Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy

Pulmonary embolism after shoulder surgery: Is it a real threat?

Pulmonary embolism (PE) is a rare but devastating complication of shoulder surgery. Apart from increased morbidity and mortality rates, it may significantly impair postoperative recovery and functional outcome. Its frequency accounts for up to 5.7% of all shoulder surgery procedures with a higher occurrence in women and patients older than 70 years. It is most commonly associated with thrombophilia, diabetes mellitus, obesity, smoking, hypertension, and a history of malignancy. PE usually occurs secondary to upper or lower-extremity deep vein thrombosis (DVT). However, in rare cases, the source of the thrombi cannot be determined. Prophylaxis for PE following shoulder surgery remains a topic of debate, and the standard of care does not routinely require prophylactic medication for DVT prophylaxis. Early ambulation and elastic stockings are important preventative measures for DVT of the lower extremity and medical agents such as aspirin, low-molecular-weight heparin, and vitamin K antagonists are indicated for high-risk patients, long-lasting operations, or concomitant severe acute respiratory syndrome coronavirus 2 infection. The most common symptoms of PE include chest pain and shortness of breath, but PE can also be asymptomatic in patients with intrinsic tolerance of hypoxia. Patients with DVT may also present with swelling and pain of the respective extremity. The treatment of PE includes inpatient or outpatient anticoagulant therapy if the patient is hemodynamically unstable or stable, respectively. Hemodynamic instability may require transfer to the intensive care unit, and cardiovascular arrest can be implicated in fatal events. An important issue for patients with PE in the postoperative period after shoulder surgery is residual stiffness due to a delay in rehabilitation and a prolonged hospital stay. Early physiotherapy and range-of-motion exercises do not adversely affect the prognosis of PE and are highly recommended to preserve shoulder mobility and function.

The IL-1β/STAT1 Axis inhibits STAT3 function via Sequestration of the transcriptional activator GLIS2, leading to postoperative vascular dysfunction

Surgery-induced endothelial dysfunction is crucial in thrombus formation, driven by the release of inflammatory mediators due to surgical trauma. The STAT family, known for amplifying inflammatory responses via cytokine activation, plays an unclear role in the signaling mechanisms from surgery to molecular activation, and their regulatory effects on inflammation vary. This study aimed to identify key signaling pathways responsible for vascular dysfunction post-surgery and to discover potential targets for predicting or preventing thrombosis. To explore this, endothelial cells were co-cultured with post-surgical trauma serum and analyzed using various assays. Bioinformatics analysis linked surgical trauma with pathways involving thrombosis, interleukins, cytokines, and STAT signaling. Elevated inflammatory mediators were observed in mouse serum post-surgical trauma, with IL-6 activating STAT3 to enhance endothelial proliferation, while IL-1β activated STAT1, inhibiting STAT3's effects. Gli-similar 2 (GLIS2), a novel coactivator of STAT3, was found to regulate STAT transcription. STAT1, however, inhibited GLIS2's interaction with STAT3, suppressing STAT3's role in endothelial proliferation. The study concludes that IL-1β-triggered STAT1 activation impedes GLIS2-STAT3 interaction, reducing STAT3's transcriptional activity and leading to endothelial dysfunction, presenting new targets for preventing post-surgical trauma endothelial dysfunction and thrombosis.

Impact of Age on the Occurrence of Vascular Complications in Patients Undergoing Anterior Lumbar Approach Surgery

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To investigate the impact of age on the incidence of vascular complications in patients undergoing anterior lumbar approach surgery.

BACKGROUND

Anterior approach lumbar spinal surgery may facilitate the use of intervertebral devices with larger endplate coverage and increased lordosis. Despite the advantages of this approach, risks related to vascular injury in older patients have been described in the literature.

PATIENTS AND METHODS

In total, 751 consecutive patients with degenerative spinal pathology who underwent stand-alone anterior lumbar interbody fusion (ALIF), ALIF combined with posterior fusion and/or instrumentation (360), total disc replacement, or hybrid procedures (ALIF and total disc replacement) were included. Data collected included general patient descriptive data, surgery details, intraoperative vascular injury, and postoperative vascular complications (deep vein thrombosis and/or pulmonary embolism). Rates of vascular complications were compared across age groups. In addition, the mean age of patients was compared between those with versus without vascular complications.

RESULTS

Overall mean age was 50.4 years (range: 20-83 yr). The mean estimated blood loss was 91.3 mL (range: 10-2800 mL). A total of 15 patients, 2.0%, had vascular complications. There were 10 cases (1.3%) of intraoperative injury to iliac arteries or iliolumbar veins (mean blood loss was 721 mL, and all were repaired intraoperatively). Postoperatively, 6 patients (0.8%) developed deep vein thrombosis and/or pulmonary embolism (one patient had both). With respect to age, there were no significant differences in rates of intraoperative, postoperative, or combined vascular complication rates across the age group ( P > 0.38). In addition, there were no statistically significant differences in the mean ages of patients with versus those without vascular complications ( P > 0.17).

CONCLUSION

Overall incidence of vascular complications was 2.0%. No relationship between vascular complications and age was demonstrated. These data suggest that increased age may not necessarily be an absolute contraindication for anterior lumbar approach surgery.

LEVEL OF EVIDENCE

Level III.

Incidence, Risk Factors, and Correlation with Caprini Score of Deep Vein Thrombosis After Colpocleisis with/without Concomitant Hysterectomy for Pelvic Organ Prolapse in Elderly Women

INTRODUCTION AND HYPOTHESIS

The objective was to investigate the incidence and risk factors of lower extremity deep vein thrombosis (DVT) in elderly women undergoing colpocleisis for pelvic organ prolapse and to evaluate the predictive efficacy of the Caprini scores.

METHODS

Data from patients who underwent colpocleisis from August 2019 to April 2024 were retrospectively analyzed. The primary endpoint was DVT detected by ultrasonography within 7 days of surgery. Univariate and multivariate logistic regression analyses were applied to identify independent risk factors. Efficacy parameters of the Caprini scores were analyzed and optimal cut-off values were selected.

RESULTS

A total of 262 patients were enrolled in the study, of whom 8.4% (22 out of 262) developed DVT postoperatively. After statistical analysis, the duration of menopause, history of inflammatory bowel disease, as well as higher levels of preoperative cholesterol and preoperative D-dimer, were identified as independent risk factors. There was a significant difference in the Caprini scores between the DVT and non-DVT groups (7.27 ± 1.28 vs 6.15 ± 0.80, p < 0.001), and the risk of DVT tended to increase with higher Caprini scores. The best performance was achieved when the threshold for the Caprini score was set to 7, at which point the area under the receiver operating characteristic curve was 0.758, the sensitivity was 0.773, and the specificity was 0.662.

CONCLUSION

There was a strong correlation between the occurrence of DVT after colpocleisis and the Caprini score, with higher Caprini scores indicating a higher risk of postoperative DVT. A significantly increased risk was suggested when this score was ≥ 7.

Prevention of complications for hospitalized patients receiving parenteral nutrition: A narrative review

Hospitalized patients may benefit from parenteral nutrition to address their compromised nutrition status attributed to limited oral/enteral intake and increased nutrient/energy requirement during acute illness. Parenteral nutrition, however, can be associated with many complications that can negatively impact patient outcomes. In this review, we focus on potential metabolic and catheter-related complications associated with parenteral nutrition use. We report on potential risk factors for such complications and highlight strategies for prevention and early recognition. To optimize outcomes, key findings include the creation and implementation of evidence-based protocols with proven efficacy. For each hospital unit delivering parenteral nutrition to patients, tracking compliance with established protocols and patient outcomes is crucial for ongoing improvement through identification of gaps, proper reeducation and training, and ongoing refinement of care protocols. Establishment of specialized inpatient nutrition support teams should be considered.

Antiphospholipid Syndrome Increases Postoperative Complications After Total Hip and Knee Arthroplasty

BACKGROUND

Antiphospholipid syndrome (APS) is a systemic autoimmune condition that predisposes patients to venous thromboembolism (VTE). Although many studies have explored risk factors for VTE after joint reconstructive procedures, the impact of APS is still unclear.

MATERIALS AND METHODS

A retrospective cohort study was conducted using TriNetX, a health care database that includes 442,494 patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA). Ninety-day postoperative complications and 1- and 2-year surgical complications were compared between patients with and without preexisting APS. Patients underwent propensity score matching in a 1:1 ratio based on relevant comorbidities.

RESULTS

Patients undergoing THA or TKA with APS, compared with those without, had higher rates of deep venous thrombosis (hip: 9.2% vs 6.0%, odds ratio, 1.589, P=.022; knee: 10.5% vs 4.1%, odds ratio, 2.763, P<.001), pulmonary embolism (hip: 6.9% vs 3.6%, odds ratio, 1.992, P=.005; knee: 8.4% vs 3.0%, odds ratio, 2.989, P<.001), and anemia (hip: 24.8% vs 18.6%, odds ratio, 1.447, P=.004; knee: 18.5% vs 13.9%, odds ratio, 1.406, P=.007). Patients undergoing THA with APS also had higher rates of urinary tract infection (5.0% vs 2.8%, odds ratio, 1.842, P=.029) and pneumonia (3.7% vs 1.8%, odds ratio, 2.119, P=.025). APS did not impact rates of surgical complications or revision surgery.

CONCLUSION

Overall, APS heightens patients' risk for complications after THA and TKA. Specific anticoagulation protocols and preoperative risk stratification should be implemented to reduce the risk of adverse events. [Orthopedics. 2024;47(5):301-307.].

Short-term versus extended chemoprophylaxis against venous thromboembolism in DIEP flap breast reconstruction: A retrospective study of 424 patients

BACKGROUND

Autologous breast reconstruction is considered high-risk for deep vein thrombosis (DVT) and thromboembolism (PE). It is therefore recommended to treat patients undergoing these complex and lengthy procedures with DVT chemoprophylaxis. The optimal anticoagulation protocol is still not established. The objective of our study was to evaluate the need of a prolonged anticoagulation in patients undergoing microsurgical breast reconstruction.

