Heparin, Enoxaparin, and Mechanical Prophylaxis Utilization Evaluation in DVT Prophylaxis in a Major Teaching Hospital in West of Iran

Background: Considering the high prevalence and risk of Deep Vein Thrombosis (DVT) and pulmonary thromboembolism (PTE) in hospitalized patients and the existence of different prophylaxis methods in these patients, the necessity of evaluating the rational administration of heparin or enoxaparin and mechanical prophylaxis is one of the important priorities. The present study aimed to evaluate the consistency of the Heparin/Enoxaparin administration in comparison to guidelines in patients admitted to Imam Reza Hospital. Methods: In this prospective study drug use evaluation (DUE), 300 hospitalized patients receiving venous thrombosis prophylaxis were enrolled, of which 150 patients were selected from surgical wards and 150 patients from internal wards. The demographic and clinical data of patients were collected using clinical records of them. We used the checklists based on the Geneva System for patients admitted to internal wards and the Caprini Questionnaire for patients in surgical wards to evaluate whether patients had received heparin/enoxaparin prophylaxis and mechanical DVT prevention according to guidelines. Results: In the surgical ward, prophylactic treatment for venous thrombosis was administered in 85 (56.6%) patients admitted to surgical wards in accordance with the clinical guideline and in the internal ward, in 42 (28%) patients, with a significant difference between two sections (P: 0.0001). Mechanical prophylaxis, including compressive socks, was performed in 99 (66%) patients in the surgical ward and in the internal ward only in 56 (37.4%) patients, according to the guideline. Drug prophylaxis was administered in surgical wards in 116 (77.3%) patients and in internal wards, in 79 (52.6%) patients according to the guideline. Conclusion: Intravenous thrombosis prophylaxis, according to the guidelines, is more common in patients admitted to surgical wards than in internal wards. But in both sectors, statistics are far from international standards.

Patients with venous thromboembolism after spontaneous intracerebral hemorrhage: a review

Background Patients with spontaneous intracerebral hemorrhage (ICH) have a higher risk of venous thromboembolism (VTE) and in-hospital VTE is independently associated with poor outcomes for this patient population. Methods A comprehensive literature search about patients with VTE after spontaneous ICH was conducted using databases MEDLINE and PubMed. We searched for the following terms and other related terms (in US and UK spelling) to identify relevant studies: intracerebral hemorrhage, ICH, intraparenchymal hemorrhage, IPH, venous thromboembolism, VTE, deep vein thrombosis, DVT, pulmonary embolism, and PE. The search was restricted to human subjects and limited to articles published in English. Abstracts were screened and data from potentially relevant articles was analyzed. Results The prophylaxis and treatment of VTE are of vital importance for patients with spontaneous ICH. Prophylaxis measures can be mainly categorized into mechanical prophylaxis and chemoprophylaxis. Treatment strategies include anticoagulation, vena cava filter, systemic thrombolytic therapy, catheter-based thrombus removal, and surgical embolectomy. We briefly summarized the state of knowledge regarding the prophylaxis measures and treatment strategies of VTE after spontaneous ICH in this review, especially on chemoprophylaxis and anticoagulation therapy. Early mechanical prophylaxis, especially with intermittent pneumatic compression, is recommended by recent guidelines for patients with spontaneous ICH. While decision-making on chemoprophylaxis and anticoagulation therapy evokes debate among clinicians, because of the concern that anticoagulants may increase the risk of recurrent ICH and hematoma expansion. Uncertainty still exists regarding optimal anticoagulants, the timing of initiation, and dosage. Conclusion Based on current evidence, we deem that initiating chemoprophylaxis with UFH/LMWH within 24–48 h of ICH onset could be safe; anticoagulation therapy should depend on individual clinical condition; the role of NOACs in this patient population could be promising.

A Review of Current and Future Antithrombotic Strategies in Surgical Patients—Leaving the Graduated Compression Stockings Behind?

