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Aspirin or enoxaparin for VTE prophylaxis after primary partial, total or revision hip or knee arthroplasty: A secondary analysis from the CRISTAL cluster randomized trial. PLoS One 2024; 19:e0298152. [PMID: 38626226 PMCID: PMC11020928 DOI: 10.1371/journal.pone.0298152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 01/09/2024] [Indexed: 04/18/2024] Open
Abstract
BACKGROUND This study compares aspirin to enoxaparin for symptomatic VTE prophylaxis within 90 days of any type of hip or knee arthroplasty performed for any diagnosis, in patients enrolled in the CRISTAL trial. MATERIALS AND METHODS CRISTAL was a cluster-randomised crossover, registry-nested non-inferiority trial across 31 hospitals in Australia. The primary publication was restricted to patients undergoing primary total hip or knee arthroplasty for a diagnosis of osteoarthritis. This report includes all enrolled patients undergoing hip or knee arthroplasty procedures (partial or total, primary or revision) performed for any indication. Hospitals were randomized to administer patients aspirin (100mg daily) or enoxaparin (40mg daily), for 35 days after hip arthroplasty and 14 days after knee arthroplasty. Crossover occurred after the patient enrolment target had been met for the first group. The primary outcome was symptomatic VTE within 90 days. Analyses were performed by randomization group. RESULTS Between April 20, 2019 and December 18, 2020, 12384 patients were enrolled (7238 aspirin group and 5146 enoxaparin). Of these, 6901 (95.3%) given aspirin and 4827 (93.8%) given enoxaparin (total 11728, 94.7%) were included in the final analyses. Within 90 days, symptomatic VTE occurred in 226 (3.27%) aspirin patients and 85 (1.76%) enoxaparin patients, significant for the superiority of enoxaparin (estimated treatment difference 1.85%, 95% CI 0.59% to 3.10%, p = 0.004). Joint-related reoperation within 90 days was lower in the enoxaparin group (109/4827 (2.26%) vs 171/6896 (2.47%) with aspirin, estimated difference 0.77%; 95% CI 0.06% to 1.47%, p = 0.03). There were no significant differences in the other secondary outcomes. CONCLUSION In patients undergoing hip or knee arthroplasty (of any type, performed for any indication) enrolled in the CRISTAL trial, aspirin compared to enoxaparin resulted in a significantly higher rate of symptomatic VTE and joint-related reoperation within 90 days. These findings extend the applicability of the CRISTAL trial results. TRIAL REGISTRATION Anzctr.org.au, identifier: ACTRN12618001879257.
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Jones A, Al-Horani RA. Venous Thromboembolism Prophylaxis in Major Orthopedic Surgeries and Factor XIa Inhibitors. Med Sci (Basel) 2023; 11:49. [PMID: 37606428 PMCID: PMC10443384 DOI: 10.3390/medsci11030049] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/26/2023] [Accepted: 08/09/2023] [Indexed: 08/23/2023] Open
Abstract
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.
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Affiliation(s)
| | - Rami A. Al-Horani
- Division of Basic Pharmaceutical Sciences, College of Pharmacy, Xavier University of Louisiana, New Orleans, LA 70125, USA;
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Carnevale Pellino V, Gatti A, Vandoni M, Patanè P, Febbi M, Ballarin S, Cavallo C, Marin L. Pneumatic Compression Combined with Standard Treatment after Total Hip Arthroplasty and Its Effects on Edema of the Operated Limb and on Physical Outcomes: A Pilot Clinical Randomized Controlled Study. J Clin Med 2023; 12:4164. [PMID: 37373857 DOI: 10.3390/jcm12124164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 06/15/2023] [Accepted: 06/19/2023] [Indexed: 06/29/2023] Open
Abstract
Total hip arthroplasty (THA) is one of the most successful orthopedic procedures and is highly effective at improving function and quality of life. However, patients commonly experience edema immediately after hospitalization and also after discharge, which can lead to health consequences and a lower quality of life. For these reasons, the aim of this study (NCT05312060) was to evaluate the effectiveness of a specific intermittent leg pneumatic compression on lower limb edema and physical outcomes in patients after total hip arthroplasty, compared to standard conservative treatment. A total of 47 patients were enrolled and randomly allocated into two groups: the pneumatic compression group (PG = 24) and the control group (CG = 23). The CG performed the standard venous thromboembolism therapy, which included pharmacological prophylaxis, compressive stockings, and electrostimulation, while the PG combined pneumatic compression with standard VTE therapy. We evaluated thigh and calf circumferences, knee and ankle ranges of motion, pain, and walking autonomy. Our results showed a greater reduction in thigh and calf circumferences for PG (p < 0.001), while other outcomes were similar for the two groups (p > 0.05). The combination of standard therapy with pneumatic leg compression was more effective at reducing lower limb edema and thigh and calf circumferences than standard treatment. Our results suggest that pressotherapy treatment is a valuable and efficient option for managing lower limb edema after THA.