METHODS

This retrospective cohort study compares our former anticoagulation protocol, which was given during the in-hospital stay, with our new protocol consisting of extended anticoagulation until postoperative day 25, in terms of DVT/PE risk reduction. A logistic regression was used to evaluate the risk of DVT/PE between the two groups, while adjusting for several covariates.

RESULTS

Our cohort consisted of 205 patients in the short-term anticoagulation group and 219 in the extended protocol group. Five patients (2.4%) in the short-term anticoagulation group had a DVT/PE event versus 4 patients (1.8%) in the extended protocol group. Logistic regression revealed no difference in the incidence of DVT/PE between the two groups. Similarly, there was no differences in terms of hematoma and infection rate between the two groups. Finally, we found an increased risk of DVT/PE in patients with a Caprini score equal or greater than 8.

CONCLUSION

In our experience, short-term anticoagulation during the hospital stay is equivalent to extended thromboprophylaxis in terms of DVT/PE prevention.

Postoperative Acute Intracranial Hemorrhage and Venous Thromboembolism in Patients with Brain Metastases Receiving Acetylsalicylic Acid Perioperatively

Cranial operations are associated with a high risk of postoperative intracranial hemorrhage (pICH) and venous thromboembolic events, along with increased mortality and morbidity. With the use of acetylsalicylic acid (ASA) for prophylaxis becoming more prevalent, the risk of bleeding when ASA is administered preoperatively is unknown, as are the effects of discontinuation upon the occurrence of thromboembolic events, especially in societies with aging demographics. To address these questions, a retrospective analysis was performed using medical records and radiological images of 1862 patients subjected to brain tumor surgery over a decade in our department. The risk of pICH was compared in patients with metastases receiving ASA treatment versus patients not receiving ASA treatment. The occurrence of venous thromboembolic events after surgery was also evaluated. The study group consisted of 365 patients with different types of brain metastases. In total, 20 patients suffered pICH and 7 of these were associated with clinical neurological deterioration postoperatively. Of the 58 patients who took ASA preoperatively, 2 patients experienced pICH, compared with 5 patients in the non-ASA impact group (p = 0.120). Patients who took ASA were not at significantly higher risk of pICH and therefore a worse outcome compared to the group without ASA. Therefore, these data suggest that in patients at high cardiovascular risk, ASA can be safely continued during elective brain tumor surgery.

Usefulness of Elastic Bandage Compression Compared to Calf Massage to Prevent Venous Thromboembolism-A Retrospective Evaluation

Background: Manual calf massage and passive ankle motion (CaM) can reduce the incidence of venous thromboembolism (VTE) after total hip arthroplasty (THA). However, these methods cannot be used in all patients; thus, elastic bandage (EB) compression is an alternative method. The efficacy of EB compression in preventing VTE has not yet been investigated; thus, this study aimed to compare the effects of EB compression and manual calf massage. Methods: Of the 363 patients who underwent unilateral primary THA at our hospital between 1 August 2018 and 31 October 2023, CaM without anticoagulation therapy was administered to 206 patients (CaM group) and 157 patients underwent EB without anticoagulation therapy (EB group). Duplex ultrasonography was performed 7 days postoperatively to check for deep vein thrombosis (DVT) in both legs. Results: The surgical time (122.2 min vs. 155.5 min), the incidence of DVT (4.5% vs. 4.8%) and pulmonary thromboembolism (PTE) (0% vs. 0.7%), intraoperative bleeding (305.4 mL vs. 301 mL), and estimated actual blood loss (846.6 mL vs. 811.6 mL) were not significantly different between the CaM and EB group. However, there was one case of symptomatic PTE in the EB group. Conclusions: The incidences of DVT, PTE, and intraoperative bleeding were not significantly different between the groups. Moreover, EB can be administered to patients with DVT and is considered to be a DVT prophylaxis method that can be used in a larger number of patients. Therefore, we recommend that EB be performed in all the patients undergoing THA.

Utilization of the Caprini risk assessment model(RAM) to predict venous thromboembolism after primary hip and knee arthroplasty: an analysis of the Healthcare Cost and Utilization Project(HCUP)

PURPOSE

This study aims to investigate the potential role of Caprini risk assessment model (RAM) in predicting the risk of venous thromboembolism (VTE) in patients undergoing total hip or knee arthroplasty (THA/TKA). No national study has investigated the role of Caprini RAM after primary THA/TKA.

METHODS

Data from The National Sample of Healthcare Cost and Utilization Project (HCUP) in 2019 were utilized for this study. The dataset consisted of 229,134 patients who underwent primary THA/TKA. Deep vein thrombosis (DVT) and pulmonary embolism (PE) were considered as VTE. The incidence of thrombosis was calculated based on different Caprini scores, and the risk of the Caprini indicator for VTE events was evaluated using a forest plot.

RESULTS

The prevalence of VTE after primary THA/TKA in the U.S. population in 2019 was found to be 4.7 cases per 1000 patients. Age, body mass index (BMI), and Caprini score showed a positive association with the risk of VTE (P < 0.05). The receiver operating characteristic (ROC) curve analysis indicated that a Caprini score of 9.5 had a sensitivity of 47.2% and a specificity of 82.7%, with an area under the curve (AUC) of 0.693 (95% CI, 0.677-0.710). The highest Youden index was 0.299. Multivariate logistic regression analysis revealed that malignancy, varicose vein, positive blood test for thrombophilia, history of thrombosis, COPD, hip fracture, blood transfusion, and age were significant risk factors for VTE. Based on these findings, a new risk stratification system incorporating the Caprini score was proposed.

CONCLUSIONS

Although the Caprini score does not seem to be a good predictive model for VTE after primary THA/TKA, new risk stratification for the Caprini score is proposed to increase its usefulness.

Untargeted blood serum proteomics identifies novel proteins related to neurological recovery after human spinal cord injury

BACKGROUND

The discovery of new prognostic biomarkers following spinal cord injury (SCI) is a rapidly growing field that could help uncover the underlying pathological mechanisms of SCI and aid in the development of new therapies. To date, this search has largely focused on the initial days after the lesion. However, during the subacute stage of SCI (weeks to months after the injury), there remains potential for sensorimotor recovery, and numerous secondary events develop in various organs. Additionally, the confounding effects of early interventions after the injury are less likely to interfere with the results.

METHODS

In this study, we conducted an untargeted proteomics analysis to identify biomarkers of recovery in blood serum samples during the subacute phase of SCI patients, comparing those with strong recovery to those with no recovery between 30 and 120 days. We analyzed the fraction of serum that is depleted of the most abundant proteins to unmask proteins that would otherwise go undetected. Linear models were used to identify peptides and proteins related to neurological recovery and we validated changes in some of these proteins using Enzyme-linked Immunosorbent Assay (ELISA).

RESULTS

Our findings reveal that differences in subacute recovery after SCI (from 30 to 120 days) are associated with an enrichment in proteins involved in inflammation, coagulation, and lipid metabolism. Technical validation using commercial ELISAs further confirms that high levels of SERPINE1 and ARHGAP35 are associated with strong neurological recovery, while high levels of CD300a and DEFA1 are associated with a lack of recovery.

CONCLUSIONS

Our study identifies new candidates for biomarkers of neurological recovery and for novel therapeutic targets after SCI.

Pharmacotherapy for Venous Thromboprophylaxis following Total Hip or Knee Arthroplasty: A Systematic Review and Network Meta-analysis

The optimal pharmacological prophylaxis for venous thromboembolism (VTE) after hip or knee arthroplasty is uncertain. We conducted a systematic review and network meta-analysis to compare the efficacy and safety of various medications. We searched multiple databases for randomized clinical trials (RCTs) comparing medications (including factor Xa inhibitors, factor IIa inhibitor, warfarin, unfractionated heparin [UFH], low-molecular-weight heparin [LMWH], aspirin, pentasaccharide) for VTE prophylaxis post-arthroplasty. Outcomes included any postoperative VTE identified with screening, major bleeding, and death. We used LMWH as the main comparator for analysis and performed trial sequential analysis (TSA) for each pairwise comparison. Certainty of evidence was assessed using GRADE (Grading of Recommendations, Assessments, Developments and Evaluations). We analyzed 70 RCTs (55,841 participants). Factor Xa inhibitors decreased postoperative VTE significantly compared with LMWH (odds ratio [OR]: 0.55, 95% confidence interval [CI]: 0.44-0.68, high certainty). Pentasaccharides probably reduce VTE (OR: 0.61, 95% CI: 0.36-1.02, moderate certainty), while the factor IIa inhibitor dabigatran may reduce VTE (OR: 0.75, 95% CI: 0.40-1.42, low certainty). UFH probably increases VTE compared with LMWH (OR: 1.31, 95% CI: 0.91-1.89, moderate certainty), and other agents like warfarin, aspirin, placebo, and usual care without thromboprophylaxis increase VTE (high certainty). Factor Xa inhibitors may not significantly affect major bleeding compared with LMWH (OR: 1.06, 95% CI: 0.81-1.39, low certainty). No medications had a notable effect on mortality compared with LMWH (very low certainty). TSA suggests sufficient evidence for the benefit of factor Xa inhibitors over LMWH for VTE prevention. Compared with LMWH and aspirin, factor Xa inhibitors are associated with reduced VTE after hip or knee arthroplasty, without an increase in bleeding and likely no impact on mortality.

Glass bead-activated clotting time (gb-ACT) for monitoring the anticoagulation effects in elderly patients with high risk of venous thromboembolism (VTE)

BACKGROUND

To find a new bedside method to monitor the anticoagulation effects of low-molecular-weight heparins (LMWHs) in patients with a high risk of venous thromboembolism (VTE).

RESEARCH DESIGN AND METHODS

A total of 32 hospitalized patients (aged ≥60 years) who were at high risk of VTE were assigned to receive subcutaneous LMWH for 5 to 14 days. Plasma anti-factor Xa (anti-Xa) activity was conducted by a chromogenic method, and the glass bead-activated whole blood clotting time (gb-ACT) value was obtained by a Sonoclot Analyzer.

