Perioperative Antithrombotic Therapy Management and Venous Thromboembolism Prophylaxis

2020 ◽  
Author(s):  
Herbert Chen ◽  
Irene Lou
Keyword(s):  
Risk Factors ◽  
Venous Thromboembolism ◽  
Antiplatelet Therapy ◽  
Antithrombotic Therapy ◽  
Bleeding Complications ◽  
Thromboembolism Prophylaxis ◽  
Therapy Management ◽  
Vte Prophylaxis ◽  
Increased Risk ◽  
Perioperative Anticoagulation

The management of perioperative anticoagulation, antiplatelet therapy, and perioperative venous thromboembolism (VTE) prophylaxis is essentially a balancing act between patient risk factors for thrombosis and surgical risk factors for bleeding. The purpose of this review is to assist surgeons with the identification of patients at increased risk for thromboembolism when antithrombotic therapy is interrupted, patients for whom bridging anticoagulation should be considered, patients who require perioperative VTE prophylaxis, and patients at increased risk for bleeding complications and to briefly review the literature and major guidelines regarding perioperative antithrombotic therapy management and perioperative VTE prophylaxis. Figures show approaches to the management of perioperative anticoagulation, antiplatelet therapy, and VTE prophylaxis.  This review contains 2 figures, 7 tables, and 61 references. Keywords: Venous thromboembolism, pulmonary embolism, anticoagulation, surgery, perioperative period, prophylaxis  

Perioperative Antithrombotic Therapy Management and Venous Thromboembolism Prophylaxis

2020 ◽  
Author(s):  
Herbert Chen ◽  
Irene Lou
Keyword(s):  
Risk Factors ◽  
Venous Thromboembolism ◽  
Antiplatelet Therapy ◽  
Antithrombotic Therapy ◽  
Bleeding Complications ◽  
Thromboembolism Prophylaxis ◽  
Therapy Management ◽  
Vte Prophylaxis ◽  
Increased Risk ◽  
Perioperative Anticoagulation

The management of perioperative anticoagulation, antiplatelet therapy, and perioperative venous thromboembolism (VTE) prophylaxis is essentially a balancing act between patient risk factors for thrombosis and surgical risk factors for bleeding. The purpose of this review is to assist surgeons with the identification of patients at increased risk for thromboembolism when antithrombotic therapy is interrupted, patients for whom bridging anticoagulation should be considered, patients who require perioperative VTE prophylaxis, and patients at increased risk for bleeding complications and to briefly review the literature and major guidelines regarding perioperative antithrombotic therapy management and perioperative VTE prophylaxis. Figures show approaches to the management of perioperative anticoagulation, antiplatelet therapy, and VTE prophylaxis.  This review contains 2 figures, 7 tables, and 61 references. Keywords: Venous thromboembolism, pulmonary embolism, anticoagulation, surgery, perioperative period, prophylaxis  

Perioperative Antithrombotic Therapy Management and Venous Thromboembolism Prophylaxis

2020 ◽  
Author(s):  
Herbert Chen ◽  
Irene Lou
Keyword(s):  
Risk Factors ◽  
Venous Thromboembolism ◽  
Antiplatelet Therapy ◽  
Antithrombotic Therapy ◽  
Bleeding Complications ◽  
Thromboembolism Prophylaxis ◽  
Therapy Management ◽  
Vte Prophylaxis ◽  
Increased Risk ◽  
Perioperative Anticoagulation

The management of perioperative anticoagulation, antiplatelet therapy, and perioperative venous thromboembolism (VTE) prophylaxis is essentially a balancing act between patient risk factors for thrombosis and surgical risk factors for bleeding. The purpose of this review is to assist surgeons with the identification of patients at increased risk for thromboembolism when antithrombotic therapy is interrupted, patients for whom bridging anticoagulation should be considered, patients who require perioperative VTE prophylaxis, and patients at increased risk for bleeding complications and to briefly review the literature and major guidelines regarding perioperative antithrombotic therapy management and perioperative VTE prophylaxis. Figures show approaches to the management of perioperative anticoagulation, antiplatelet therapy, and VTE prophylaxis.  This review contains 2 figures, 7 tables, and 61 references. Keywords: Venous thromboembolism, pulmonary embolism, anticoagulation, surgery, perioperative period, prophylaxis  

