS (P < 0.00001).Based on results from eight included studies, the incidence of proximal DVT was 7 of 517 (1%) units in the treatment group and 28 of 518 (5%) units in the control group. The Peto OR was 0.26 (95% CI 0.13 to 0.53) with an overall effect favouring treatment with GCS (P = 0.0002). Based on results from five included studies, the incidence of PE was 5 of 283 (2%) participants in the treatment group and 14 of 286 (5%) in the control group. The Peto OR was 0.38 (95% CI 0.15 to 0.96) with an overall effect favouring treatment with GCS (P = 0.04). Limited data were available to accurately assess the incidence of adverse effects and complications with the use of GCS. AUTHORS' CONCLUSIONS GCS are effective in diminishing the risk of DVT in hospitalised patients, with strong evidence favouring their use in general and orthopaedic surgery. However, evidence for their effectiveness in medical patients is limited to one trial.
Collapse
Affiliation(s)
- Ashwin Sachdeva
- Department of Urology, Freeman Hospital, Newcastle upon Tyne, UK
| | | | | | | |
Collapse
|
18
|
Gardiner DA, Kelly B. Improving rates of intermittent pneumatic compression therapy utilization. Hosp Pract (1995) 2013; 41:40-7. [PMID: 23948620 DOI: 10.3810/hp.2013.08.1067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The most preventable causes of death in the hospitalized patient are deep vein thrombosis (DVT) and pulmonary embolism. Despite the long-term (> 15 years) availability of evidence-based consensus guidelines for prevention of venous thromboembolism, thromboprophylaxis remains underused. Improving staff and patient utilization of prophylactic treatment for postoperative patients reduces hospital-acquired venous thromboembolism and improves patient outcomes. Anecdotal evidence and observations of intermittent pneumatic compression (IPC) therapy utilization at the authors' institution suggested that ordered IPC therapy was not consistently in use with postsurgical patients. OBJECTIVES We sought to increase the use of IPC devices by all staff on our hospital pilot units and to promote sustained use of IPC devices. METHODS Multiple methodologies were employed to address this issue, including point prevalence audits, root-cause analyses, a nursing survey, and a pilot project on selected surgical units. RESULTS Statistically significant improvements on the pilot units were achieved by implementing a 3-tier interventional plan. CONCLUSION Our pilot project demonstrated that nurse education, patient education, and nurse attention to solving systems issues can significantly improve IPC use in surgical patients.
Collapse
Affiliation(s)
- D A Gardiner
- Surgical Trauma and Surgery, Thomas Jefferson University Hospitals, Philadelphia, PA.
| | | |
Collapse
|
19
|
Ho KM, Tan JA. Stratified meta-analysis of intermittent pneumatic compression of the lower limbs to prevent venous thromboembolism in hospitalized patients. Circulation 2013; 128:1003-20. [PMID: 23852609 DOI: 10.1161/circulationaha.113.002690] [Citation(s) in RCA: 134] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Optimal thromboprophylaxis for patients at risk of bleeding remains uncertain. This meta-analysis assessed whether intermittent pneumatic compression (IPC) of the lower limbs was effective in reducing venous thromboembolism and whether combining pharmacological thromboprophylaxis with IPC would enhance its effectiveness. METHODS AND RESULTS Two reviewers searched MEDLINE, EMBASE, and the Cochrane controlled trial register (1966-February 2013) for randomized, controlled trials and assessed the outcomes and quality of the trials independently. Trials comparing IPC with pharmacological thromboprophylaxis, thromboembolic deterrent stockings, no prophylaxis, and a combination of IPC and pharmacological thromboprophylaxis were considered. Trials that used IPC <24 hours or compared different types of IPC were excluded. A total of 16 164 hospitalized patients from 70 trials met the inclusion criteria and were subjected to meta-analysis. IPC was more effective than no IPC prophylaxis in reducing deep vein thrombosis (7.3% versus 16.7%; absolute risk reduction, 9.4%; 95% confidence interval [CI], 7.9-10.9; relative risk, 0.43; 95% CI, 0.36-0.52; P<0.01; I(2)=34%) and pulmonary embolism (1.2% versus 2.8%; absolute risk reduction, 1.6%; 95% CI, 0.9-2.3; relative risk, 0.48; 95% CI, 0.33-0.69; P<0.01; I(2)=0%). IPC was also more effective than thromboembolic deterrent stockings in reducing deep vein thrombosis and appeared to be as effective as pharmacological thromboprophylaxis but with a reduced risk of bleeding (relative risk, 0.41; 95% CI, 0.25-0.65; P<0.01; I(2)=0%). Adding pharmacological thromboprophylaxis to IPC further reduced the risk of deep vein thrombosis (relative risk, 0.54; 95% CI, 0.32-0.91; P=0.02; I(2)=0%) compared with IPC alone. CONCLUSIONS IPC was effective in reducing venous thromboembolism, and combining pharmacological thromboprophylaxis with IPC was more effective than using IPC alone.
Collapse
Affiliation(s)
- Kwok M Ho
- Department of Intensive Care, Royal Perth Hospital, University of Western Australia, Wellington Street, Perth, WA 6000, Australia.
| | | |
Collapse
|
20
|
Nicolaides A, Hull RD, Fareed J. Neurosurgery. Clin Appl Thromb Hemost 2013; 19:161-3. [PMID: 23529484 DOI: 10.1177/1076029612474840h] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
21
|
Current world literature. Curr Opin Cardiol 2012; 27:556-64. [PMID: 22874129 DOI: 10.1097/hco.0b013e32835793f0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|