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Pannucci CJ, Wheeler CK, Cyr KM, Cyr AJ. Breast Implants Decrease Chest Wall Trauma in Low-speed, Unrestrained Motor Vehicle Crash: An Experimental Model. Plast Reconstr Surg Glob Open 2023; 11:e5161. [PMID: 37502223 PMCID: PMC10371328 DOI: 10.1097/gox.0000000000005161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 06/13/2023] [Indexed: 07/29/2023]
Abstract
Breast implants improve quality of life in patients seeking improved breast aesthetics, and are known to minimize human injury in the less common scenario of penetrating trauma. People commonly sustain rib and sternum fractures and thoracic injury in motor vehicle crashes (MVC), a form of blunt traumatic injury. Whether breast implants minimize injury during MVC is unknown. This study examines the potential protective effect of breast implants in low speed, unrestrained MVC. Methods Control (medical gel) and implant (medical gel with embedded breast implant) blocks were subjected to load approximating a low speed, 10mph MVC (n=12 blocks per group). Colormetric pressure film measured pressure at the neo-chest wall position in response to load, across the gel block base. Maximum pressure and average pressure across the gel block base were compared, by group. Results Presence of an implant significantly decreased, by 22.8%, maximum pressure experienced by the neo-chest wall (333.0 ± 58.7 psi vs 431.6 ± 37.3 psi, p=0.0006). Average pressure experienced by the neo-chest wall across the gel block base was also significantly decreased, by 28.1%, in the implant group (53.4 ± 5.6 psi vs 74.3 ± 15.7 psi, p=0.0017). Subjective analysis of all implant and control blocks supported an overall reduction in pressure for the implant group. Conclusions Presence of a breast implant decreased maximum pressure at the chest wall by 23%, and average pressure by 28%. Patients with breast implants involved in low speed, unrestrained MVC may be less likely to sustain rib and sternum fractures and thoracic injury, when compared to patients without implants.
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Affiliation(s)
| | | | - Krista M. Cyr
- Center for Limb Loss and MoBility (CLiMB), VA Puget Sound Health Care System Seattle, Wash
| | - Adam J. Cyr
- Mary Bridge Children’s Hospital, Seattle, Wash
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Othman S, Bertolaccini CM, Pannucci CJ. Unfractionated Heparins, Low-Molecular-Weight Heparins, and Indirect Factor Xa Inhibitors in Plastic and Reconstructive Surgery: An Evidence-Based Review. Plast Reconstr Surg 2023:00006534-990000000-01873. [PMID: 37189249 DOI: 10.1097/prs.0000000000010695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
SUMMARY Venous thromboembolism can present with devastating complications and sequalae, particularly in the surgical patient. Current data supports prophylactic anticoagulant use in the high-risk inpatient, defined as those with a 2005 Caprini Risk Assessment Model score of ≥7. The most utilized chemoprophylaxis agents include unfractionated heparin, low-molecular-weight heparins, and indirect factor Xa inhibitors. The authors review their mechanisms of action, metabolism, reversal agents, indications, contraindications, advantages, and disadvantages in plastic and reconstructive surgery.
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Affiliation(s)
- Sammy Othman
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwell Health, New York, New York
| | - Corinne M Bertolaccini
- Department of Pharmacy Services, Lahey Hospital & Medical Center, Burlington, Massachusetts
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Pannucci CJ, Fleming KI, Varghese TK, Stringham J, Huang LC, Pickron TB, Prazak AM, Bertolaccini C, Momeni A. Low Anti-Factor Xa Level Predicts 90-Day Symptomatic Venous Thromboembolism in Surgical Patients Receiving Enoxaparin Prophylaxis: A Pooled Analysis of Eight Clinical Trials. Ann Surg 2022; 276:e682-e690. [PMID: 33086312 PMCID: PMC8639105 DOI: 10.1097/sla.0000000000004589] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the relationship between enoxaparin dose adequacy, quantified with anti-Factor Xa (aFXa) levels, and 90-day symptomatic venous thromboembolism (VTE) and postoperative bleeding. SUMMARY BACKGROUND DATA Surgical patients often develop "breakthrough" VTE events-those which occur despite receiving chemical anticoagulation. We hypothesize that surgical patients with low aFXa levels will be more likely to develop 90-day VTE, and those with high aFXa will be more likely to bleed. METHODS Pooled analysis of eight clinical trials (N = 985) from a single institution over a 4 year period. Patients had peak steady state aFXa levels in response to a known initial enoxaparin dose, and were followed for 90 days. Survival analysis log-rank test examined associations between aFXa level category and 90-day symptomatic VTE and bleeding. RESULTS Among 985 patients, 2.3% (n = 23) had symptomatic 90-day VTE, 4.2% (n = 41) had 90-day clinically relevant bleeding, and 2.1% (n = 21) had major bleeding. Patients with initial low aFXa were significantly more likely to have 90-day VTE than patients with adequate or high aFXa (4.2% vs 1.3%, P = 0.007). In a stratified analysis, this relationship was significant for patients who received twice daily (6.2% vs 1.5%, P = 0.003), but not once daily (3.0% vs 0.7%, P = 0.10) enoxaparin. No association was seen between high aFXa and 90-day clinically relevant bleeding (4.8% vs 2.9%, P = 0.34) or major bleeding (3.6% vs 1.6%, P = 0.18). CONCLUSIONS This manuscript establishes inadequate enoxaparin dosing as a plausible mechanism for breakthrough VTE in surgical patients, and identifies anticoagulant dose adequacy as a novel target for process improvement measures.
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Affiliation(s)
| | - Kory I Fleming
- Division of Plastic Surgery, University of Utah, Salt Lake City, Utah
| | - Thomas K Varghese
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - John Stringham
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Lyen C Huang
- Division of General Surgery, University of Utah, Salt Lake City, Utah
| | - T Bartley Pickron
- Division of General Surgery, University of Utah, Salt Lake City, Utah
| | - Ann Marie Prazak
- Department of Pharmacy, University of Utah, Salt Lake City, Utah
| | | | - Arash Momeni
- Division of Plastic Surgery, Stanford University, Palo Alto, California
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Pannucci CJ, Momeni A, Januszyk M. The Majority of Venous Thromboembolism Events Should Occur in Lower Risk Aesthetic Surgery Patients: A Simulation Study. Plast Reconstr Surg Glob Open 2022; 10:e4573. [PMID: 36246074 PMCID: PMC9556122 DOI: 10.1097/gox.0000000000004573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 08/16/2022] [Indexed: 11/07/2022]
Abstract
Evidence-based venous thromboembolism (VTE) prevention among aesthetic patients is lacking. This study seeks to (1) quantify 2005 Caprini scores in primary breast augmentation patients, (2) determine the proportion of patients with potentially modifiable VTE risk factors, and (3) project, using Monte Carlo simulation, the expected distribution of Caprini scores among aesthetic surgery patients who develop VTE. Methods The observational study (part 1) screened consecutive primary breast augmentation patients for VTE risk using the 2005 Caprini score. Aggregate scores were compiled, and the proportion of patients with potentially modifiable risk factors were identified. Part 2 used Monte Carlo simulation to generate risk score distributions for VTE events predicted to occur among randomly sampled patient cohorts with baseline Caprini risk profiles derived from the part 1 data. Results One hundred patients had mean age of 35.7 years and mean body mass index of 23.8 kg/m2. Median 2005 Caprini score was 3 (range, 2-8), with the majority (96%) having scores of ≤6. Twenty-eight percent of patients had at least one potentially modifiable risk factor or risk factor potentially benefiting from further investigation. Monte Carlo simulations demonstrated that for a population with 96% Caprini ≤6 (and 4% Caprini ≥7), 80% of VTE events would be expected to occur in patients with Caprini scores ≤6. Conclusions The majority of breast augmentation patients in this study (96%) have 2005 Caprini scores ≤6. Twenty-eight percent of patients have potentially modifiable risk factors. The majority of patients with VTE after aesthetic surgery are expected to have lower Caprini risk scores.
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Affiliation(s)
| | - Arash Momeni
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Michael Januszyk
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, Calif
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Bennett E, Delgado-Corcoran C, Pannucci CJ, Wilcox R, Heyrend C, Faustino EV. Outcomes of Prophylactic Enoxaparin Against Venous Thromboembolism in Hospitalized Children. Hosp Pediatr 2022; 12:617-625. [PMID: 35531629 DOI: 10.1542/hpeds.2021-006386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To assess the biochemical and clinical outcomes of hospitalized children who received prophylactic enoxaparin. METHODS We conducted a retrospective observational study of hospitalized children aged <18 years who received prophylactic enoxaparin against hospital-acquired venous thromboembolism (HA-VTE). Weight-based enoxaparin dosing was administered using a pharmacy-driven protocol, which later included a low molecular weight, anti-Xa level directed-dose adjustment strategy. Primary biochemical and clinical outcomes were achievement of goal anti-Xa range of 0.2 to 0.5 IU/mL and development of HA-VTE, respectively. Secondary clinical outcome was development of clinically relevant bleed. RESULTS We analyzed 194 children with 13 (6.7%) infants aged <1 year and 181 (93.3%) older children aged ≥1 year. After the initial dose, only 1 (11.1%) infant, but 62 (57.9%) older children, achieved goal. Median number of anti-Xa levels until goal was 2 (interquartile range: 2-3) in infants and 1 (interquartile range: 1-2) in older children (P = .01). HA-VTE developed in 2 (15.4%) infants and 9 (5.0%) older children. Among children with anti-Xa level, HA-VTE developed less frequently in children who achieved (2.1%) than in those who did not achieve (13.6%) goal (P = .046). A total of 4 (2.1%) older children and no infants developed clinically relevant bleed. Among children with anti-Xa level, frequency of bleeding was comparable between children who did (3.2%) and did not achieve (0%) goal (P >.99). CONCLUSIONS Our findings suggest the effectiveness and safety of an anti-Xa level directed strategy of prophylactic enoxaparin. However, this strategy should be investigated in prospective controlled studies.