RESULTS

A correlation between the gb-ACT values and the anti-Xa levels was suggested (R = 0.447, p = 0.002), and it was stronger in the older group aged 80 years above (R = 0.467, p = 0.008) and in the group of patients with an eGFR of 30 ~ 60 mL/min (R = 0.565, p = 0.005). The area under the curve (AUC) for gb-ACT by receiver operating characteristic (ROC) curve evaluation was 0.725 (p = 0.011), and the gb-ACT >282.5s provided a sensitivity of 60% and specificity of 74% for anti-Xa >0.800 IU/ml.

CONCLUSIONS

The gb-ACT values detected by a Sonoclot Analyzer could act as a novel bedside method in the monitoring of LMWH anticoagulation.

Comparative efficacy of aspirin versus direct oral anticoagulants for venous thromboembolism prophylaxis following primary total hip arthroplasty or total knee arthroplasty: A systematic review and meta-analysis of randomised controlled trials

Introduction

Venous thromboembolisms (VTEs), including deep vein thrombosis (DVT) and pulmonary embolisms (PE), are common after total knee (TKA) and hip arthroplasty (THA). Recent studies suggest that aspirin effectively prevents VTE following major orthopaedic surgery. This meta-analysis compares randomised controlled trials (RCTs) evaluating aspirin versus direct oral anticoagulants (DOACs) for VTE prevention after primary THA and TKA.

Methods

We included RCTs from 2017 to 2023 that looked at aspirin versus DOACs for VTE prophylaxis in primary THA and TKA. A search strategy was conducted which used Boolean operators and MESH terms. Primary outcomes included VTE rates, symptomatic, asymptomatic DVT and PE. Secondary outcomes were mortality and bleeding complications. Statistical analysis was performed using REVMAN software. An odds ratio with a 95% confidence interval was generated for the pooled studies. Heterogeneity was assessed using the I 2 variable, and publication bias was evaluated with a funnel plot.

Results

Seven RCTs with 3967 patients were included for analysis. Rivaroxaban 10 mg OD was compared to varying doses of aspirin (81-300 mg). There were no significant differences between the groups in the incidence of VTE (OR: 1.21, 95% CI: 0.72-2.01), PE (OR: 1.01, 95% CI: 0.39-2.61), asymptomatic DVT (OR: 1.39, 95% CI: 0.64-3.00), suspected DVT (OR: 1.13, 95% CI: 0.49-2.61) and major bleeding (OR: 0.84, 95% CI: 0.55-1.27).

Discussion

Aspirin is as effective as rivaroxaban for primary thromboprophylaxis post-THA and TKA, without increased incidence of complications. Further research is needed to determine the optimal dosing regimen of aspirin and its long-term efficacy in preventing VTE.

Level of Evidence

Level I.

A prospective study on risk assessment and prophylaxis of venous thromboembolism in general surgery patients

Aims and Objective

To evaluate the patients at risk of venous thromboembolism (VTE) based on Caprini VTE risk assessment scale and the effect of implementation of this scale on the use of thromboprophylaxis.

Materials and Methods

A prospective study was conducted, including patients who underwent major elective surgical procedures. Demographic details were noted, and VTE prophylaxis offered if needed. According to the VTE risk assessment scale, patients were categorised into very low-, low-, moderate-, and high-risk categories. The data were analysed statistically.

Results

A total of 500 patients (women = 259; men = 241) were enrolled in this study. Of them, eight women and nine men developed VTE (P = 0.691). The maximum number of patients who developed VTE belonged to 61-70 years group (n = 7). According to VTE risk assessment, 61 patients were categorised as low-risk, 217 patients as moderate-risk, and 222 patients were categorised as high-risk. A significant (P < 0.0005) correlation was found between body mass index (BMI) and VTE development. In obese patients with BMI >25, 14 patients developed VTE. Out of total, 329 patients received prophylaxis for deep vein thrombosis. Of 284 patients who received pharmacologic prophylaxis, only three developed VTE (P = 0.002). Of 145 patients who received mechanical prophylaxis, 75 had high risk and none of them developed VTE. Four patients had mortality, and a significant (P = 0.022) correlation was found between mortality and VTE development.

Conclusion

According to Caprini risk assessment scale, the prophylaxis for VTE was effective in patients undergoing major elective general surgery, resulting in significant lowering of morbidity and mortality.

Comparison of enoxaparin 40 mg versus 60 mg dosage for venous thromboprophylaxis in patients undergoing bariatric surgery: A randomized controlled trial

BACKGROUND

Venous thromboembolism (VTE) is a common cause of morbidity and mortality after bariatric surgery. Morbid obesity is an independent risk factor for VTE, with goals of prophylactic anti-factor Xa levels within 0.2-0.5 IU/mL. The recommended dosing regimen of enoxaparin for VTE prophylaxis in patients with morbid obesity is lacking in available guidelines.

OBJECTIVES

To evaluate the achieving prophylactic anti-factor Xa levels with different dosages of enoxaparin for morbid obesity patients.

SETTING

We conducted a study at Chulalongkorn Bariatric and Metabolic Institute, King Chulalongkorn Memorial Hospital.

METHODS

We conducted a randomized controlled trial comparing anti-factor Xa levels 4 h after the administration of enoxaparin. All recruited patients randomly received 40 mg or 60 mg of enoxaparin 12 h before the operation. Blood specimens were collected 4 h after the administration of enoxaparin.

RESULTS

In total, 56 patients who presented between April 2019 and March 2020 at King Chulalongkorn Memorial Hospital were recruited. Of these patients, 28 received 40 mg and 28 received 60 mg of enoxaparin. In both groups, the rates of achieving target levels were 53.57% and 78.57%, respectively (p-value = 0.048). The mean anti-factor Xa levels were 0.19 IU/mL ± 0.06 IU/mL and 0.28 and 0.28 ± 0.10 IU/mL, respectively (p < 0.001). No significant difference was found in the estimated blood loss between the groups. No patient obtained anti-factor Xa levels exceeding 0.5 IU/mL. In both groups, no symptomatic VTE occurred.

CONCLUSIONS

A 60 mg of enoxaparin regimen achieved more prophylactic anti-factor Xa levels than 40 mg in obese patients undergoing bariatric surgery without any adverse events.

Machine learning models for prediction of postoperative venous thromboembolism in gynecological malignant tumor patients

AIM

To identify risk factors that associated with the occurrence of venous thromboembolism (VTE) within 30 days after hysterectomy among gynecological malignant tumor patients, and to explore the value of machine learning (ML) models in VTE occurrence prediction.

METHODS

A total of 1087 patients between January 2019 and January 2022 with gynecological malignant tumors were included in this single-center retrospective study and were randomly divided into the training dataset (n = 870) and the test dataset (n = 217). Univariate logistic regression analysis was used to identify risk factors that associated with the occurrence of postoperative VTE in the training dataset. Machine learning models (including decision tree (DT) model and logistic regression (LR) model) to predict the occurrence of postoperative VTE were constructed and internally validated.

RESULTS

The incidence of developing 30-day postoperative VTE was 6.0% (65/1087). Age, previous VTE, length of stay (LOS), tumor stage, operative time, surgical approach, lymphadenectomy (LND), intraoperative blood transfusion and gynecologic Caprini (G-Caprini) score were identified as risk factors for developing postoperative VTE in gynecological malignant tumor patients (p < 0.05). The AUCs of LR model and DT model for predicting VTE were 0.722 and 0.950, respectively.

CONCLUSION

The ML models, especially the DT model, constructed in our study had excellent prediction value and shed light upon its further application in clinic practice.

Prophylactic Enoxaparin Dosing Using Anti-Factor Xa Levels in Hepatic Surgery Patients: A Pilot Study

This study examines the safety and efficacy of using peak anti-Xa levels to achieve prophylactic enoxaparin (Lovenox, Sanofi-Aventis) levels in patients who underwent hepatic surgery. Prospectively enrolled patients undergoing major and minor hepatic procedures received postoperative enoxaparin dosing. The enoxaparin dose was adjusted to attain a peak anti-Xa level ≥ 0.20 U/ml. This group was compared to a historical cohort of patients who underwent similar procedures and received standard postoperative VTE chemoprophylaxis dosing. Inpatient postoperative VTE rates were higher in the control group when compared to the experimental group (0 patients [0.00%] vs 4 patients [8.16%]; P = .035). There was no statistically significant difference in number of postoperative blood transfusions, discharge hemoglobin, or in-hospital bleeding events. Adjusting enoxaparin dosing to achieve prophylactic peak anti-Xa levels of ≥0.20 IU/ml was associated with a reduced incidence of symptomatic inpatient postoperative VTE in patients who underwent hepatic surgery without increasing postoperative bleeding events.

Unique Medical Considerations for the Athlete Undergoing Anesthesia

Athletes are among a unique group such that they may possess a serious underlying pathologic condition that may often go unnoticed given their high caliber of physical fitness. However, several considerations should be investigated, especially in the perioperative period, in order to minimize morbidity and mortality. Namely, cardiac pathologic condition can result in sudden death, and pulmonary pathologic condition may affect airway and respiratory management. Moreover, patients undergoing orthopedic surgery are at the highest risk for venous thromboembolism. Regardless of the condition, it is crucial to be vigilant and explore the unique medical considerations for the athlete undergoing anesthesia.

Postoperative Venous Thromboembolism Following Hysterectomy in the Department of Defense

INTRODUCTION

Hysterectomy is the most common major gynecologic procedure performed in the USA. Surgical complications, such as venous thromboembolism (VTE), are known risks that can be mitigated by preoperative risk stratification and perioperative prophylaxis. Based on recent data, the current post-hysterectomy VTE rate is found to be 0.5%. Postoperative VTE significantly impacts health care costs and patients' quality of life. Additionally, for active duty personnel, it can negatively impact military readiness. We hypothesize that the incidence of post-hysterectomy VTE rates will be lower within the military beneficiary population because of the benefits of universal health care coverage.

