Perioperative Venous Thromboembolism

Effect of different acupuncture sequences of Huiyangjiuzhen acupoints on blood glucose and hemorheology in the anesthetized rabbits

Background and objective

Hemorheology and blood glucose are commonly used to estimate the risks of thrombosis and stress hyperglycemia after anaesthesia. The sequence of acupoint stimulation might influence the therapeutic effects of acupuncture. In the current study, we aimed at investigating the effect of different acupuncture sequences of "Huiyangjiuzhen" acupoints on the blood glucose and hemorheology in anesthetized rabbits.

Methods

Twenty-five rabbits were randomly divided into five groups, including the control group (CG), the positive-sequence group (PSG), the reverse-sequence group (RSG), the disorder-sequence group (DSG), and the random group (RG). Except for the CG and RG, the rabbits in other groups were acupunctured with different sequences of "Huiyangjiuzhen"acupoints when the rabbits were anesthetized. The acupoints in rabbits of the RG were chosen randomly. The levels of blood glucose and hemorheology indexes before and after anaesthesia was detected.

Results

In the PSG, Hηb 200/s, Mηb 30/s, Hηr 200/s, ERI, hematocrit and plasma viscosity levels were decreased, and the blood glucose level was not changed. In the DSG, the levels of Mηb 30/s and hematocrit were decreased, and the blood glucose was increased. In the CG, RSG and RG, no hemorheology indexes were changed and the blood glucose was increased.

Conclusion

"Huiyangjiuzhen" acupuncture could decrease the risks of post-operative thrombosis and stress hyperglycemia in anesthetized rabbits. This effectiveness depends on both acupuncture and acupuncture sequence at the "Huiyangjiuzhen" acupoints.

Impact of Prolonged Operative Duration on Postoperative Symptomatic Venous Thromboembolic Events After Thoracolumbar Spine Surgery

OBJECTIVE

To determine the effect of operative duration on the rate of postoperative symptomatic venous thromboembolic (VTE) events in patients undergoing thoracolumbar spine fusion.

METHODS

We identified all thoracolumbar spine fusion patients between 2012 and 2021. Operative duration was defined as time from skin incision to skin closure. A 1:1 propensity match was conducted incorporating patient and surgical characteristics. Logistic regression was performed to assess predictors of postoperative symptomatic VTE events. A receiver operating characteristic curve was created to determine a cutoff time for increased likelihood of VTE.

RESULTS

We identified 101 patients with VTE and 1108 patients without VTE. Seventy-five patients with VTE were matched to 75 patients without VTE. Operative duration (339 vs. 262 minutes, P = 0.010) and length of stay (5.00 vs. 3.54 days, P = 0.008) were significantly longer in patients with a VTE event. Operative duration was an independent predictor of VTE on multivariate regression (odds ratio: 1.003, 95% confidence interval: 1.001-1.01, P = 0.021). For each additional hour of operative duration, the risk of VTE increased by 18%. A cutoff time of 218 minutes was identified (area under the curve [95% confidence interval] = 0.622 [0.533-0.712]) as an optimal predictor of increased risk for a VTE event.

CONCLUSIONS

Operative duration significantly predicted symptomatic VTE, especially after surgical time cutoff of 218 minutes. Each additional hour of operative duration was found to increase VTE risk by 18%. We also identify the impact of VTE on 90-day readmission rates, suggesting significantly higher costs and opportunity for hospital acquired conditions, in line with prior literature.

Complications of Vascular Disease

Vascular diseases and their sequelae increase perioperative risk for noncardiac surgical patients. In this review, the authors discuss vascular diseases, their epidemiology and pathophysiology, risk stratification, and management strategies to reduce adverse perioperative outcomes.

Perioperative considerations for cancer patients with obesity: A narrative review

Cancer in patients with obesity has become increasingly common throughout much of the world. Based on our experiences in a specialized cancer center, we have developed a set of standards and expectations that should streamline the surgical journey for this patient population. These recommendations should inform the perioperative management of oncology patients with obesity and help raise awareness of this critical and under-discussed topic.

One-Year Incidences of Venous Thromboembolism, Bleeding, and Death in Patients With Lung Cancer (Cancer-VTE Subanalysis)

Introduction

This subanalysis aimed to provide real-world data on venous thromboembolism (VTE) from patients with lung cancer in the Cancer-VTE Registry.