The Efficacy of Dextran-40 as a Venous Thromboembolism Prophylaxis Strategy in Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

2017 ◽  
Vol 83 (2) ◽  
pp. 134-140 ◽  
Author(s):  
Jason M. Foster ◽  
Richard Sleightholm ◽  
Duncan Watley ◽  
Steven Wahlmeier ◽  
Asish Patel
Keyword(s):  
Venous Thromboembolism ◽  
Intraperitoneal Chemotherapy ◽  
Hyperthermic Intraperitoneal Chemotherapy ◽  
Medical Center ◽  
Bleeding Complications ◽  
Bleeding Events ◽  
Thromboembolism Prophylaxis ◽  
Dextran 40 ◽  
Perioperative Bleeding ◽  
Increased Risk

The incidence of venous thromboembolism (VTE) in peritoneal malignancies can approach 30 to 50 per cent without prophylaxis. Prophylaxis in cytoreductive surgeries (CRS) presents a challenge to preoperative heparin-based therapy because of an increased risk of coagulopathy and potential for bleeding. Herein, we report the large series of CRS and hyperthermic intraperitoneal chemotherapy receiving dextran-40 prophylaxis. Retrospective chart review of peritoneal malignancies patients undergoing CRS at University of Nebraska Medical Center identified 69 individuals who received dextran-40 between 2010 and 2013. The incidences of VTEs, perioperative bleeding, complications, morbidity, and mortality were determined in-hospital and at 90 days. Of the 69 patients treated, the 30-day VTE rate was 8.7 per cent, and no pulmonary embolisms, bleeding, anaphylactoid reaction, or mortality were observed with dextran usage. The specific VTE events included three upper extremity and three lower extremity VTEs. No additional VTE events were identified between 30 and 90 days. In conclusion, dextran-40 prophylaxis was not associated with any perioperative bleeding events, and the observed incidence of VTE was comparable to reported heparin-based prophylaxis in CRS/hyperthermic intraperitoneal chemotherapy patients. This data supports further exploration of dextran-40 as a VTE prophylactic agent in complex surgical oncology cases.

The International Medical Prevention Registry on Venous Thromboembolism (IMPROVE): Venous Thromboembolism Prophylaxis Practices in Acutely Ill Medical Patients.

Blood ◽  
2004 ◽  
Vol 104 (11) ◽  
pp. 1762-1762 ◽  
Author(s):  
Victor F. Tapson ◽  
Herve Decousus ◽  
Jean-Fran[ccedi]ois Bergmann ◽  
Beng H. Chong ◽  
James B. Froehlich ◽  
...  
Keyword(s):  
Risk Factors ◽  
Venous Thromboembolism ◽  
Major Surgery ◽  
Medical Illness ◽  
Medical Patients ◽  
Median Length ◽  
Thromboembolism Prophylaxis ◽  
Vte Prophylaxis ◽  
Elastic Stockings