MATERIALS AND METHODS

The Military Health System (MHS) Data Repository and Management Analysis and Reporting Tool was used to conduct a retrospective cohort study of postoperative VTE rates within 60 days of surgery among women who underwent a hysterectomy at a military treatment facility between October 1, 2013, and July 7, 2020. Patient demographics, Caprini risk assessment, preoperative VTE prophylaxis, and surgical details were obtained by chart review. Statistical analysis was performed using the chi-squared test and Student t-test.

RESULTS

Among the 23,391 women who underwent a hysterectomy at a military treatment facility from October 2013 to July 2020, 79 (0.34%) women were diagnosed with VTE within 60 days of their surgery. This post-hysterectomy VTE incidence rate (0.34%) is significantly lower than the current national rate (0.5%, P < .0015). There were no significant differences in postoperative VTE rates with regard to race/ethnicity, active duty status, branch of service, or military rank. Most women with post-hysterectomy VTE had a moderate-to-high (4.29 ± 1.5) preoperative Caprini risk score; however, only 25% received preoperative VTE chemoprophylaxis.

CONCLUSION

MHS beneficiaries (active duty personnel, dependents, and retirees) have full medical coverage with little to no personal financial burden for their health care. We hypothesized a lower VTE rate in the Department of Defense because of universal access to care and a presumed younger and healthier population. The postoperative VTE incidence was significantly lower in the military beneficiary population (0.34%) compared to the reported national incidence (0.5%). Additionally, despite all VTE cases having moderate-to-high preoperative Caprini risk scores, the majority (75%) received only sequential compression devices for preoperative VTE prophylaxis. Although post-hysterectomy VTE rates are low within the Department of Defense, additional prospective studies are needed to determine if stricter adherence to preoperative chemoprophylaxis can further reduce post-hysterectomy VTE rates within the MHS.

Prediction model of deep vein thrombosis risk after lower extremity orthopedic surgery

Purpose

This investigation was conceived to engineer and appraise a pioneering clinical nomogram, crafted to bridge the extant chasm in literature regarding the postoperative risk stratification for deep vein thrombosis (DVT) in the aftermath of lower extremity orthopedic procedures. This novel tool offers a sophisticated and discerning algorithm for risk prediction, heretofore unmet by existing methodologies.

Methods

In this retrospective observational study, clinical records of hospitalized patients who underwent lower extremity orthopedic surgery were collected at the Wuxi TCM Hospital Affiliated to the Nanjing University of Chinese Medicine between Jan 2017 and Oct 2019. The univariate and multivariate analysis with the backward stepwise method was applied to select features for the predictive nomogram. The performance of the nomogram was evaluated with respect to its discriminant capability, calibration ability, and clinical utility.

Result

A total of 5773 in-hospital patients were eligible for the study, with the incidence of deep vein thrombosis being approximately 1 % in this population. Among 31 variables included, 5 of them were identified to be the predictive features in the nomogram, including age, mean corpuscular hemoglobin concentration (MCHC), D-dimer, platelet distribution width (PDW), and thrombin time (TT). The area under the receiver operating characteristic (ROC) curve in the training and validation cohort was 85.9 % (95%CI: 79.96 %-90.04 %) and 85.7 % (95%CI: 78.96 %-90.69 %), respectively. Both the calibration curves and decision curve analysis demonstrated the overall satisfactory performance of the model.

Conclusion

Our groundbreaking nomogram is distinguished by its unparalleled accuracy in discriminative and calibrating functions, complemented by its tangible clinical applicability. This innovative instrument is set to empower clinicians with a robust framework for the accurate forecasting of postoperative DVT, thus facilitating the crafting of bespoke and prompt therapeutic strategies, aligning with the rigorous standards upheld by the most esteemed biomedical journals.

Thromboprophylaxis in hospitalized trauma patients: a systematic review and meta-analysis of implementation strategies

Introduction

Venous thromboembolism (VTE) prophylaxis implementation strategies are well-studied in some hospitalized medical and surgical patients. Although VTE is associated with substantial mortality and morbidity in trauma patients, implementation strategies for the prevention of VTE in trauma appear to be based on limited evidence. Therefore, we conducted a systematic review and meta-analysis of published literature on active implementation strategies for VTE prophylaxis administration in hospitalized trauma patients and the impact on VTE events.

Methods

A systematic review and meta-analysis was performed in adult hospitalized trauma patients to assess if active VTE prevention implementation strategies change the proportion of patients who received VTE prophylaxis, VTE events, and adverse effects such as bleeding or heparin-induced thrombocytopenia as well as hospital length of stay and the cost of care. An academic medical librarian searched Medline, Scopus, and Web of Science until December 2022.

Results

Four studies with a total of 1723 patients in the active implementation strategy group (strategies included education, reminders, human and computer alerts, audit and feedback, preprinted orders, and/or root cause analysis) and 1324 in the no active implementation strategy group (guideline creation and dissemination) were included in the analysis. A higher proportion of patients received VTE prophylaxis with an active implementation strategy (OR=2.94, 95% CI (1.68 to 5.15), p<0.01). No significant difference was found in VTE events. Quality was deemed to be low due to bias and inconsistency of studies.

Conclusions

Active implementation strategies appeared to improve the proportion of major trauma patients who received VTE prophylaxis. Further implementation studies are needed in trauma to determine effective, sustainable strategies for VTE prevention and to assess secondary outcomes such as bleeding and costs.

Level of evidence

Systematic review/meta-analysis, level III.

PROSPERO registration number

CRD42023390538.

Utility and Clinical Outcomes of Perioperative Inferior Vena Cava Filter Prophylaxis in Spine Surgery Patients

STUDY DESIGN

Single-center retrospective chart review study.

OBJECTIVE

This study aimed to assess the clinical outcomes of prophylactic inferior vena cava (IVC) filter use for pulmonary embolism (PE) prevention in spine surgery patients.

SUMMARY OF BACKGROUND DATA

IVC filters can serve an important prophylactic role in preventing PE, though research involving spine surgery patients is sparse.

MATERIALS AND METHODS

This Institutional Review Board-approved single-center retrospective study assessed the characteristics and outcomes of patients who underwent spine surgery and received perioperative IVC filters for PE prophylaxis from January 2007 until December 2021. Clinical outcomes centered primarily on the occurrence of venous thromboembolism (VTE) as well as complications related to filter placement and retrieval. Thrombi that may have been entrapped by the filters were recorded incidentally on computed tomography or during the filter retrieval procedure.

RESULTS

This cohort included 380 spine surgery patients (female 51%/male 49%; median age, 61) who had received perioperative prophylactic IVC filters. The mean dwell time was 6.7 months (1-39 mo), with an overall 62% retrieval rate. Retrievals were further categorized by retrieval complexity, with 92% classified as routine and 8% as involving advanced removal techniques, while complications involved 1% (four retrievals) and were all minor. Regarding VTE event occurrence, deep vein thrombi (DVT) were experienced by 11% of patients in the postplacement period, with 1% (n=4) experiencing a PE. There were 11 incidences of thrombi that were found within or near the filters (2.9%). A multivariate analysis further assessed patient characteristics that correlated with the occurrence of PE, DVT, entrapped filter thrombi, advanced technique filter removal, and removal complications.

CONCLUSIONS

IVC filters in this high-risk spine surgery cohort achieved a relatively low rate of DVT and PE as well as a low complication rate, whereas several patient characteristics were identified that correlated with VTE events and filter retrieval outcomes.

Evaluation of venous thromboembolism risk assessment models for hospital inpatients: the VTEAM evidence synthesis

Background

Pharmacological prophylaxis during hospital admission can reduce the risk of acquired blood clots (venous thromboembolism) but may cause complications, such as bleeding. Using a risk assessment model to predict the risk of blood clots could facilitate selection of patients for prophylaxis and optimise the balance of benefits, risks and costs.

Objectives

We aimed to identify validated risk assessment models and estimate their prognostic accuracy, evaluate the cost-effectiveness of different strategies for selecting hospitalised patients for prophylaxis, assess the feasibility of using efficient research methods and estimate key parameters for future research.

Design

We undertook a systematic review, decision-analytic modelling and observational cohort study conducted in accordance with Enhancing the QUAlity and Transparency Of health Research (EQUATOR) guidelines.

Setting

NHS hospitals, with primary data collection at four sites.

Participants

Medical and surgical hospital inpatients, excluding paediatric, critical care and pregnancy-related admissions.

Interventions

Prophylaxis for all patients, none and according to selected risk assessment models.

Main outcome measures

Model accuracy for predicting blood clots, lifetime costs and quality-adjusted life-years associated with alternative strategies, accuracy of efficient methods for identifying key outcomes and proportion of inpatients recommended prophylaxis using different models.

Results

We identified 24 validated risk assessment models, but low-quality heterogeneous data suggested weak accuracy for prediction of blood clots and generally high risk of bias in all studies. Decision-analytic modelling showed that pharmacological prophylaxis for all eligible is generally more cost-effective than model-based strategies for both medical and surgical inpatients, when valuing a quality-adjusted life-year at £20,000. The findings were more sensitive to uncertainties in the surgical population; strategies using risk assessment models were more cost-effective if the model was assumed to have a very high sensitivity, or the long-term risks of post-thrombotic complications were lower. Efficient methods using routine data did not accurately identify blood clots or bleeding events and several pre-specified feasibility criteria were not met. Theoretical prophylaxis rates across an inpatient cohort based on existing risk assessment models ranged from 13% to 91%.

Limitations

Existing studies may underestimate the accuracy of risk assessment models, leading to underestimation of their cost-effectiveness. The cost-effectiveness findings do not apply to patients with an increased risk of bleeding. Mechanical thromboprophylaxis options were excluded from the modelling. Primary data collection was predominately retrospective, risking case ascertainment bias.

Conclusions

Thromboprophylaxis for all patients appears to be generally more cost-effective than using a risk assessment model, in hospitalised patients at low risk of bleeding. To be cost-effective, any risk assessment model would need to be highly sensitive. Current evidence on risk assessment models is at high risk of bias and our findings should be interpreted in this context. We were unable to demonstrate the feasibility of using efficient methods to accurately detect relevant outcomes for future research.