Methods

The primary outcome was the number of baseline VTE events in patients with lung cancer. The 1-year cumulative incidences of symptomatic VTE; composite VTE (symptomatic and incidental VTE requiring treatment); bleeding; cerebral infarction, transient ischemic attack, and systemic embolic events; and all-cause death were calculated. Clinical trial registration: UMIN000024942.

Results

The study enrolled a total of 2377 patients with lung cancer; of these, 119 (5.0%) had VTE (six [0.3%], symptomatic, and 113 [4.8%], asymptomatic) and 14 (0.6%) had pulmonary embolism at baseline. During the follow-up period (mean, 337.7 d), the incidence was 0.6% for symptomatic VTE, 1.8% for composite VTE, 1.5% for bleeding events, 1.3% for cerebral infarction, transient ischemic attack, and systemic embolism, and 19.1% for all-cause death. Composite VTE frequency did not vary by anticancer drug type. Patients with (versus without) VTE at baseline had higher hazard ratios (HRs) for composite VTE (unadjusted HR: 5.29; Gray test p < 0.001) and symptomatic VTE (unadjusted HR: 4.89; Gray test p = 0.007). Patients with VTE at baseline had higher HRs for bleeding events (unadjusted HR: 3.27; Gray test p = 0.010) and all-cause death (unadjusted HR: 2.73; log-rank test p < 0.001) than patients without. In multivariable analysis, patients with baseline VTE prevalence and Eastern Cooperative Oncology Group Performance Status of 2 had increased composite VTE risk during cancer therapy. There were no other risk factors for composite VTE.

Conclusions

Our findings emphasize the importance of VTE screening at cancer diagnosis.

Optimizing Perioperative Venous Thromboembolism Chemoprophylaxis on a Gynecologic Oncology Service

BACKGROUND

Perioperative venous thromboembolism (VTE) is a significant cause of morbidity and mortality after gynecologic cancer surgery. Here we report a quality improvement intervention to increase perioperative VTE chemoprophylaxis compliance.

STUDY DESIGN

All operations performed by a gynecologic oncologist at a tertiary urban university medical center admitted to the hospital for at least one midnight were included. Using a pre/post design with a washout period, we sought to increase perioperative VTE chemoprophylaxis compliance from 22% in the historical control (HC) cohort to 90% in the quality improvement (QI) cohort. The perioperative VTE chemoprophylaxis process was standardized by addressing four domains: preoperative VTE chemoprophylaxis, surgical time-out, postoperative VTE chemoprophylaxis, and intervention education and compliance tracking. Pearson's chi-square test was used to compare HC vs QI cohort compliance.

RESULTS

There were 130 surgical cases in the HC cohort and 131 in the QI cohort. Forty-two percent underwent laparotomy, and 57% had cancer at the time of operation. VTE chemoprophylaxis compliance improved from 22% in the HC cohort to 82% in the QI cohort (p < 0.001). Preoperative VTE chemoprophylaxis compliance improved from 76% in the HC cohort to 94% in the QI cohort (p < 0.001), and postoperative VTE chemoprophylaxis compliance improved from 27% to 87% (p < 0.001). Thirty-day postoperative VTE occurred in three patients (2%) in the HC cohort and none in the QI cohort (p = 0.08).

CONCLUSIONS

A low-cost and low-technology QI initiative intervention improved perioperative compliance with VTE chemoprophylaxis.

Search for Venous Endothelial Biomarkers Heralding Venous Thromboembolism in Space: A Qualitative Systematic Review of Terrestrial Studies

Background: The recent discovery of a venous thrombosis in the internal jugular vein of an astronaut has highlighted the need to predict the risk of venous thromboembolism in otherwise healthy individuals (VTE) in space. Virchow’s triad defines the three classic risk factors for VTE: blood stasis, hypercoagulability, and endothelial disruption/dysfunction. Among these risk factors, venous endothelial disruption/dysfunction remains incompletely understood, making it difficult to accurately predict risk, set up relevant prophylactic measures and initiate timely treatment of VTE, especially in an extreme environment.

