Efficacy of intermittent pneumatic compression for venous thromboembolism prophylaxis in patients undergoing gynecologic surgery: A systematic review and meta-analysis

Efficacy of intermittent pneumatic compression on breast cancer-related upper limb lymphedema: a systematic review and meta-analysis in clinical studies

Background

Complete decongestive therapy (CDT) and intermittent pneumatic compression (IPC) are the most common combination of treatments in breast cancer-related upper limb lymphedema. The effects of IPC as an addition to CDT are inconsistent in different studies. This meta-analysis aimed to explore whether IPC could bring additional benefits to CDT.

Methods

Literatures were retrieved from databases with full-text publications ranging from January 1995 to March 2024. Fixed-effect models were applied to subsequent analysis if no heterogeneity was detected by using the Inverse formula. Publication bias was assessed using the Begg's test and Eagger's test.

Results

Twelve studies were finally included for further analysis. Results showed that additional application of IPC to CDT could further improve lymphedema within 4 weeks after the treatment period [standard mean difference (SMD) =-0.2 mL, 95% confidence interval (CI): -0.33 to -0.07 mL]. However, this additional benefit was weakened within about 9.4±2.6 weeks' follow-up duration after ceasing physical therapy (SMD =-0.15 mL, 95% CI: -0.33 to 0.04 mL).

Conclusions

Periodically continuous treatment should be suggested to maintain the effect of CDT + IPC to promote lymph drainage and lymphedema improvement. Nonetheless, the treatment involved in the studies ranged from 4 to 12 weeks, therefore potential bias might exist.

Effects of intermittent pneumatic compression devices interventions to prevent deep vein thrombosis in surgical patients: A systematic review and meta-analysis of randomized controlled trials

This review aimed to determine the effectiveness of Intermittent Pneumatic Compression (IPC) intervention on Deep Vein Thrombosis (DVT) in surgical patients. An electronic database search was conducted with PubMed, OVID-MEDLINE, EMBASE, and CENTRAL, from September 22 to 28, 2023. Three researchers independently selected the studies, assessed their methodological quality, and extracted relevant data. We conducted a meta-analysis of the effect of IPC versus the control group and summarized the intervention results from the included studies. Of the 2,696 articles identified 16 randomized control trials met the inclusion criteria for review. IPC interventions significantly affected DVT prevention (OR = 0.81, 95% CI: 0.59-1.11). In the subgroup analysis, there was a significant pooled effect (OR = 0.41, 95% CI: 0.26-0.65]), when the comparison group was no prophylaxis group. However, when the comparison groups were the pharmacologic prophylaxis group ([OR = 1.32, 95% CI 0.78-2.21]) and IPC combined with the pharmacologic prophylaxis group (OR = 2.43, 95% CI: 0.99-5.96) did not affect DVT prevention. The pooled effects of Pulmonary Embolism (PE) (OR = 5.81, 95% CI: 1.25-26.91) were significant. IPC intervention showed a significant effect on bleeding prevention (OR = 0.17, 95% CI: 0.08-0.36) when compared to IPC combined with the pharmacologic groups. IPC intervention effectively prevented DVT, PE, and bleeding in surgical patients. Therefore, we propose that IPC intervention be applied to surgical patients to avoid DVT, pulmonary embolism, and bleeding in the surgical nursing field as scientific evidence suggests.