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Affiliation(s)
- Vittoria Carnevale Pellino
- Laboratory of Adapted Motor Activity (LAMA), Department of Public Health, Experimental Medicine and Forensic Science, University of Pavia, 27100 Pavia, Italy
| | - Alessandro Gatti
- Laboratory of Adapted Motor Activity (LAMA), Department of Public Health, Experimental Medicine and Forensic Science, University of Pavia, 27100 Pavia, Italy
| | - Matteo Vandoni
- Laboratory of Adapted Motor Activity (LAMA), Department of Public Health, Experimental Medicine and Forensic Science, University of Pavia, 27100 Pavia, Italy
| | - Pamela Patanè
- Industrial Engineering Department, University of Tor Vergata, 00133 Rome, Italy
- Laboratory for Rehabilitation Medicine and Sport (LARMS), 00133 Rome, Italy
| | - Massimiliano Febbi
- Laboratory for Rehabilitation Medicine and Sport (LARMS), 00133 Rome, Italy
- Department of Research, ASOMI College of Sciences, 2080 Marsa, Malta
| | - Stefania Ballarin
- Laboratory for Rehabilitation Medicine and Sport (LARMS), 00133 Rome, Italy
| | - Caterina Cavallo
- Luxembourg Health & Sport Sciences Research Institute A.s.b.l., 4530 Luxembourg, Luxembourg
| | - Luca Marin
- Laboratory of Adapted Motor Activity (LAMA), Department of Public Health, Experimental Medicine and Forensic Science, University of Pavia, 27100 Pavia, Italy
- Department of Research, ASOMI College of Sciences, 2080 Marsa, Malta
- Department of Rehabilitation, Istituto di Cura "Città di Pavia", 27100 Pavia, Italy
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Amarase C, Tanavalee A, Larbpaiboonpong V, Lee MC, Crawford RW, Matsubara M, Zhou Y. Asia-Pacific venous thromboembolism consensus in knee and hip arthroplasty and hip fracture surgery: Part 2. Mechanical venous thromboembolism prophylaxis. Knee Surg Relat Res 2021; 33:20. [PMID: 34193307 PMCID: PMC8243471 DOI: 10.1186/s43019-021-00101-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 04/04/2021] [Indexed: 12/28/2022] Open
Affiliation(s)
- Chavarin Amarase
- Department of Orthopaedics, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | - Aree Tanavalee
- Department of Orthopaedics, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand.