Methods: A qualitative systematic review focused on endothelial disruption/dysfunction was conducted following the guidelines produced by the Space Biomedicine Systematic Review Group, which are based on Cochrane review guidelines. We aimed to assess the venous endothelial biochemical and imaging markers that may predict increased risk of VTE during spaceflight by surveying the existing knowledge base surrounding these markers in analogous populations to astronauts on the ground.

Results: Limited imaging markers related to endothelial dysfunction that were outside the bounds of routine clinical practice were identified. While multiple potential biomarkers were identified that may provide insight into the etiology of endothelial dysfunction and its link to future VTE, insufficient prospective evidence is available to formally recommend screening potential astronauts or healthy patients with any currently available novel biomarker.

Conclusion: Our review highlights a critical knowledge gap regarding the role biomarkers of venous endothelial disruption have in predicting and identifying VTE. Future population-based prospective studies are required to link potential risk factors and biomarkers for venous endothelial dysfunction to occurrence of VTE.

Deep vein thrombosis and pulmonary embolism after heart transplantation

INTRODUCTION

Venous thromboembolism (VTE), such as deep vein thrombosis (DVT) and pulmonary embolism (PE), is an important and serious postoperative complication after heart transplantation. We sought to characterize in-hospital VTE after heart transplantation and its association with clinical outcomes.

METHOD

Adult (≧18 years) patients undergoing heart transplantation from 2015 to 2019 at our center were retrospectively reviewed. Post-transplant VTE was defined as newly diagnosed venous system thrombus by imaging studies.

RESULTS

There were 254 patients. The cohort's median age was 55 years. A total of 61 patients were diagnosed with VTE, including 1 with right atrial thrombus, 54 with upper extremity DVT in which one patient subsequently developed PE, 4 with lower extremity DVT, and 2 with upper and lower extremity DVT. The cumulative incidence of VTE was 42% at 60-days of post heart transplant. Patients with VTE had longer hospital stay (p<0.001), higher in-hospital mortality (p = 0.010), and worse 5-year survival (p = 0.009). On the multivariable Cox analysis, history of DVT/PE and intubation for more than 3 days were associated with an increased risk of in hospital VTE.

CONCLUSION

The incidence of VTE in heart transplant recipients is high. Post-transplant surveillance, and appropriate preventive measures and treatment strategies after diagnosis are warranted. This article is protected by copyright. All rights reserved.

Benefits and harms of direct oral anticoagulation and low molecular weight heparin for thromboprophylaxis in patients undergoing non-cardiac surgery: systematic review and network meta-analysis of randomised trials

OBJECTIVE

To systematically compare the effect of direct oral anticoagulants and low molecular weight heparin for thromboprophylaxis on the benefits and harms to patients undergoing non-cardiac surgery.

DESIGN

Systematic review and network meta-analysis of randomised controlled trials.

DATA SOURCES

Medline, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL), up to August 2021.

REVIEW METHODS

Randomised controlled trials in adults undergoing non-cardiac surgery were selected, comparing low molecular weight heparin (prophylactic (low) or higher dose) with direct oral anticoagulants or with no active treatment. Main outcomes were symptomatic venous thromboembolism, symptomatic pulmonary embolism, and major bleeding. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used for network meta-analyses. Abstracts and full texts were screened independently in duplicate. Data were abstracted on study participants, interventions, and outcomes, and risk of bias was assessed independently in duplicate. Frequentist network meta-analysis with multivariate random effects models provided odds ratios with 95% confidence intervals, and GRADE (grading of recommendations, assessment, development, and evaluation) assessments indicated the certainty of the evidence.

RESULTS

68 randomised controlled trials were included (51 orthopaedic, 10 general, four gynaecological, two thoracic, and one urological surgery), involving 45 445 patients. Low dose (odds ratio 0.33, 95% confidence interval 0.16 to 0.67) and high dose (0.19, 0.07 to 0.54) low molecular weight heparin, and direct oral anticoagulants (0.17, 0.07 to 0.41) reduced symptomatic venous thromboembolism compared with no active treatment, with absolute risk differences of 1-100 per 1000 patients, depending on baseline risks (certainty of evidence, moderate to high). None of the active agents reduced symptomatic pulmonary embolism (certainty of evidence, low to moderate). Direct oral anticoagulants and low molecular weight heparin were associated with a 2-3-fold increase in the odds of major bleeding compared with no active treatment (certainty of evidence, moderate to high), with absolute risk differences as high as 50 per 1000 in patients at high risk. Compared with low dose low molecular weight heparin, high dose low molecular weight heparin did not reduce symptomatic venous thromboembolism (0.57, 0.26 to 1.27) but increased major bleeding (1.87, 1.06 to 3.31); direct oral anticoagulants reduced symptomatic venous thromboembolism (0.53, 0.32 to 0.89) and did not increase major bleeding (1.23, 0.89 to 1.69).