Venous Thromboembolism Prophylaxis in Gynecologic Oncology: A MITO-MaNGO Survey

Cancer-associated thrombosis is the second leading cause of death in cancer patients, and its incidence has been increasing in recent years. This survey was aimed at gathering information regarding the management of thromboembolic prophylaxis within the MITO (Multicenter Italian Trials in Ovarian Cancer)-MaNGO (Mario Negri Gynecologic Oncology) groups. We designed a self-administered, multiple-choice online questionnaire available only for MITO-MaNGO members for one month, starting in May 2022 and ending in June 2022. We processed one response form per center, and 50 responses were analyzed, with most of the respondents (78%) over 40 years old. We found that 82% of them consider thromboembolic prophylaxis in gynecologic oncology to be relevant. In 82% of the centers, a standardized protocol on venous thromboembolism (VTE) prophylaxis is used, which is applied to both patients undergoing surgery and those undergoing chemotherapy. In the remaining 18% of centers, prophylaxis is used exclusively for patients undergoing chemotherapy treatment. Prophylaxis of patients undergoing surgery and chemotherapy treatment is managed in most cases by the surgeon (72%) and oncologist (76%), respectively. Only 26% of respondents use a thromboembolic risk assessment scale, and of these, those used are the Caprini Score (6%), Khorana Score (6%), and Wells Score (2%). The respondents have good knowledge of low-molecular-weight heparin (90%) and average knowledge of dicumarolics (40%), direct oral anticoagulants (DOACs) (68%), and antiplatelet agents (40%). The results of our survey indicate that there is a good awareness of thromboembolic prophylaxis in gynecologic oncology. Nevertheless, it is used less in outpatients than in patients undergoing surgery. Moreover, the thromboembolic risk assessment scores are barely used.

Should intermittent pneumatic compression devices be standard therapy for the prevention of venous thromboembolic events in major surgery? Protocol for a randomised clinical trial (IMPOSTERS)

INTRODUCTION

Venous thromboembolism (VTE) is a recognised postsurgical risk. Current prevention methods involve low molecular weight heparin (LMWH), graduated compression stockings (GCS), and intermittent pneumatic compression devices (IPCDs). Australian guidelines, commonly adopted by surgeons, recommend LMWH with GCS and/or IPCDs. IPCDs pose clinical risks, increase care burden, are poorly tolerated, and are costly single-use plastic items. Utilising only LMWH and GCS, without IPCDs, could be more practical, patient-friendly, and cost-effective, with added environmental benefits.

METHODS

This is a multicentre, prospective, two-arm randomised controlled non-inferiority trial at five New South Wales (NSW) hospitals, in Australia. We propose to randomise 4130 participants in a 1:1 ratio between arm A: LMWH+GCS+IPCDs (n=2065) or arm B: LMWH+GCS (n=2065). The primary outcome of interest is symptomatic VTE (deep vein thrombosis/pulmonary embolism) identified at the day 30 phone follow-up (FU), confirmed by ultrasound or imaging. Radiologists interpreting the lower-extremity ultrasonography will be blinded to intervention allocation. Secondary outcomes are quality of life at baseline, days 30 and 90 FU using the 5-level European Quality of Life Score, compliance and adverse events with IPCDs, GCS, and LMWH, as well as healthcare costs (from the perspective of the patient and the hospital), and all-cause mortality. The trial has 90% power to detect a 2% non-inferiority margin to detect a reduction rate of VTE from 4% to 2%.

ETHICS AND DISSEMINATION

This study has been approved by the Hunter New England Human Research Ethics Committee (2022/ETH02276) protocol V.10, 13 July 2023. Study findings will be presented at local and national conferences and in scientific research journals.

TRIAL REGISTRATION NUMBER

ANZCTR12622001527752.

Placenta Accreta Spectrum Part II: hemostatic considerations based on an extended review of the literature

"Placenta accreta spectrum" (PAS) is a rare but serious pregnancy condition where the placenta abnormally adheres to the uterine wall and fails to spontaneously release after delivery. When it occurs, PAS is associated with high maternal morbidity and mortality-as PAS management can be particularly challenging. This two-part review summarizes current evidence in PAS management, identifies its most challenging aspects, and offers evidence-based recommendations to improve management strategies and PAS outcomes. The first part of this two-part review highlighted the general anesthetic approach, surgical and interventional management strategies, specialized "centers of excellence," and multidisciplinary PAS treatment teams. The high rates of PAS morbidity and mortality are often provoked by PAS-associated coagulopathies and peripartal hemorrhage (PPH). Anesthesiologists need to be prepared for massive blood loss, transfusion, and to manage potential coagulopathies. In this second part of this two-part review, we specifically reviewed the current literature pertaining to hemostatic changes, blood loss, transfusion management, and postpartum venous thromboembolism prophylaxis in PAS patients. Taken together, the two parts of this review provide a comprehensive survey of challenging aspects in PAS management for anesthesiologists.