Future work

Further research should evaluate routine prophylaxis strategies for all eligible hospitalised patients. Models that could accurately identify individuals at very low risk of blood clots (who could discontinue prophylaxis) warrant further evaluation.

Study registration

This study is registered as PROSPERO CRD42020165778 and Researchregistry5216.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR127454) and will be published in full in Health Technology Assessment; Vol. 28, No. 20. See the NIHR Funding and Awards website for further award information.

Aspirin prophylaxis is not associated with increased risk of venous thromboembolism in arthroplasty for femoral neck fractures: a non-inferiority study

PURPOSE

Venous thromboembolism (VTE) is a known complication of hip arthroplasty for femoral neck fractures (FNF) with various prophylactic anticoagulants utilized to decrease risk. The purpose of this study was to assess the efficacy and perioperative outcomes associated with aspirin for VTE prophylaxis following arthroplasty for FNF.

METHODS

Medical records of 1,220 patients who underwent hip hemiarthroplasty (HHA) or total hip arthroplasty (THA) at an urban academic center from 2011 to 2022 were retrospectively reviewed. Patient characteristics and perioperative outcomes, including length of stay (LOS), VTE, 90-day hospital encounters, and discharge disposition, were collected. Outcomes for patients prescribed aspirin (n = 214) were compared to those prescribed non-aspirin VTE prophylaxis (n = 1006) using propensity score matching.

RESULTS

Patients who received aspirin had higher rates of THA (36.0 vs 26.7%; p = 0.008). There were no significant risk-adjusted differences in the incidence of VTE (0.5 vs 0.5%, p = 1.000) and 90-day readmissions (10.4 vs 12.3%, p = 0.646) between patients prescribed aspirin and non-aspirin VTE prophylaxis, respectively. Patients prescribed non-aspirin agents had higher rates of non-home discharge (73.9 vs 58.5%; p < 0.001) and longer LOS (143.5 vs 124.9 h; p = 0.005). Sub-analysis of patients prescribed aspirin and non-aspirin prophylaxis based on comorbidity scores demonstrated no difference in VTE incidence for low (0.0 vs 1.6%, p = 1.000) and high scores (0.0 vs 0.0%, p = 1.000), respectively.

CONCLUSION

Aspirin is not associated with increased incidence of VTE after HHA or THA for FNF. Aspirin prophylaxis should be considered in hip fracture patients to mitigate bleeding risk, particularly those with low to intermediate VTE risk.

LEVEL OF EVIDENCE

Level III, Retrospective study.

Venous Thromboembolism Prophylaxis in Otolaryngologic Patients Using Caprini Assessment

OBJECTIVE

The aim was to determine the utilization of Caprini guideline-indicated venous thromboembolism (VTE) prophylaxis and impact on VTE and bleeding outcomes in otolaryngology (ORL) surgery patients.

METHODS

Elective ORL surgeries performed between 2016 and 2021 were retrospectively identified. Logistic regression models were used to examine the association between patient characteristics and receiving appropriate prophylaxis, inpatient, 30- and 90-day VTE and bleeding events.

RESULTS

A total of 4955 elective ORL surgeries were analyzed. Thirty percent of the inpatient cohort and 2% of the discharged cohort received appropriate risk-stratified VTE prophylaxis. In those who did not receive appropriate prophylaxis, overall inpatient VTE was 3.5-fold higher (0.73% vs. 0.20%, p = 0.015), and all PE occurred in this cohort (0.47% vs. 0.00%, p = 0.005). All 30- and 90-day discharged VTE events occurred in those not receiving appropriate prophylaxis. Inpatient, 30- and 90-day discharged bleeding rates were 2.10%, 0.13%, and 0.33%, respectively. Although inpatient bleeding was significantly higher in those receiving appropriate prophylaxis, all 30- and 90-day post-discharge bleeding events occurred in patients not receiving appropriate prophylaxis. On regression analysis, Caprini score was significantly positively associated with likelihood of receiving appropriate inpatient prophylaxis (odds ratio [OR] 1.05, confidence interval [CI] 1.03-1.07) but was negatively associated in the discharge cohort (OR 0.43, CI 0.36-0.51). Receipt of appropriate prophylaxis was associated with reduced odds of inpatient VTE (OR 0.24, CI 0.06-0.69), but not with risk of bleeding.

CONCLUSION

Although Caprini VTE risk-stratified prophylaxis has a positive impact in reducing inpatient and post-discharge VTE, it must be balanced against the risk of inpatient postoperative bleeding.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:1169-1182, 2024.

Deep Vein Thrombosis Prophylaxis in Orthopedic Surgery

Deep vein thrombosis (DVT) is a complex and multifactorial process arising from a variety of factors, including recent surgical procedures, traumatic events, and periods of prolonged immobility. The extended period of stasis post-orthopedic surgery places patients at a notably high risk of developing DVT, and DVT-related pulmonary embolism (PE) ranks as the third most common cause of death in orthopedic surgery patients. This review examines the multifaceted risk factors contributing to the development of DVT in orthopedic patients. Additionally, it addresses the importance of DVT prophylaxis in orthopedic settings, the efficacy and safety of various prophylactic methods encompassing both mechanical and pharmacological approaches, and the economic dimensions of DVT prophylaxis, including scrutiny of cost-effectiveness and the exploration of strategies for optimization.

Incidence and preventive treatment for deep vein thrombosis with our own preventive protocol in total hip and knee arthroplasty

The aim of the present study was to investigate the perioperative and postoperative incidence of deep vein thrombosis (DVT) and validate the effectiveness of our own preventive treatment protocol for venous thromboembolism (VTE) occurrence in lower extremity arthroplasty patients. The subjects were 1,054 patients (mean age: 74.3 years) who underwent total hip arthroplasty (THA) or total knee arthroplasty (TKA) at our institutions between April 2014 and March 2017. We examined the frequencies of pre- and post-operative DVT by lower extremity Doppler images, and the incidence rate at proximal or distal regions as well as that according to preoperative DVT status were evaluated. Preoperative DVT was detected in 6.5% (69 cases) of our cohort and those were located 1.4% (15 cases) at proximal and 5.1% (54 cases) at distal regions. A significantly higher rate of postoperative DVT development was observed in preoperative DVT+ THA patients (P = 0.0075), but not in TKA patients only with a higher tendency (P = 0.56). The overall incidence of DVT up to 2 weeks after surgeries was 27.3% (288 cases); however, the rate in proximal femur regions was suppressed to 2.8% (30 cases), and there was no symptomatic pulmonary thromboembolism (PTE) case. The results demonstrated the importance of regular Doppler examination for early detection of postoperative DVT occurrence and the following immediate treatment initiation. Our own VTE preventive treatment protocol could reduce the development of proximal DVT, and the periodic monitoring as well as prompt treatment might prevent the fatal PTE. osteoarthritis (OA), rheumatoid arthritis (RA).

Comparison of efficacy and safety between aspirin and oral anticoagulants for venous thromboembolism prophylaxis after major orthopaedic surgery: a meta-analysis of randomized clinical trials

Background: venous thromboembolism (VTE) is one of the most common complications after major orthopaedic surgery. Recent studies have suggested that aspirin may also be effective in preventing VTE, but it is still controversial whether it can be routinely used. Objectives: To compare the efficacy and safety of aspirin against oral anticoagulants in the prevention of VTE following total hip arthroplasty (THA), total knee arthroplasty (TKA) or hip fracture surgery (HFS). Methods: Relevant publications have been obtained using electronic search databases such as PubMed, Embase, Web of Science, Cochrane Library, and Clinical Trials. gov. from inception to 20 July 2023. Only RCTs evaluating the efficacy and safety of aspirin compared with oral anticoagulants undergoing major orthopaedic surgery were included in the meta-analysis. The primary outcome reported was any VTE event (including deep vein thrombosis (DVT) and pulmonary embolism (PE)). Secondary outcomes included mortality, major bleeding (including gastrointestinal bleed, cerebrovascular hemorrhage, or any bleeding requiring a return to the theater), minor bleeding (ecchymosis, epistaxis, hematuria), and wound complications. The risk of bias for all included studies was assessed according to the Cochrane Collaboration's tool. Results: After screening 974 studies, 12 randomized clinical trials (RCTs) were included, involving 5,088 participants, including 2,540 participants in aspirin, 2,205 participants in rivaroxaban, and 323 participants in warfarin. Aspirin was found to be less effective than oral anticoagulants in thromboprophylaxis after major orthopedic surgery (RR = 1.206, 95% CI 1.053-1.383). After subgroup analysis according to the type of oral anticoagulant, the results showed that aspirin was similar to rivaroxaban and inferior to warfarin. Considering that the studies in the warfarin group were all conducted before 2000, our results need to be further confirmed. In addition, the aspirin group had a higher risk of VTE than the control group in other subgroups, including a follow-up time of ≤3 months, type of procedure as TKA, high-dose aspirin (≥650 mg qd), and no combined use of mechanical prophylaxis. In terms of safety events, aspirin did not show significant differences in major bleeding (RR = 0.952, 95% CI 0.499-1.815), all-cause mortality (RR = 1.208, 95% CI 0.459-3.177), and wound-related events (RR = 0.618, 95% CI 0.333-1.145) compared with oral anticoagulants, and aspirin was associated with a reduction in the risk of minor bleeding (RR = 0.685, 95% CI 0.552-0.850) events and total bleeding (RR = 0.726, 95% CI 0.590-0.892). Conclusion: Aspirin reduces bleeding risk after major orthopedic surgery compared with oral anticoagulants, but may sacrifice VTE prevention to some extent. Updated evidence is needed to analyze the thromboprophylaxis effects of aspirin in patients undergoing major orthopedic surgery. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=463481, identifier CRD42023463481.

Association Between Venous Thromboembolism Prophylaxis and the Incidence of Thromboembolism Following Orthopedic Procedures: A Cross-Sectional Study

INTRODUCTION

Venous thromboembolism (VTE) is a significant concern following orthopedic procedures, necessitating effective prophylactic measures. The rates of VTE prophylaxis, however, vary widely between institutions and nations, falling between 13% and 70% on average. In the absence of adequate thromboprophylaxis, pulmonary embolism, which accounts for 5% to 10% of mortality in hospitalized patients, is one of the leading causes of death. This study investigates the relationship between VTE prophylaxis and thromboembolism incidence, considering patient characteristics, risk assessment completion, anticoagulant prescription, and weight-bearing status.