CONCLUSIONS

Direct oral anticoagulants and low molecular weight heparin reduced venous thromboembolism compared with no active treatment but probably increased major bleeding to a similar extent. Direct oral anticoagulants probably prevent symptomatic venous thromboembolism to a greater extent than prophylactic low molecular weight heparin.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018106181.

Successful Resuscitation Following Intraoperative Acute Pulmonary Embolism With a Focus on Control of Bleeding After Thrombolytic Therapy: A Case Report

Acute pulmonary embolism is a serious perioperative complication. Current guidelines focus on hemodynamic stabilization and rapid restoration of pulmonary artery blood flow. However, various complications, most notably bleeding, are associated with treatment of the embolism. We report a case of acute pulmonary embolism with cardiopulmonary arrest during orthopedic surgery. Prompt thrombolysis and gaining control of both thrombolytic therapy-induced bleeding from the wound and a hepatic cyst enabled the patient to recover without neurological deficits.

Glucocorticoid excess and COVID-19 disease

The pandemic of coronavirus disease (COVID-19), a disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is causing high and rapid morbidity and mortality. Immune system response plays a crucial role in controlling and resolving the viral infection. Exogenous or endogenous glucocorticoid excess is characterized by increased susceptibility to infections, due to impairment of the innate and adaptive immune system. In addition, diabetes, hypertension, obesity and thromboembolism are conditions overrepresented in patients with hypercortisolism. Thus patients with chronic glucocorticoid (GC) excess may be at high risk of developing COVID-19 infection with a severe clinical course. Care and control of all comorbidities should be one of the primary goals in patients with hypercortisolism requiring immediate and aggressive treatment. The European Society of Endocrinology (ESE), has recently commissioned an urgent clinical guidance document on management of Cushing's syndrome in a COVID-19 period. In this review, we aim to discuss and expand some clinical points related to GC excess that may have an impact on COVID-19 infection, in terms of both contagion risk and clinical outcome. This document is addressed to all specialists who approach patients with endogenous or exogenous GC excess and COVID-19 infection.

Treatment Strategy for Cancer-associated Venous Thromboembolism During Chemotherapy: The Keep ACT2 Concept

BACKGROUND/AIM

The frequency of detecting cancer-associated venous thromboembolism (CAT) during chemotherapy is increasing. It is not desirable to discontinue chemotherapy for CAT. In this study, we investigated the feasibility of simultaneous progression of anticoagulant and anticancer therapy, focusing on drug interactions.

PATIENTS AND METHODS

We retrospectively evaluated patients with gastroenterological CAT from February 2017 to December 2020 at the Gifu University Hospital. When both chemotherapy and CAT treatments using edoxaban were performed in parallel and the thrombus disappeared, patients were defined as being Keep-ACT ² (keeping anticancer therapy and anticoagulant therapy) successful. The effect and safety of treatment strategy focusing on cytochrome P450 (CYP) metabolism using edoxaban were evaluated.

RESULTS

A total of 114 patients with CAT during chemotherapy were treated with edoxaban. Keep-ACT ² was successful in 101 (88.6%) cases. Clinically relevant non-major bleeding was observed in 5 cases (4.4%). All 114 patients were using some drug affected by CYP metabolism, and the median number of affected cases was 5.

CONCLUSION

Combined use of edoxaban for CAT may lead to sustainable therapy for gastroenterological cancer patients who are administered several drugs.