Pilot Study of Effects of Intermittent Pneumatic Compression in the Immediate Peri-Operative Period on Hemodynamic Parameters in Patients After Laparoscopic Gynecologic Surgery

The randomized controlled study investigated the impacts of immediate peri-operative Intermittent pneumatic compression (IPC) on hemodynamic indicators in patients undergoing laparoscopic gynecologic surgery. Patients scheduled for elective laparoscopic gynecologic surgery were randomized to control (IPC not used), pre-operative IPC, post-operative IPC, and peri-operative IPC (performed both before and after surgery) groups. Systolic blood pressure (SBP), mean blood pressure (MBP) cardiac output (CO), heart rate (HR) and systemic vascular resistance (SVR) were measured at different time points. The results showed that SBP changes not obviously over time in the control and peri-operative IPC group. Compared with values before surgery, the pre-operative IPC group had a lower SBP (P < 0.01) at the end of PACU stay, whereas the post-operative IPC group had a higher SBP (P < 0.01) after surgery. All groups exhibited little or no variation in HR, CO and SVR. Conclusion is peri-operative IPC has no major adverse effects on hemodynamic parameters.

A Systematic Review of the Guidelines on Venous Thromboembolism Prophylaxis in Gynecologic Oncology

(1) Background: This review aimed to summarize the indications for venous thromboembolic (VTE) events' prophylaxis in a gynecological cancer population, according to the most recent guidelines. (2) Methods: A systematic review of the guidelines in PubMed, SCOPUS, Web of Science, EMBASE, and CINHAL regarding VTE prevention in gynecological cancer patients was conducted according to PRISMA criteria. We compared the recommendations given by oncological and hematological societies regarding VTE prevention in gynecological cancer patients published from January 2010 through March 2021. We searched for the following keywords: "venous thromboembolism prevention", "cancer", and "guidelines". The AGREE II checklist was used to critically analyze the guidelines' quality. (3) Results: There were 1003 documents available; 14 met the inclusion criteria, 5 were excluded and, eventually, the guidelines of 10 societies were evaluated. (4) Conclusions: The guidelines agree that low-molecular-weight heparin (LMWH) and fondaparinux achieve better results in VTE prevention in gynecological cancer patients. Direct oral anticoagulants (DOACs) can be used to prevent VTE in outpatients and high-risk medical patients after discharge. VTE risk scores should be applied to all oncological patients to identify those who would benefit from a prevention program. More attention should be paid to mechanical prophylactic methods due to the high bleeding risk of gynecological cancer patients.

Guideline No. 417: Prevention of Venous Thromboembolic Disease in Gynaecological Surgery

OBJECTIVE

The primary objective of this clinical practice guideline is to provide gynaecologists with an algorithm and evidence to guide the use of thromboprophylaxis in gynaecological surgery.

TARGET POPULATION

All patients undergoing gynaecological surgery for benign or malignant indications.

BENEFITS, HARMS, AND COSTS

The implementation of this guideline will benefit patients undergoing gynaecological surgery and provide physicians with a standard algorithm for the use of perioperative thromboprophylaxis.