Abstract Background Despite consensus group recommendations indicating that medical patients should receive appropriate venous thromboembolism (VTE) prophylaxis, prophylaxis practices remain poorly characterized. This analysis of IMPROVE, a prospective study of acutely ill medical patients, describes in-hospital prophylaxis practices prior to the publication of updated VTE prevention guidelines by the American College of Chest Physicians. Methods Patient recruitment began in July 2002. Patients ≥18 years old, and hospitalized for ≥3 days with an acute medical illness are enrolled consecutively. Exclusion criteria are: therapeutic antithrombotics/thrombolytics at admission; major surgery or trauma during 3 months prior to admission; and VTE treatment begun within 24 hours of admission. Results Data were from 4315 patients (32% from USA) enrolled up to 30 June 2004 in 37 hospitals in 11 countries (76% with 3-month follow-up data). Patients are 50% female, median (IQR) age 69 (50–80) years, median length of hospital stay 8 (5–14) days, median weight 68 (58–80) kg, and 40% were immobile for ≥3 days (median length of immobility 7 [4–14] days, including immobility immediately prior to admission). In-hospital VTE prophylaxis was received by 41% of patients (Table 1). Of patients with no risk factors (44%), one risk factor (40%), or ≥2 risk factors (16%), 25%, 49%, and 67% received prophylaxis, respectively. 12% of IMPROVE patients would have been eligible for inclusion in the MEDENOX study. Of these, only 52% received prophylaxis in hospital. Prophylaxis was provided to 6% of patients during the 3-month follow-up period, and continued in 11% of patients after discharge. Conclusions Only 41% of IMPROVE patients received VTE prophylaxis, with considerable variation in types and regimens of prophylaxis used. While MEDENOX showed the benefits of VTE prophylaxis (enoxaparin 40 mg) in acutely ill medical patients, only half of MEDENOX-eligible patients received prophylaxis. Table 1. Use of in-hospital VTE prophylaxis (N=4315) VTE prophylaxis Patients receiving VTE prophylaxis, % ROW, rest of world; *Excluding elastic stockings and aspirin ≥1 type of VTE prophylaxis* 41 LMWH - USA (Q12h, Qd) 7 (5, 1) LMWH- ROW (Q12h, Qd) 31 (29, 2) UFH - USA (Q12h, Q8h) 28 (15, 11) UFH - ROW (Q12h, Q8h) 6 (5, 0) Intermittent pneumatic compression (USA, ROW) 6 (19, 0) Aspirin (USA, ROW) 4 (7, 3) Elastic stockings (USA, ROW) 6 (3, 8)

scholarly journals Development of pulmonary embolism in a nonhospitalized patient with COVID-19 who did not receive venous thromboembolism prophylaxis

2020 ◽  
Vol 77 (23) ◽  
pp. 1957-1960
Author(s):  
Ellen M Uppuluri ◽  
Nancy L Shapiro
Keyword(s):  
Risk Factors ◽  
Emergency Department ◽  
Pulmonary Embolism ◽  
Venous Thromboembolism ◽  
Chest Pain ◽  
Young Patient ◽  
Lower Lobe ◽  
Thromboembolism Prophylaxis ◽  
Vte Prophylaxis ◽  
Thrombotic Complications

Abstract Purpose Coronavirus disease 2019 (COVID-19) has been associated with thrombotic complications such as stroke and venous thromboembolism (VTE), and VTE prophylaxis for hospitalized patients with COVID-19 is recommended. However, extended postdischarge VTE prophylaxis and VTE prophylaxis for nonhospitalized patients with COVID-19 are not routinely recommended due to uncertain benefit in these populations. Summary Here we report development of a pulmonary embolism (PE) in a young patient without other VTE risk factors who was treated for COVID-19 in an emergency department (ED) and discharged home without VTE prophylaxis, which was consistent with current recommendations. The patient presented to the ED 12 days later with complaints of chest pain for 1 day and was found to have a PE within the segmental and subsegmental branches of the left lower lobe. Conclusion This case suggests that nonhospitalized patients with COVID-19 may be at higher risk for VTE than patients with other medical illnesses and warrants further research into the risk of VTE in outpatients with COVID-19.

Effectiveness and Safety of Twice Daily Versus Thrice Daily Subcutaneous Unfractionated Heparin for Venous Thromboembolism Prophylaxis at a Tertiary Medical Center

2020 ◽  
pp. 089719002096121
Author(s):  
Meghan W. Sorgi ◽  
Erin Roach ◽  
Seth R. Bauer ◽  
Stephanie Bass ◽  
Michael Militello ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
Unfractionated Heparin ◽  
Propensity Scores ◽  
Medical Center ◽  
Matched Cohort ◽  
Thromboembolism Prophylaxis ◽  
Full Cohort ◽  
Vte Prophylaxis ◽  
Major Bleed ◽  
Increased Risk