| | | | - Myung Chul Lee
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Ross W Crawford
- Orthopaedic Research Unit, Queensland University of Technology, Brisbane, Australia
| | - Masaaki Matsubara
- epartment of Orthopaedic Surgery, Nissan Tamagawa Hospital, Tokyo, Japan
| | - Yixin Zhou
- Department of Orthopaedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Beijing, China
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Yoon JY, Kim S, Chang JS, Yoon PW, Kim JW. Venous thromboembolism after delayed surgery for a hip fracture: A retrospective cohort study. Geriatr Gerontol Int 2020; 20:1151-1156. [PMID: 33058481 DOI: 10.1111/ggi.14055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 09/15/2020] [Accepted: 09/24/2020] [Indexed: 01/14/2023]
Abstract
AIM The purpose of this study was to investigate the demographic characteristics and prevalence of postoperative venous thromboembolism (VTE) in delayed hip fracture patients referred to our hospital (a tertiary referral center), and further verify the effect of intensive prophylaxis protocol in preventing the occurrence of VTE. METHODS We retrospectively evaluated 264 hip fracture patients whose surgery was delayed by >24 h. The patients were divided into two groups, according to the VTE prophylaxis protocol (conventional vs intensive). We evaluated the time from injury to surgery, and analyzed the prevalence of postoperative symptomatic VTE between the groups. The patient outcome measures, including in-hospital mortality and 30-day-mortality after hip surgery, were also evaluated. RESULTS The mean time from injury to operation was 127.4 h (95% confidence interval 92.2-162.7 h). The incidence of postoperative symptomatic VTE was 5.9% in the conventional prophylaxis group and 0.8% in the intensive prophylaxis group. The intensive prophylaxis group had a significantly lower incidence of postoperative VTE (P = 0.036). Eight patients with deep vein thrombosis on preoperative screening who underwent inferior vena cava filter insertion did not develop postoperative symptomatic VTE. Logistic regression analysis results also showed that the protocol statistically reduced the development of VTE (odds ratio 0.14, 95% CI 0.02-1.21, P = 0.042). CONCLUSIONS Delayed hip fracture surgery resulted in a higher incidence of VTE in patients who received conventional prophylaxis; however, our intensive prophylaxis protocol successfully prevented postoperative symptomatic VTE, including pulmonary embolism. Geriatr Gerontol Int 2020; 20: 1151-1156.
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Affiliation(s)
- Jae Youn Yoon
- Department of Orthopaedic Surgery, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
| | - Shinseok Kim
- Department of Orthopaedic Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jae Suk Chang
- Department of Orthopaedic Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Pil Whan Yoon
- Department of Orthopaedic Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Ji Wan Kim
- Department of Orthopaedic Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
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Lee JK, Koo JW, Jeong SY, Choi S, Park KC, Hwang KT. Perioperative symptomatic venous thromboembolism after immediate chemoprophylaxis in patients with pelvic and lower-extremity fractures. Sci Rep 2020; 10:5431. [PMID: 32214183 PMCID: PMC7096457 DOI: 10.1038/s41598-020-62333-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 03/12/2020] [Indexed: 12/05/2022] Open
Abstract
The purpose of this study was to investigate the incidence of symptomatic venous thromboembolism (VTE) after chemoprophylaxis in patients with pelvic and lower-extremity fractures, and to identify risk factors for VTEs in this subgroup of patients. To detect VTE, multi-detector computed tomography (CT) angiography was performed. Of 363 patients assessed, the incidence of symptomatic VTE was 12.4% (45 patients), and the incidence of symptomatic PE was 5.2% (19 patients). For the risk-factor analysis, a higher Charlson comorbidity index (p = 0.037), and a history of external fixator application (p = 0.007) were associated with increased VTE risk. Among patients who had VTE, male sex (p = 0.017), and above-the-knee fractures (p = 0.035) were associated with increased pulmonary embolism (PE) risk. In conclusions, the incidence of VTE in post-traumatic patients is not low after chemoprophylaxis. Risk factors for VTE and PE are different among patients with pelvic and lower-extremity fractures.
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Affiliation(s)
- Jin Kyu Lee
- Department of Orthopedic Surgery, Hanyang University Hospital, Seongdong-gu, Seoul, Republic of Korea
| | - Ja Wook Koo
- Department of Orthopedic Surgery, Hanyang University Hospital, Seongdong-gu, Seoul, Republic of Korea
| | - Soo-Young Jeong
- Department of Orthopedic Surgery, Hanyang University Hospital, Seongdong-gu, Seoul, Republic of Korea
| | - Sihoon Choi
- Department of Orthopedic Surgery, Hanyang University Hospital, Seongdong-gu, Seoul, Republic of Korea
| | - Ki-Chul Park
- Department of Orthopedic Surgery, Hanyang University Guri Hospital, Guri, Gyeonggi-do, Republic of Korea
| | - Kyu-Tae Hwang
- Department of Orthopedic Surgery, Hanyang University Hospital, Seongdong-gu, Seoul, Republic of Korea.