EVIDENCE

The following search terms were entered into MEDLINE, Google Scholar, and Cochrane in 2017 and 2018: VTE, PE, DVT, thromboprophylaxis, gynaecological surgery, heparin, graduated compression stocking, intermittent pneumatic stocking, obesity, pediatrics, minimally invasive surgery, heparin induced thrombocytopenia, regional anesthesia). Articles included were randomized controlled trials, meta-analyses, systematic reviews, and observational studies. Additional publications were identified from the reference lists of these articles. There were no date limits, but search results were limited to English language articles only. Searches were updated and incorporated into the guideline up to September 2018.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

INTENDED USERS

Gynaecologists and other members of the surgical team. RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

Intermittent pneumatic compression (IPC) combined with an electric stimulator in the prevention of venous thromboembolism in stroke patients

OBJECTIVE

To explore the clinical value of intermittent pneumatic compression (IPC) combined with an electric stimulator in the prevention of venous thromboembolism in stroke patients.

METHODS

58 stroke patients with hemiplegia admitted to the Department of Neurology in our hospital were recruited as the study cohort and randomly placed into a control group or an observation group, with 29 patients in each group. The control group was administered routine care and IPC, and the observation group was administered electric stimulation in addition to the treatment administered to the control group. We conducted a comparison and an analysis of the occurrences of thrombosis, the blood rheology indexes, the femoral vein flow rates, and the nursing satisfaction levels in the two groups. The circumferences of the hemiplegia patients' lower extremities were measured and recorded, and the circumferences of the healthy sides and the affected limbs were compared.

RESULTS

On the 7th day after the intervention, the observation group had a higher incidence of deep vein thrombosis (DVT) than the control group (6.90% vs. 31.03%, P<0.05). The hemorheology indexes were lower after the treatment, and the hemorheology indexes in the observation group were higher compared with the control group (P<0.05). The observation group had a higher femoral vein flow velocity than the control group (P<0.05). On the 7th and 14th days after the intervention, the peak flow and average flow velocities in the observation group exceeded those of the control group (P<0.05). The nursing satisfaction rate in the observation group was higher than it was in the control group (96.55% vs. 82.76%, P<0.05). After 7 and 14 days of treatment, smaller changes in the hemiplegic limbs of the observation group were observed, compared to the control group (P<0.05).

CONCLUSION

IPC combined with an electrical stimulator can enhance the patients' blood hypercoagulability, effectively prevent the occurrence of DVT, and improve the nursing satisfaction levels.

Prevention of Venous Thromboembolism in Gynecologic Surgery: ACOG Practice Bulletin, Number 232

Deep vein thrombosis (DVT) and pulmonary embolism (PE) are collectively referred to as "venous thromboembolic events" (VTE). Despite advances in prophylaxis, diagnosis, and treatment, VTE remains a leading cause of cost, disability, and death in postoperative and hospitalized patients (1, 2). Beyond the acute sequelae of leg pain, edema, and respiratory distress, VTE may result in chronic conditions, including postthrombotic syndrome (3), venous insufficiency, and pulmonary hypertension. This Practice Bulletin has been revised to reflect updated literature on the prevention of VTE in patients undergoing gynecologic surgery and the current surgical thromboprophylaxis guidelines from the American College of Chest Physicians (4). Discussion of gynecologic surgery and chronic antithrombotic therapy is beyond the scope of this document.

A quality improvement initiative to reduce venous thromboembolism on a gynecologic oncology service

OBJECTIVE

To describe and evaluate the effects of implementation of a venous thromboembolism (VTE) prophylaxis quality improvement (QI) initiative on a gynecologic oncology service at a single institution.

METHODS

Prior to 2018, no consensus gynecologic oncology VTE prophylaxis protocol existed at the authors' academic institution. Published, evidence-based guidelines were reviewed to create a standardized VTE risk stratification algorithm. Interventions to improve perioperative heparin administration and sequential compression device (SCD) compliance as well as provider/patient education efforts were introduced in January 2018. Initial efforts included nursing and patient SCD education, internal dissemination of VTE prophylaxis guidelines, and creation of a VTE 'dashboard' to track performance. During a second phase, VTE prophylaxis guidelines were reviewed and further refined, non-compliant operative cases reviewed weekly, and guidelines incorporated into the electronic medical record. Performance was measured using Tableau data software (www.tableau.com) and by separately evaluating adherence to the developed guidelines in three retrospective cancer-enriched surgical cohorts (2016-2017, 2018, 2019).

