Cutoff values of plasma d-dimer level in patients with diagnosis of the venous thromboembolism after elective spinal surgery. Asian Spine J. 2015;9:232-238. [PMID: 25901235 PMCID: PMC4404538 DOI: 10.4184/asj.2015.9.2.232]

Venous Thromboembolism Prophylaxis in Elective Spine Surgery

STUDY DESIGN

Review.

OBJECTIVE

Venothromboembolic (VTE) complications, composed of deep vein thrombosis and pulmonary embolism are commonly observed in the perioperative setting. There are approximately 500 000 postoperative VTE cases annually in the United States and orthopedic procedures contribute significantly to this incidence. Data on the use of VTE prophylaxis in elective spinal surgery is sparse. This review aims to provide an updated consensus within the literature defining the risk factors, diagnosis, and the safety profile of routine use of pharmacological prophylaxis for VTE in elective spine surgery patients.

METHODS

A comprehensive review of the literature and compilation of findings relating to current identified risk factors for VTE, diagnostic methods, and prophylactic intervention and safety in elective spine surgery.

RESULTS

VTE prophylaxis use is still widely contested in elective spine surgery patients. The outlined benefits of mechanical prophylaxis compared with chemical prophylaxis varies among practitioners.

CONCLUSION

The benefits of any form of VTE prophylaxis continues to remain a controversial topic in the elective spine surgery setting. A specific set of guidelines for implementing prophylaxis is yet to be determined. As more risk factors for thromboembolic events are identified, the complexity surrounding intervention selection increases. The benefits of prophylaxis must also continue to be balanced against the increased risk of bleeding events and neurologic injury.

Application value of D-dimer testing and Caprini risk assessment model (RAM) to predict venous thromboembolism (VTE) in Chinese non-oncological urological inpatients: a retrospective study from a tertiary hospital

Background

The Caprini risk assessment model (RAM) and D-dimer testing have been widely used in the prediction of venous thromboembolism (VTE). However, the clinical significance of these testing options are limited in non-oncological urological inpatients because of the low specificity.

Methods

This retrospective study included 1,453 patients who were admitted to the non-oncological unit of the Department of Urology, Xiangya Hospital, Central South University, from January 2018 to December 2018. The highest score of Caprini RAM and the highest D-dimer level were collected in this retrospective study. Ultrasound examinations of the lower extremities or computed tomographic pulmonary arteriography (CTPA) were applied to patients who were suspected of having VTE, if necessary.

Results

A total of 1,453 patients were collected in this study, which included 34 VTE and 1,419 non-VTE patients. The threshold of D-dimer was 0.89 µg/mL, according to the receiver operating characteristic (ROC) curve, with a sensitivity of 82.4%, a specificity of 83.3%, and a negative predictive value (NPV) of 99.5%. The cut-off of the Caprini RAM was 5, with a sensitivity of 76.5%, a specificity of 58.7%, and an NPV of 99.0%. The area under the curve (AUC) was higher for D-dimer (0.86) than for the Caprini score (0.73).

Conclusions

The application of 0.89 µg/mL and a score of 5 as cut-offs for D-dimer testing and Caprini RAM, respectively, could safely decrease the proportion of Chinese non-oncological urological inpatients who needed to undergo further examinations. These new findings may enhance the application value of D-dimer testing and Caprini RAM for Chinese non-oncological urological inpatients.

Frequency and Risk Factor of Lower-limb Deep Vein Thrombosis after Major Orthopedic Surgery in Vietnamese Patients

BACKGROUND

Deep venous thrombosis (DVT) is a prevalent complication of orthopedic surgery. According in many studies. The incidence of DVT may be up to 50% if thromboprophylaxis is not available.

AIM

The objective of this study was to check the degree of disease, clinical characteristics and analyzed factors in vulnerabilities with lower-limp DVT after orthopedic surgery in a Vietnam teaching hospital.

METHODS

Orthopedic patients who met criteria were recruited at our hospital between August 2017 and June 2018. Ultrasound was used to discovering lower-limp DVT in pre-surgery and 7 days after surgery in all patients.

RESULTS

The incidence of DVT after orthopedic surgery was 7.2%. Patients with older age (> 60) have a risk of 2 times higher of DVT after surgery than normal people (p < 0.05). The incidence of postoperative DVT was higher in immobile individuals > 72 hours (p < 0.05). Patients with prolonged surgical time (>120 minutes) had a higher risk of postoperative DVT than non-surgical patients' surgery (p < 0.05).

CONCLUSIONS

DVT remains a common complication following orthopedic surgery. Older age, immobility status, and surgical time have been found to be risky factors for the development of postoperative lower-limp DVT in orthopedic patients.

