Venous thromboembolism risk and prophylaxis in the acute hospital care setting: report from the ENDORSE study in Egypt

Improving Venous Thromboembolism Prophylaxis Administration in an Acute Surgical Unit

OBJECTIVES

Venous thromboembolism (VTE) prophylaxis regimes frequently have a wide variation in application. Nepean acute surgical unit was established in 2006 as a novel model for emergency surgical care. As part of the model's rollout, there were several areas of clinical management targeted for improvement, one being VTE prophylaxis compliance. It was decided all patients older than 18 years treated for a variety of acute surgical conditions within the acute surgical unit should be administered routine VTE prophylaxis with heparin and compression stockings. A novel multifaceted intervention was implemented at the time to achieve this goal. The primary aim of this study was to determine VTE prophylaxis administration rates before and after this intervention.

METHODS

A before-after study conducted as a retrospective review of medical records of all patients 18 years or older, having an appendicectomy in 3 periods: Before acute surgical unit (ASU) (November 2004 to October 2006), Early ASU (November 2006 to October 2008), and Established ASU (January 2012 to December 2013). Outcomes were mechanical and pharmacological VTE prophylaxis administration rates for each group.

RESULTS

There were 1149 patients included in the study: Before ASU, 167; Early ASU, 375; and Established ASU, 607. There was a significant stepwise increase in parmacological VTE prophylaxis administration: Before ASU, 54.5%; Early ASU, 74.7%; and Established ASU, 96.9% (Before versus Early: odds ratio [OR], 2.46; 95% confidence interval [CI], 1.68-3.61; P < 0.001; Early versus Established: OR, 10.500; 95% CI, 6.29-17.53; P < 0.001). Mechanical VTE prophylaxis was significantly increased in the established group (Before versus Established: OR, 47.18; 95% CI, 25.61-86.91; P < 0.001).

CONCLUSIONS

There was a significant increase in VTE prophylaxis administration after the implementation of our multifaceted intervention. Allocating a responsible provider dedicated to VTE prophylaxis prescription and compliance checking was a key component to this intervention.

Development of the Nurses' Intention to Use Deep Vein Thrombosis Preventive Measures Questionnaire

BACKGROUND AND PURPOSE

Deep vein thrombosis (DVT) is a serious condition resulting in poor patient outcomes. Therefore, methods to improve nurses' use of preventive measures for DVT are paramount. The purpose of this study was to develop and validate an instrument that captured nurses' intentions to use DVT preventive measures.

METHODS

Instrument development occurred in several stages stemming from the recommended formatted structure associated with theory of planned behavior (TPB). Content validity was established with a panel of experts, then the instrument was pilot tested with a sample of intensive care unit (ICU) nurses.

RESULTS

The final instrument consisted of four subscales, each subscale was tested with four items by content validity index (CVI) ranging between 0.8 and 1.0, and an overall S-CVI/Ave of 0.93.

CONCLUSIONS

The instrument demonstrated high content validity. Future research will test the instrument for psychometric properties.

Incidence of Venous Thromboembolism, Risk Factors and Prophylaxis in Hospitalized Patients in the South West Region of Cameroon

Background

Venous thromboembolism (VTE) is a serious complication in hospitalized patients. It is associated with considerable morbidity and mortality. Therefore, its prevention is of great importance. There is paucity of data on the incidence of VTE in hospitalized patients in Cameroon. The aim of this study was to determine the incidence of symptomatic VTE, its risk factors and the proportion of patients at risk that receive thromboprophylaxis in patients hospitalized in the medical and surgical units in two hospitals in the South West Region of Cameroon.

Methods

A prospective study was performed in the medical and surgical units from January to March 2018. All consecutive eligible patients admitted for at least 3 days were included. Patient profile and risk factors were recorded. Patients were followed and evaluated for signs and symptoms of VTE until discharge from hospital. Suspected VTE was confirmed using compression ultrasonography and computed tomography.

Results

A total of 314 patients were included of which 58.7% were females. The mean age was 46±17.9 years. Patients aged <40 years represented 42% of the study population. Three cases of symptomatic VTE were recorded. The incidence of symptomatic VTE was 1% (95% CI: 0.3-2.8%). The prevalence of VTE risk was 93.6% with 32.5% being at high risk. The risk was 94.6% in medical patients and 92.8% in surgical patients. Among the patients at risk, only 32.5% received thromboprophylaxis. Thromboprophylaxis was significantly higher in surgical patients compared to medical patients (45.2% versus 18.7%; p<0.0001).

Conclusion

The incidence of VTE in hospitalized medical and surgical patients appeared low but likely underestimated considering the high prevalence of patients at risk of VTE coupled with the underutilization of thromboprophylaxis. Clinicians should assess risk of VTE in conjunction with the clinical situation to determine the most appropriate type of prophylaxis as well as the duration of prophylaxis for VTE.

