TO ASSESS THE INCIDENCE OF DVT AMONG PATIENTS OF LOWER LIMB SURGERIES /LOWER LIMB TRAUMA ADMITTED TO ST. STEPHEN?S HOSPITAL

Background: This study therefore aimed to assess the incidence of DVT among patients of lower limb surgeries /lower limb trauma admitted to St. Stephen?s hospital Methods: The prospective study was conducted at St Stephen?s hospital from Jan 2019 to December 2019 for duration of 1 year, and 104 patients were part of the study. Results: The overall prevalence of DVT in our study was found to be 2.8%. Out of 3 DVT cases 2 were found in males (3.4%) and 1 was a female (2.1%). Conclusion: There is comparable incidence of DVT in our patients as compared to the incidence found in world literature. There is a need to institute DVT prophylaxis in patients undergoing major lower limb surgeries. Keywords: DVT, Lower limb, Trauma

Incidences of deep vein thrombosis and major bleeding under the administration of fondaparinux for thromboprophylaxis after periacetabular osteotomy: a retrospective observational study

ABSTRACT Periacetabular osteotomy (PAO) is an effective joint-preserving procedure for patients with developmental dysplasia of the hip. Although deep vein thrombosis (DVT) is considered a serious complication of orthopaedic surgery, there is no consensus regarding a thromboprophylaxis strategy after PAO. We have routinely administered fondaparinux for DVT prophylaxis in adult patients undergoing PAO. The aim of this study was to investigate the incidences of DVT and major bleeding under the administration of fondaparinux for thromboprophylaxis after PAO. A total of 95 patients (100 hips) who underwent PAO with post-operative administration of fondaparinux for thromboprophylaxis were retrospectively enrolled. The incidences of DVT on ultrasound, major bleeding, and administration cessation were evaluated. Asymptomatic DVT occurred in one patient, major bleeding occurred in 14 hips and the administration of fondaparinux was stopped in 17 hips. Given the observed incidence of major bleeding, safer DVT prophylaxis modalities should be considered during PAO.

Gall bladder carcinoma associated with anticoagulation-resistant, progressive, multi-focal venous thrombosis and gangrene of all limbs: a case report and review of literature

Cancer being a prothrombotic state, frequently has vascular complications, venous thrombosis, embolism, recurrent venous thromboembolism and a high frequency of anticoagulant failure. We present a rare case of anticoagulant-resistant, progressive, multifocal venous thrombosis and gangrene in all four limbs in a patient with carcinoma gallbladder. A 49 year old lady with locally advanced gallbladder cancer who had been on routine perioperative deep venous thrombosis (DVT) prophylaxis presented two months later with deep venous thrombosis of both lower limbs progressing to venous gangrene of both feet, despite being on anticoagulation. 7 days later, she presented with venous gangrene of both hands. Shortly thereafter, she developed right facial paralysis due to thrombus in the segmental branch of the left MCA despite being on anticoagulation. The hypercoagulable state in cancer involves procoagulant molecules produced by tumor cells, suppression of fibrinolytic activity and platelet activation and is contributed by interactions between the coagulation cascade, complement pathway and immune system. Upto 15% of patients with cancer will develop DVT following surgery, despite standard DVT prophylaxis. Extended DVT prophylaxis should be considered in high-risk patients. Patients with metastases should continue with indefinite anticoagulant therapy after a thrombotic event. In patients without metastasis, anticoagulant treatment is recommended for as long as the cancer is active and while the patient is receiving antitumor therapy. This rare case has been presented to highlight the hypercoagulable state of cancer, the importance of long-term anticoagulation in advanced and metastatic cancers and the high rate of anticoagulation failure associated with unfavourable tumor biology.

Design and Retrospective Application of a Spine Trauma DVT Prophylaxis Protocol on Level 1 Trauma Center Patient Database

Study Design: Systematic literature review. Objectives: The impact of thromboembolic disease on the morbidity and mortality of patients with acute spinal cord injury is well documented, with rates as high as 67%-100% among untreated patients. The efficacy of mechanical prophylaxis as a stand-alone measure has been questioned, so we sought to determine a safe perioperative window for chemical anticoagulation use after spine surgery. Many surgeons have concerns anticoagulants may cause post-operative hematoma. Methods: A systematic literature review was performed, ultimately yielding 13 articles. Based on the existing literature and input from our multidisciplinary institutional trauma committee, a Spine Trauma DVT Prophylaxis Protocol was developed. Results: Effort was placed to identify cases within our institution in which patients suffered vertebral column fractures and/or spinal cord injuries. Of these 466 vertebral column fractures and/or spinal cord injuries, 4 patients were identified and diagnosed with DVTs while admitted. Conclusions: Of these patients, there is a clear dilemma with regard to safety of chemoprophylaxis use versus risk of developing a DVT. Though none of the patients developed a PE, utilizing the protocol would have led to earlier IVC filter placement or initiation of a VTE surveillance protocol in 2 of the patients. Initiation of enoxaparin before surgery in one patient (despite delay of surgical timing) may have avoided his subsequent LUE DVT. Though not appropriate for all clinical scenarios, we are confident that our treatment algorithm will prove beneficial for patient care in avoiding DVTs and helping trauma surgeons with evidence-based clinical decision making.