Background: The direct comparison of twice daily (BID) and thrice daily (TID) dosing of subcutaneous low dose unfractionated heparin (LDUH) for venous thromboembolism (VTE) prophylaxis in a mixed inpatient population is not well-studied. Objective: This study evaluated the effectiveness and safety of BID compared to TID dosing of LDUH for prevention of VTE. Methods: Retrospective, single-center analysis of patients who received LDUH for VTE prophylaxis between July and September 2015. Outcomes were identified by ICD-9 codes. A matched cohort was created using propensity scores and multivariate analysis was conducted to identify independent risk factors for VTE. The primary outcome was incidence of symptomatic VTE. Results: In the full cohort, VTE occurred in 0.71% of patients who received LDUH BID compared to 0.77% of patients who received LDUH TID ( p = 0.85). There was no difference in major ( p = 0.85) and minor ( p = 0.52) bleeding between the BID and TID groups. For the matched cohort, VTE occurred in 1.4% of BID patients and 2.1% of TID patients ( p = 0.32). Major bleed occurred in 0.36% of BID patients and 0.52% of TID patients ( p = 0.7), while a minor bleed was seen in 3.4% of BID patients and 2.1% of TID patients ( p = 0.13). Personal history of VTE ( p = 0.002) and weight ( p = 0.035) were independently associated with increased risk of VTE. Conclusion: This study did not demonstrate a difference in effectiveness or safety between BID and TID dosing of LDUH for VTE prevention.

The Impact Of a Standardized Protocol On Thromboprophylaxis, Venous Thromboembolism and Bleeding Rates In Hospitalized Patients With Hematological Malignancies

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 1729-1729
Author(s):  
Erica A. Peterson ◽  
Hayley Merkeley ◽  
Elena Cavazzi ◽  
Leena Chen ◽  
Agnes Y.Y. Lee
Keyword(s):  
Risk Factors ◽  
Venous Thromboembolism ◽  
Left Ventricular ◽  
Hospitalized Patients ◽  
Bleeding Complications ◽  
Historical Cohort ◽  
Thrombotic Risk ◽  
Vte Prophylaxis ◽  
Standardized Protocol ◽  
The Impact

Abstract Background Venous thromboembolism (VTE) is a frequent complication in patients with underlying cancer. This risk is higher during hospitalization for acute medical conditions. Consequently, routine thromboprophylaxis is recommended in hospitalized cancer patients. A retrospective review of admissions to the Leukemia/Bone Marrow Transplant (LBMT) unit at our institution between January and June 2010 demonstrated that VTE prophylaxis was prescribed in only 6.6% of admissions. In March 2012, a mandatory VTE risk assessment and thromboprophylaxis protocol was introduced in the LBMT unit as part of a hospital-wide policy to improve thromboprophylaxis compliance for all hospitalized patients. Objectives The primary goal is to assess the impact of the VTE thromboprophylaxis protocol on the use of thromboprophylaxis in the LBMT unit. Secondary aims of this study are to evaluate the incidence of VTE (including catheter-related thrombosis [CRT]) and bleeding after the introduction of the protocol. Methods A retrospective chart review of all admissions to the Vancouver General Hospital LBMT unit between March 1, 2012 and February 28, 2013 was performed (intervention cohort [IC]). Only the first admission for each patient during the study period was included in the analysis. Data were extracted from electronic medical records using standardized forms. The primary outcome, rate of VTE prophylaxis, was compared to historical data from January 2010 to June 2010 (historical cohort [HC]). Results 361 patients were included in the IC and 166 patients were included in the HC. All baseline patient characteristics, thrombotic risk factors and bleeding risk factors were similar between the cohorts with the exception of the presence of thrombocytopenia (82.0% IC vs. 68.7% HC, p=0.001) (Table 1 ). At least one dose of thromboprophylaxis was prescribed in 14.0% of admissions in the IC vs. 6.6% of admissions in the HC. This increase was statistically significant (p=0.01). Despite the low prophylaxis prevalence, VTE was uncommon, occurring in only 1.9% patients in the IC (pulmonary embolism [PE] in 5 patients, CRT in 1 patient and left ventricular thrombus in 1 patient) vs. 2.4% patients in the HC (deep vein thrombosis +/- PE in 3 patients, CRT and PE in 1 patient) (p=0.7). In contrast, bleeding complications were frequent (even in the absence of anticoagulants), with 13.3% of patients in the IC and 19.3% of patients in the HC experiencing at least one bleeding episode (p=0.08). 22 patients (6.1%) in the IC and 8 patients (4.8%) in the HC died during the study period. While fatal bleeding events occurred in 2 patients in each cohort in the absence of anticoagulation, no deaths due to VTE were observed. Conclusions After introduction of a standardized protocol, VTE prophylaxis rate in hospitalized LBMT patients significantly increased by over 2-fold but remains low. No changes in bleeding and VTE rates were observed despite the increase in prophylaxis compliance. Although thrombocytopenia is likely the prime reason for withholding prophylaxis, further review is ongoing to elucidate the reasons why thromboprophylaxis was not prescribed in the majority of patients. Disclosures: No relevant conflicts of interest to declare.