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Affiliation(s)
- Erin Bennett
- Section of Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Claudia Delgado-Corcoran
- Section of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah.,Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, Utah
| | | | - Roger Wilcox
- Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, Utah
| | - Caroline Heyrend
- Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, Utah
| | - Edward Vincent Faustino
- Section of Critical Care, Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
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Pannucci CJ. Commentary on: Venous Thromboembolism and Bleeding Events With Chemoprophylaxis in Abdominoplasty: A Systematic Review and Pooled Analysis of 1596 Patients. Aesthet Surg J 2021; 41:1290-1292. [PMID: 33647965 DOI: 10.1093/asj/sjaa391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Pannucci CJ, Fleming KI, Bertolaccini C, Agarwal J, Rockwell WB, Mendenhall SD, Kwok A, Goodwin I, Gociman B, Momeni A. Optimal Dosing of Prophylactic Enoxaparin after Surgical Procedures: Results of the Double-Blind, Randomized, Controlled FIxed or Variable Enoxaparin (FIVE) Trial. Plast Reconstr Surg 2021; 147:947-958. [PMID: 33761517 DOI: 10.1097/prs.0000000000007780] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The accepted "one-size-fits-all" dose strategy for prophylactic enoxaparin may not optimize the medication's risks and benefits after surgical procedures. The authors hypothesized that weight-based administration might improve the pharmacokinetics of prophylactic enoxaparin when compared to fixed-dose administration. METHODS The FIxed or Variable Enoxaparin (FIVE) trial was a randomized, double-blind trial that compared the pharmacokinetic and clinical outcomes of patients assigned randomly to postoperative venous thromboembolism prophylaxis using enoxaparin 40 mg twice daily or enoxaparin 0.5 mg/kg twice daily. Patients were randomized after surgery and received the first enoxaparin dose at 8 hours after surgery. Primary hypotheses were (1) weight-based administration is noninferior to a fixed dose for avoiding underanticoagulation (anti-factor Xa <0.2 IU/ml) and (2) weight-based administration is superior to fixed-dose administration for avoiding overanticoagulation (anti-factor Xa >0.4 IU/ml). Secondary endpoints were 90-day venous thromboembolism and bleeding. RESULTS In total, 295 patients were randomized, with 151 assigned to fixed-dose and 144 to weight-based administration of enoxaparin. For avoidance of under anticoagulation, weight-based administration had a greater effectiveness (79.9 percent versus 76.6 percent); the 3.3 percent (95 percent CI, -7.5 to 12.5 percent) greater effectiveness achieved statistically significant noninferiority relative to the a priori specified -12 percent noninferiority margin (p = 0.004). For avoidance of overanticoagulation, weight-based enoxaparin administration was superior to fixed-dose administration (90.6 percent versus 82.2 percent); the 8.4 percent (95 percent CI, 0.1 to 16.6 percent) greater effectiveness showed significant safety superiority (p = 0.046). Ninety-day venous thromboembolism and major bleeding were not different between fixed-dose and weight-based cohorts (0.66 percent versus 0.69 percent, p = 0.98; 3.3 percent versus 4.2 percent, p = 0.72, respectively). CONCLUSION Weight-based administration showed superior pharmacokinetics for avoidance of underanticoagulation and overanticoagulation in postoperative patients receiving prophylactic enoxaparin. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, I.
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Affiliation(s)
- Christopher J Pannucci
- From the Divisions of Plastic Surgery and Health Services Research and the Department of Pharmacy Services, University of Utah; Plastic Surgery Northwest; and the Division of Plastic and Reconstructive Surgery, Stanford University
| | - Kory I Fleming
- From the Divisions of Plastic Surgery and Health Services Research and the Department of Pharmacy Services, University of Utah; Plastic Surgery Northwest; and the Division of Plastic and Reconstructive Surgery, Stanford University
| | - Corinne Bertolaccini
- From the Divisions of Plastic Surgery and Health Services Research and the Department of Pharmacy Services, University of Utah; Plastic Surgery Northwest; and the Division of Plastic and Reconstructive Surgery, Stanford University
| | - Jayant Agarwal
- From the Divisions of Plastic Surgery and Health Services Research and the Department of Pharmacy Services, University of Utah; Plastic Surgery Northwest; and the Division of Plastic and Reconstructive Surgery, Stanford University
| | - W Bradford Rockwell
- From the Divisions of Plastic Surgery and Health Services Research and the Department of Pharmacy Services, University of Utah; Plastic Surgery Northwest; and the Division of Plastic and Reconstructive Surgery, Stanford University
| | - Shaun D Mendenhall
- From the Divisions of Plastic Surgery and Health Services Research and the Department of Pharmacy Services, University of Utah; Plastic Surgery Northwest; and the Division of Plastic and Reconstructive Surgery, Stanford University
| | - Alvin Kwok
- From the Divisions of Plastic Surgery and Health Services Research and the Department of Pharmacy Services, University of Utah; Plastic Surgery Northwest; and the Division of Plastic and Reconstructive Surgery, Stanford University
| | - Isak Goodwin
- From the Divisions of Plastic Surgery and Health Services Research and the Department of Pharmacy Services, University of Utah; Plastic Surgery Northwest; and the Division of Plastic and Reconstructive Surgery, Stanford University
| | - Barbu Gociman
- From the Divisions of Plastic Surgery and Health Services Research and the Department of Pharmacy Services, University of Utah; Plastic Surgery Northwest; and the Division of Plastic and Reconstructive Surgery, Stanford University
| | - Arash Momeni
- From the Divisions of Plastic Surgery and Health Services Research and the Department of Pharmacy Services, University of Utah; Plastic Surgery Northwest; and the Division of Plastic and Reconstructive Surgery, Stanford University
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8
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Bertolaccini CM, Prazak AMB, Goodwin IA, Kwok A, Mendenhall SD, Rockwell WB, Agarwal J, Pannucci CJ. Prevention of Venous Thromboembolism in Microvascular Surgery Patients Using Weight-Based Unfractionated Heparin Infusions. J Reconstr Microsurg 2021; 38:395-401. [PMID: 34428806 DOI: 10.1055/s-0041-1735225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Unfractionated heparin infusions are commonly used in microvascular surgery to prevent microvascular thrombosis. Previously, fixed-dose heparin infusions were believed to provide sufficient venous thromboembolism (VTE) prophylaxis; however, we now know that this practice is inadequate for the majority of patients. Anti-factor Xa (aFXa) level is a measure of unfractionated heparin efficacy and safety. This study evaluated the pharmacodynamics of weight-based dose heparin infusions and the impacts of real-time aFXa-guided heparin dose adjustments. METHODS This prospective clinical trial enrolled adult microvascular surgery patients who received a weight-based heparin dose following a microsurgical procedure. Steady-state aFXa levels were monitored, and patients with out-of-range levels received dose adjustments. The study outcomes assessed were aFXa levels at a dose of heparin 10 units/kg/hour, time to adequate aFXa level, number of dose adjustments required to reach in-range aFXa levels, and clinically relevant bleeding and VTE at 90 days. RESULTS Twenty-one patients were prospectively recruited, and usable data were available for twenty patients. Four of twenty patients (20%) had adequate prophylaxis at a heparin dose of 10 units/kg/hour. Among patients who received dose adjustments and achieved in-range aFXa levels, the median number of dose adjustments was 2 and the median weight-based dose was 11 units/kg/hour. The percentage of patients with in-range levels was significantly increased (65 vs. 15%, p = 0.0002) as a result of real-time dose adjustments. The rate of VTE at 90 days was 0%, and clinically relevant bleeding rate at 90 days was 15%. CONCLUSION Weight-based heparin infusions at a rate of 10 units/kg/hour provide a detectable level of anticoagulation for some patients following microsurgical procedures, but most patients require dose adjustment to ensure adequate VTE prophylaxis.
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Affiliation(s)
| | - Ann Marie B Prazak
- Department of Pharmacy Services, University of Utah Health, Salt Lake City, Utah
| | - Isak A Goodwin
- Division of Plastic Surgery, University of Utah Health, Salt Lake City, Utah
| | - Alvin Kwok
- Division of Plastic Surgery, University of Utah Health, Salt Lake City, Utah
| | - Shaun D Mendenhall
- Division of Plastic Surgery, University of Utah Health, Salt Lake City, Utah
| | - W Bradford Rockwell
- Division of Plastic Surgery, University of Utah Health, Salt Lake City, Utah
| | - Jayant Agarwal
- Division of Plastic Surgery, University of Utah Health, Salt Lake City, Utah
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Nolan IT, Haley C, Morrison SD, Pannucci CJ, Satterwhite T. Estrogen Continuation and Venous Thromboembolism in Penile Inversion Vaginoplasty. J Sex Med 2020; 18:193-200. [PMID: 33243691 DOI: 10.1016/j.jsxm.2020.10.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/18/2020] [Accepted: 10/24/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Estrogen therapy and penile inversion vaginoplasty (PIV) are necessary, life-saving interventions for many transfeminine patients. Patients undergoing PIV are generally at low baseline risk for venous thromboembolism (VTE) based on Caprini Score. Estrogen therapy may increase VTE risk in surgical patients, but its cessation may be psychiatrically dysphoric for transfeminine patients. AIM This study examines whether perioperative estrogen cessation impacts VTE risk in patients undergoing PIV. METHODS This was a pre-post study of patients undergoing PIV. From 2014 through 2018, all patients stopped estrogen therapy for 2 weeks before surgery and resumed 1 week postoperatively (group 1). Starting in 2019, all patients continued estrogen therapy perioperatively, with dose reductions for those whose dose was >6 mg/day (group 2). OUTCOMES The primary outcome was 90-day VTE rate. RESULTS 178 patients were included in the study, with 117 in group 1 and 61 in group 2. Median Caprini Score was 4 in group 1 (interquartile range: 3-6) and 3 in group 2 (interquartile range: 3-4) (P = .011). Complications per patient were higher in group 1 (2.2 vs 0.9, P < .001), with a longer follow-up (14.1 vs 10.2 months, P < .001). Rates of 90-day VTE were not different between groups (0.0% vs 1.6%, P = .166). CLINICAL IMPLICATIONS Patients undergoing PIV are generally at low risk for VTE, based on 2005 Caprini Scores. This study provides preliminary evidence that perioperative estrogen therapy continuation does not appear to substantially increase VTE risk in transfeminine patients undergoing PIV with low Caprini Scores, although more investigation is needed to establish true safety. STRENGTHS & LIMITATIONS Strengths include the pre-post design and single-surgeon experience, high proportion of patients with 90-day follow-up, and relatively large series to understand baseline VTE risk by Caprini Score in a PIV population. The main weakness of this study is its limited power to measure true differences in VTE risk based on estrogen continuation. CONCLUSIONS This study suggests that perioperative estrogen continuation may be safe for patients undergoing PIV, the overwhelming majority of whom are at low baseline VTE risk. However, clinicians should weigh the magnitude of the risks and benefits of estrogen cessation on a case-by-case basis. Nolan IT, Haley C, Morrison SD, et al. Estrogen Continuation and Venous Thromboembolism in Penile Inversion Vaginoplasty. J Sex Med 2021;18:193-200.