Monitoring of Enoxaparin during Hemodialysis Covered by Regional Citrate Anticoagulation in Acute Kidney Injury: A Prospective Cohort Study

Background: Current guidelines recommend the monitoring of anti-factor Xa (anti-Xa) levels to avoid an accumulation of low-molecular-weight heparins in patients with acute kidney injury, but there is no evidence on how to proceed with such monitoring during continuous renal replacement therapy. Against this background, we investigated the potential accumulation of enoxaparin administered subcutaneously for venous thromboembolism prophylaxis in critically ill patients during continuous renal replacement therapy covered by regional citrate anticoagulation. Methods: Anti-Xa levels were measured at baseline (≤12 h before renal replacement therapy) and on three consecutive days (A to C) when enoxaparin had reached trough levels. Supplementary testing included modified assays of rotational thromboelastometry known to be highly sensitive for low-molecular-weight heparins. Results: The 16 men and 13 women included were adults comparable in age, body mass index, thromboembolism risk assessment, and clinical severity of the disease. Throughout the four examinations, the median trough levels of anti-Xa remained below the detection limit of the test (<0.1 IU mL⁻¹), with interquartile ranges of <0.1 to 0.14 IU mL⁻¹ at baseline and <0.1 to 0.16 IU mL⁻¹ on days A/B/C. All rotational thromboelastometry parameters of clot initiation and clot formation dynamics did not significantly change from baseline to day C. Conclusions: Neither anti-Xa levels nor modified assays of rotational thromboelastometry revealed any accumulation of enoxaparin administered for thromboprophylaxis during continuous renal replacement therapy covered by regional citrate anticoagulation. Although generally recommended in patients with acute kidney injury, monitoring of anti-Xa levels should be questioned in this defined setting.

The risks and benefits of early venous thromboembolism prophylaxis after elective spinal surgery: A single-centre experience

BACKGROUND

There is a wide ranging incidence of venous thromboembolism after surgery and it continues to be a major cause of morbidity after spinal procedures.This study's aim was to investigate the relationship between timing and administration of venous thromboembolism (VTE) pharmacologic chemoprophylaxis after spinal surgery and the resulting VTE and bleeding complications by reviewing current practices and outcomes at a high-volume single institution to better define opportunities for perioperative intervention to prevent VTE without increasing bleeding complications.

METHODS

All patients who underwent elective one or two-stage lumbar spinal fusion procedures were identified. A logistic regression was used to evaluate (1) risk of symptomatic VTE within 30 days of surgery and (2) bleeding-related complications. The odds of developing a VTE as well as bleeding-related complications were compared among the three treatment groups: no chemoprophylaxis, chemoprophylaxis < 24h of surgery and chemoprophylaxis given > 24h post-surgery.

RESULTS

When adjusted for doses administered, the odds of developing a postoperative VTE within 30 days were 0.189 (95% confidence interval (0.044, 0.808)) in patients who received anticoagulation < 24h postoperatively, compared to those who received no anticoagulation (p = 0.025). There was no difference in bleeding rates.

CONCLUSION

Patients undergoing elective spinal surgery who received anticoagulation within 24h of the conclusion of their procedure had an 81% reduction in the odds of developing a deep vein thrombosis within 30 days with no significant difference in bleeding complications.

The Attributable Mortality of Postoperative Bleeding Exceeds the Attributable Mortality of Postoperative Venous Thromboembolism

BACKGROUND

Bleeding and venous thromboembolic disease are considered important sources of postoperative morbidity and mortality. Clinically, treatment of these 2 disorders is often competing. We sought to better understand the relative contributions of bleeding and venous thromboembolic disease to postoperative attributable mortality in a national cohort.

METHODS

A retrospective analysis of the 2006-2017 American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) database was performed to assess the adjusted odds ratio and attributable mortality for postoperative bleeding and venous thromboembolism, adjusted by year.

RESULTS

After adjustment for confounding variables, bleeding exhibited a high postoperative attributable mortality in every year studied. Venous thromboembolism appeared to contribute minimal attributable mortality.

CONCLUSIONS

Bleeding complications are a consistent source of attributable mortality in surgical patients, while the contribution of venous thromboembolic disease appears to be minimal in this analysis. Further studies are warranted to better understand the etiology of this disparity.

