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Berndtson AE, Cross A, Yorkgitis BK, Kennedy R, Kochuba MP, Tignanelli C, Tominaga GT, Jacobs DG, Ashley DW, Ley EJ, Napolitano L, Costantini TW. American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma clinical protocol for postdischarge venous thromboembolism prophylaxis after trauma. J Trauma Acute Care Surg 2024; 96:980-985. [PMID: 38523134 DOI: 10.1097/ta.0000000000004307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
ABSTRACT Trauma patients are at an elevated risk for developing venous thromboembolism (VTE), which includes pulmonary embolism and deep vein thrombosis. In the inpatient setting, prompt pharmacologic prophylaxis is utilized to prevent VTE. For patients with lower extremity fractures or limited mobility, VTE risk does not return to baseline levels postdischarge. Currently, there are limited data to guide postdischarge VTE prophylaxis in trauma patients. The goal of these postdischarge VTE prophylaxis guidelines are to identify patients at the highest risk of developing VTE after discharge and to offer pharmacologic prophylaxis strategies to limit this risk.
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Affiliation(s)
- Allison E Berndtson
- From the Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery (A.E.B., T.W.C.), UC San Diego School of Medicine, San Diego, California; University of Oklahoma Health Science Center (A.C.), Oklahoma City, Oklahoma; Division of Acute Care Surgery, Department of Surgery (B.K.Y., M.P.K.), University of Florida-Jacksonville, Jacksonville, Florida; Department of Surgery (R.K.), Baylor University Medical Center, Dallas, Texas; Department of Surgery (C.T.), University of Minnesota, Minneapolis, Minnesota; Trauma Services (G.T.T.), Scripps Memorial Hospital La Jolla, La Jolla, California; Division of Acute Care Surgery, Department of Surgery (D.G.J.), Atrium Health-Carolinas Medical Center, Charlotte, North Carolina; Mercer University School of Medicine (D.W.A.), Atrium Health Navicent, Macon, Georgia; Cedars-Sinai Medical Center (E.J.L.), Los Angeles, California; and Trauma and Surgical Critical Care, Department of Surgery (L.N.), University of Michigan Health System, Ann Arbor, Michigan
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Ivankovic V, McAlpine K, Delic E, Carrier M, Stacey D, Auer RC. Extended-duration thromboprophylaxis for abdominopelvic surgery: Development and evaluation of a risk-stratified patient decision aid to facilitate shared decision making. Res Pract Thromb Haemost 2022; 6:e12831. [PMID: 36397933 PMCID: PMC9663316 DOI: 10.1002/rth2.12831] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 09/02/2022] [Accepted: 09/17/2022] [Indexed: 11/16/2022] Open
Abstract
Background Extended-duration thromboprophylaxis is used to decrease risk of venous thromboembolism (VTE) after surgery but may increase the risk of bleeding. The decision to complete a course of extended-duration thromboprophylaxis can be challenging. Objective The objective of this study was to develop an acceptable patient decision aid (PtDA) to facilitate shared decision making for the use of extended-duration thromboprophylaxis following major abdominal surgery. Methods An evidence-based, risk-stratified PtDA was created. The evidence on benefits and harms of a 28-day postoperative course of low-molecular-weight heparin (LMWH) versus in-hospital prophylaxis only were synthesized. Outcomes included minor bleeding, major bleeding, clinically significant VTE, and fatal VTE. Risks were calculated and reported by Caprini score. Alpha testing of the PtDA draft with various stakeholders was performed using a 10-question survey to assess acceptability of the PtDA with patients, thrombosis experts, and surgeons. The primary outcome was the acceptability of the PtDA. Results Acceptability testing was performed with 11 patients, 11 thrombosis experts, and 11 surgeons. Most responders felt the language on the PtDA was easy to follow (28/33, 85%), and that the information was well balanced between management options (9/11 [82%] patients; 17/21 [80%] clinicians). Most patients (9/11, 82%) and clinicians (18/22, 82%) believed it would be a useful clinical tool, and were satisfied with the overall quality of the PtDA (27/33, 82%). Conclusions A risk-stratified, evidence-based PtDA was created to facilitate shared decision making for the use of extended-duration LMWH following major abdominal surgery. This clinical tool was acceptable with patients and physicians and is available at https://decisionaid.ohri.ca/decaids.html.