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Affiliation(s)
- Ian T Nolan
- Hansjörg Wyss Department of Plastic Surgery, Grossman School of Medicine, New York University, New York City, NY, USA.
| | - Caleb Haley
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Shane D Morrison
- Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA, USA
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Pannucci CJ. Commentary on: Venous Thromboembolism Prophylaxis in Aesthetic Surgery: A Survey of Plastic Surgeons' Practices. Aesthet Surg J 2020; 40:1370-1372. [PMID: 32678437 DOI: 10.1093/asj/sjaa094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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11
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Vasilakis V, Klein GM, Trostler M, Mukit M, Marquez JE, Dagum AB, Pannucci CJ, Khan SU. Postoperative Venous Thromboembolism Prophylaxis Utilizing Enoxaparin Does Not Increase Bleeding Complications After Abdominal Body Contouring Surgery. Aesthet Surg J 2020; 40:989-995. [PMID: 31639195 DOI: 10.1093/asj/sjz274] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) chemoprophylaxis warrants an individualized, risk-stratified approach, and constitutes a relatively controversial topic in plastic surgery. OBJECTIVES The aim of this study was to determine the safety of a 7-day postoperative enoxaparin regimen for VTE prophylaxis compared with a single preoperative dose of heparin in abdominal body contouring surgery. METHODS This single-institution pre-post study investigated the safety of a 7-day enoxaparin postoperative regimen in abdominal body contouring procedures performed by a single surgeon from 2007 to 2018. Four procedures were included: traditional panniculectomy, abdominoplasty, fleur-de-lis panniculectomy, and body contouring liposuction. Group I patients received a single dose of 5000 U subcutaneous heparin in the preoperative period, and no postoperative chemical prophylaxis was administered. Group II patients received 40 mg subcutaneous enoxaparin in the immediate preoperative period, then once daily for 7 days postoperatively. RESULTS A total of 195 patients were included in the study, 66 in Group I and 129 in Group II. The groups demonstrated statistically similar VTE risk profiles, based on the 2005 Caprini risk-assessment model. There were no statistically significant differences in the 2 primary outcomes: postoperative bleeding and VTE events. Group I patients had higher reoperation rates (22.7% vs 10.1%, P = 0.029), which was secondary to higher rates of revision procedures. CONCLUSIONS A 7-day postoperative course of once-daily enoxaparin for VTE risk reduction in abdominal body contouring surgery does not significantly increase the risk of bleeding. Implementation of this regimen for postdischarge chemoprophylaxis, when indicated following individualized risk stratification, is appropriate. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Vasileios Vasilakis
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY
| | - Gabriel M Klein
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY
| | - Michael Trostler
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY
| | - Muntazim Mukit
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY
| | - Jocellie E Marquez
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY
| | - Alexander B Dagum
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY
| | | | - Sami U Khan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY
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Pannucci CJ, Fleming KI, Bertolaccini CB, Prazak AM, Huang LC, Pickron TB. Assessment of Anti-Factor Xa Levels of Patients Undergoing Colorectal Surgery Given Once-Daily Enoxaparin Prophylaxis: A Clinical Study Examining Enoxaparin Pharmacokinetics. JAMA Surg 2020; 154:697-704. [PMID: 31116389 DOI: 10.1001/jamasurg.2019.1165] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Importance Between 4% and 12% of patients undergoing colorectal surgery and receiving enoxaparin, 40 mg per day, have a postoperative venous thromboembolism (VTE) event. An improved understanding of why "breakthrough" VTE events occur despite guideline-compliant prophylaxis is an important patient safety question. Objective To determine the proportion of patients undergoing colorectal surgery who received adequate anticoagulation based on peak anti-factor Xa (aFXa) levels while receiving enoxaparin at 40 mg per day. Design, Setting, and Participants This prospective, nonrandomized clinical trial was conducted between February 2017 and July 2018 with 90-day follow-up at a quaternary academic medical center in the Intermountain West and included patients undergoing colorectal surgery who had surgery after receiving general anesthesia, were admitted for at least 3 days, and received enoxaparin, 40 mg once daily. Interventions All patients had aFXa levels measured after receiving enoxaparin 40 mg per day. Patients whose aFXa level was out of range entered the trial's interventional arm where real-time enoxaparin dose adjustment and repeated aFXa measurement were performed. Main Outcomes and Measures Primary outcome: in-range peak aFXa levels (goal range, 0.3-0.5 IU/mL) with enoxaparin, 40 mg per day. Secondary outcomes: (1) in-range trough aFXa levels (goal range, 0.1-0.2 IU/mL) and (2) the proportion of patients with in-range peak aFXa levels from enoxaparin, 40 mg once daily, vs the real-time enoxaparin dose adjustment protocol. Results Over 16 months, 116 patients undergoing colorectal surgery (65 women [56.0%]; 99 white individuals [85.3%], 13 Hispanic or Latino individuals [11.2%], and 4 Pacific Islander individuals [3.5%]; mean [range] age, 52.1 [18-85] years) were enrolled. Among 106 patients (91.4%) whose peak aFXa level was appropriately drawn, 72 (67.9%) received inadequate anticoagulation (aFXa < 0.3 IU/mL) with enoxaparin, 40 mg per day. Weight and peak aFXa levels were inversely correlated (r2 = 0.38). Forty-seven patients (77%) had a trough aFXa level that was not detectable (ie, most patients had no detectable level of anticoagulation for at least 12 hours per day). Real-time enoxaparin dose adjustment was effective. Patients were significantly more likely to achieve an in-range peak aFXa with real-time dose adjustment as opposed to fixed dosing alone (85.4% vs 29.2%, P < .001). Conclusions and Relevance This study supports the finding that most patients undergoing colorectal surgery receive inadequate prophylaxis from enoxaparin, 40 mg once daily. These findings may explain the high rate of "breakthrough" VTE observed in many clinical trials. Trial Registration ClinicalTrials.gov identifier: NCT02704052.
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Affiliation(s)
- Christopher J Pannucci
- Division of Plastic Surgery, University of Utah, Salt Lake City.,Division of Health Services Research, University of Utah, Salt Lake City
| | - Kory I Fleming
- Division of Plastic Surgery, University of Utah, Salt Lake City
| | | | | | - Lyen C Huang
- Division of General Surgery, University of Utah, Salt Lake City
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Henke PK, Kahn SR, Pannucci CJ, Secemksy EA, Evans NS, Khorana AA, Creager MA, Pradhan AD. Call to Action to Prevent Venous Thromboembolism in Hospitalized Patients: A Policy Statement From the American Heart Association. Circulation 2020; 141:e914-e931. [PMID: 32375490 DOI: 10.1161/cir.0000000000000769] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Venous thromboembolism (VTE) is a major preventable disease that affects hospitalized inpatients. Risk stratification and prophylactic measures have good evidence supporting their use, but multiple reasons exist that prevent full adoption, compliance, and efficacy that may underlie the persistence of VTE over the past several decades. This policy statement provides a focused review of VTE, risk scoring systems, prophylaxis, and tracking methods. From this summary, 5 major areas of policy guidance are presented that the American Heart Association believes will lead to better implementation, tracking, and prevention of VTE events. They include performing VTE risk assessment and reporting the level of VTE risk in all hospitalized patients, integrating preventable VTE as a benchmark for hospital comparison and pay-for-performance programs, supporting appropriations to improve public awareness of VTE, tracking VTE nationwide with the use of standardized definitions, and developing a centralized data steward for data tracking on VTE risk assessment, prophylaxis, and rates.
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Pannucci CJ, Fleming KI, Bertolaccini C, Moulton L, Stringham J, Barnett S, Lin J, Varghese TK. Fixed or Weight-Tiered Enoxaparin After Thoracic Surgery for Venous Thromboembolism Prevention. Ann Thorac Surg 2020; 109:1713-1721. [PMID: 32045583 DOI: 10.1016/j.athoracsur.2019.12.058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 11/19/2019] [Accepted: 12/23/2019] [Indexed: 01/27/2023]
Abstract
BACKGROUND Venous thromboembolism is an important patient safety issue in thoracic surgery patients. The optimal enoxaparin dose remains unclear. This multicenter pre/post clinical trial compared the pharmacokinetics of fixed versus weight-tiered enoxaparin, and their impact on 90-day venous thromboembolism and bleeding. METHODS Thoracic surgery patients were prospectively enrolled using a pre/post study design. Cohort 1 received enoxaparin 40 mg daily, and cohort 2 received a weight-tiered regimen: less than 70 kg received 30 mg daily; 70 kg to 89.9 kg received 40 mg once daily; and 90 kg or more received 50 mg daily. The primary study outcome was peak anti-factor Xa levels in response to fixed or weight-tiered enoxaparin. Secondary outcomes included trough anti-factor Xa, 90-day symptomatic venous thromboembolism, and 90-day clinically relevant bleeding. RESULTS One hundred thirty-one patients were prospectively enrolled, including 65 in the fixed-dose cohort and 66 in the weight-tiered cohort. No patient was lost to follow-up. Weight-tiered enoxaparin was not significantly more likely to produce adequate anticoagulation (peak anti-factor Xa 0.3 IU/mL or greater) when compared with fixed-dose enoxaparin (44.3% vs 48.2%, P = .67). Weight-tiered enoxaparin was not more likely to avoid over-anticoagulation (peak anti-factor Xa 0.5 IU/mL or greater) when compared with fixed-dose enoxaparin (3.3% vs 3.6%, P = 1.00). The groups had no significant difference in trough anti-factor Xa. Observed rates of 90-day symptomatic venous thromboembolism and clinically relevant bleeding were low (0% and 3.1%, respectively) and were not significantly different between groups. CONCLUSIONS This multicenter pre/post clinical trial did not show a pharmacokinetic advantage to weight-tiered enoxaparin, when compared with fixed-dose enoxaparin, in thoracic surgery patients. (Clinicaltrials.gov identifier: NCT03251963.).