Perioperative Venous Thromboembolism Prophylaxis

Venous thromboembolism (VTE) is a preventable cause of postoperative morbidity and mortality; however, audits suggest that the use of thromboprophylaxis is underused. In this review, we describe our approach to prevention of postoperative VTE and provide guidance on how to formulate an optimal VTE prophylaxis plan. We recommend that all patients undergo thrombosis- and bleeding-risk assessment as part of their preoperative evaluation. The risk of thrombosis can be estimated based on patient- and procedure-specific factors, using validated risk-assessment models such as the Caprini score. There are no validated models to predict perioperative bleeding; however, several risk factors have been proposed. Patients should ambulate early and frequently after surgery. We recommend no additional prophylaxis in patients at very low risk of VTE (Caprini score 0). Patients at low risk of VTE (Caprini 1 to 2) are recommended to receive either mechanical or pharmacological prophylaxis. Patients at moderate (Caprini 3 to 4) to high risk of VTE (Caprini ≥5) are recommended pharmacological prophylaxis either alone or combined with mechanical prophylaxis. Patients at high risk of bleeding should receive mechanical prophylaxis until their risk of bleeding is reduced and pharmacological prophylaxis can be reconsidered. Populations for which the Caprini score has not been validated (such as orthopedic surgery) are recommended prophylaxis based on individual and procedure-specific risk factors. Prophylaxis is typically continued until the patient is ambulatory or until hospital dismissal; however, longer durations can be considered in certain circumstances (high-risk patients undergoing malignant abdominopelvic operations, bariatric operations, and certain orthopedic operations).

Venous Thromboembolism Prophylaxis in Aesthetic Surgery: A Survey of Plastic Surgeons' Practices

BACKGROUND

Deep venous thrombosis and pulmonary embolism, collectively known as venous thromboembolism (VTE), are among the most feared yet preventable surgical complications. Although many recommendations exist to reduce the risk of VTE, the actual VTE prophylaxis practices of aesthetic plastic surgeons remain unknown.

OBJECTIVES

The primary aim of this study was to elucidate plastic surgeons' experiences with VTE, preferred VTE prophylaxis practices, and areas in which VTE prevention may be improved.

METHODS

Members of The Aesthetic Society were queried via a 55-question electronic survey regarding their experience with VTE as well as their VTE prophylaxis practices. Anonymous responses were collected and analyzed by the Mayo Clinic Survey Research Center.

RESULTS

The survey was sent to 1729 of The Aesthetic Society members, of whom 286 responded. Fifty percent, 38%, and 6% of respondents reported having had a patient develop a deep venous thrombosis, pulmonary embolism, or death secondary to VTE, respectively. Procedures performed on the back or trunk were associated with the highest rate of VTE. Lower extremity procedures were associated with a significantly higher rate of VTE than expected. Over 90% of respondents reported utilizing a patient risk stratification assessment tool. Although at least one-half of respondents reported that the surgical facility in which they operate maintains some form of VTE prophylaxis protocol, 39% self-reported nonadherence with these protocols.

CONCLUSIONS

Considerable variability exists in VTE prophylaxis practices among The Aesthetic Society responders. Future efforts should simplify guidelines and tailor prophylaxis recommendations to the aesthetic surgery population. Furthermore, education of plastic surgeons performing aesthetic surgery and more diligent surgical venue supervision is needed to narrow the gap between current recommendations and actual practices.

How would we treat our own heparin-induced thrombocytopenia during cardiac surgery?

The aim of this article is to provide a comprehensive review of the current state of knowledge on heparin-induced thrombocytopenia (HIT) in cardiac surgery. The management of HIT patients undergoing cardiac surgery with cardiopulmonary bypass is complex and requires an interdisciplinary and patient-tailored approach because available evidence is limited and current anticoagulation strategies have potential risks. An index case is used to discuss both the established and new perioperative therapeutic options in HIT patients undergoing urgent cardiac surgery with cardiopulmonary bypass.

A European consensus statement on the use of four-factor prothrombin complex concentrate for cardiac and non-cardiac surgical patients