OBJECTIVES

To evaluate the knowledge gap by examining the relationship between VTE prevention and the prevalence of thromboembolism also to examine the anticoagulant prescription trends for patients being discharged from orthopedic operations and to investigate the connection between post-procedure weight-bearing status and the development of VTE problems.

METHODOLOGY

A retrospective, cross-sectional design was employed, analyzing 200 orthopedic procedure patients from January to June of 2023 performed at Rehman Medical Institute. After getting ethical approval from the institutional ethical approval board, data were collected on the basis of variables encompassing patient attributes, surgery details, VTE risk factors, prophylaxis type, and VTE complications. Data was entered and analyzed via IBM SPSS Statistics for Windows, Version 22 (Released 2013; IBM Corp., Armonk, New York, United States), and the data were run through various tests including descriptive statistics, cross-tabulations, and chi-square. Results were then presented in the form of a table.

RESULTS

Among 200 individuals 24 individuals experienced VTE, while 176 did not. Significant gender-based VTE differences were observed (p = 0.01). Hypertension (HTN) showed a significant association (p = 0.04) with VTE. Major surgeries were correlated with higher VTE incidence (p = 0.03). Pharmacological prophylaxis reduced the occurrence of VTE (p = 0.01). Early mobilization and Ted stockings were correlated with lower VTE incidence (p = 0.04, p = 0.12).

CONCLUSION

This study reveals gender-specific VTE differences, emphasizes the role of HTN, surgical nature, and prophylaxis in VTE incidence, and supports tailored prophylactic strategies. Our findings align with previous research and emphasize the significance of tailored prophylaxis strategies. By examining multiple factors, including gender, co-morbidities, surgical characteristics, and prophylactic methods, our study contributes to the evidence base that supports clinical decision-making and enhances patient safety in orthopedic surgery.

Perioperative anticoagulation in head and neck free flap reconstructions: Experience of an anticoagulative scheme and its modification

OBJECTIVES

Microvascular anastomoses in microvascular reconstructions induce rheological changes in the anastomosed vessels and are usually counteracted by anticoagulative medication. There is no regimen commonly agreed on. This study provides an easy to use anticoagulative regimen.

PATIENTS AND METHODS

Consecutive cases of either anticoagulative regimen between 2013 and 2018 that underwent microvascular reconstruction in the head and neck area were included in this retrospective study, resulting in 400 cases in total. Two different anticoagulative regimens were applied to 200 patients in each group: (a) intraoperatively administered unfractionated 5000 I.U. high molecular weight heparin (HMWH) and postoperatively low molecular weight heparin (LMWH, Enoxaparin) 1 mg/kg/body weight postoperatively and (b) intraoperatively LMWH 0.5 mg/kg/body weight as well as 12 h later and 1 mg/kg/body weight postoperatively.

RESULTS

The LMWH cohort showed fewer overall thromboembolic (8.5% vs. 11%; p = .40) and peripheral thrombotic events (1% vs. 3.5%; p = .18) and lung embolisms (3% vs. 4%; p = .59). The number of thromboses at the site of the anastomosis was equally distributed. In regard to flap-specific complications, LMWH was associated with a positive effect, in particular with respect to total flap losses (5% vs. 7%; p = .40) and wound-healing disorders (14.5% vs. 20%; p = .145).

CONCLUSION

Findings indicate that intra- and postoperatively administered LMWH as the only anticoagulative medication seems reliable in our clinical routine of head and neck free flap reconstructions.

Anticoagulant therapy in orthopedic surgery - a review on anticoagulant agents, risk factors, monitoring, and current challenges

Orthopedic surgeries are associated with high-risk of thromboembolism which occurs in 40% to 60% of orthopedic patients in the absence of thromboprophylaxis. Conventionally heparin anticoagulants were used for thromboprophylaxis and currently direct oral anticoagulants (DOACs) are widely used due to their minimal complexity. Anticoagulant use carries bleeding risk and requires optimal laboratory monitoring through conventional thrombin-based assays, anti-Xa assay, anti-IIa assay and contemporary ecarin chromogenic assay (ECA) and rotational thromboelastometry. Monitoring requires multiple hospital visits and hence, the development of point-of-care assays is gaining momentum. Also, a thorough risk assessment model (RAM) is necessary for successful anticoagulant therapy since it enables personalized approach for better thromboprophylaxis outcomes. Despite welcoming changes, lack of guideline consensus, population-based thromboprophylaxis, deficiencies in risk stratification and non-adherence are still a concern. Stronger clinical and process support system with uniform guidelines approaches and patient-specific RAM can aid in the successful implementation of anticoagulant therapy.

Risk assessment scales to predict risk of lower extremity deep vein thrombosis among multiple trauma patients: a prospective cohort study

BACKGROUND

Deep vein thrombosis (DVT) is a common complication in orthopedic patients. Previous studies have focused on major orthopedic surgery.There are few studies with multiple trauma. We aimed to describe the prevalence of DVT and compare the predictive power of the different risk assessment scales in patients with multiple trauma.

METHODS

This prospective cohort study involved multiple trauma patients admitted to our hospital between October 2021 and December 2022. Data were prospectively collected for thrombotic risk assessments using the Risk Assessment Profile for thromboembolism(RAPT), the DVT risk assessment score (DRAS), and the Trauma Embolic Scoring System (TESS), respectively. The receiver operation characteristic (ROC) curve and the area under the curve (AUC) were evaluated to compare the predictive power. The whole leg duplex ultrasound of both lower extremities Doppler ultrasound was used to determine DVT incidence.

RESULTS

A total of 210 patients were included, and the incidence of DVT was 26.19%. Distal DVT accounted for 87.27%; postoperative DVT, 72.73%; and bilateral lower extremity thrombosis, 30.91%. There were significant differences in age, education degree, pelvic fracture, surgery, ISS, D-dimer level, length of hospital stay and ICU stay between the thrombosis group and the non-thrombosis group. The AUCs for RAPT, DRAS, and TESS were 0.737, 0.710, and 0.683, respectively. There were no significant differences between the three ROC curves.

CONCLUSIONS

The incidence of DVT was relatively high during hospitalization. We prospectively validated the tests to predict risk of DVT among patients with multiple trauma to help trauma surgeons in the clinical administration of DVT prophylaxis.

Incidence and Risk Factors for Postoperative Venous Thromboembolism After Gender Affirming Vaginoplasty: A Retrospective Analysis of a Large Insurance Claims Database

OBJECTIVES

To investigate the incidence and associated risk factors of venous thromboembolism (VTE) after gender affirming vaginoplasty.

METHODS

We searched International Business Machines Corporation (IBM) Marketscan, a commercial claims database, for Current Procedural Terminology and International Classification of Diseases (ICD) procedure codes to identify patients who underwent gender affirming vaginoplasty from 2011-2020. We quantified deep venous thrombosis and pulmonary embolism using ICD-9 and ICD-10 codes found within 90 days after surgery. Univariate and multivariate analyses were performed to establish association between VTE events and age, residency location, and comorbidities.

RESULTS

We identified 1588 patients who underwent gender affirming vaginoplasty. Overall, 1.1% of patients experienced a VTE within 90 days following surgery. Patients who experienced postoperative VTE were older, more likely to have had a prior VTE, less likely to be from an urban area, and more likely to have a higher Charlson Comorbidity Index score. Among patients with postoperative VTE, 47.1% had previous VTE. Among patients without a postoperative VTE, 1.3% had previous VTE.

CONCLUSION

In patients undergoing gender affirming vaginoplasty, the incidence of postoperative VTE was 1.1%. Older age, rurality, increased comorbidities, and prior VTE were associated with increased risk of postoperative VTE. Current guidelines do not recommend cessation of gender affirming hormone therapy (GAHT) prior to vaginoplasty. Further research is needed to evaluate if certain high-risk patients would benefit from perioperative adjustment of GAHT or perioperative VTE prophylaxis.

Interpretable machine learning models for predicting venous thromboembolism in the intensive care unit: an analysis based on data from 207 centers

BACKGROUND

Venous thromboembolism (VTE) is a severe complication in critically ill patients, often resulting in death and long-term disability and is one of the major contributors to the global burden of disease. This study aimed to construct an interpretable machine learning (ML) model for predicting VTE in critically ill patients based on clinical features and laboratory indicators.

METHODS

Data for this study were extracted from the eICU Collaborative Research Database (version 2.0). A stepwise logistic regression model was used to select the predictors that were eventually included in the model. The random forest, extreme gradient boosting (XGBoost) and support vector machine algorithms were used to construct the model using fivefold cross-validation. The area under curve (AUC), accuracy, no information rate, balanced accuracy, kappa, sensitivity, specificity, precision, and F1 score were used to assess the model's performance. In addition, the DALEX package was used to improve the interpretability of the final model.

RESULTS

This study ultimately included 109,044 patients, of which 1647 (1.5%) had VTE during ICU hospitalization. Among the three models, the Random Forest model (AUC: 0.9378; Accuracy: 0.9958; Kappa: 0.8371; Precision: 0.9095; F1 score: 0.8393; Sensitivity: 0.7791; Specificity: 0.9989) performed the best.

CONCLUSION

ML models can be a reliable tool for predicting VTE in critically ill patients. Among all the models we had constructed, the random forest model was the most effective model that helps the user identify patients at high risk of VTE early so that early intervention can be implemented to reduce the burden of VTE on the patients.

A prediction nomogram for deep venous thrombosis risk in patients undergoing primary total hip and knee arthroplasty: a retrospective study

INTRODUCTION

Deep venous thrombosis (DVT) prediction after total hip and knee arthroplasty remains challenging. Early diagnosis and treatment of DVT are crucial. This research aimed to develop a nomogram for early DVT prediction.