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Affiliation(s)
| | - Kory I Fleming
- Division of Plastic Surgery, University of Utah, Salt Lake City, Utah
| | | | - Lauren Moulton
- Huntsman Cancer Hospital Intensive Care Unit, University of Utah, Salt Lake City, Utah
| | - John Stringham
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Shari Barnett
- Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Jules Lin
- Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Thomas K Varghese
- Huntsman Cancer Hospital Intensive Care Unit, University of Utah, Salt Lake City, Utah
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15
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Berlin NL, Pannucci CJ, Wilkins EG. Commentary on: Oral Contraceptive Management in Aesthetic Surgery: A Survey of Current Practice Trends. Aesthet Surg J 2019; 39:NP515-NP516. [PMID: 29452337 DOI: 10.1093/asj/sjx260] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Christopher J Pannucci
- Division of Plastic Surgery, Division of Health Services Research, University of Utah, Salt Lake City, UT
| | - Edwin G Wilkins
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI
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Abstract
BACKGROUND Lower extremity trauma with soft tissue loss presents a challenge to the reconstructive surgeon. Cross-leg flaps, first described by Hamilton in 1854, are still used to salvage traumatized lower extremities in patients not suitable for free tissue transfer, or those who are receiving care in locations with limited resources. METHODS A scoping review methodology was used to examine the evidence supporting the use of cross-leg flaps in modern healthcare. RESULTS There have been 409 cases of cross-leg flaps reported in the modern literature, with the majority of flap cases occurring outside the United States in Turkey, India, and Japan. The most common indication was trauma, mentioned in 93.2% of patients (n = 353 of 379), and anatomic limitation, including inadequate vasculature, was the main reason for not performing free tissue transfer (52.8% of patients; n = 170 of 322). The majority are cross-leg fasciocutaneous flaps (85.8%, n = 273 of 318), based off the posterior tibial artery (27.5%, n = 50 of 182) and peroneal artery (26.9%, n = 49 of 182) and, covering defects of the distal third of the leg (55.5%, n = 151 of 272), or the foot (27.9%, n = 76 of 272). The pedicles are typically divided at 3 weeks (mean 20.9 days) after external fixation is used as the immobilization method (57.7%, n = 184 of 319). Flap survival was 100% across all publications except one (n = 349 of 350 patients), making cross-leg flaps a robust and reliable reconstructive option. CONCLUSION In resource-limited environments or in patients who are unsuitable for microvascular free tissue transfer, the cross-leg flap remains an impactful and reliable option for limb salvage.
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Affiliation(s)
| | - Thomas Wright
- Division of Plastic Surgery, University of Utah Health, Salt Lake City, Utah
| | - Mary McFarland
- Eccles Health Sciences Library, University of Utah Health, Salt Lake City, Utah
| | - Michelle Fiander
- College of Pharmacy, University of Utah Health, Salt Lake City, Utah
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Pannucci CJ, Kurnik NM, Brzezienski M, Higdon KK, Rebecca AM. The Protective Effect of Breast Implants in Penetrating Trauma. Aesthetic Surgery Journal Open Forum 2019. [DOI: 10.1093/asjof/ojz004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Breast implants are typically placed for cosmetic or reconstructive purposes, and are recognized to have a substantial impact on aesthetics and quality of life. In addition, the presence of a breast implant on the chest wall has a potential benefit of force diffusion or force absorption in traumatic injury. This article reports a series of three patients with preexisting breast implants who suffered penetrating chest trauma. In each case, the presence of a breast implant was potentially lifesaving. We describe the cases in detail, provide a conceptual discussion, and discuss directions for future research.
Level of Evidence: 5
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Affiliation(s)
| | - Nicole M Kurnik
- Resident Physician of Plastic Surgery, Mayo Clinic, Phoenix, AZ
| | | | - K Kye Higdon
- Associate Professor of Plastic Surgery, Vanderbilt University, Nashville, TN
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Pannucci CJ. Venous Thromboembolism in Aesthetic Surgery: Risk Optimization in the Preoperative, Intraoperative, and Postoperative Settings. Aesthet Surg J 2019; 39:209-219. [PMID: 29846505 DOI: 10.1093/asj/sjy138] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The purpose of this Continuing Medical Education (CME) article is to provide a framework for practicing surgeons to conceptualize and quantify venous thromboembolism risk among the aesthetic and ambulatory surgery population. The article provides a practical approach to identify and minimize venous thromboembolism risk in the preoperative, intraoperative, and postoperative settings.
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Affiliation(s)
- Christopher J Pannucci
- Division of Plastic Surgery, Division of Health Services Research, at the University of Utah, Salt Lake City, UT
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Moores N, Conway H, Donato D, Gociman B, Pannucci CJ, Agarwal J. Is release of the posterior lamella enough? A cadaveric exploration of posterior component separation techniques. Am J Surg 2018; 218:533-536. [PMID: 30591182 DOI: 10.1016/j.amjsurg.2018.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 12/05/2018] [Accepted: 12/10/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND As posterior component separation techniques continue to gain popularity there is uncertainty regarding the degree of fascial advancement afforded by the various techniques. Our study seeks to compare the degree anterior rectus sheath translation seen in full transversus abdominus release compared to simple release of the posterior lamella of the rectus sheath. METHODS Ten hemi-abdomens in five fresh cadavers were dissected. One hemi-abdomen underwent external oblique release. The contralateral hemi-abdomen underwent retrorectus dissection and initial release of the internal lamella of the internal oblique, followed by full transversus abdominus release. A 4 kg weight was suspended from the fascia and excursion was measured after 1) external oblique separation, 2) posterior lamella of the internal oblique separation, and 3) transversus abdominis separation. RESULTS Average unilateral hemifascial translation after release of the external oblique provided an average unilateral hemi-fascial translation of 3.38 cm (+/- 0.69). Release of the posterior lamella of the internal oblique provided 3.98 cm (+/- 0.94). After transversus release the average translation increased to 4.31 cm (+/- 0.89). CONCLUSIONS In this cadaveric study, the majority (92%) of fascial advancement afforded by posterior component separation was achieved by an intermediate step in the transversus abdominus release operation: division of the posterior lamella of the internal oblique.
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Affiliation(s)
- N Moores
- University of Utah, Division of Plastic Surgery, 30N 1900 E, #3B400, Salt Lake City, UT, 84132, USA.
| | - H Conway
- Huntsman Cancer Institute, 2000 Circle of Hope dr, Rm 5524.12, Salt Lake City, UT, 84123, USA.
| | - D Donato
- University of Utah, Division of Plastic Surgery, 30N 1900 E, #3B400, Salt Lake City, UT, 84132, USA.
| | - B Gociman
- University of Utah, Division of Plastic Surgery, 30N 1900 E, #3B400, Salt Lake City, UT, 84132, USA.
| | - C J Pannucci
- University of Utah, Division of Plastic Surgery, 30N 1900 E, #3B400, Salt Lake City, UT, 84132, USA.
| | - J Agarwal
- University of Utah, Division of Plastic Surgery, 30N 1900 E, #3B400, Salt Lake City, UT, 84132, USA.
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Bertolaccini CM, Prazak AMB, Agarwal J, Goodwin IA, Rockwell WB, Pannucci CJ. Adequacy of Fixed-Dose Heparin Infusions for Venous Thromboembolism Prevention after Microsurgical Procedures. J Reconstr Microsurg 2018; 34:729-734. [PMID: 29788512 DOI: 10.1055/s-0038-1655735] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
BACKGROUND In microvascular surgery, patients often receive unfractionated heparin infusions to minimize risk for microvascular thrombosis. Patients who receive intravenous (IV) heparin are believed to have adequate prophylaxis against venous thromboembolism (VTE). Whether a fixed dose of IV heparin provides detectable levels of anticoagulation, or whether the "one size fits all" approach provides adequate prophylaxis against VTE remains unknown. This study examined the pharmacodynamics of fixed-dose heparin infusions and the effects of real-time, anti-factor Xa (aFXa) level driven heparin dose adjustments. METHODS This prospective clinical trial recruited adult microvascular surgery patients placed on a fixed-dose (500 units/h) unfractionated heparin infusion during their initial microsurgical procedure. Steady-state aFXa levels, a marker of unfractionated heparin efficacy and safety, were monitored. Patients with out-of-range aFXa levels received protocol-driven real-time dose adjustments. Outcomes of interest included aFXa levels in response to heparin 500 units/h, number of dose adjustments required to achieve goal aFXa levels, time to reach goal aFXa level, and 90-day clinically relevant bleeding and VTE. RESULTS Twenty patients were recruited prospectively. None of 20 patients had any detectable level of anticoagulation in response to heparin infusions at 500 units/h. The median number of dose adjustments required to reach goal level was five, and median weight-based dose to reach goal level was 11.8 units/kg/h. Real-time dose adjustments significantly increased the proportion of patients with in-range levels (60 vs. 0%, p = 0.0001). The 90-day VTE rate was 5% and 90-day clinically relevant bleeding rate was 5%. CONCLUSIONS Fixed-dose heparin infusions at a rate of 500 units/h do not provide a detectable level of anticoagulation after microsurgical procedures and are insufficient for the majority of patients who require VTE prophylaxis. Weight-based heparin infusions at 10 to 12 units/kg/h deserve future study in patients undergoing microsurgical procedures to increase the proportion of patients receiving adequate VTE prophylaxis.
