Top Ten Reasons For Failure To Prevent Postoperative Thrombosis

Transcription

1 Top Ten Reasons For Failure To Prevent Postoperative Thrombosis Joseph A. Caprini, MD, MS, FACS, RVT, FACCWS Louis W. Biegler Chair of Surgery NorthShore University HealthSystem, Evanston, IL Clinical Professor of Surgery University of Chicago Pritzker School of Medicine, Chicago, IL

2 Disclosures Nothing to disclose related to this subject

3 Young Patients Having Surgery Rarely Suffer From VTE

4 Fatal Pulmonary Embolus Patient was a 31 year old obese female suffered a fibular fracture and placed in short-leg cast Seven days later began to complain of mild shortness of breath and slight anxiety returning to work Day 8 stayed home since symptoms slightly worse Day 9 suffered cardiac arrest and died at home Autopsy showed large bilateral pulmonary emboli and DNA analysis positive for Factor V Leiden She had a father and sister with past PE NO ONE ASKED HER ABOUT FAMILY HISTORY NOR WARNED HER ABOUT SYMPTOMS OF VENOUS THROMBOEMBOLISM Settled in favor of the patient s family 2015

5 Best Way To Protect Patients With Past VTE Is Using A Perioperative Vena-cava Filter

6 Summary VC Filters VTE is a serious problem & IVC Filters do not treat VTE IVC Filters have absolutely NO benefit for: Prevention of DVT Extension of DVT Recurrence of DVT Post thrombotic syndrome Lack of evidence on efficacy and cost-effectiveness Number of IVC filters is increasing dramatically Variations (States, Hospitals, Trauma Centers, Patient Insurance Status, Malpractice Claims) If IVC filter leads to incomplete treatment of VTE, patient s condition may actually worsen

7 Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism (PREPIC2) The filter was successfully inserted in 193 patients and retrieved 153 of 164 patients. By 3 months, recurrent pulmonary embolism had occurred in 6 patients (3.0%; all fatal) in the filter group and in 3 patients (1.5%; 2 fatal) in the control group (P =.50). Results were similar at 6 months. No difference was observed between the 2 groups regarding the other outcomes. Filter thrombosis occurred in 3 patients JAMA. 2015;313(16): doi: /jama

8 We Consider Patients On Crutches Or A Leg Cast To Be Ambulatory So They Do Not Need Prophylaxis

9 Low Molecular Weight Heparin For Prevention Of Venous Thromboembolism In Patients With Lower-leg Immobilization Immobilization of the lower limb with plaster cast or brace in adult patients is associated with deep venous thrombosis (DVT). Six randomized controlled trials were found and judged to be of sufficient quality to use in a meta-analysis. The trials involved 1490 patients: 750 patients received LMWH subcutaneously once daily; 740 patients received no prophylaxis or placebo. Incidence rates of DVT ranging from 4.3% to 40% were found in the control group We conclude that LMWH should be considered in adult patients with immobilization of the lower leg to prevent occurrence of venous thromboembolism. It should not only be considered in patients with an above-knee cast but also in patients with a below-knee cast. LMWH can safely be used for this indication Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD DOI: / CD pub3.

10 We Never See Venous Thromboembolism After Foot And Ankle Surgery

11 The Impact Of Risk Assessment On The Implementation Of Venous Thromboembolism Prophylaxis In Foot And Ankle Surgery Study included 216 patients. A variety of operative procedures was carried out with the common denominator being a below knee cast for at least 4 weeks and non-weight bearing for an average of 6 weeks in 130 patients No VTE developed in the hallux subgroup, (patients allowed to weight bear), the incidence of VTE in the cast/non-weight bearing group was 8.46%. Ninety percent of patients in the VTE group had a total risk factor score of 5 or more compared to 73% in the non- DVT group. average timing to the diagnosis of VTE in this current study was 33.1 days. Given the overall incidence of VTE in the non-weight bearing group prophylaxis is recommended for these patients. Saragas, NP et al Foot and Ankle Surgery 20 (2014) 85 89