METHODS

A total of 317 patients undergoing primary total hip and knee arthroplasty in Sun Yat-sen Memorial Hospital were enrolled between May 2020 and September 2022. Data from May 2020 to February 2022 were used as the development datasets to build the nomogram model (n = 238). Using multivariate logistic regression, independent variables and a nomogram for predicting the occurrence of DVT were identified. Datasets used to validate the model for internal validation ranged from March 2022 to September 2022 (n = 79). The nomogram's capacity for prediction was also compared with the Caprini score.

RESULTS

For both the development and validation datasets, DVT was found in a total of 38 (15.97%) and 9 patients (11.39%) on post-operative day 7 (pod7), respectively. 59.6% patients were symptomatic DVT (leg swelling). The multivariate analysis revealed that surgical site (Knee vs. Hip), leg swelling and thrombin-antithrombin complex (TAT) were associated with DVT. The previously indicated variables were used to build the nomogram, and for the development and validation datasets, respectively. In development and validation datasets, the area under the receiver operating characteristic curve was 0.836 and 0.957, respectively. In both datasets, the predictive value of the Nomogram is greater than the Caprini score.

CONCLUSIONS

A proposed nomogram incorporating surgical site (Knee vs. Hip), leg swelling, and thrombin antithrombin complex (TAT) may facilitate the identification of patients who are more prone to develop DVT on pod7.

Predisposing Factors and Incidence of Venous Thromboembolism among Hospitalized Patients with Sickle Cell Disease

Though patients with sickle cell disease (SCD) are at risk of developing venous thromboembolism (VTE), clear estimates of its incidence and predisposing factors in hospitalized SCD patients are not available. Therefore, this issue was addressed to facilitate an early diagnosis and initiate appropriate prophylactic and treatment strategies. A retrospective observational study was conducted on patients with SCD who were admitted to an academic center in Saudi Arabia over a 10-year period. We identified 1054 admissions of 394 patients with SCD. Of the 3% of patients identified with VTE, 50% experienced pulmonary embolism (PE), 34.3% exhibited deep vein thrombosis (DVT), 6.3% exhibited cerebral vein thrombosis, and 9.4% showed other forms of VTE. In pregnant SCD patients, 6.4% developed a VTE event during their hospital admission. Of the risk factors, high white blood cell count, length of stay, and presence of any additional risk factor for VTE was associated significantly with higher risk of VTE. In our study, this risk seems to be much lower, which is likely attributed to the use of VTE prophylactic strategies implemented in our center. Nevertheless, further studies are needed to establish the ideal prophylactic strategy in patients with SCD.

Inhibition of Factor XI: A New Era in the Treatment of Venous Thromboembolism in Cancer Patients?

Direct oral anticoagulants against activated factor X and thrombin were the last milestone in thrombosis treatment. Step by step, they replaced antivitamin K and heparins in most of their therapeutic indications. As effective as the previous anticoagulant, the decreased but persistent risk of bleeding while using direct oral anticoagulants has created space for new therapeutics aiming to provide the same efficacy with better safety. On this basis, drug targeting factor XI emerged as an option. In particular, cancer patients might be one of the populations that will most benefit from this technical advance. In this review, after a brief presentation of the different factor IX inhibitors, we explore the potential benefit of this new treatment for cancer patients.

Rivaroxaban versus enoxaparin for thromboprophylaxis in orthopedic surgery: A meta-analysis

INTRODUCTION

Venous thromboembolism is highly associated with orthopedic surgery, so thromboprophylaxis is an important consideration for orthopedic surgeons. The new oral anticoagulants have clear advantages for clinical practice.

OBJECTIVES

To analyze the efficacy and safety of rivaroxaban versus enoxaparin for thromboprophylaxis in different orthopedic surgeries.

MATERIAL AND METHODS

Systematic electronic search of clinical trials was carried out. Data extraction of efficacy outcomes (deep venous thrombosis, pulmonary embolism and death) and safety outcomes (major bleeding and clinical relevant bleeding) was realized.

RESULTS

Six randomized and controlled clinical trials were included in this meta-analysis. Compared with enoxaparin the risk of venous thromboembolism was lower with rivaroxaban both in different orthopedic surgeries (RR: 0.51; 95% CI: 0.36-0.73; P=.0002). This result was even better and more homogeneous in the analysis of symptomatic deep venous thrombosis outcome (RR: 0.43; 95% CI: 0.28-0.65; P<.0001; I2=0%; P=.49). The risk of bleeding was not significantly higher with rivaroxaban (RR: 1.20; 95% CI: 0.97-1.49; P=.09).

CONCLUSIONS

Rivaroxaban should be considerate such as a more effective alternative for thromboprophylaxis in orthopedic surgery.

Factors associated with perioperative deep vein thrombosis in arthroscopic anterior cruciate ligament reconstruction

BACKGROUND

Anterior cruciate ligament reconstruction (ACLR) is reportedly associated with a higher incidence of deep vein thrombosis (DVT) incidence than other arthroscopic surgical procedures. The aim of this study is to retrospectively investigate the incidence and type of DVT and evaluate the relationship between DVT and risk factors among all patients who underwent ACLR under uniform conditions consisting of mechanical prophylaxis, no medical prophylaxis, and preoperative and postoperative lower extremity venous ultrasonography.

METHODS

Of the 114 patients who underwent arthroscopic primary ACLR at our hospital who did not have a compound ligament injury or revision surgery, 112 patients were included. Two patients were not examined. DVT evaluation consisted of whole-leg ultrasonography at 1 week after surgery. We evaluated age, sex, body mass index, comorbidities, operative time, tourniquet time, presence of concurrent surgery (meniscus repair/resection or osteochondral column grafting), and non-weight-bearing status at 1 week after surgery as risk factors for DVT.

RESULTS

DVT was found in 33 (29.5%) of 112 patients. Of these, 22 (19.6%) had distal DVT and 11 (9.8%) had proximal DVT. Non-weight-bearing status at 1 week after surgery was a statistically significant risk factor for proximal DVT (P = .034).

CONCLUSIONS

Non-weight-bearing status is an independent risk factor for DVT, suggesting that early weight bearing may reduce the occurrence of DVT.

Challenges Faced and Lessons Learned from Our Trial of VTE Prophylaxis

Challenges and Lessons from Our VTE Prophylaxis TrialIn this Clinical Trials Case Study, the authors describe the challenges faced and lessons learned conducting a trial of venous thromboembolism prophylaxis among hospitalized older adults.

Just What the Doctor Ordered: Missed Ordering of Venous Thromboembolism Chemoprophylaxis Is Associated With Increased VTE Events in High-risk General Surgery Patients

OBJECTIVE

To define the impact of missed ordering of venous thromboembolism (VTE) chemoprophylaxis in high-risk general surgery populations.

BACKGROUND

The primary cause of preventable death in surgical patients is VTE. Although guidelines and validated risk calculators assist in dosing recommendations, there remains considerable variability in ordering and adherence to recommended dosing.

METHODS

All adult inpatients who underwent a general surgery procedure between 2016 and 2019 and were entered into Atrium Health National Surgical Quality Improvement Program registry were identified. Patients at high risk for VTE (2010 Caprini score ≥5) and without bleeding history and/or acute renal failure were included. Primary outcome was 30-day postoperative VTE. Electronic medical record identified compliance with "perfect" VTE chemoprophylaxis orders (pVTE): no missed orders and no inadequate dose ordering. Multivariable analysis examined association between pVTE and 30-day VTE events.

RESULTS

A total of 19,578 patients were identified of which 4252 were high-risk inpatients. Hospital compliance of pVTE was present in 32.4%. pVTE was associated with shorter postoperative length of stay and lower perioperative red blood cell transfusions. There was 50% reduced odds of 30-day VTE event with pVTE (odds ratio: 0.50; 95% CI, 0.30-0.80) and 55% reduction in VTE event/mortality (odds ratio: 0.45; 95% CI, 0.31-0.63). After controlling for relevant covariates, pVTE remained significantly associated with decreased odds of VTE event and VTE event/mortality.

CONCLUSIONS

pVTE ordering in high-risk general surgery patients was associated with 42% reduction in odds of postoperative 30-day VTE. Comprehending factors contributing to missed or suboptimal ordering and development of quality improvement strategies to reduce them are critical to improving outcomes.

Do Prophylactic Inferior Vena Cava Filters Affect the Rates of Venous Thromboembolism and Pulmonary Embolism in Patients Undergoing Major Spine Surgery?

STUDY DESIGN

Retrospective Analysis.

BACKGROUND

Venous thromboembolism (VTE) represents a significant cause of morbidity and mortality in major spine surgery. Placement of prophylactic inferior vena cava filters (IVCF) in patients undergoing major spine surgery was previously adopted at our institution. This study reports our experience and compares VTE rates between patients with and without preoperative IVCF placement.

METHODS

A Retrospective comparative study was conducted on adult patients who underwent IVCF placement and those who did not prior to their spinal fusion procedure, between 2013 and 2016. Thoracolumbar fusions (anterior and/or posterior) of 7 or more levels, spinal osteotomies, and a minimum of a 3-month follow-up were included. Traumatic, oncologic, and cervical pathology were excluded. Primary outcomes measured included the incidence of overall VTE (DVT/PE), death, IVCF related complications, and IVCF retrieval.

RESULTS

386 patients who underwent major spine surgery, 258 met the eligibility criteria. Of those patients, 105 patients (40.7%) had prophylactic IVCF placement. All patients had postoperative SCDs and chemoprophylaxis. The presence of an IVCF was associated with an increased rate of overall VTE (14.3% vs 6.5%, P ≤ .05) and DVT episodes (8.6% vs 2.6%, P = .04). The rate of PE for the IVCF group and non-IVCF group was 8.6% and 4.6%, respectively, which was not statistically significant (P = .32). The all-cause mortality rate overall of 2.3% was statistically similar between both groups (P = 1.0). The IVCF group had higher rates of hematoma/seroma vs the non-IVCF group (12.4% vs 3.9%, P ≤ .05). 99 IVCFs were retrievable designs, and 85% were successfully retrieved. Overall IVCF-related complication rate was 11%.