Venous thromboembolism (VTE) remains an important consideration within surgery, with recent evidence looking to refine clinical guidance. This review provides a contemporary update of existing clinical evidence for antithrombotic regimens for surgical patients, providing future directions for prophylaxis regimens and research. For moderate to high VTE risk patients, existing evidence supports the use of heparins for prophylaxis. Direct oral anticoagulants (DOACs) have been validated within orthopaedic surgery, although there remain few completed randomised controlled trials in other surgical specialties. Recent trials have also cast doubt on the efficacy of mechanical prophylaxis, especially when adjuvant to pharmacological prophylaxis. Despite the ongoing uncertainty in higher VTE risk patients, there remains a lack of evidence for mechanical prophylaxis in low VTE risk patients, with a recent systematic search failing to identify high-quality evidence. Future research on rigorously developed and validated risk assessment models will allow the better stratification of patients for clinical and academic use. Mechanical prophylaxis’ role in modern practice remains uncertain, requiring high-quality trials to investigate select populations in which it may hold benefit and to explore whether intermittent pneumatic compression is more effective. The validation of DOACs and aspirin in wider specialties may permit pharmacological thromboprophylactic regimens that are easier to administer.

Does intraoperative mechanical prophylaxis prevent venous thromboembolism in total knee arthroplasty? – effectiveness of passive-assisted ankle motion in surgical/non-surgical side

Background Gradual compression stocking (GCS) and intermittent pneumatic compression device (IPCD) are used for intraoperative mechanical prophylaxis against venous thromboembolism (VTE) during total knee arthroplasty (TKA). In this study, we applied a passive-assisted ankle motion in combination with GCS and IPCD during TKA and evaluated its effectiveness in preventing postoperative VTE. Methods We included 77 patients who underwent primary unilateral TKA. Patients were divided into group A (53 patients who underwent GCS and IPCD on their non-surgical side limb) and group B (24 patients who underwent passive ankle dorsiflexion motion in addition to GCS and IPCD on their non-surgical side limb). Deep vein thrombosis (DVT) was assessed using lower extremity ultrasonography (US). The incidence of VTE in each affected limb was compared between the two groups. Results US was performed 4 days after surgery on average. The incidence of DVT in groups A and B was 47.2 and 70.8 %, respectively. In group A, 22.6 % of DVTs were found only on the surgical side, 11.3 % on the non-surgical side, and 13.2 % on both sides. On the other hand, in group B, 41.7 % of DVTs were found only on the surgical side, 4.2 % on the non-surgical side, and 25.0 % on both sides. No significant difference in the incidence of VTE was noted between the 2 groups. Conclusions The intraoperative application of passive ankle motion plus GCS and IPCD might not further reduce the incidence of postoperative DVT in TKA patients.

Risk factors for venous thromboembolism in patients with diabetes undergoing joint arthroplasty

Background Venous thromboembolism (VTE) is a significant complication after joint arthroplasty. Diabetes is related to a few changes in coagulation and fibrinolysis that may lead to thrombophilia. We aimed to investigate the incidence of postoperative VTE and associated risk factors among patients with diabetes undergoing total hip (THA) or total knee anthroplasty (TKA) in a single centre in China. Methods Patients with diabetes who underwent THA or TKA from January 2016 to December 2018 (n = 400) at Beijing Jishuitan Hospital were recruited in this study. Lower limb venous Doppler ultrasound was performed before and after surgery to confirm deep venous thrombosis (DVT). Computer tomography pulmonary angiography was done to confirm pulmonary embolism (PE) for those with new postoperative DVT and typical symptoms of PE. A multivariate logistic regression model was conducted to examine factors associated with the development of postoperative VTE. Results The overall incidence of postoperative VTE in patients with diabetes after THA or TKA was 46.8 % (187 out of 400). Among the 187 VTE patients, 7.5 % (14 out of 187) had proximal vein thrombosis and 92.5 % (173 out of 187) had distal vein thrombosis. No PE occurred. Female patients and patients undergoing TKA had higher incidence of postoperative VTE. Patients who developed postoperative VTE were older, and had higher levels of preoperative D-Dimer and Caprini score. A high level of preoperative D-dimer (OR = 2.11, 95 %CI = 1.35–3.30) and the surgery of TKA (OR = 2.29, 95 %CI = 1.29–4.01) significantly increased the risk of developing postoperative VTE. Postoperative initiation of concomitant mechanical prophylaxis and low molecular weight heparin (LMWH) was protective for postoperative VTE (OR = 0.56, 95 %CI = 0.37–0.86). Conclusions VTE is common in patients with diabetes undergoing joint arthroplasty. Patients undergoing TKA or with a high level of preoperative D-dimer are at a considerable risk of developing postoperative VTE. There may be a protective role of postoperative initiation of concomitant mechanical prophylaxis and LMWH for VTE.