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Affiliation(s)
| | - Kristen McAlpine
- Division of Urology, Department of SurgeryUniversity of TorontoTorontoOntarioCanada
| | - Edita Delic
- Department of Surgery, University of OttawaThe Ottawa Hospital Research InstituteOttawaOntarioCanada
| | - Marc Carrier
- Department of Medicine University of OttawaThe Ottawa Hospital Research InstituteOttawaOntarioCanada
| | - Dawn Stacey
- School of Nursing, University of OttawaOttawa Hospital Research InstituteOttawaOntarioCanada
| | - Rebecca C. Auer
- Department of Surgery, University of OttawaThe Ottawa Hospital Research InstituteOttawaOntarioCanada
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Schulman S, Carlson V, Serrano PE, Sne N, Kahnamoui K, Mithoowani S, Ikesaka R, Gross PL. Adherence to apixaban for extended thromboprophylaxis after major abdominal or pelvic surgery for cancer: A prospective cohort study. J Surg Oncol 2022; 126:386-393. [PMID: 35362102 DOI: 10.1002/jso.26876] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 03/10/2022] [Accepted: 03/21/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND Due to lack of data, direct oral anticoagulants are not considered by guidelines for venous thromboembolism (VTE) prophylaxis after cancer surgery. Adherence to low-molecular-weight heparin injections in this setting is sometimes poor. AIM Analysis of adherence to oral apixaban for extended thromboprophylaxis. METHODS Consecutive patients discharged after major surgery for abdominal/pelvic cancer and considered eligible for extended prophylaxis were offered apixaban 2.5 mg twice daily. Primary outcomes were adherence metrics-proportion of prescriptions filled, persistence (not prematurely discontinued), proportion of days covered (PDC) based on apixaban pill counts, and modified Morisky medication adherence scale at Days 28-30. Secondary outcomes were bleeding, VTE, and serious adverse events until Day 90. RESULTS We included 53 patients, 51 were analyzed. Of 45 patients with prescriptions all had it filled (95% confidence interval [CI], 92%-100%). Persistence was 98% (95% CI, 90%-100%). PDC was ≥80% for 48 patients (94%; 95% CI, 84%-99%). We found good adherence (0/6 answers "yes") in 75% and moderate (1/6 answers "yes") in 25%. No major bleed or VTE occurred while on apixaban. CONCLUSION Our results support good adherence with apixaban for VTE prophylaxis up to 28 days after major abdominal or pelvic cancer surgery.
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Affiliation(s)
- Sam Schulman
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada.,Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Vanessa Carlson
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Pablo E Serrano
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Niv Sne
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Kamyar Kahnamoui
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Siraj Mithoowani
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Rick Ikesaka
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Peter L Gross
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
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Chindamo MC, Paiva EF, Carmo Jr PRD, Rocha ATC, Marques MA. Desafios da profilaxia estendida do tromboembolismo venoso em pacientes clínicos e cirúrgicos. J Vasc Bras 2022; 21:e20210195. [PMID: 35836745 PMCID: PMC9250351 DOI: 10.1590/1677-5449.202101951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 04/06/2022] [Indexed: 12/05/2022] Open
Abstract
Patients hospitalized for acute medical and surgical illnesses are at risk of developing venous thromboembolism (VTE) during hospitalization and after discharge. Extended pharmacological prophylaxis beyond the hospital stay is recommended for patients undergoing surgeries at high risk for VTE and for selected groups of hospitalized medical patients. This practice involves several challenges, from identification of at-risk populations eligible for extended prophylaxis to choice of the most appropriate anticoagulant and definition of the ideal duration of use. This review will present the main VTE risk assessment models for hospitalized medical and surgical patients, the current recommendations for use of extended prophylaxis, and its limitations and benefits.