Evaluation of a D-Dimer Protocol for Detection of Venous Thromboembolism

BACKGROUND

The use of venous duplex ultrasonography (VDU) for confirmation of deep venous thrombosis in neurosurgical patients is costly and requires experienced personnel. We evaluated a protocol using D-dimer levels to screen for venous thromboembolism (VTE), defined as deep venous thrombosis and asymptomatic pulmonary embolism.

METHODS

We used a retrospective bioinformatics analysis to identify neurosurgical inpatients who had undergone a protocol assessing the serum D-dimer levels and had undergone a VDU study to evaluate for the presence of VTE from March 2008 through July 2017. The clinical risk factors and D-dimer levels were evaluated for the prediction of VTE.

RESULTS

In the 1918 patient encounters identified, the overall VTE detection rate was 28.7%. Using a receiver operating characteristic curve, an area under the curve of 0.58 was identified for all D-dimer values (P = 0.0001). A D-dimer level of ≥2.5 μg/mL on admission conferred a 30% greater relative risk of VTE (sensitivity, 0.43; specificity, 0.67; positive predictive value, 0.27; negative predictive value, 0.8). A D-dimer value of ≥3.5 μg/mL during hospitalization yielded a 28% greater relative risk of VTE (sensitivity, 0.73; specificity, 0.32; positive predictive value, 0.24; negative predictive value, 0.81). Multivariable logistic regression showed that age, male sex, length of stay, tumor or other neurological disease diagnosis, and D-dimer level ≥3.5 μg/mL during hospitalization were independent predictors of VTE.

CONCLUSIONS

The D-dimer protocol was beneficial in identifying VTE in a heterogeneous group of neurosurgical patients by prompting VDU evaluation for patients with a D-dimer values of ≥3.5 μg/mL during hospitalization. Refinement of this screening model is necessary to improve the identification of VTE in a practical and cost-effective manner.

Current status of venous thromboembolism development during the perioperative period for colorectal cancer, its prevention with enoxaparin, and monitoring methods

Background: There is a high incidence of venous thromboembolism (VTE) during the perioperative period for cancer. Therefore, there is an urgent need to elucidate the perioperative onset and appropriate prophylaxis for VTE. Purpose: VTE during the perioperative period for colorectal cancer was evaluated by lower limb venous ultrasonic examinations (lower limb echo) under enoxaparin prophylaxis. We also examined the relationship between hemorrhagic adverse events and anti-Xa factor activity. Patients and methods: Eighty-three subjects who underwent lower limb echo during the perioperative period for colorectal cancer were prospectively included. Enoxaparin was administered for 5 days, from day 1 to day 5 after surgery. Lower limb echo was performed before surgery and on day 5 after surgery. The activated partial thromboplastin time, D-dimer levels, and anti-Xa factor activity were measured before surgery and on days 1, 3, 5, 7, and 9 after surgery. Results: VTEs before surgery were observed on lower limb echo for 16 patients (19.2%). Three patients (3.6%) had a new thrombus during the perioperative period. The preoperative D-dimer level was an independent prognostic factor for newly formed postoperative VTEs (p=0.0036; odds ratio, 19.37). Three patients (3.6%) had hemorrhagic events; however, there was no significant trend for anti-Xa factor activity. Conclusion: VTE prevention using enoxaparin was relatively safe, and D-dimer measurements before surgery were useful for predicting perioperative VTE.

Venous thromboembolism prophylaxis after hip preservation surgery: a review and presentation of institutional experience

Venous thromboembolism (VTE) is a serious complication after major orthopedic procedures. The best options for prevention of the VTE are still debated. The most popular evidence-based guidelines for prevention and treatment of VTE in orthopedic surgery addressed the total hip or knee arthroplasty and hip fractures as the major orthopedic surgeries. Majority of studies have evaluated the different modalities of the VTE prophylaxis in patients undergiong hip or knee arthroplasty. Hip preservation surgeries (HPS) including mini-open femoroacetabular osteoplasty, surgical dislocation of the hip, arthroscopic procedures, and periacetabular osteotomy (PAO) are gained popularity in recent two decades. The majority of these patients are young, healthy and active and may not be considered at high risk for VTE. The frequency of VTE in patients undergoing PAO seems to be low between 0 and 5%. There is a paucity of data regarding rates of VTE in young healthy patients undergoing HPS as well as the optimal prevention methods for VTE. Hence current VTE prevention guidelines do not cover HPS adequately. We aimed to review the available literature regarding VTE events and VTE prophylaxis options after HPS. We discussed the available and potential options for prophylaxis of VTE events in these procedures along with our experience in a large cohort of hip preservation surgery.