Increased Enoxaparin Dosing for Venous Thromboembolism Prophylaxis in General Trauma Patients

2016 ◽  
Vol 51 (4) ◽  
pp. 323-331 ◽  
Author(s):  
Cheri K. Walker ◽  
Elizabeth A. Sandmann ◽  
Taylor J. Horyna ◽  
Mark A. Gales
Keyword(s):  
Venous Thromboembolism ◽  
Trauma Patient ◽  
Patient Population ◽  
Standard Dose ◽  
Bleeding Complications ◽  
Trauma Patients ◽  
Dosing Regimen ◽  
Thromboembolism Prophylaxis ◽  
General Trauma ◽  
Vte Prophylaxis

Objective: To review the evidence regarding increased enoxaparin dosing for venous thromboembolism (VTE) prophylaxis in the general trauma patient population. Data Sources: A search of MEDLINE databases (1946 to October 2016) was conducted using the search terms enoxaparin, thromboembolism prophylaxis, venous thromboembolism, trauma, anti-factor Xa, and weight-based dosing. Additional references were identified from a review of literature citations. Study Selection and Data Extraction: Search results were limited to English-language studies conducted in humans. Trials that included only obese patients or nontrauma patients were excluded. Data Synthesis: A total of 7 trials (958 patients) explored the use of increased dosing of enoxaparin for VTE prophylaxis in trauma patients. Patients were divided by enoxaparin dosing strategies: standard dosing of 30 mg twice daily (BID; n = 509), higher initial dosing regimen (n = 216), or dosing based on anti-FXa level adjustments (n = 233). The majority of the 42 total VTE events (64.3%) occurred in the standard dosing regimen. Within each group, VTE was reported in 5.3% of patients in the standard dosing group, 3.2% in the higher initial dosing group, and 4% in the anti-FXa adjustment group. Initial subtherapeutic anti-FXa levels occurred in 33% to 92% of standard dose patients and 9% to 39% of higher initial dose patients. The average weight-based dose required to achieve a therapeutic level ranged between 0.43 and 0.54 mg/kg/dose BID. The overall rate of bleeding was low, with 3 incidents (0.37%) reported. Conclusion: Standard-dose enoxaparin prophylaxis may not be optimal for the general trauma patient population. Weight-based enoxaparin dosing (0.5 mg/kg/dose BID) is an option in trauma patients considered to be at a lower risk of bleeding complications.

scholarly journals Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: ASCO Clinical Practice Guideline Update

2020 ◽  
Vol 38 (5) ◽  
pp. 496-520 ◽  
Author(s):  
Nigel S. Key ◽  
Alok A. Khorana ◽  
Nicole M. Kuderer ◽  
Kari Bohlke ◽  
Agnes Y.Y. Lee ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
Medical Condition ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Signs And Symptoms ◽  
Cochrane Library ◽  
Thromboembolism Prophylaxis ◽  
Vte Prophylaxis ◽  
Patients With Cancer ◽  
Increased Risk

