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Kobzeva-Herzog AJ, Ravandur A, Wilson SB, Rosenkranz P, Talutis SD, Macht R, Cassidy MR, Siracuse JJ, McAneny D. Sustained success of a Caprini postoperative venous thromboembolism prevention protocol over one decade. Am J Surg 2024:115783. [PMID: 38834419 DOI: 10.1016/j.amjsurg.2024.115783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 05/04/2024] [Accepted: 05/27/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND The objective of this study was to review the long-term efficacy of a post-operative venous thromboembolism (VTE) prevention program at our institution. METHODS We performed a review of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data at our hospital from January 2008-December 2022. The primary outcome was risk-adjusted VTE events. RESULTS In 2009, a postoperative general surgery patient was three times more likely to have a postoperative VTE event than predicted (O/E ratio 3.02, 95% CI 1.99-4.40). After implementing a mandatory VTE risk assessment model and a risk-commensurate prophylaxis protocol in the electronic medical record in 2011, the odds ratio of a patient developing a postoperative VTE declined to 0.70 by 2014 (95% CI 0.40-1.23). This success persisted through 2022. CONCLUSIONS Since the implementation of a standardized postoperative VTE prevention program in 2011, our institution has sustained a desirably low likelihood of VTE events in general surgery patients.
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Affiliation(s)
- Anna J Kobzeva-Herzog
- Department of Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, MA, USA.
| | - Akshay Ravandur
- Department of Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, MA, USA
| | - Spencer B Wilson
- Department of Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, MA, USA
| | - Pamela Rosenkranz
- Department of Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, MA, USA
| | - Stephanie D Talutis
- Division of Vascular Surgery, Cardiovascular Center, Tufts Medical Center, Boston, MA, USA
| | - Ryan Macht
- Department of Surgery, Dignity Health Medical Foundation-Sequoia Hospital, Belmont, CA, USA
| | - Michael R Cassidy
- Department of Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, MA, USA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, MA, USA
| | - David McAneny
- Department of Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, MA, USA
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2
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Edwards MA, Brennan E, Rutt AL, Muraleedharan D, Casler JD, Spaulding A, Colibaseanu D. Venous Thromboembolism Prophylaxis in Otolaryngologic Patients Using Caprini Assessment. Laryngoscope 2024; 134:1169-1182. [PMID: 37740910 DOI: 10.1002/lary.31041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 08/13/2023] [Accepted: 08/28/2023] [Indexed: 09/25/2023]
Abstract
OBJECTIVE The aim was to determine the utilization of Caprini guideline-indicated venous thromboembolism (VTE) prophylaxis and impact on VTE and bleeding outcomes in otolaryngology (ORL) surgery patients. METHODS Elective ORL surgeries performed between 2016 and 2021 were retrospectively identified. Logistic regression models were used to examine the association between patient characteristics and receiving appropriate prophylaxis, inpatient, 30- and 90-day VTE and bleeding events. RESULTS A total of 4955 elective ORL surgeries were analyzed. Thirty percent of the inpatient cohort and 2% of the discharged cohort received appropriate risk-stratified VTE prophylaxis. In those who did not receive appropriate prophylaxis, overall inpatient VTE was 3.5-fold higher (0.73% vs. 0.20%, p = 0.015), and all PE occurred in this cohort (0.47% vs. 0.00%, p = 0.005). All 30- and 90-day discharged VTE events occurred in those not receiving appropriate prophylaxis. Inpatient, 30- and 90-day discharged bleeding rates were 2.10%, 0.13%, and 0.33%, respectively. Although inpatient bleeding was significantly higher in those receiving appropriate prophylaxis, all 30- and 90-day post-discharge bleeding events occurred in patients not receiving appropriate prophylaxis. On regression analysis, Caprini score was significantly positively associated with likelihood of receiving appropriate inpatient prophylaxis (odds ratio [OR] 1.05, confidence interval [CI] 1.03-1.07) but was negatively associated in the discharge cohort (OR 0.43, CI 0.36-0.51). Receipt of appropriate prophylaxis was associated with reduced odds of inpatient VTE (OR 0.24, CI 0.06-0.69), but not with risk of bleeding. CONCLUSION Although Caprini VTE risk-stratified prophylaxis has a positive impact in reducing inpatient and post-discharge VTE, it must be balanced against the risk of inpatient postoperative bleeding. LEVEL OF EVIDENCE 3 Laryngoscope, 134:1169-1182, 2024.