P16: PHYSICAL THERAPIES FOR DVT PROPHYLAXIS IN SURGICAL PATIENTS: A SYSTEMATIC REVIEW AND EVIDENCE QUALITY APPRAISAL

Introduction Venous thromboembolism represents a significant clinical and socioeconomic burden. Surgical patients are an inherently high-risk cohort for VTE although traditional prophylactic pharmacological therapies are contraindicated in select cohorts. Novel physical therapies such as calf exercises and electrostimulation have been proposed for such patients. The aim of this systematic review is to appraise the clinical utility of novel physical therapies used for DVT prophylaxis in surgical and trauma patients. Method A systematic review of MEDLINE, EMBASE and CINAHL using a PRISMA-compliant methodology up to July 2019 was conducted. Abstract screening and data extraction were performed in duplicate. Risk of bias and quality assessments were performed for each study using the GRADE framework. Result A total of 272 articles were identified, of which 10 met inclusion criteria. Five studies evaluated the use of calf electrostimulation, the remaining studies evaluated active toe movement, bespoke compression bandages, blood flow restriction exercises, calf massage and a portable compression device. Four randomized controlled trials demonstrated a significant reduction in radiological DVT incidence with electrostimulation, post-operative massage and pneumatic compression versus controls. All included studies had a moderate to high risk of bias. Conclusion The role of physical therapies as prophylactic measures in VTE remain equivocal. No study demonstrated a significant reduction in clinically evident DVT. The physical therapies can be beneficial in patients who also received pharmacological therapy, whilst physical therapies alone may be of no benefit. Heterogenous study design and poor methodological quality limit comparison of study findings at present. Take-home message Physical therapies as prophylactic measures in venous thromboembolism may offer benefit when combined with pharmacotherapy. When used alone, physical therapies may offer no benefit.

Deep Venous Thrombosis Prophylaxis Practices in Surgical Intensive Care Unit Patients: A Cross-sectional Study

Introduction: Deep Venous Thrombosis (DVT) is one of the critical complications which can occur in patients subsequent to surgeries. The patients in Surgical Intensive Care Units (SICU) have increased propensity to have DVT due to prolonged immobilisation, invasive interventions and other risk factors. It is important to prevent DVT as this can lead to catastrophic Pulmonary Embolism (PE) and balance the risk of haemorrhages due to pharmacotherapy. Aim: To observe the DVT prophylaxis methods and to compare the incidence of DVT in the different methods used in SICU. Materials and Methods: The present study was a prospective cross-sectional study in which 62 patients, aged between 18-70 years admitted in SICU for more than or equal to two days, were included in the study. Patients on drugs affecting cardiovascular system and having significant co-morbidities and coagulation abnormalities, that can impact the occurrence of DVT, were excluded. All patients were followed-up till 28 days or ICU discharge, whichever was later. Patients were evaluated for type of prophylaxis for DVT that included any of mechanical interventions {such as stockings or Sequential Compression Devices (SCD)} or pharmacotherapy (Low molecular weight heparin or Unfractionated heparin) or a combination of both. Statistical analysis was carried out using Student’s t-test and Chi-square test. Results: Thirty (48.39%) patients were given both mechanical and pharmacotherapy, 12 (19.35%) had used only mechanical interventions and 20 (32.26%) had used pharmacotherapy alone for DVT prophylaxis. The overall incidence of DVT was 3.33% (one patient) for patients receiving both mechanical and pharmacotherapy whereas it was 10% (two) for those receiving pharmacotherapy alone and 16.67% (two) for those using mechanical intervention alone. Incidence of haemorrhage was highest in pharmacotherapy alone {three patients (15%)}. The overall dose of drugs used as pharmacotherapy was the least in those receiving dual interventions compared to that of patients receiving pharmacotherapy alone. Conclusion: Pharmacotherapy and pressure stockings together are an ideal therapy for DVT prophylaxis.