RESULTS

Compared to the baseline period, we observed a reduction in VTE rate during the 2018-2019 VTE QI implementation period from 2.1% (19/905) to 1.0% (20/2015, p = 0.02) among gynecologic oncology inpatients. In the retrospective cancer-enriched cohorts, adherence to evidence based guidelines improved: 31.0% in 2016-2017, 69.1% in 2018, and 82.4% in 2019 (p < 0.001). There were no significant differences in rates of peri-operative blood transfusion, surgical site infections, hematomas, or vaginal cuff dehiscences.

CONCLUSIONS

Implementation of a robust VTE prophylaxis QI initiative has resulted in improved VTE prophylaxis guideline adherence and higher rates of pre-operative heparin administration.

Consensus on thromboprophylaxis in gynecological surgery

Objective: To draw a synthesis of the available evidence regarding interventions for the prevention of venous thromboembolic events during the perioperative care of women with benign gynecological pathology, with the aim of reducing the associated morbidity and mortality. Materials and methods: The development group included healthcare professionals, decision-makers and one patient representative. All the participants stated their disclosures. Answerable clinical questions were built and outcomes were graded. The search for information was conducted in Medline, Embase, Epistemonikos and LILACS, but it also included grey literature and was updated on September 22, 2020, with no date or language restrictions. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach was used to determine the quality of the evidence and the strength of the recommendations. Formal consensus was developed in accordance with the RAND/UCLA methodology. The document was submitted to peer review before publication. Results: The abbreviated version of the “consensus on the prevention of venous thromboembolic events during the perioperative care of women with benign gynecological pathology” is presented together with the supporting evidence and respective recommendations. Conclusions: The key recommendations for implementation include the use of the Caprini scale and of interventions consistent with the individual perioperative risk level.

American Society of Hematology 2021 guidelines for management of venous thromboembolism: prevention and treatment in patients with cancer

BACKGROUND

Venous thromboembolism (VTE) is a common complication among patients with cancer. Patients with cancer and VTE are at a markedly increased risk for morbidity and mortality.

OBJECTIVE

These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about the prevention and treatment of VTE in patients with cancer.

METHODS

ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The guideline development process was supported by updated or new systematic evidence reviews. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess evidence and make recommendations.

RESULTS

Recommendations address mechanical and pharmacological prophylaxis in hospitalized medical patients with cancer, those undergoing a surgical procedure, and ambulatory patients receiving cancer chemotherapy. The recommendations also address the use of anticoagulation for the initial, short-term, and long-term treatment of VTE in patients with cancer.

CONCLUSIONS

Strong recommendations include not using thromboprophylaxis in ambulatory patients receiving cancer chemotherapy at low risk of VTE and to use low-molecular-weight heparin (LMWH) for initial treatment of VTE in patients with cancer. Conditional recommendations include using thromboprophylaxis in hospitalized medical patients with cancer, LMWH or fondaparinux for surgical patients with cancer, LMWH or direct oral anticoagulants (DOAC) in ambulatory patients with cancer receiving systemic therapy at high risk of VTE and LMWH or DOAC for initial treatment of VTE, DOAC for the short-term treatment of VTE, and LMWH or DOAC for the long-term treatment of VTE in patients with cancer.

Association Between Preoperative Blood Transfusion and Postoperative Venous Thromboembolism: Review Meta-Analysis

BACKGROUND

Several studies have shown that preoperative blood transfusion is associated with postoperative venous thromboembolism (VTE). In this study, a meta-analysis was performed to explore the relationship between preoperative blood transfusion and postoperative VTE.