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Mihara M, Tamaki Y, Nakura N, Takayanagi S, Saito A, Ochiai S, Hirakawa K. Clinical efficacy of risk-stratified prophylaxis with low-dose aspirin for the management of symptomatic venous thromboembolism after total hip arthroplasty. J Orthop Sci 2020; 25:156-160. [PMID: 30902536 DOI: 10.1016/j.jos.2019.02.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 02/07/2019] [Accepted: 02/12/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Pulmonary thromboembolism (PTE) and deep vein thrombosis (DVT) are serious complications after total hip arthroplasty (THA). Aspirin has been considered a safe and cost-effective prophylaxis for venous thromboembolism (VTE), and there have been some reports about the incidence of PTE (0%-0.57%) and DVT (0.1%-0.35%) with low-dose aspirin for prophylaxis after THA. The aim of this study was to investigate the incidence of postoperative symptomatic VTE in our hospital and to evaluate the clinical efficacy of our prophylactic regimen. PATIENT AND METHODS We retrospectively reviewed the medical records of consecutive patients who underwent THA in our hospital between 2011 and 2016. A total of 3295 hips (male: 337 patients, 365 hips; female: 2527 patients, 2930 hips) were enrolled in this study. Patients were divided into low-risk and high-risk groups. Low-risk patients were administered aspirin (100 mg/day) for 28 days postoperatively. High-risk patients, such as those diagnosed with obesity and/or with a history of VTE, received anticoagulants (enoxaparin or edoxaban) for 5 days postoperatively, followed by a dose of aspirin for 28 days. Based on our criteria, 218 of 3295 hips were considered high risk. RESULTS No VTE-related mortality was observed. One patient developed symptomatic PTE, and one patient developed symptomatic DVT. Both were successfully treated. Postoperative fatal bleeding or bleeding from any organ such as gastrointestinal and cerebral hemorrhage were not observed. A low incidence (0.03%) was observed for symptomatic DVT and PTE. CONCLUSIONS This study demonstrated that the hospital's risk-stratified protocol using low-dose aspirin or anticoagulants was clinically effective in preventing symptomatic VTE. These results were considerably better than those reported from Western countries. However, all patients in this study were the Japanese. It was unclear whether similar results were given to non-Japanese patients. Therefore, this protocol needs severe carefulness to be applied to non-Japanese populations.
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Affiliation(s)
- Masahiko Mihara
- Shonan Kamakura Joint Reconstruction Center, 5-4-17 Dai, Kamakura, Kanagawa, 247-0061, Japan.
| | - Yasunobu Tamaki
- Shonan Kamakura Joint Reconstruction Center, 5-4-17 Dai, Kamakura, Kanagawa, 247-0061, Japan
| | - Nariaki Nakura
- Shonan Kamakura Joint Reconstruction Center, 5-4-17 Dai, Kamakura, Kanagawa, 247-0061, Japan; Kitakyushu General Hospital, 1-1 Higashijono-machi, Kokurakita-ku, Kita-Kyushu, Fukuoka, 802-8517, Japan
| | - Satoshi Takayanagi
- Shonan Kamakura Joint Reconstruction Center, 5-4-17 Dai, Kamakura, Kanagawa, 247-0061, Japan
| | - Akira Saito
- Shonan Kamakura Joint Reconstruction Center, 5-4-17 Dai, Kamakura, Kanagawa, 247-0061, Japan
| | - Shunsuke Ochiai
- Shonan Kamakura Joint Reconstruction Center, 5-4-17 Dai, Kamakura, Kanagawa, 247-0061, Japan
| | - Kazuo Hirakawa
- Shonan Kamakura Joint Reconstruction Center, 5-4-17 Dai, Kamakura, Kanagawa, 247-0061, Japan
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Morris RJ. Research quality in the study of mechanical methods of deep vein thrombosis prophylaxis. Phlebology 2019; 35:297-304. [PMID: 31554474 DOI: 10.1177/0268355519877761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
There is a lack of good-quality recent clinical data to support the use of mechanical methods to prevent deep vein thrombosis. Recommendations and meta-analyses have to rely on old data from evaluations of devices that are no longer available, with diagnostic methods that are obsolete. The aim of this narrative review is to examine the reasons why better recent evidence is not available, and how this will affect innovation in mechanical deep vein thrombosis prophylaxis. Analysis of recent published trials shows great variability in techniques and technologies, which complicates evaluation of the effectiveness of properties of intermittent pneumatic compression, graduated compression stockings, and electrical stimulation devices. Negative controlled trials have become difficult to conduct, and low rates of deep vein thrombosis have left many comparative trials of devices underpowered. There is a risk that if new approaches to enable clinical research are not developed that technological advancement of mechanical prophylaxis will be inhibited.