CONCLUSIONS

No statistical difference in PE or mortality rates existed between the IVCF and the control group. Patients with IVCF placement experienced approximately twice the rate of VTE and three times the rate of DVT compared to those without IVCF. The IVCF-related complication rate was 11%. Based on the results of this study, the authors recommend against the routine use of prophylactic IVCFs in adults undergoing major spine surgery.

LEVEL OF EVIDENCE

III.

Venous Thromboembolism Prophylaxis in Major Orthopedic Surgeries and Factor XIa Inhibitors

Venous thromboembolism (VTE), comprising pulmonary embolism (PE) and deep vein thrombosis (DVT), poses a significant risk during and after hospitalization, particularly for surgical patients. Among various patient groups, those undergoing major orthopedic surgeries are considered to have a higher susceptibility to PE and DVT. Major lower-extremity orthopedic procedures carry a higher risk of symptomatic VTE compared to most other surgeries, with an estimated incidence of ~4%. The greatest risk period occurs within the first 7-14 days following surgery. Major bleeding is also more prevalent in these surgeries compared to others, with rates estimated between 2% and 4%. For patients undergoing major lower-extremity orthopedic surgery who have a low bleeding risk, it is recommended to use pharmacological thromboprophylaxis with or without mechanical devices. The choice of the initial agent depends on the specific surgery and patient comorbidities. First-line options include low-molecular-weight heparins (LMWHs), direct oral anticoagulants, and aspirin. Second-line options consist of unfractionated heparin (UFH), fondaparinux, and warfarin. For most patients undergoing knee or hip arthroplasty, the initial agents recommended for the early perioperative period are LMWHs (enoxaparin or dalteparin) or direct oral anticoagulants (rivaroxaban or apixaban). In the case of hip fracture surgery, LMWH is recommended as the preferred agent for the entire duration of prophylaxis. However, emerging factor XI(a) inhibitors, as revealed by a recent meta-analysis, have shown a substantial decrease in the occurrence of VTE and bleeding events among patients undergoing major orthopedic surgery. This discovery poses a challenge to the existing paradigm of anticoagulant therapy in this specific patient population and indicates that factor XI(a) inhibitors hold great promise as a potential strategy to be taken into serious consideration.

Deep vein thrombosis and validation of the Caprini risk assessment model in Chinese orthopaedic trauma patients: a multi-center retrospective cohort study enrolling 34,893 patients

BACKGROUND

The risk of venous thromboembolism among orthopaedic trauma patients is high, but prevalence of deep vein thrombosis (DVT) remains unknown. In addition, the Caprini risk assessment model (RAM) score in orthopaedic trauma patients is undetermined in previous research. This study is aimed to determine the incidence of DVT and then validate the Caprini RAM in orthopaedic trauma patients.

METHODS

This is a retrospective cohort study enrolling orthopaedic trauma inpatients from seven tertiary and secondary hospitals during a 3-year period (from April 1, 2018 through April 30, 2021). Caprini RAM scores were assessed by experienced nurses on admission. The patients with suspected DVT were verified through duplex ultrasonography by qualified radiologists, and then prospectively followed once a year after discharge.

RESULTS

In total, 34,893 patients were enrolled in our study. The Caprini RAM identified 45.7% of patients at low risk (Caprini score 0-2), 25.9% at medium risk (3-4), and 28.3% at high risk (5-6), highest risk (7-8), and superhigh risk (> 8). Patients with Caprini score > 5 were likely to be older, female, and with longer length of hospital stay. Moreover, 8695 patients had received ultrasonography to detect DVT. The prevalence of DVT was determined to be 19.0% [95% confidence interval (CI) 18.2-19.9%], which significantly increased with Caprini score. The area under curve of the Caprini RAM for DVT was 0.77 (95% CI 0.76-0.78) with a threshold of 4.5. Furthermore, 6108 patients who had received ultrasonography completed the follow-up. DVT patients had a hazard ratio of 1.75 (95% CI 1.11-2.76; P = 0.005) in the mortality, compared to non-DVT ones. Caprini scores were significantly associated with increase in the mortality [odds ratio (OR) 1.14; 95% CI 1.07-1.21; P < 0.001]; DVT remained an independent effect (OR 1.5; 95% CI 1.02-2.26; P = 0.042).

CONCLUSIONS

The Caprini RAM may be valid in Chinese orthopaedic trauma patients. Prevalence of DVT and higher Caprini score were significantly associated with increased all-cause mortality among orthopaedic trauma patients after discharge. Further study is warranted to explore the causes of higher mortality in patients with DVT.

Venous Thromboembolism (VTE) in Post-Prostatectomy Patients: Systematic Review and Meta-Analysis

Radical prostatectomy (RP) is one of the recommended treatments to achieve oncological outcomes in localized prostate cancer. However, a radical prostatectomy is a major abdominopelvic surgery. Venous thromboembolism (VTE) is a well-known complication associated with surgical procedures, including RP. There is a lack of consensus regarding VTE prophylaxis in urological procedures. The aim of this systematic review and meta-analysis was to investigate different aspects of VTE in post-radical prostatectomy patients. A comprehensive literature search was performed, and relevant data were extracted. The primary aim was to perform a systematic review and meta-analysis (wherever possible) of VTE occurrence in post-RP patients in relation to surgical approach, pelvic lymph node dissection, and type of prophylaxis (mechanical or combined prophylaxis). The secondary aim was to investigate the incidence and other risk factors of VTE in post-RP patients. A total of 16 studies were included for quantitative analysis. Statistical methods for analysis included the DerSimonian-Laird random effects. We were able to conclude that the overall incidence of VTE in post-radical prostatectomy is 1% (95% CI) and minimally invasive procedures (MIS), including laparoscopic, as well as robotic procedures for radical prostatectomy and RP without pelvic lymph node dissection (PLND), are associated with less risk of developing VTE. Additional pharmacological prophylaxis to mechanical methods may not be necessary in all cases and should be considered in high-risk patients only.

Significance of heparin induced thrombocytopenia (HIT) in COVID-19: a systematic review and meta-analysis

Heparin-induced thrombocytopenia (HIT) occurs in approximately 3% of patients receiving heparinoids. About 30-75% of patients with type 2 of HIT develop thrombosis as a result of platelet activation. The most important clinical symptom is thrombocytopenia. Patients with severe COVID-19 are among those receiving heparinoids. This meta-analysis performed to picture the current knowledge and results of published studies in this field. Three search engines were searched and 575 papers were found. After evaluation, 37 articles were finally selected of which 13 studies were quantitatively analyzed. The pooled frequency rate of suspected cases with HIT in 13 studies with 11,241 patients was 1.7%. The frequency of HIT was 8.2% in the extracorporeal membrane oxygenation subgroup with 268 patients and 0.8% in the hospitalization subgroup with 10,887 patients. The coincidence of these two conditions may increase the risk of thrombosis. Of the 37 patients with COVID-19 and confirmed HIT, 30 patients (81%) were treated in the intensive care unit or had severe COVID-19. The most commonly used anticoagulants were UFH in 22 cases (59.4%). The median platelet count before treatment was 237 (176-290) x 10³/µl and the median nadir platelet count was 52 (31-90.5) x 10³/µl.

Thirty day low-dose versus regular-dose aspirin for venous thromboembolism prophylaxis in primary total joint arthroplasty

BACKGROUND

The optimal dosing of aspirin (ASA) monotherapy for prophylaxis after total joint arthroplasty is debatable. The objective of this study was to compare two ASA regimens with regards to symptomatic deep venous thrombosis (DVT), pulmonary embolism (PE), bleeding, and infection 90 days after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA).

METHODS

We retrospectively identified 625 primary THA and TKA surgeries in 483 patients who received ASA for 4 weeks post-op. 301 patients received 325 mg once daily (QD) and 324 patients received 81 mg twice daily (BID). Patients were excluded if they were minors, had a prior venous thromboembolism (VTE), had ASA allergy, or received other VTE prophylaxis drugs.

RESULTS

There was a significant difference in rate of bleeding and suture reactions between the two groups. Bleeding was 7.6% for 325 mg QD and 2.5% for 81 mg BID (p = .0029 Χ2, p = .004 on multivariate logistic regression analysis). Suture reactions were 3.3% for 325 mg QD and 1.2% for 81 mg BID (p = .010 Χ2, p = .027 on multivariate logistic regression analysis). Rates of VTE, symptomatic DVT, and PE were not significantly different. The incidence of VTE was 2.7% for 325 mg QD and 1.5% for 81 mg BID (p = .4056). Symptomatic DVT rates were 1.6% for 325 mg QD and 0.9% for 81 mg BID (p = .4139). Deep infection was 1.0% for 325 mg QD and 0.31% for 81 mg BID (p = .3564).

CONCLUSION

Low-dose ASA in patients with limited comorbidities undergoing primary THA and TKA is associated with significant lower rates of bleeding and suture reactions than high dose ASA. Low-dose ASA was not inferior to higher dose ASA for the prevention of VTE, wound complications, and infection 90 days postoperatively.

Implementation science approaches to optimizing venous thromboembolism prevention in patients with traumatic injuries: Findings from the 2022 Consensus Conference to Implement Optimal Venous Thromboembolism Prophylaxis in Trauma

ABSTRACT

Disease burden of venous thromboembolism (VTE) without pharmacologic prophylaxis is high in trauma patients. Although VTE prophylaxis guidelines exist, studies on real-world use of VTE prophylaxis in trauma shows limited uptake of guideline recommendations. Despite existing guidelines, reports indicate that VTE prophylaxis implementation across trauma centers is lagging. Implementation barriers of VTE prophylaxis in trauma are multifactorial, and VTE prescribing practices require further optimization. Implementation science methods can help standardize and improve care; well-established approaches in medical and surgical hospitalized patients and their effects on clinical outcomes such as VTE and bleeding complications must be investigated because they apply to trauma patients. Nonadministration of VTE prophylaxis medications in hospitalized patients is associated with VTE events and remains a barrier to providing optimal defect-free care. Further investigations are required for VTE prophylaxis implementation across all trauma populations.