Platelet-derived growth factor-beta as a new marker of deep venous thrombosis

Background:

Deep venous thrombosis (DVT) is associated with significant morbidity and mortality. Thus, there is a great need to demonstrate a more efficient biomarker that would confirm the diagnosis of DVT. Our work aimed to evaluate the role of platelet-derived growth factor-beta (PDGF-B) as a new marker of DVT and its correlation with other radiological and laboratory tools used for the diagnosis.

Materials and Methods:

A case–control study enrolled forty patients selected from our university hospital between April 2018 and August 2018, who divided into two groups: Group I (n = 20) consisted of patients diagnosed with acute venous thrombosis and Group II (n = 20) consisted of patients diagnosed with chronic venous thrombosis. Twenty samples were collected from age- and gender-matched apparently healthy controls to be used as a control. Venous duplex ultrasonography, routine laboratory investigations, D-dimer (DD), and protein expression of PDGF-B were performed on all patients.

Results:

There was a highly significant increase in a protein expression of PDFG-B in all cases of acute and chronic venous thrombosis compared to the control group with P < 0.001; furthermore, it was more specific than DD for the detection of DVT (specificity 95% and 90%, respectively).

Conclusion:

Our study submits a novel association of PDGF-B plasma levels with DVT, and PDGF-B is considered to be a more specific indicator for DVT than is DD.

Value of CT pulmonary angiography to predict short-term outcome in patient with pulmonary embolism

To evaluate the role of CT pulmonary angiography (CTPA) in the assessment of pulmonary embolism (PE) severity and the related CT cardiac changes, reflecting the clinical status of the patients and predicting the outcome. A prospective study of 184 patients presented with suspicious acute PE. All patients underwent CTPA followed by ECHO. Pulmonary artery obstructive index (PAOI) using Qanadli Score was calculated and cardiac changes recorded. The patients' outcome was followed up for 30 days. Only 150 patients completed the study; 26.7% needed ICU admission while 13.3% died during follow-up. There was a significant relationship between the PAOI and the risk classification, right ventricular dysfunction (RVD) diagnosed by ECHO and the patients' short outcome. We found PAOI cut off value 45% for mortality and 35% for ICU admission and 27.5% for RVD with 60, 75 and 90% sensitivity and 80, 73.3 and 68.6% specificity respectively. CT RV/LV ratio was the most sensitive parameter to predict RV dysfunction followed by pulmonary artery diameter. CTPA is not only used for diagnosis but also to assess the severity of PE, the effect on the right ventricular function and subsequently the need for ICU admission and prediction of the outcome.

Epidemiology of venous thromboembolism in Africa: a systematic review

Essentials Venous thromboembolism (VTE) is among the three main causes of cardiovascular disease worldwide. This review is the first to summarize the epidemiology of VTE in African populations. The prevalence of VTE in Africa is high following surgery, in pregnancy and post-partum. At least one quarter of patients at risk of VTE in Africa are not receiving prophylaxis.

SUMMARY

Background Venous thromboembolism (VTE) is among the three leading causes of cardiovascular disease worldwide. Despite its high burden, there has been no previous study summarizing the epidemiology of VTE in African populations. Hence, we conducted this systematic review to determine the prevalence, incidence and mortality associated with VTE, and to evaluate the use of VTE prophylaxis in Africa. Methods We searched PubMed, Scopus and African Journals Online to identify articles published on VTE in Africa from inception to November 19, 2016, without language restriction. The reference list of eligible articles were further scrutinized to identify potential additional studies. Results Overall, we included 21 studies. The great majority of the studies yielded a moderate risk of bias. The prevalence of deep vein thrombosis (DVT) varied between 2.4% and 9.6% in postoperative patients, and between 380 and 448 per 100 000 births per year in pregnant and postpartum women. The prevalence of pulmonary embolism (PE) in medical patients varied between 0.14% and 61.5%, with a mortality rate of PE between 40% and 69.5%. The case-fatality rate after surgery was 60%. Overall, 31.7-75% of the patients were at risk of VTE, and between 34.2% and 96.5% of these received VTE prophylaxis. Conclusion The prevalence of VTE and associated mortality are high following surgery, and in pregnant and postpartum women in Africa. At least one-quarter of patients who are at risk for VTE in Africa are not receiving prophylaxis. These results are generated from studies with small sample size, highlighting an urgent need for well-designed studies with larger sample size to evaluate the true burden of VTE in Africa.

Lower limb gangrene postcardiac surgery

A 67-year-old gentleman presented with a 1-day history of left foot pain. He had recently been discharged following a coronary artery bypass graft; during the admission, he had received an intravenous heparin infusion. Examination revealed black-purple discolouration of the first and second digits of the left foot with pitting oedema to the level of the knee. The posterior tibial and dorsalis pedis pulses were both shown to be patent. A new thrombocytopenia was noted. Ultrasound imaging revealed multiple deep vein thrombosis. The history of recent heparin exposure coupled with venous gangrene secondary to deep vein thrombosis was consistent with heparin-induced thrombocytopenia. He was treated acutely with intravenous danaparoid and later with warfarin. There was complete resolution of the venous gangrene at 1 month follow-up.