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Affiliation(s)
| | | | | | | | - Marcos Arêas Marques
- Universidade do Estado do Rio de Janeiro, Brasil; Universidade Federal do Estado do Rio de Janeiro, Brasil
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Chindamo MC, Paiva EF, Carmo Jr PRD, Rocha ATC, Marques MA. Challenges of extended venous thromboembolism prophylaxis in medical and surgical patients. J Vasc Bras 2022. [DOI: 10.1590/1677-5449.202101952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abstract Patients hospitalized for acute medical and surgical illnesses are at risk of developing venous thromboembolism (VTE) during hospitalization and after discharge. Extended pharmacological prophylaxis beyond the hospital stay is recommended for patients undergoing surgeries at high risk for VTE and for selected groups of hospitalized medical patients. This practice involves several challenges, from identification of at-risk populations eligible for extended prophylaxis to choice of the most appropriate anticoagulant and definition of the ideal duration of use. This review will present the main VTE risk assessment models for hospitalized medical and surgical patients, the current recommendations for use of extended prophylaxis, and its limitations and benefits.
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Affiliation(s)
| | | | | | | | - Marcos Arêas Marques
- Universidade do Estado do Rio de Janeiro, Brasil; Universidade Federal do Estado do Rio de Janeiro, Brasil
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McGinnis JM, Helpman L, Gundayao M, Nancekivell KL, Russell J, Linkins LA, Ruo L, Serrano PE. Evaluating compliance of extended venous thromboembolism prophylaxis following abdominopelvic surgery for cancer: A multidisciplinary quality improvement project. J Surg Oncol 2021; 125:437-447. [PMID: 34677828 DOI: 10.1002/jso.26728] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/08/2021] [Accepted: 10/12/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Despite quality evidence supporting postoperative extended venous thromboembolism prophylaxis (eVTEp) following abdominopelvic cancer surgery, baseline use of eVTEp at our institution was 3%. Our project aim was to improve the proportion of patients prescribed eVTEp following surgery for gynecologic, hepatobiliary, and colorectal cancers by a 30% absolute increase. METHODS We performed an interrupted time series study using quality improvement methodology. Postoperative order sets, pre-printed prescriptions, process checklists, and multimodal education were introduced. Process and outcome data were collected and analyzed on statistical process control charts. RESULTS We included 324 patients with gynecologic and hepatobiliary cancers. Despite efforts to include them, the colorectal team did not participate. The monthly mean order set-use was 58% (SD = 14%), by specialty: gynecology 79%, hepatobiliary 47%. The proportion of patients prescribed eVTEp increased from 3% to 70% (SD = 14%). The target goal was surpassed and sustained by both cohorts. Patient compliance was 73% (n = 117/160, SD = 16%). Of those who stopped eVTEp early, 45% (n = 14/31) objected because of the injectable nature. Bleeding events were infrequent (0.6%, n = 2/324). CONCLUSIONS Three process changes and multimodal education resulted in a significant increase in eVTEp use. Failure to identify improvement champions limited project expansion to colorectal patients. Patient compliance was largely limited by the injectable nature of the medication.
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Affiliation(s)
- Justin M McGinnis
- Division of Gynecologic Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Limor Helpman
- Division of Gynecologic Oncology, McMaster University, Hamilton, Ontario, Canada
| | | | - Kelly-Lynn Nancekivell
- Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Jacqueline Russell
- Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Lori-Ann Linkins
- Division of Hematology and Thromboembolism, McMaster University, Hamilton, Ontario, Canada
| | - Leyo Ruo
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Pablo E Serrano
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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