Modern four-factor prothrombin complex concentrate was designed originally for rapid targeted replacement of the coagulation factors II, VII, IX and X. Dosing strategies for the approved indication of vitamin K antagonist-related bleeding vary greatly. They include INR and bodyweight-related protocols as well as fixed dose regimens. Particularly in the massively bleeding trauma and cardiac surgery patient, four-factor prothrombin complex concentrate is used increasingly for haemostatic resuscitation. Members of the Transfusion and Haemostasis Subcommittee of the European Association of Cardiothoracic Anaesthesiology performed a systematic literature review on four-factor prothrombin complex concentrate. The available evidence has been summarised for dosing, efficacy, drug safety and monitoring strategies in different scenarios. Whereas there is evidence for the efficacy of four-factor prothrombin concentrate for a variety of bleeding scenarios, convincing safety data are clearly missing. In the massively bleeding patient with coagulopathy, our group recommends the administration of an initial bolus of 25 IU.kg^-1 . This applies for: the acute reversal of vitamin K antagonist therapy; haemostatic resuscitation, particularly in trauma; and the reversal of direct oral anticoagulants when no specific antidote is available. In patients with a high risk for thromboembolic complications, e.g. cardiac surgery, the administration of an initial half-dose bolus (12.5 IU.kg^-1 ) should be considered. A second bolus may be indicated if coagulopathy and microvascular bleeding persists and other reasons for bleeding are largely ruled out. Tissue-factor-activated, factor VII-dependent and heparin insensitive point-of-care tests may be used for peri-operative monitoring and guiding of prothrombin complex concentrate therapy.

Images in Anesthesiology: Pulmonary Thromboembolism

Supplemental Digital Content is available in the text.

Association of Acute Venous Thromboembolism With In-Hospital Outcomes of Coronary Artery Bypass Graft Surgery

Background

While venous thromboembolism (VTE) prophylaxis is a strong recommendation after most surgeries, it is controversial in cardiac surgeries such as coronary artery bypass grafting (CABG), because of perceived low VTE incidence and increased bleeding risk. Prior studies may not have been adequately powered to study outcomes of VTE in this population. We sought to investigate the postoperative incidence and outcomes of CABG patients using a large national inpatient database.

Methods and Results

We utilized the 2013 to 2014 National Inpatient Sample to identify all patients >18 years of age who underwent CABG (without concomitant valvular procedures), and had VTE during the hospital stay. We then compared clinically relevant outcomes in patients with and without VTE. We identified 331 950 CABG procedures. Of these, 1.3% (n=4205) had VTE. Patients with VTE were more likely to be older (mean 67.2±10.4 years versus 65.2±10.4 years, P<0.001). VTE was associated with higher incidence of inpatient mortality (6.8% versus 1.7%; adjusted odds ratio 1.92 [95% CI 1.40–2.65]; P<0.001) and complications. VTE was also associated with higher cost (mean±SE $81 995±$923 versus $48 909±$55) and longer length of stay (mean±SE 17.06±0.16 days versus 8.52±0.01 days).

Conclusions

Our analysis of >330 000 CABG procedures suggests that while postoperative VTE after CABG is rare, it is associated with increased morbidity and mortality. Randomized controlled trials are needed to identify optimal strategies for VTE prophylaxis in these patients.

Recurrent thrombosis after carotid endarterectomy secondary to activated protein C resistance and essential thrombocytosis: A case report

RATIONALE

Thrombosis is a major cause of morbidity in the perioperative period. Although many risk factors are known, activated protein C resistance is a prominent risk for thrombosis. Activated protein C resistance frequently occurs with recurrent thromboembolism.

PATIENT CONCERNS

A 59-year-old Korean woman patient with hypertension was admitted due to dysarthria and left side motor weakness.

DIAGNOSIS AND INTERVENTIONS

Magnetic resonance imaging showed subacute cerebral infarction with right frontoparietal lobe and stenosis at the right internal carotid artery. She underwent right carotid endarterectomy under general anesthesia. However, recurrent thrombosis on postoperative day 1 was noted at patient's right carotid artery, which prompted emergency surgery. Additional preoperative laboratory review revealed findings for activated protein C resistance, low protein S activity, antinuclear antibody (>1:160), anti-cardiolipin IgM antibody (16.6), and thrombocytosis, Janus kinase and factor V Leiden mutations. At the intensive care unit, heparin was continually infused until postoperative day 12 and was then switched to warfarin.

OUTCOMES

Patient was discharged at postoperative day 21 without any event. Patient had no signs of recurrence within the 3-year follow-up period, and she is still on oral warfarin and clopidogrel.

LESSONS

Screening test for hypercoagulability can be used to identify patients at higher risk of postoperative complications. If hypercoagulability state is confirmed by laboratory testing, a suitable anticoagulant treatment plan should be made within the perioperative period.

Temporal trends in venous thromboembolism after radical cystectomy

PURPOSE

To determine whether the rate of venous thromboembolism (VTE) following radical cystectomy (RC) is changing overtime.