METHODS

Published articles were identified through a comprehensive review of PubMed and EMBASE. Data from studies reporting relative risks, odds ratios, or hazard ratios comparing the risk of postoperative VTE among participants who had preoperative blood transfusion versus those without preoperative blood transfusion were analyzed. A random-effect model was used to calculate pooled odds ratios and 95% confident intervals (CIs).

RESULTS

Eight studies, which included 3,504,778 participants, aligned with our inclusion criteria and were included in the meta-analysis. Pooled analysis showed an association between preoperative blood transfusion and postoperative VTE, with an odds ratio of 2.95 (95% CI: 1.65-5.30; I² = 89.1%). In subgroup analyses, the positive association between preoperative blood transfusion and postoperative VTE was still exist in studies with confounders adjustment. Sensitivity analysis by one-study-removed analysis confirmed the robustness of our results.

CONCLUSIONS

Our study indicated that preoperative blood transfusion was associated with higher odds of postoperative VTE. Further large-scale prospective cohort studies are needed to investigate the causality between preoperative blood transfusion and postoperative VTE.

Dual mechanical and pharmacological thromboprophylaxis decreases risk of pulmonary embolus after laparotomy for gynecologic malignancies

OBJECTIVES

Patients with gynecologic malignancies have high rates of post-operative venous thromboembolism. Currently, there is no consensus for peri-operative thromboprophylaxis specific to gynecologic oncology. We aimed to compare rates of symptomatic pulmonary embolus within 30 days post-operatively, and to identify risk factors for pulmonary embolus.

METHODS

The Division of Gynecologic Oncology at Sunnybrook Health Sciences Centre implemented dual thromboprophylaxis for laparotomies in December 2017. We conducted a prospective study of laparotomies for gynecologic malignancies from December 2017 to October 2018, with comparison to historical cohort from January 2016 to November 2017 using the institutional National Surgical Quality Improvement Program database (NSQIP). Pre-intervention, patients received low molecular weight heparin during admission and extended 28-day prophylaxis was continued at the surgeon's discretion. Post-intervention, all patients received both mechanical thromboprophylaxis with sequential compression devices during admission and 28-day prophylaxis with low molecular weight heparin.

RESULTS

There were 371 and 163 laparotomies pre- and post-intervention, respectively. Patient characteristics (age, body mass index, diabetes, smoking, tumor stage), rate of malignant cases, operative blood loss and duration, and length of stay were similar between groups. After implementation, pulmonary emboli rates decreased from 5.1% to 0% (p=0.001). There were more cytoreductive procedures pre-intervention (p≤0.0001) but surgical complexity scores were similar (p=0.82). Univariate analysis revealed that surgery pre-intervention (OR 4.25, 95% CI 1.04 to 17.43, p=0.04), length of stay ≥5 days (OR 11.94, 95% CI 2.65 to 53.92, p=0.002), and operative blood loss ≥500 mL (OR 2.85, 95% CI 1.05 to 7.8, p=0.04) increased risk of pulmonary embolus. On multivariable analysis, surgery pre-intervention remained associated with more pulmonary emboli (OR 4.16, 95% CI 1.03 to 16.79, p=0.045), when adjusting for operative blood loss.

CONCLUSION

Dual thromboprophylaxis after laparotomy significantly reduced rates of pulmonary embolus in this high-risk patient population.

American Society of Hematology 2019 guidelines for management of venous thromboembolism: prevention of venous thromboembolism in surgical hospitalized patients

BACKGROUND

Venous thromboembolism (VTE) is a common source of perioperative morbidity and mortality.

OBJECTIVE

These evidence-based guidelines from the American Society of Hematology (ASH) intend to support decision making about preventing VTE in patients undergoing surgery.

METHODS

ASH formed a multidisciplinary guideline panel balanced to minimize bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline-development process, including performing systematic reviews. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment.

RESULTS

The panel agreed on 30 recommendations, including for major surgery in general (n = 8), orthopedic surgery (n = 7), major general surgery (n = 3), major neurosurgical procedures (n = 2), urological surgery (n = 4), cardiac surgery and major vascular surgery (n = 2), major trauma (n = 2), and major gynecological surgery (n = 2).