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Affiliation(s)
- Rhys J Morris
- Department of Medical Physics and Clinical Engineering, University Hospital of Wales, Cardiff, UK
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Evaluation of an Electro-Pneumatic Device for Artificial Capillary Pulse Generation used in a Prospective Study in Animals for Surgical Neck Wound Healing. Sci Rep 2019; 9:9837. [PMID: 31285533 PMCID: PMC6614409 DOI: 10.1038/s41598-019-46397-0] [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: 06/19/2018] [Accepted: 06/25/2019] [Indexed: 11/25/2022] Open
Abstract
The paper examines the development and testing of an electro-pneumatic device for wound healing therapy after surgery in the neck area. The device generates air pressure values in a miniaturized cuff using electronic circuitry to drive an electro-valve and air compressor. The device works in two distinct modes: continuous pressure mode and pulsating pressure mode. The pressure value setting can vary from 3 to 11 mmHg, and the pulsating pressure mode’s operating frequency range is approximately 0.1 to 0.3 Hz. Laboratory measurements were conducted to evaluate the device’s correct functioning in both continuous and pulsating pressure modes. A four-day prospective study with animals (n = 10) was also conducted to evaluate neck wound healing therapy using the electro-pneumatic device. Out of the twelve histological parameters analysed to reveal the differences between the experimental and control wounds, only one demonstrated a significant difference. Out of the ten animals treated with the device, three showed a significant difference in terms of benefit after therapy. We can therefore conclude that the device potentially improves the wound healing process in the neck area if the pre-set air pressure value does not exceed 8 mmHg.
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Dhakal P, Wang L, Gardiner J, Shrotriya S, Sharma M, Rayamajhi S. Effectiveness of Sequential Compression Devices in Prevention of Venous Thromboembolism in Medically Ill Hospitalized Patients: A Retrospective Cohort Study. Turk J Haematol 2019; 36:193-198. [PMID: 31042860 PMCID: PMC6682779 DOI: 10.4274/tjh.galenos.2019.2018.0413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objective: To evaluate the effectiveness of sequential compression devices (SCDs) for venous thromboembolism (VTE) prevention in medically ill hospitalized patients. Materials and Methods: Adult patients admitted to a teaching hospital from April 2015 to March 2016 were included. Patients on anticoagulants with or without SCDs were excluded. We analyzed VTE risk, length of hospital stay, and other comorbidities among propensity score-matched patients on SCDs and those without thromboprophylaxis (NONE). Results: Among 30,824 patients, 67 patients (0.22%) developed VTE during their hospital stays, with deep vein thrombosis (DVT) in 55 cases and pulmonary embolism (PE) in 12. VTE was seen in 47 out of 20,018 patients on SCDs (41 DVT, 6 PE) and 20 out of 10,819 patients without SCDs (14 DVT, 6 PE). Risk-adjusted analysis showed no significant difference in VTE incidence in the SCD group compared to NONE (odds ratio 0.99, 95% confidence interval 0.57-1.73, p=0.74). Conclusion: Compared to the NONE group, SCDs are not associated with decreased VTE incidence during hospital stay.
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Affiliation(s)
- Prajwal Dhakal
- University of Nebraska Medical Center, Department of Internal Medicine, Division of Oncology and Hematology, Omaha, Nebraska, USA,Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Ling Wang
- Michigan State University, Department of Medicine, East Lansing, Michigan, USA
| | - Joseph Gardiner
- Michigan State University, Department of Epidemiology and Biostatistics, East Lansing, Michigan, USA
| | - Shiva Shrotriya
- Michigan State University, Department of Medicine, East Lansing, Michigan, USA
| | - Mukta Sharma
- Michigan State University, Department of Medicine, East Lansing, Michigan, USA
| | - Supratik Rayamajhi
- Michigan State University, Department of Medicine, East Lansing, Michigan, USA
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