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Affiliation(s)
| | - Ann Marie B Prazak
- Department of Pharmacy Services, University of Utah Health, Salt Lake City, Utah
| | - Jayant Agarwal
- Division of Plastic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, Utah
| | - Isak A Goodwin
- Division of Plastic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, Utah
| | - W Bradford Rockwell
- Division of Plastic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, Utah
| | - Christopher J Pannucci
- Division of Plastic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, Utah
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Pannucci CJ, Fleming KI, Holoyda K, Moulton L, Prazak AM, Varghese TK. Enoxaparin 40 mg per Day Is Inadequate for Venous Thromboembolism Prophylaxis After Thoracic Surgical Procedure. Ann Thorac Surg 2018; 106:404-411. [PMID: 29626461 DOI: 10.1016/j.athoracsur.2018.02.085] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 02/21/2018] [Accepted: 02/26/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Many patients undergoing thoracic surgical procedures have venous thromboembolism (VTE) events despite the receipt of chemical prophylaxis. Enoxaparin's pharmacologic impact can be quantified by using anti-Factor Xa (aFXa) levels. We hypothesized that enoxaparin 40 mg once daily would be inadequate for most inpatients undergoing thoracic surgical procedures and that a real-time dose adjustment algorithm would be effective. METHODS This prospective clinical trial enrolled inpatients who were to undergo a thoracic surgical procedure and placed on enoxaparin 40 mg once daily for VTE prophylaxis after surgical procedures. aFXa levels were used to measure the anticoagulant effect of enoxaparin once steady state had been reached. Patients whose aFXa levels were out of range received real-time enoxaparin dose adjustment and had repeat aFXa levels drawn. RESULTS Ninety-three inpatients undergoing thoracic surgical procedures were prospectively enrolled. The majority of patients (67.4%) had low peak aFXa levels (<0.3 IU/mL), indicative of inadequate enoxaparin prophylaxis, and 30.3% of patients had in-range aFXa levels (0.3 to 0.5 IU/mL). Patient weight had a moderate correlation (r2 0.38) with peak aFXa level. Patient weight, female sex, and preoperative creatinine were independent predictors of peak aFXa in a linear regression model. Real-time, protocol-driven enoxaparin dose adjustment allowed a significantly increased proportion of patients to achieve in-range aFXa levels (30.3% vs 97.6%, p < 0.001). CONCLUSIONS Enoxaparin 40 mg once daily is inadequate for most inpatients undergoing thoracic surgical procedures, based on a pharmacodynamic study of aFXa levels. Future research should examine the impact of weight-based once daily enoxaparin dosing versus twice daily enoxaparin dosing on prophylaxis adequacy.
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Affiliation(s)
| | - Kory I Fleming
- Division of Plastic Surgery, University of Utah, Salt Lake City, Utah
| | - Kathleen Holoyda
- Division of Plastic Surgery, University of Utah, Salt Lake City, Utah
| | - Lauren Moulton
- Huntsman Cancer Hospital Intensive Care Unit, University of Utah, Salt Lake City, Utah
| | - Ann Marie Prazak
- Department of Pharmacy Services, University of Utah, Salt Lake City, Utah
| | - Thomas K Varghese
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
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Pannucci CJ, Fleming KI. Comparison of face-to-face interaction and the electronic medical record for venous thromboembolism risk stratification using the 2005 Caprini score. J Vasc Surg Venous Lymphat Disord 2018; 6:304-311. [PMID: 29452956 DOI: 10.1016/j.jvsv.2017.10.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 10/02/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Perioperative venous thromboembolism (VTE) risk can be quantified with the 2005 Caprini score. The Caprini score has previously been validated by review of the electronic medical record (EMR) in >3000 plastic surgery patients. However, the accuracy of Caprini-based risk stratification using the EMR, as opposed to face-to-face contact with the patient, remains unknown. METHODS Plastic and reconstructive surgery patients who had surgery under general anesthesia, required postoperative admission, and were started on enoxaparin prophylaxis were identified. The 2005 Caprini scores were calculated retrospectively using EMR review only (no direct contact with the patients) to establish cohort 1. The 2005 Caprini scores were calculated prospectively using face-to-face interaction with the patients, followed by EMR review, to establish cohort 2. For all included patients, EMR review or face-to-face screening was personally performed by the authors. We compared the proportions of patients with identified Caprini risk factors and the aggregate risk scores of patients between cohorts. RESULTS Complete data were available for 536 unique patients in the EMR review cohort and 207 unique patients in the face-to-face cohort. Patients whose risk scores were calculated face to face had higher Caprini scores than those calculated by EMR review alone. The face-to-face cohort had a higher proportion of patients risk stratified as Caprini 7-8 (29.5% vs 24.8%) and Caprini >8 (26.6% vs 10.5%) compared with the EMR review cohort. Patients risk stratified by face-to-face discussion were significantly more likely to be stratified into a higher risk Caprini stratum. Face-to-face discussion identified a 2-fold increase in patients with personal history of deep venous thrombosis (12.6% vs 6.3%; P = .005), a 3-fold increase in patients with family history of VTE (16.9% vs 5.2%; P < .001), and a 20-fold increase in patients with personal history of multiple lost pregnancies (13.6% vs 0.6%; P < .001) compared with EMR review. Observed differences for family history of VTE and history of pregnancy loss persisted after propensity score analysis, created using component variables in the 2005 Caprini score plus gender; this supports the conclusion that observed differences were not due to site variation or case mix. CONCLUSIONS When it is used in isolation, the EMR may provide inaccurate estimation of patient-level VTE risk using the 2005 Caprini score. This study demonstrates that EMR review may miss key VTE risk factors, such as personal or family history of VTE, history of pregnancy loss, and others; this omission results in lower estimates of perioperative VTE risk. The importance of provider-patient interaction for accurate VTE risk stratification cannot be overstated.
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Affiliation(s)
- Christopher J Pannucci
- Division of Plastic Surgery, Division of Health Services Research, University of Utah, Salt Lake City, Utah; Division of Plastic Surgery, University of Utah, Salt Lake City, Utah.
| | - Kory I Fleming
- Division of Plastic Surgery, University of Utah, Salt Lake City, Utah
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Pannucci CJ. The Vast Majority of Aesthetic Surgery Patients are at Low Risk for Venous Thromboembolism and Do Not Require Chemical Prophylaxis. Aesthet Surg J 2017; 37:NP109-NP110. [PMID: 29025240 DOI: 10.1093/asj/sjx053] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Christopher J Pannucci
- Division of Plastic Surgery, Division of Health Services Research, University of Utah, Salt Lake City, UT
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Wall V, Fleming KI, Tonna JE, Nunez J, Lonardo N, Shipley RW, Nirula R, Pannucci CJ. Anti-Factor Xa measurements in acute care surgery patients to examine enoxaparin dose. Am J Surg 2017; 216:222-229. [PMID: 28736059 DOI: 10.1016/j.amjsurg.2017.07.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 06/26/2017] [Accepted: 07/03/2017] [Indexed: 01/20/2023]
Abstract
BACKGROUND The purpose of this study was to determine if fixed dose enoxaparin prophylaxis provided effective anticoagulation for acute care surgery patients and to examine whether a real-time enoxaparin dose adjustment algorithm optimized anticoagulation. METHODS Acute care surgical patients placed on enoxaparin prophylaxis 30 mg twice daily were recruited prospectively. Peak steady state aFXa levels were drawn with a goal peak aFXa range of 0.2-0.4 IU/ml. A real time dose adjustment algorithm was implemented for patients with out-of-range levels. RESULTS Fifty five patients were included. 56.4% of patients had low aFXa levels (<0.2 IU/mL). Real-time enoxaparin dose adjustment significantly increased the proportion of patients who achieved in-range peak aFXa levels, compared to standard dosing (74.5% vs 41.8%, p < 0.001). Patients with initial inadequate peak aFXa levels had a higher rate of 90-day post-operative VTE, although not statistically significant (16.1% vs. 8.3%, p = 0.50). CONCLUSION The majority of acute care surgery patients receive inadequate VTE prophylaxis with fixed enoxaparin dosing.
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Affiliation(s)
- Vanessa Wall
- School of Medicine, University of Utah, 30 N 1900 E, Salt Lake City, UT 84132, United States.
| | - Kory I Fleming
- Division of Plastic Surgery, University of Utah, 30 N 1900 E, Salt Lake City, UT 84132, United States.
| | - Joseph E Tonna
- Division of Cardiothoracic Surgery, University of Utah, 30 N 1900 E, Salt Lake City, UT 84132, United States; Critical Care, University of Utah, 30 N 1900 E, Salt Lake City, UT 84132, United States; Division of Emergency Medicine, University of Utah, 30 N 1900 E, Salt Lake City, UT 84132, United States.
| | - Jade Nunez
- Division of General Surgery, University of Utah, 30 N 1900 E, Salt Lake City, UT 84132, United States.
| | - Nick Lonardo
- Department of Pharmacy Services, University of Utah, 30 N 1900 E, Salt Lake City, UT 84132, United States.
| | - R Wayne Shipley
- Department of Pharmacy Services, University of Utah, 30 N 1900 E, Salt Lake City, UT 84132, United States.
| | - Ram Nirula
- Division of General Surgery, University of Utah, 30 N 1900 E, Salt Lake City, UT 84132, United States.
| | - Christopher J Pannucci
- Division of Plastic Surgery, Division of Health Services Research, University of Utah, 30 N 1900 E, Salt Lake City, UT 84132, United States.
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Pannucci CJ, Cyr AJ, Moores NG, Young JB, Szegedi M. A Ballistics Examination of Firearm Injuries Involving Breast Implants. J Forensic Sci 2017; 63:571-576. [PMID: 28683519 DOI: 10.1111/1556-4029.13589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 05/01/2017] [Accepted: 06/06/2017] [Indexed: 10/19/2022]
Abstract
This ballistics study examines whether saline breast implants can decrease tissue penetration in firearm injuries. We hypothesize that the fluid column within a saline breast implant can alter bullet velocity and/or bullet pattern of mushrooming. The two experimental groups included saline implants with 7.4 cm projection and a no implant group. The experimental design allowed the bullet to pass-through an implant and into ballistics gel (n = 10) or into ballistics gel without passage through an implant (n = 11). Shots that passed through an implant had 20.6% decreased penetration distance when compared to shots that did not pass-through an implant; this difference was statistically significant (31.9 cm vs. 40.2 cm, p < 0.001). Implant group bullets mushroomed prior to gel entry, but the no implant group mushroomed within the gel. Bullet passage through a saline breast implant results in direct bullet velocity reduction and earlier bullet mushrooming; this causes significantly decreased ballistics gel penetration.