CONCLUSIONS

For patients undergoing major surgery in general, the panel made conditional recommendations for mechanical prophylaxis over no prophylaxis, for pneumatic compression prophylaxis over graduated compression stockings, and against inferior vena cava filters. In patients undergoing total hip or total knee arthroplasty, conditional recommendations included using either aspirin or anticoagulants, as well as for a direct oral anticoagulant over low-molecular-weight heparin (LMWH). For major general surgery, the panel suggested pharmacological prophylaxis over no prophylaxis, using LMWH or unfractionated heparin. For major neurosurgery, transurethral resection of the prostate, or radical prostatectomy, the panel suggested against pharmacological prophylaxis. For major trauma surgery or major gynecological surgery, the panel suggested pharmacological prophylaxis over no prophylaxis.

Optimizing Preanesthesia Care for the Gynecologic Patient

In the past, best practices for perioperative management have been based as much on dogma as science. The creation of optimized perioperative pathways, known as enhanced recovery after surgery, has been shown to simultaneously improve patient outcomes and reduce cost. In this article, we critically review interventions (and omission of interventions) that should be considered by every surgical team to optimize preanesthesia care. This includes patient education, properly managing existing medical comorbidities, optimizing nutrition, and the use of medications before incision that have been shown to reduce surgical stress, opioid requirements, and postoperative complications. Anesthetic techniques, the use of adjunct medications administered after incision, and postoperative management are beyond the scope of this review. When possible, we have relied on randomized trials, meta-analyses, and systematic reviews to support our recommendations. In some instances, we have drawn from the general and colorectal surgery literature if evidence in gynecologic surgery is limited or of poor quality. In particular, hospital systems should aim to adhere to antibiotic and thromboembolic prophylaxis for 100% of patients, the mantra, "nil by mouth after midnight" should be abandoned in favor of adopting a preoperative diet that maintains euvolemia and energy stores to optimize healing, and bowel preparation should be abandoned for patients undergoing gynecologic surgery for benign indications and minimally invasive gynecologic surgery.

Sequential compression device compliance in pregnant women requiring antepartum admission

BACKGROUND

A quality improvement study done at the Medical College of Wisconsin between 2014 and 2016 demonstrated that, at baseline, sequential compression devices (SCD) were ordered for 46.0% of admitted antepartum women. In response, provider education and a prechecked SCD order in the electronic antepartum admission order set were implemented.

OBJECTIVE

To examine the effect of these interventions on SCD compliance during antepartum admissions.

STUDY DESIGN

This was a prospective observational study of antepartum women admitted for nondelivery indication for more than 24 hours, from June 2017 through March 2018, in a single tertiary center. The study was conducted a year after provider education and implementation of a prechecked order for SCD in the electronic antepartum admission order set. Women with an active venous thromboembolism (VTE) and those already receiving pharmacologic thromboprophylaxis were excluded. The primary outcome was the rate of SCD compliance, assessed both among obstetric providers and patients. SCD compliance for providers was defined as SCD order present in patient's electronic medical record and documenting the presence of SCD in patient's room. SCD compliance for patients was defined as documentation that the patient was wearing SCD that were turn on while in bed during morning study rounds.

RESULTS

During the study period a total of 182 rounding encounters were documented for 76 women. SCD was ordered in 77.6% (59/76) of the admissions. Out of the 59 electronic orders for SCD, 45 orders (h 76.3%) were placed on hospital day 1 (and 42 orders had confirmation of SCD present in the room (71.2%)). SCD were in active use in 45.2% (19/42) of these women. When evaluating the daily course of the hospitalization (n = 182), SCD were ordered in 86.8% (158/182) of the encounters and present in the room in 72.2% (114/158) of the daily encounters. After excluding 10 women who were ambulatory at the time of rounding (n = 104), SCD were observed being used in 31.7% (33/104) of the nonambulatory women encounters with SCD ordered and present in the room.