MATERIALS AND METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was used to identify patients who underwent RC for bladder cancer from 2011 to 2016. VTE was defined as pulmonary embolism or deep vein thrombosis within 30 days of RC. VTE rate by year was assessed using the Cochran-Armitage test for trend. Associations between patient features and VTE were evaluated with multivariable logistic regression.

RESULTS

A total of 8,241 patients undergoing RC were identified, of whom 348 (4.2%) were diagnosed with VTE. VTE was diagnosed at a median of 13 days (IQR: 7-19) after RC, with 171 (49%) occurring after hospital discharge. Notably, the rate of VTE after RC was found to significantly decrease over time, from 5.1% in 2011 to 2.8% in 2016 (P = 0.001). On multivariable analysis, clinical factors significantly associated with increased odds of VTE included congestive heart failure (odds ratio [OR] = 2.83, P = 0.01), prolonged operative time (OR: 1.48-1.56, P = 0.02-0.01), and receipt of a perioperative blood transfusion (OR = 1.27; P = 0.04). When postoperative complications were adjusted for, sepsis/septic shock (OR = 2.37, P<0.001) and perioperative infection (OR = 1.74, P<0.001) were likewise found to be associated with VTE.

CONCLUSIONS

The rate of VTE after RC significantly decreased in recent years, potentially reflecting improvements in perioperative care. The specific casual factors underlying this trend, in addition to efforts to address identified risk factors for VTE, warrant continued study.

Utility of Viscoelastic Assays Beyond Coagulation: Can Preoperative Thrombelastography Indices Predict Tumor Histology, Nodal Disease, and Resectability in Patients Undergoing Pancreatectomy?

BACKGROUND

Hypercoagulability and malignancy have been linked since the 1860s. However, the impact of different neoplasms on multiple components of the coagulation system remains poorly understood. Thrombelastography (TEG) enables measurement of coagulation incorporating clotting through fibrinolysis. We hypothesize that specific TEG indices that are associated with hypercoagulability can be appreciated in patients with adenocarcinoma undergoing pancreatic resection.

STUDY DESIGN

Blood samples were obtained from patients undergoing pancreatic resection before surgical incision and assayed with TEG. The 4 indices of coagulation measured by TEG included in the analysis were R time, angle, maximum amplitude, and lysis at 30 minutes. Patient tumor type, nodal disease, and mass resectability were contrasted with TEG indices.

RESULTS

One hundred patients were enrolled over 18 months. The majority (63%) of patients had adenocarcinoma. Patients with adenocarcinoma had increased angle compared with other lesions (49 degrees [interquartile range {IQR} 37 to 59 degrees] vs 43 degrees [IQR 32 to 49 degrees]; p = 0.011). When excluding patients that underwent neoadjuvant therapy, patients with adenocarcinoma had shorter R times (13 minutes [IQR 9 to 16 minutes] vs 14 minutes [IQR 12 to 18 minutes]; p = 0.051), steeper angles (49 degrees [IQR 40 to 59 degrees] vs 43 degrees [IQR 32 to 49 degrees]; p = 0.010), and higher maximum amplitude (67 mm [IQR 61 to 69 mm] vs 62 mm [IQR 57 to 67 mm]; p = 0.017). Nodal disease was associated with a significantly increased angle (49 degrees [IQR 42 to 59 degrees] vs 40 degrees [IQR 32 to 50 degrees]; p = 0.002) and maximum amplitude (64 mm [IQR 61 to 69 mm] vs 62 mm [IQR 56 to 67 mm]; p = 0.017). Patients who underwent successful mass resection had longer R times (14 minutes [IQR 11 to 17 minutes] vs 10 minutes [IQR 9 to 15]; p = 0.033) and shorter angles (44 degrees [IQR 35 to 55 degrees] vs 58 degrees [IQR 45 to 66 degrees]; p = 0.025).

CONCLUSIONS

Patients with adenocarcinoma undergoing pancreatic resection have multiple TEG abnormalities consistent with hypercoagulability. These TEG outputs are associated with tumor type, nodal disease, and probability of a successful resection. The use of preoperative TEG has the potential to aid surgeon and patient discussions on anticipated disease burden and prognosis before resection.