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Affiliation(s)
- Christopher J Pannucci
- Division of Plastic Surgery, Division of Health Services Research, University of Utah, Salt Lake City, UT
| | - Adam J Cyr
- ARCCA Incorporated Forensic Engineering, Seattle, WA
| | - Neal G Moores
- Division of Plastic Surgery, University of Utah, Salt Lake City, UT
| | - Jason B Young
- Division of Acute Care Surgery, University of Utah, Salt Lake City, UT
| | - Martin Szegedi
- Department of Radiation Oncology, University of Utah, Salt Lake City, UT
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Borab ZM, Lanni MA, Tecce MG, Pannucci CJ, Fischer JP. Use of Computerized Clinical Decision Support Systems to Prevent Venous Thromboembolism in Surgical Patients: A Systematic Review and Meta-analysis. JAMA Surg 2017; 152:638-645. [PMID: 28297002 PMCID: PMC5831455 DOI: 10.1001/jamasurg.2017.0131] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Accepted: 01/04/2017] [Indexed: 01/05/2023]
Abstract
Importance Health care professionals do not adequately stratify risk or provide prophylaxis for venous thromboembolism (VTE) among surgical patients. Computerized clinical decision support systems (CCDSSs) have been implemented to assist clinicians and improve prophylaxis for VTE. Objective To evaluate the effect of implementing CCDSSs on the ordering of VTE prophylaxis and the rates of VTE. Data Sources PubMed, MEDLINE via OVID, EMBASE via OVID, Scopus, Cochrane CENTRAL Register of Controlled Trials, and clinicaltrials.gov were searched in June 2016 for articles published in English from October 15, 1991, to February 16, 2016. A manual search of references from relevant articles was also performed. Study Selection Clinical trials and observational studies among surgical patients comparing CCDSSs with VTE risk stratification and assistance in ordering prophylaxis vs routine care without decision support were included. Of the 188 articles screened, 11 (5.9%) were eligible for meta-analysis. Data Extraction and Synthesis Meta-analysis of Observational Studies in Epidemiology guidelines were followed. Two reviewers extracted data and assessed quality independently. Main Outcomes and Measures Rates of prophylaxis for VTE and VTE events. Random- and fixed-effects models were used to summarize odds ratios and risk ratios. Results Eleven articles (9 prospective cohort trials and 2 retrospective cohort trials) comprising 156 366 individuals (104 241 in the intervention group and 52 125 in the control group) were included. The use of CCDSSs was associated with a significant increase in the rate of appropriate ordering of prophylaxis for VTE (odds ratio, 2.35; 95% CI, 1.78-3.10; P < .001) and a significant decrease in the risk of VTE events (risk ratio, 0.78; 95% CI, 0.72-0.85; P < .001). Conclusions and Relevance Use of CCDSSs increases the proportion of surgical patients who were prescribed adequate prophylaxis for VTE and correlates with a reduction in VTE events.
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Affiliation(s)
- Zachary M. Borab
- Wyss Department of Plastic and Reconstructive Surgery, New York University School of Medicine, New York
| | - Michael A. Lanni
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Michael G. Tecce
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | | | - John P. Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
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Pannucci CJ, Rocconi RP. The limited utility of currently available venous thromboembolism risk assessment tools in gynecologic oncology patients. Am J Obstet Gynecol 2016; 215:673-674. [PMID: 27390115 DOI: 10.1016/j.ajog.2016.06.052] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 06/27/2016] [Indexed: 11/18/2022]
Affiliation(s)
| | - Rodney P Rocconi
- Division of Gynecology Oncology, University of South Alabama Mitchell Cancer Institute, Mobile, AL
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Pannucci CJ, Rondina MT. Should we be following anti-factor Xa levels in patients receiving prophylactic enoxaparin perioperatively? Surgery 2016; 161:329-331. [PMID: 27712881 DOI: 10.1016/j.surg.2016.07.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 07/27/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Christopher J Pannucci
- Division of Plastic Surgery, Division of Health Services Research, University of Utah, Salt Lake City, UT.
| | - Matthew T Rondina
- Division of General Internal Medicine, Department of Medicine, University of Utah Molecular Medicine Program, Salt Lake City, UT; George E. Wahlen VAMC GRECC, Salt Lake City, UT
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Pannucci CJ, Varghese TK, Graves KK, Prazak AM. Supratherapeutic anti-factor Xa levels in patients receiving prophylactic doses of enoxaparin: A case series. Int J Surg Case Rep 2016; 28:114-116. [PMID: 27693871 PMCID: PMC5048076 DOI: 10.1016/j.ijscr.2016.09.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 09/21/2016] [Accepted: 09/22/2016] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION Enoxaparin prophylaxis prevents venous thromboembolism in surgical patients. Real time anti-Factor Xa monitoring for surgical patients on enoxaparin prophylaxis is increasingly common. PRESENTATION OF CASES We report on three cancer patients with therapeutic or supratherapeutic anti-Factor Xa levels while on prophylactic doses of enoxaparin after surgical procedures. In all cases, elevated anti-Factor Xa levels were the result of blood specimens being removed from a heparinized chemoport. DISCUSSION This case series highlights the importance of peripheral venipuncture or appropriate blood wasting from central access sites for anti-Factor Xa levels. CONCLUSION Inappropriately drawn anti-Factor Xa levels may contribute to prophylaxis interruption or unnecessary workup for renal or liver failure.
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Affiliation(s)
- Christopher J Pannucci
- Division of Plastic Surgery, Division of Health Services Research, University of Utah, 30 North 1900 East, 3B400, Salt Lake City, UT 84132, United States.
| | - Thomas K Varghese
- Division of Cardiothoracic Surgery, University of Utah, 30 North 1900 East, SOM 3C-127, Salt Lake City, UT 84132, United States
| | - Kencee K Graves
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah, 30 North 1900 East, 5R218, Salt Lake City, UT 84132, United States
| | - Ann Marie Prazak
- Department of Pharmacy Services, University of Utah, 50 North Medical Center Drive, A050, Salt Lake City, UT 84132, United States
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Obi AT, Pannucci CJ, Nackashi A, Abdullah N, Alvarez R, Bahl V, Wakefield TW, Henke PK. Validation of the Caprini Venous Thromboembolism Risk Assessment Model in Critically Ill Surgical Patients. JAMA Surg 2016; 150:941-8. [PMID: 26288124 DOI: 10.1001/jamasurg.2015.1841] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Appropriate risk stratification for venous thromboembolism (VTE) is essential to providing appropriate thromboprophylaxis and avoiding morbidity and mortality. OBJECTIVE To validate the Caprini VTE risk assessment model in a previously unstudied high-risk cohort: critically ill surgical patients. DESIGN, SETTING, AND PARTICIPANTS We performed a retrospective cohort study of 4844 adults (≥18 years old) admitted to a 20-bed surgical intensive care unit in a large tertiary care academic hospital during a 5-year period (July 1, 2007, through June 30, 2012). MAIN OUTCOMES AND MEASURES The main study outcome was VTE (defined as patients with deep vein thrombosis or pulmonary embolism) that occurred during the patient's initial hospital admission. RESULTS The study population was distributed among risk levels as follows: low, 5.3%; moderate, 19.9%; high, 31.6%; highest, 25.4%; and superhigh, 14.9%. The overall incidence of inpatient VTE was 7.5% and increased with risk level: 3.5% in low-risk patients, 5.5% in moderate-risk patients, 6.6% in high-risk patients, 8.6% in highest-risk patients, and 11.5% in superhigh-risk patients. Patients with Caprini scores greater than 8 were significantly more likely to develop inpatient VTE events when compared with patients with Caprini scores of 7 to 8 (odds ratio [OR], 1.37; 95% CI, 1.02-1.85; P = .04), 5 to 6 (OR, 1.35; 95% CI, 1.16-1.57; P < .001), 3 to 4 (OR, 1.30; 95% CI, 1.16-1.47; P < .001), or 0 to 2 (OR, 1.37; 95% CI, 1.16-1.64; P < .001). Similarly, patients with Caprini scores of 7 to 8 were significantly more likely to develop inpatient VTE when compared with patients with Caprini scores of 5 to 6 (OR, 1.33; 95% CI, 1.01-1.75; P = .04), 3 to 4 (OR, 1.27; 95% CI, 1.08-1.51; P = .005), or 0 to 2 (OR, 1.38; 95% CI, 1.10-1.74; P = .006). CONCLUSIONS AND RELEVANCE The Caprini VTE risk assessment model is valid. This study supports the use of individual risk assessment in critically ill surgical patients.