Venous thromboembolism complications in shoulder surgery: current concepts

Venous thromboembolism (VTE) is a rare yet known complication of shoulder surgery. Concerning shoulder arthroplasty, reported rates of VTE range from 0.2% to 16%. Unlike many lower extremity procedures, particularly total hip and knee arthroplasty, chemical prophylactic guidelines for VTE in shoulder surgeries have not been established. Some argue that doing so is unnecessary. On the contrary, mechanical prophylaxis is nearly universally accepted in shoulder surgery, particularly for more lengthy procedures. With limited VTE incidence in shoulder surgery, treatment is anecdotally derived from the hip and knee arthroplasty literature. Recent studies have successfully identified risk factors for VTE related to the patient and to the surgery itself. Awareness of these risk factors by the surgeon and declaration of these factors to the patient should be discussed as part of the informed consent process. Further investigational studies and larger patient cohorts will be necessary to optimise VTE prevention in shoulder surgeries.

Venous Thromboembolism Prophylaxis in Adolescent Patients with Sickle Cell Disease: A Multicenter Cohort Study

Background: Evolving pediatric data, including case reports, case series, and combined adult and adolescent cohort studies, suggest an increased prevalence of venous thromboembolism (VTE) in children with Sickle Cell Disease (SCD) who undergo central venous catheter (CVC) placement (Ko RH and Thornburg C, Front Pediatr, 2017). Additionally, VTE has been shown to affect patients with SCD at a younger age compared to African-American controls (Stein PD, et al, Am J Med, 2006). Anecdotally, pediatric hematologists acknowledge the VTE risk in pediatric patients with SCD and have been using thromboprophylaxis in their patients despite the lack of standardized guidelines. The goal of this retrospective cohort study is to assess the utilization of pharmacologic and non-pharmacologic thromboprophylaxis in adolescent patients with SCD using a large pediatric database. Methods: The data source for this multicenter cohort study was the Pediatric Health Information Systems (PHIS), an administrative database that contains clinical and resource utilization data for inpatient, ambulatory surgery, emergency department, and observation unit patient encounters for 49 freestanding children's hospitals in the US. ICD-9-CM and ICD-10-CM codes were used to identify subjects, including SCD genotype (SS, SC and SB0 thal) and other comorbidities (acute chest syndrome, vaso-occlusive crisis, osteomyelitis, and bacteremia). We included subjects, aged 13-21 years, admitted to any PHIS hospital between 01/01/2010 - 12/31/2019. Subjects with a history of VTE were excluded. Supply billing codes were used to identify CVC placement and mechanical prophylaxis. Pharmaceutical billing codes were used to identify anticoagulant use. Results: 6,903 unique patients (3,147 male) met inclusion criteria with a median age of 17.2 years (13.0-21.9 years). These patients comprised a total of 33,298 admissions, with 2,434 (7.3%) admissions identified as receiving pharmacologic or mechanical prophylaxis (Table 1). 4.3% of the total admissions received mechanical prophylaxis and 3.3% received pharmacologic prophylaxis. Enoxaparin was the most commonly used anticoagulant, utilized in 91.3% of admissions in which pharmacologic anticoagulation was prescribed. The use of thromboprophylaxis was noted to increase over the study period, with significant increases observed in both pharmacologic and mechanical prophylaxis(p<.0001; Figure 1). The percentage of unique patients receiving thromboprophylaxis at each participating institution is shown in Figure 2. WConclusions: Use of both pharmacologic and mechanical thromboprophylaxis in hospitalized adolescent patients with SCD has increased in the last decade. However, there is variability amongst pediatric hospitals regarding the use and preferred method of thromboprophylaxis. Prospective cohort studies are needed to determine VTE risk factors in adolescents and children with SCD and the efficacy of prophylaxis regimens. These studies will help guide the development of VTE prophylaxis regimens. Disclosures Davila: ATHN: Other: Grant Funding; Spire Learning: Speakers Bureau. O'Brien:Bristol Myers Squibb: Consultancy, Membership on an entity's Board of Directors or advisory committees. OffLabel Disclosure: The use of Direct Oral Anticoagulants and Enoxaparin in children