CONCLUSION

A prechecked antepartum order set for SCD increased the rate of provider compliance with SCD. However, this increase did not result in high patient compliance with SCD among antepartum women requiring admission for longer than 24 hours.

CONDENSATION

A prechecked order for SCD did not lead to high SCD compliance among admitted antepartum women.

Surgical technical evidence review for gynecologic surgery conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery

BACKGROUND

The Agency for Healthcare Research and Quality, in partnership with the American College of Surgeons and the Armstrong Institute at Johns Hopkins, developed the Safety Program for Improving Surgical Care and Recovery, which integrates principles of implementation science into adoption of enhanced recovery pathways and promotes evidence-based perioperative care.

OBJECTIVE

The objective of this study is to review the enhanced recovery pathways literature in gynecologic surgery and provide the framework for an Improving Surgical Care and Recovery pathway for gynecologic surgery.

STUDY DESIGN

We searched PubMed and Cochrane Central Register of Controlled Trials databases from 1990 through October 2017. Studies were included in hierarchical and chronological order: meta-analyses, systematic reviews, randomized controlled trials, and interventional and observational studies. Enhanced recovery pathways components relevant to gynecologic surgery were identified through review of existing pathways. A PubMed search for each component was performed in gynecologic surgery and expanded to include colorectal surgery as needed to have sufficient evidence to support or deter a process. This review focuses on surgical components; anesthesiology components are reported separately in a companion article in the anesthesiology literature.

RESULTS

Fifteen surgical components were identified: patient education, bowel preparation, elimination of nasogastric tubes, minimization of surgical drains, early postoperative mobilization, early postoperative feeding, early intravenous fluid discontinuation, early removal of urinary catheters, use of laxatives, chewing gum, peripheral mu antagonists, surgical site infection reduction bundle, glucose management, and preoperative and postoperative venous thromboembolism prophylaxis. In addition, 14 components previously identified in the colorectal Improving Surgical Care and Recovery pathway review were included in the final pathway.

CONCLUSION

Evidence and existing guidelines support 29 protocol elements for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery in gynecologic surgery.

Semiautomatic intermittent pneumatic compression device applied to deep vein thrombosis in major orthopedic surgery

Objective

To investigate the effect of additional semiautomatic intermittent pneumatic compression device (IPCD) in the prevention of deep vein thrombosis (DVT) of lower extremity in these patients undergoing major orthopedic surgery, when compared with the conventional graduated compression stockings alone.

Methods

The data of 112 patients undergoing major orthopedic surgery were retrospectively analyzed. 51 patients who ever received IPCD and graduated compression stockings during major orthopedic surgery were taken as the experimental group, and 61 patients who only received the conventional graduated compression stockings during surgery were taken as the observation group. The Doppler sonography was utilized to detect the presence of DVT and pulmonary embolism pre- and postoperatively. Besides, the mean and peak velocity of blood flow in femoral vein were recorded before and after surgery. And then, the comparisons between the two groups were made, respectively.

Results

When compared with the conventional graduated compression stockings alone, the intraoperative application of IPCD and stockings contributed the significant reduction of DVT (3.92%, 2/51 versus 9.84%, 6/61, X² = 5.632, P = 0.034). In terms of the mean and peak velocity of blood flow in femoral vein, the postoperative difference was higher in the observation group than those in the control group (149.56 ± 26.35 versus 130.15 ± 22.56 mm/s, P < 0.05). With respect to perioperative blood loss, the difference between the two groups was statistically significant (800.5 ± 320.7 versus 950.1 ± 305.9 ml, P = 0.031).

Conclusions

Intraoperative application of IPCD could promote blood circulation of lower limbs, and significantly decrease the incidence of potentially fatal DVT in patients undergoing major orthopedic surgery, when compared with the conventional graduated compression stockings.