PURPOSE To provide updated recommendations about prophylaxis and treatment of venous thromboembolism (VTE) in patients with cancer. METHODS PubMed and the Cochrane Library were searched for randomized controlled trials (RCTs) and meta-analyses of RCTs published from August 1, 2014, through December 4, 2018. ASCO convened an Expert Panel to review the evidence and revise previous recommendations as needed. RESULTS The systematic review included 35 publications on VTE prophylaxis and treatment and 18 publications on VTE risk assessment. Two RCTs of direct oral anticoagulants (DOACs) for the treatment of VTE in patients with cancer reported that edoxaban and rivaroxaban are effective but are linked with a higher risk of bleeding compared with low-molecular-weight heparin (LMWH) in patients with GI and potentially genitourinary cancers. Two additional RCTs reported on DOACs for thromboprophylaxis in ambulatory patients with cancer at increased risk of VTE. RECOMMENDATIONS Changes to previous recommendations: Clinicians may offer thromboprophylaxis with apixaban, rivaroxaban, or LMWH to selected high-risk outpatients with cancer; rivaroxaban and edoxaban have been added as options for VTE treatment; patients with brain metastases are now addressed in the VTE treatment section; and the recommendation regarding long-term postoperative LMWH has been expanded. Re-affirmed recommendations: Most hospitalized patients with cancer and an acute medical condition require thromboprophylaxis throughout hospitalization. Thromboprophylaxis is not routinely recommended for all outpatients with cancer. Patients undergoing major cancer surgery should receive prophylaxis starting before surgery and continuing for at least 7 to 10 days. Patients with cancer should be periodically assessed for VTE risk, and oncology professionals should provide patient education about the signs and symptoms of VTE. Additional information is available at www.asco.org/supportive-care-guidelines .

scholarly journals Minor Hematochezia Decreases Use of Venous Thromboembolism Prophylaxis in Patients with Inflammatory Bowel Disease

2019 ◽  
Vol 26 (9) ◽  
pp. 1394-1400 ◽  
Author(s):  
Adam S Faye ◽  
Kenneth W Hung ◽  
Kimberly Cheng ◽  
John W Blackett ◽  
Anna Sophia Mckenney ◽  
...  
Keyword(s):  
Inflammatory Bowel Disease ◽  
Venous Thromboembolism ◽  
Bowel Disease ◽  
Hospitalized Patients ◽  
High Yield ◽  
Thromboembolism Prophylaxis ◽  
Vte Prophylaxis ◽  
Factors Associated ◽  
Increased Risk ◽  
Inflammatory Bowel

Abstract Background Despite increased risk of venous thromboembolism (VTE) among hospitalized patients with inflammatory bowel disease (IBD), pharmacologic prophylaxis rates remain low. We sought to understand the reasons for this by assessing factors associated with VTE prophylaxis in patients with IBD and the safety of its use. Methods This was a retrospective cohort study conducted among patients hospitalized between January 2013 and August 2018. The primary outcome was VTE prophylaxis, and exposures of interest included acute and chronic bleeding. Medical records were parsed electronically for covariables, and logistic regression was used to assess factors associated with VTE prophylaxis. Results There were 22,499 patients studied, including 474 (2%) with IBD. Patients with IBD were less likely to be placed on VTE prophylaxis (79% with IBD, 87% without IBD), particularly if hematochezia was present (57% with hematochezia, 86% without hematochezia). Among patients with IBD, admission to a medical service and hematochezia (adjusted odds ratio 0.27; 95% CI, 0.16–0.46) were among the strongest independent predictors of decreased VTE prophylaxis use. Neither hematochezia nor VTE prophylaxis was associated with increased blood transfusion rates or with a clinically significant decline in hemoglobin level during hospitalization. Conclusion Hospitalized patients are less likely to be placed on VTE prophylaxis if they have IBD, and hematochezia may drive this. Hematochezia appeared to be minor and was unaffected by VTE prophylaxis. Education related to the safety of VTE prophylaxis in the setting of minor hematochezia may be a high-yield way to increase VTE prophylaxis rates in patients with IBD.

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