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Affiliation(s)
- Andrea T Obi
- Section of Vascular Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor
| | | | | | - Newaj Abdullah
- Department of Surgery, Wayne State University School of Medicine, Detroit, Michigan
| | - Rafael Alvarez
- Office of Performance Assessment and Clinical Effectiveness, University of Michigan Health System, Ann Arbor
| | - Vinita Bahl
- Office of Performance Assessment and Clinical Effectiveness, University of Michigan Health System, Ann Arbor
| | - Thomas W Wakefield
- Office of Performance Assessment and Clinical Effectiveness, University of Michigan Health System, Ann Arbor
| | - Peter K Henke
- Office of Performance Assessment and Clinical Effectiveness, University of Michigan Health System, Ann Arbor
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Pannucci CJ, Cuker A. Commentary on: Rivaroxaban for Venous Thromboembolism Prophylaxis in Abdominoplasty: A Multicenter Experience. Aesthet Surg J 2016; 36:67-70. [PMID: 26342100 DOI: 10.1093/asj/sjv129] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2015] [Indexed: 11/13/2022] Open
Affiliation(s)
- Christopher J Pannucci
- Dr Pannucci is an Assistant Professor, Division of Plastic Surgery, University of Utah, Salt Lake City, Utah. Dr Cuker is an Assistant Professor of Medicine, Division of Hematology/Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Adam Cuker
- Dr Pannucci is an Assistant Professor, Division of Plastic Surgery, University of Utah, Salt Lake City, Utah. Dr Cuker is an Assistant Professor of Medicine, Division of Hematology/Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Pannucci CJ, Basta MN, Fischer JP, Kovach SJ. Creation and validation of a condition-specific venous thromboembolism risk assessment tool for ventral hernia repair. Surgery 2015; 158:1304-13. [DOI: 10.1016/j.surg.2015.04.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Revised: 04/03/2015] [Accepted: 04/03/2015] [Indexed: 11/16/2022]
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Pannucci CJ. Commentary on: Contraceptive Vaginal Rings: Do They Pose an Increased Risk of Venous Thromboembolism in Aesthetic Surgery? Aesthet Surg J 2015; 35:728-9. [PMID: 26082089 DOI: 10.1093/asj/sju155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2014] [Indexed: 11/12/2022] Open
Affiliation(s)
- Christopher J Pannucci
- Dr Pannucci is an Assistant Professor, Division of Plastic Surgery, University of Utah, Salt Lake City, UT, USA
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Pannucci CJ, Gerety PA, Nelson JA, Fischer JP, Kovach SJ. Use of intercostal perforating veins and long arterial grafts for latissimus myocutaneous free flap reconstruction of radiated low back wounds. J Reconstr Microsurg 2015; 31:396-400. [PMID: 25769082 DOI: 10.1055/s-0035-1546293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
| | - Patrick A Gerety
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jonas A Nelson
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John P Fischer
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephen J Kovach
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Pannucci CJ, Gerety PA, Wang AR, Zhang P, Mies C, Kanchwala SK. Feasibility of the internal mammary lymph node flap as a vascularized lymph node transfer: A cadaveric dissection study. Microsurgery 2015; 36:485-90. [PMID: 25752677 DOI: 10.1002/micr.22398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 12/10/2014] [Accepted: 02/18/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND We performed cadaveric dissections to examine the feasibility of an internal mammary-based lymph node flap as a donor site for vascularized lymph node transfer. METHODS Internal mammary vessels and adjacent nodes were dissected in ten fresh cadaver specimens. Surgeon inspection and palpation identified the number of nodes in the specimen. Specimens were examined macro- and microscopically by a pathologist for correlation of lymph node counts. Kappa statistic correlated surgeon- and pathologist-reported node counts. RESULTS Surgeon- and pathologist-reported node counts were moderately correlated (kappa 0.57). Inspection and palpation correctly predicted node presence or absence in 80% of specimens. Sixty percent of flaps contained between 1 and 3 nodes, with a mean of 2.0 nodes when nodes were present. CONCLUSIONS Inspection and palpation predicts the presence or absence of nodes in 80% of flaps. Nodes were present in 60% of internal mammary-based flaps, and one to three nodes can be transferred. © 2015 Wiley Periodicals, Inc. Microsurgery 36:485-490, 2016.
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Affiliation(s)
| | - Patrick A Gerety
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA
| | - Amber R Wang
- Department of Pathology, University of Pennsylvania, Philadelphia, PA
| | - Paul Zhang
- Department of Pathology, University of Pennsylvania, Philadelphia, PA
| | - Carolyn Mies
- Department of Pathology, University of Pennsylvania, Philadelphia, PA
| | - Suhail K Kanchwala
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA
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Kozlow JH, Patel SP, Jejurikar S, Pannucci CJ, Cederna PS, Brown DL. Complications after sternal reconstruction: a 16-y experience. J Surg Res 2015; 194:154-60. [DOI: 10.1016/j.jss.2014.09.044] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 09/22/2014] [Accepted: 09/22/2014] [Indexed: 11/24/2022]
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Wilkins EG, Pannucci CJ. Commentary on: Doppler ultrasound imaging of plastic surgery patients for deep venous thrombosis detection: a prospective controlled study. Aesthet Surg J 2015; 35:215-7. [PMID: 25681106 DOI: 10.1093/asj/sju005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Edwin G Wilkins
- Dr Wilkins is Professor of Surgery, Section of Plastic Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan. Dr Pannucci is Assistant Professor, Division of Plastic Surgery, Department of Surgery, University of Utah, Salt Lake City, UT
| | - Christopher J Pannucci
- Dr Wilkins is Professor of Surgery, Section of Plastic Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan. Dr Pannucci is Assistant Professor, Division of Plastic Surgery, Department of Surgery, University of Utah, Salt Lake City, UT
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Bahl V, Shuman AG, Hu HM, Jackson CR, Pannucci CJ, Alaniz C, Chepeha DB, Bradford CR. Chemoprophylaxis for Venous Thromboembolism in Otolaryngology. JAMA Otolaryngol Head Neck Surg 2014; 140:999-1005. [DOI: 10.1001/jamaoto.2014.2254] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Vinita Bahl
- Office of Clinical Affairs, Department of Performance Assessment and Clinical Effectiveness, University of Michigan Health System, Ann Arbor
| | - Andrew G. Shuman
- Department of Otolaryngology–Head and Neck Surgery, University of Michigan Medical School, Ann Arbor
| | - Hsou Mei Hu
- Office of Clinical Affairs, Department of Performance Assessment and Clinical Effectiveness, University of Michigan Health System, Ann Arbor
| | - Christopher R. Jackson
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christopher J. Pannucci
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Cesar Alaniz
- College of Pharmacy and Pharmacy Services, University of Michigan Health System, Ann Arbor
| | - Douglas B. Chepeha
- Department of Otolaryngology–Head and Neck Surgery, University of Michigan Medical School, Ann Arbor
| | - Carol R. Bradford
- Department of Otolaryngology–Head and Neck Surgery, University of Michigan Medical School, Ann Arbor
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Pannucci CJ, Nelson JA, Chung CU, Fischer JP, Kanchwala SK, Kovach SJ, Serletti JM, Wu LC. Medicinal leeches for surgically uncorrectable venous congestion after free flap breast reconstruction. Microsurgery 2014; 34:522-6. [DOI: 10.1002/micr.22277] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 04/29/2014] [Accepted: 05/02/2014] [Indexed: 11/06/2022]
Affiliation(s)
| | - Jonas A. Nelson
- Division of Plastic Surgery; University of Pennsylvania; Philadelphia PA
| | - Cyndi U. Chung
- Division of Plastic Surgery; University of Pennsylvania; Philadelphia PA
| | - John P. Fischer
- Division of Plastic Surgery; University of Pennsylvania; Philadelphia PA
| | | | - Stephen J. Kovach
- Division of Plastic Surgery; University of Pennsylvania; Philadelphia PA
| | - Joseph M. Serletti
- Division of Plastic Surgery; University of Pennsylvania; Philadelphia PA
| | - Liza C. Wu
- Division of Plastic Surgery; University of Pennsylvania; Philadelphia PA
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Abstract
BACKGROUND VTE is the proximate cause of 100,000 deaths in the United States each year. Perioperative VTE risk among surgical patients varies by 20-fold, which highlights the importance of risk stratification to identify high-risk patients, in whom chemoprophylaxis can decrease VTE risk, and low-risk patients, for whom the risk-benefit relationship of prophylaxis may be unfavorable. METHODS We used data from a statewide surgical quality collaborative for surgical procedures performed between 2010 and 2012. Regression-based techniques identified predictors of 90-day VTE while adjusting for procedural complexity and comorbid conditions. A weighted risk index was created and was validated subsequently in a separate, independent dataset. RESULTS Data were available for 10,344 patients, who were allocated randomly to a derivation or validation cohort. The 90-day VTE rate was 1.4%; 66.2% of the derivation cohort and 65.5% of the validation cohort received chemoprophylaxis. Seven risk factors were incorporated into a weighted risk index: personal history of VTE, current cancer, sepsis/septic shock/systemic inflammatory response syndrome, age≥60 years, BMI≥40 kg/m2, male sex, and family history of VTE. Prediction for 90-day VTE was similar in the derivation and validation cohorts (areas under the receiver operator curve, 0.72 and 0.70, respectively). An 18-fold variation in 90-day VTE rate was identified. CONCLUSIONS A weighted risk index quantifies 90-day VTE risk among surgical patients and identifies an 18-fold variation in VTE risk among the overall surgical population.
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Affiliation(s)
| | - Sandra Laird
- Michigan Surgical Quality Collaborative, Ann Arbor, MI
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Pannucci CJ, Obi A, Alvarez R, Abdullah N, Nackashi A, Hu HM, Bahl V, Henke PK. Inadequate venous thromboembolism risk stratification predicts venous thromboembolic events in surgical intensive care unit patients. J Am Coll Surg 2014; 218:898-904. [PMID: 24680577 DOI: 10.1016/j.jamcollsurg.2014.01.046] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 01/09/2014] [Accepted: 01/13/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Surgical intensive care unit (SICU) patients are known to be at high risk for venous thromboembolism (VTE). The 2005 Caprini Risk Assessment Model (RAM) predicts VTE risk in surgical patients. However, a physician's ability to accurately complete this RAM and the effect that inaccurate RAM completion might have on VTE risk remain unknown. STUDY DESIGN Between 2009 and 2012, physicians completed a 2005 Caprini score for all SICU admissions at our institution. For comparison, we used a previously validated, computer-generated score. Regression-based techniques examined the effect of inadequate risk stratification on inpatient VTE risk, when controlling for other confounders. RESULTS Among 3,338 consecutive SICU admissions, 55.2% had computer-generated scores that were higher than the physician-reported score, and 20.6% of scores were equal. Computer-generated scores were higher than physician-reported scores for both median (6 vs 5) and interquartile range (5 to 8 vs 3 to 7). Inter-rater reliability between the 2 scores was poor (kappa = 0.238). Risk score underestimation by ≥2 points was significantly associated with inpatient VTE (7.67% vs 4.59%, p = 0.002). Regression analysis demonstrated that each additional day's delay in chemoprophylaxis (odds ratio [OR] 1.05, 95% CI 1.01 to 1.08, p = 0.011) and under-risk stratification by ≥2 points (OR 2.46, 95% CI 1.53 to 3.96, p < 0.001) were independent predictors of inpatient VTE, as were higher admission APACHE score, personal history of VTE, recent pneumonia, and younger age. CONCLUSIONS Physicians under-risk stratify SICU patients when using the 2005 Caprini RAM. As hospitals incorporate electronic medical records into daily practice, computer-calculated Caprini scores may result in more accurate VTE risk stratification. Inadequate VTE risk assessment and delay to chemoprophylaxis carry independent and significant increased risk for VTE.