Deep Vein Thrombosis and Pulmonary Embolism Considerations in Orthopedic Surgery

Patients undergoing orthopedic surgery have an increased risk for deep venous thrombosis (DVT) and pulmonary embolism (PE). These complications are considered detrimental, as they cause major postoperative morbidity and mortality and lead to a substantial health care burden. Because of the high incidence and serious nature of these complications, it is essential for orthopedic surgeons to have a comprehensive knowledge of the risk factors, diagnosis, and treatment of acute DVT and PE. Perioperative management of orthopedic patients to prevent postoperative DVT and PE and optimize postoperative outcomes is also discussed in this review.

possible role of soluble fibrin monomer complex after gastroenterological surgery

AIM

To examine the role of soluble fibrin monomer complex (SFMC) in the prediction of hypercoagulable state after gastroenterological surgery.

METHODS

We collected data on the clinical risk factors and fibrin-related makers from patients who underwent gastroenterological surgery at Hiroshima University Hospital between April 1, 2014 and March 31, 2015. We investigated the clinical significance of SFMC, which is known to reflect the early plasmatic activation of coagulation, in the view of these fibrin related markers.

RESULTS

A total of 123 patients were included in the present study. There were no patients with symptomatic VTE. Thirty-five (28%) patients received postoperative anticoagulant therapy. In the multivariate analysis, a high SFMC level on POD 1 was independently associated with D-dimer elevation on POD 7 (OR = 4.31, 95%CI: 1.10-18.30, P = 0.03). The cutoff SFMC level was 3.8 μg/mL (AUC = 0.78, sensitivity, 63%, specificity, 89%). The D-dimer level on POD 7 was significantly reduced in high-SFMC patients who received anticoagulant therapy in comparison to high-SFMC patients who did not.

CONCLUSION

The SFMC on POD 1 strongly predicted the hypercoagulable state after gastroenterological surgery than the clinical risk factors and the other fibrin related markers.

A Novel Prioritization Method in Identifying Recurrent Venous Thromboembolism-Related Genes

Identifying the genes involved in venous thromboembolism (VTE) recurrence is important not only for understanding the pathogenesis but also for discovering the therapeutic targets. We proposed a novel prioritization method called Function-Interaction-Pearson (FIP) by creating gene-disease similarity scores to prioritize candidate genes underling VTE. The scores were calculated by integrating and optimizing three types of resources including gene expression, gene ontology and protein-protein interaction. As a result, 124 out of top 200 prioritized candidate genes had been confirmed in literature, among which there were 34 antithrombotic drug targets. Compared with two well-known gene prioritization tools Endeavour and ToppNet, FIP was shown to have better performance. The approach provides a valuable alternative for drug targets discovery and disease therapy.

Postoperative complications of spine surgery

A variety of surgical approaches are available for the treatment of spine diseases. Complications can arise intraoperatively, in the immediate postoperative period, or in a delayed fashion. These complications may lead to severe or even permanent morbidity if left unrecognized and untreated [1-4]. Here we review a range of complications in the early postoperative period from more benign complications such as postoperative nausea and vomiting (PONV) to more feared complications leading to permanent loss of neurological function or death [5]. Perioperative pain management is covered in a separate review (Chapter 8).

Prevalence and Risk Factors of Deep Vein Thrombosis in Patients Undergoing Lumbar Interbody Fusion Surgery: A Single-Center Cross-Sectional Study

This cross-sectional study was designed to obtain the current prevalence of deep vein thrombosis (DVT) and analyze related risk factors in patients undergoing lumbar interbody fusion. Medical record data were collected from Department of Spinal Surgery, The Third Hospital of Hebei Medical University, between July 2014 and March 2015. Both univariate analysis and binary logistic regression analysis were performed to determine risk factors for DVT. A total of 995 patients were admitted into this study, including 484 men and 511 women, aged from 14 to 89 years old (median 50, IQR 19). The detection rate of lower limb DVT by ultrasonography was 22.4% (223/995) in patients undergoing lumbar interbody fusion. Notably, average VAS (visual analog scale) score in the first 3 days after surgery in the DVT group was more than that in the non-DVT group (Z = -21.69, P < 0.001). The logistic regression model was established as logit P = -13.257 + 0.056*X1 - 0.243*X8 + 2.085*X10 + 0.001*X12, (X1 = age; X8 = HDL; X10 = VAS; X12 = blood transfusion; x = 677.763, P < 0.001). In conclusion, advanced age, high postoperative VAS scores, and blood transfusion were risk factors for postoperative lower limb DVT. As well, the logistic regression model may contribute to an early evaluation postoperatively to ascertain the risk of lower limb DVT in patients undergoing lumbar interbody fusion surgery.