12 Most VTE Occur During Hospitalization So Outpatient Prophylaxis Is Unnecessary

13 Time Course And Clinical Presentation Of Postoperative VTE In RIETE Cumulative incidence % PE Distal DVT Proximal DVT Arcelus JI, et al. Thromb Haemost. 2008;99: % Days 55% of VTEs were diagnosed after prophylaxis was discontinued hours 48 hours 7 days 15 days 30 days 60 days Clinically overt PE 22 (2.8%) 41 (5.2%) 149 (19%) 376 (48%) 608 (77%) 787 Distal DVT 2 (1.1%) 5 (2.78%) 34 (19%) 98 (54%) 145 (80%) 182 Proximal DVT 9 (1.4%) 21 (3.3%) 91 (14%) 248 (39%) 432 (68%) 633

14 When Do Pulmonary Emboli Occur Total PEs were 6,624 out of 2,001,405 patients: NSQIP Database: : (2,130 PEs out of 651,940 patients) Marangoni, Jim :Legacy Good Samaritan Medical Center

15 Following SCIP Guidelines During Hospitalization Is Adequate To Prevent Postoperative VTE

16 Association Between Surgical Care Improvement Program Venous Thromboembolism Measures And Postoperative Events Study evaluated SCIP-VTE adherence for 30,531 operations from 2006 to 2009 linked with VA Surgical Quality Improvement Program data. It was noted that 89.9% of the patients adhered to the SCIP-VTE measure and 1.4% suffered a VTE event. The incidence of VTE events in those not complying with the SCIP-VTE mandate was 1.3% The authors concluded that there was no association between SCIP-VTE adherence and the incidence of postoperative VTE. Altom LK, Deierhoi RJ, Grams J et al; Am J Surg: (2012) 204,

17 Negative D-dimer Levels 30 Days After Stopping Anticoagulants Is Sufficient To Predict A Low Incidence Of Recurrent DVT

18 We Do Not Ask About Family History Of Thrombosis Since It Doesn t Matter

19 Familial Risk Of Venous Thromboembolism In total 183,515 patients with VTE were included whose relatives were hospitalized for VTE, and those whose relatives were unaffected by VTE. The present data showed an increased VTE risk among not only first-degree relatives but also secondand third-degree relatives. Other studies suggest that only 30% of family history is explained by the major known inherited Thrombophilias. Zöller B, Ohlsson H, Sundquist J, Sundquist K: Thromb Haemost 2013; 109:

20 Patients Having Outpatient Surgery Are Ambulatory So They Do Not Need Prophylaxis

21 Identifying Patients at High Risk for Venous Thromboembolism Requiring Treatment After Outpatient Surgery Prospective observational cohort study using the ACS-NSQIP database in patients who had outpatient surgery or surgery with subsequent 23-hour observation. Patients were assigned to derivation (N = 173,501) or validation (N = 85,730) cohorts and Logistic regression examined independent risk factors for 30-day VTE A weighted index was created and validated using the main outcome measure of 30-day VTE requiring treatment. The risk index identifies a high-risk subgroup of patients with 30-day VTE rates of 1.18%. Pannucci CJ, Shanks A, Moote M, et al: Ann Surg 2012;255: )

22 Postoperative Anxiety And Shortness Of Breath Are Normal Reactions To Surgery And Will Resolve With Time

23 Acute Pulmonary Emboli The mortality rate associated with PE exceeds 15% in the first 3 months after diagnosis. In nearly 25% of patients with PE, the initial clinical manifestation is sudden death. Patients without underlying cardiopulmonary disease may appear anxious but otherwise well compensated despite an anatomically large PE. Mild shortness of breath, weakness, and increased heart rate may be subtle premonitory signs in young patients before the fatal event occurs. Piazza G, Goldhaber SZ: Circulation. 2006;114:e28-e32.)