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Affiliation(s)
| | - Andrea Obi
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Rafael Alvarez
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Newaj Abdullah
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Andrew Nackashi
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Hsou Mei Hu
- Office of Performance Assessment and Clinical Effectiveness, University of Michigan, Ann Arbor, MI
| | - Vinita Bahl
- Office of Performance Assessment and Clinical Effectiveness, University of Michigan, Ann Arbor, MI
| | - Peter K Henke
- Section of Vascular Surgery, University of Michigan, Ann Arbor, MI.
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Obi AT, Alvarez R, Pannucci CJ, Bahl V, Napolitano LM, Wakefield TW, Henke PK. Venous thromboembolism risk assessment scoring in the critically ill: the impact of misclassification. J Am Coll Surg 2013. [DOI: 10.1016/j.jamcollsurg.2013.07.166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Pannucci CJ, Osborne NH, Wahl WL. Acquired inpatient risk factors for venous thromboembolism after thermal injury: reply. J Burn Care Res 2013; 34:e273. [PMID: 23835627 DOI: 10.1097/bcr.0b013e3182957738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Aliu O, Pannucci CJ, Chung KC. Qualitative Analysis of the Perspectives of Volunteer Reconstructive Surgeons on Participation in Task-Shifting Programs for Surgical-Capacity Building in Low-Resource Countries. World J Surg 2012; 37:481-7. [DOI: 10.1007/s00268-012-1885-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Pannucci CJ, Collar RM, Johnson TM, Bradford CR, Rees RS. The role of full-thickness scalp resection for management of primary scalp melanoma. Ann Plast Surg 2012; 69:165-8. [PMID: 21734540 DOI: 10.1097/sap.0b013e31822592e7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Scalp melanoma is aggressive and has a proclivity for regional metastasis. We hypothesize that subperiosteal scalp melanoma resection reduces in-transit/satellite recurrence, when compared with subgaleal resection. METHODS We identified patients with intermediate to deep, primary scalp melanoma referred to head/neck surgery over an 8-year period. Patients were compared based on scalp resection depth, including subperiosteal (resection to the level of calvarium) and subgaleal (resection including skin, subcutaneous tissue, and galea). The dependent variables were in-transit/satellite recurrence and time to in-transit/satellite recurrence. RESULTS Among 48 identified patients, the in-transit/satellite recurrence rate was 16.7%. Subgaleal resection patients had higher in-transit/satellite recurrence rates than subperiosteal resection patients (24.0% vs. 8.7%, P=0.155). Among node-negative patients, subgaleal resection had significantly higher in-transit/satellite metastasis rates when compared with subperiosteal resection (26.3% vs. 0%, P=0.047). CONCLUSION For node-negative, primary scalp melanoma, subperiosteal resection significantly decreases in-transit/satellite recurrence when compared with subgaleal resection. Given our small sample size, further studies are necessary to confirm these results.
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Affiliation(s)
- Christopher J Pannucci
- Section of Plastic Surgery, Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan 48105, USA
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Pannucci CJ, Barta RJ, Portschy PR, Dreszer G, Hoxworth RE, Kalliainen LK, Wilkins EG. Assessment of postoperative venous thromboembolism risk in plastic surgery patients using the 2005 and 2010 Caprini Risk score. Plast Reconstr Surg 2012; 130:343-353. [PMID: 22495215 DOI: 10.1097/prs.0b013e3182589e49] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Venous thromboembolism is an important patient safety issue. The authors sought to compare the predictive capacity of the 2005 and 2010 Caprini Risk Assessment Models for perioperative venous thromboembolism risk. METHODS The authors performed a retrospective, observational, crossover study using an established surgical outcomes database. A total of 3334 adult plastic surgery patients were identified. Patients were risk-stratified using both the 2005 and 2010 Caprini Risk Assessment Models. Each patient served as his or her own control, resulting in precise matching for identified and unidentified confounders. The outcome of interest was 60-day, symptomatic venous thromboembolism. The predictive capacities of the 2005 and 2010 Caprini risk scores were compared. RESULTS Use of the 2010 Caprini Risk Assessment Model resulted in a systematic increase in the aggregate risk score. The median 2010 Caprini score was significantly higher than the median 2005 Caprini score (6 versus 5, p<0.001). When compared with the 2010 model, the 2005 Caprini Risk Assessment Model was able to better separate the lowest and highest risk patients from one another. Patients classified as "super-high" risk (Caprini score>8) using the 2005 Caprini Risk Assessment Model were significantly more likely to have a 60-day venous thromboembolism event when compared with patients classified as super-high risk using the 2010 guidelines (5.85 percent versus 2.52 percent, p=0.021). CONCLUSIONS When compared with the 2010 Caprini Risk Assessment Model, the 2005 Caprini Risk Assessment Model provides superior risk stratification. The 2005 Caprini Risk Assessment Model is the more appropriate method to risk-stratify plastic surgery patients for perioperative venous thromboembolism risk. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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Affiliation(s)
- Christopher J Pannucci
- Ann Arbor, Mich.; St. Paul, Minn.; and Dallas, Texas From the Section of Plastic Surgery, University of Michigan; the Department of Plastic and Hand Surgery, Regions Hospital; and the Department of Plastic Surgery, University of Texas Southwestern Medical Center
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Shuman AG, Hu HM, Pannucci CJ, Jackson CR, Bradford CR, Bahl V. Stratifying the risk of venous thromboembolism in otolaryngology. Otolaryngol Head Neck Surg 2012; 146:719-24. [PMID: 22261490 DOI: 10.1177/0194599811434383] [Citation(s) in RCA: 100] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The consequences of perioperative venous thromboembolism (VTE) are devastating; identifying patients at risk is an essential step in reducing morbidity and mortality. The utility of perioperative VTE risk assessment in otolaryngology is unknown. This study was designed to risk-stratify a diverse population of otolaryngology patients for VTE events. STUDY DESIGN Retrospective cohort study. SETTING Single-institution academic tertiary care medical center. SUBJECTS AND METHODS Adult patients presenting for otolaryngologic surgery requiring hospital admission from 2003 to 2010 who did not receive VTE chemoprophylaxis were included. The Caprini risk assessment was retrospectively scored via a validated method of electronic chart abstraction. Primary study variables were Caprini risk scores and the incidence of perioperative venous thromboembolic outcomes. RESULTS A total of 2016 patients were identified. The overall 30-day rate of VTE was 1.3%. The incidence of VTE in patients with a Caprini risk score of 6 or less was 0.5%. For patients with scores of 7 or 8, the incidence was 2.4%. Patients with a Caprini risk score greater than 8 had an 18.3% incidence of VTE and were significantly more likely to develop a VTE when compared to patients with a Caprini risk score less than 8 (P < .001). The mean risk score for patients with VTE (7.4) was significantly higher than the risk score for patients without VTE (4.8) (P < .001). CONCLUSION The Caprini risk assessment model effectively risk-stratifies otolaryngology patients for 30-day VTE events and allows otolaryngologists to identify patient subgroups who have a higher risk of VTE in the absence of chemoprophylaxis.
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Affiliation(s)
- Andrew G Shuman
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan 48109, USA.
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Pannucci CJ, Henke PK, Cederna PS, Strachn SM, Brown SL, Moote MJ, Campbell DA. The effect of increased hip flexion using stirrups on lower-extremity venous flow: a prospective observational study. Am J Surg 2011; 202:427-32. [PMID: 21788007 PMCID: PMC3183348 DOI: 10.1016/j.amjsurg.2011.04.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Revised: 04/21/2011] [Accepted: 04/21/2011] [Indexed: 01/29/2023]
Abstract
BACKGROUND Patient positioning during surgeries for colorectal cancer may represent an unrecognized risk factor for deep venous thrombosis. METHODS Twelve healthy control patients were positioned supine with knee flexion at 90°. Duplex ultrasound examined common femoral vein (CFV) and proximal femoral vein diameter, peak systolic velocity, and volume flow with hip flexion at 0°, 30°, 60°, and 90°. Data were analyzed using the paired t test. RESULTS In the CFV, hip flexion to 90° was associated with a significant increase in mean volume flow when compared with hip flexion at 0° (.59 vs .36 L/min; P = .05) and 30° (.59 vs .35 L/min; P = .038). In both the CFV and proximal femoral vein, increased hip flexion was associated with significantly reduced vessel diameter and increased peak systolic velocity. CONCLUSIONS Intraoperative positioning of the lower extremities represents a modifiable risk factor for deep venous thrombosis. When stirrups are used, hip flexion of 90° maximizes venous drainage from the legs.
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Pannucci CJ, Alderman AK, Brown SL, Wakefield TW, Wilkins EG. The effect of abdominal wall plication on intra-abdominal pressure and lower extremity venous flow: a case report. J Plast Reconstr Aesthet Surg 2011; 65:392-4. [PMID: 21855437 DOI: 10.1016/j.bjps.2011.08.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Accepted: 08/04/2011] [Indexed: 11/19/2022]
Abstract
Abdominal wall plication is known to cause increased intra-abdominal pressure (IAP). Whether plication-associated increased IAP causes lower extremity venous stasis, a recognized risk factor for DVT, remains unknown. A 55-year-old woman had a unilateral pedicled TRAM procedure for mastectomy reconstruction. Prior to plication, duplex ultrasound measured proximal femoral vein (PFV) cross-sectional diameter and volume-flow. PFV measurements were repeated immediately after plication and on post-operative days (POD) 1, 2, and 4. Bladder pressure was measured at similar timepoints. PFV volume-flow decreased from 0.22 L/min to 0.16 L/min (73% of baseline) immediately post-plication and reached a nadir of 0.08 L/min (36% of baseline) on POD 2. Bladder pressure increased from 13 mm Hg to 19 mm Hg after plication, and peaked at 31 mm Hg after intra-operative trunk flexion to 30°. Thus, abdominal wall plication was associated with increased intra-abdominal pressure and ultrasound-documented lower extremity venous stasis that persisted for 48 h after surgery.
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