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Affiliation(s)
- Michael A Edwards
- Advanced GI and Bariatric Surgery Division, Department of Surgery, Mayo Clinic, Jacksonville, Florida, U.S.A
| | - Emily Brennan
- Division of Health Care Delivery Research, Mayo Clinic, Robert D. and Patricia E. Kern Center, Jacksonville, Florida, U.S.A
| | - Amy L Rutt
- Mayo Clinic, Department of Otolaryngology/Head and Neck Surgery, Jacksonville, Florida, U.S.A
| | - Divya Muraleedharan
- Advanced GI and Bariatric Surgery Division, Department of Surgery, Mayo Clinic, Jacksonville, Florida, U.S.A
| | - John D Casler
- Mayo Clinic, Department of Otolaryngology/Head and Neck Surgery, Jacksonville, Florida, U.S.A
| | - Aaron Spaulding
- Division of Health Care Delivery Research, Mayo Clinic, Robert D. and Patricia E. Kern Center, Jacksonville, Florida, U.S.A
| | - Dorin Colibaseanu
- Colon and Rectal Surgery Division, Mayo Clinic, Jacksonville, Florida, U.S.A
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3
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Hanba C, Lewis C. Enhanced Recovery After Surgery for Head and Neck Oncologic Surgery Requiring Microvascular Reconstruction. Otolaryngol Clin North Am 2023; 56:801-812. [PMID: 37380326 DOI: 10.1016/j.otc.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
It has been demonstrated since the 1990's that surgical outcomes can be improved through protocolized perioperative interventions. Since then, multiple surgical societies have engaged in adopting Enhanced Recovery After Surgery (ERAS) Societal recommendations to improve patient satisfaction, decrease the cost of interventions, and improve outcomes. In 2017, ERAS released consensus recommendations detailing the perioperative optimization of patients undergoing head and neck free flap reconstruction. This population was identified as a high resource demand, oftentimes burdened with challenging comorbidity, and poorly described cohort for which a perioperative management protocol could help to optimize outcomes. The following pages aim to further detail perioperative strategies to streamline patient recovery after head and neck reconstructive surgery.
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Affiliation(s)
- Curtis Hanba
- Department of Otolaryngology-Head and Neck Surgery, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
| | - Carol Lewis
- Department of Otolaryngology-Head and Neck Surgery, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
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4
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Lobastov K, Urbanek T, Stepanov E, Lal BK, Marangoni J, Krauss ES, Cronin M, Dengler N, Segal A, Welch HJ, Gianesini S, Chen X, Caprini JA. The Thresholds of Caprini Score Associated With Increased Risk of Venous Thromboembolism Across Different Specialties: A Systematic Review. Ann Surg 2023; 277:929-937. [PMID: 36912040 DOI: 10.1097/sla.0000000000005843] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 02/18/2023] [Indexed: 03/14/2023]
Abstract
OBJECTIVE Estimation of the specific thresholds of the Caprini risk score (CRS) that are associated with the increased incidence of venous thromboembolism (VTE) across different specialties, including identifying the highest level of risk. BACKGROUND Accurate risk assessment remains an important but often challenging aspect of VTE prophylaxis. One well-established risk assessment model is CRS, which has been validated in thousands of patients from many different medical and surgical specialties. METHODS A search of MEDLINE and the Cochrane Library was performed in March 2022. Manuscripts that reported on (1) patients admitted to medical or surgical departments and (2) had their VTE risk assessed by CRS and (3) reported on the correlation between the score and VTE incidence, were included in the analysis. RESULTS A total of 4562 references were identified, and the full text of 202 papers was assessed for eligibility. The correlation between CRS and VTE incidence was reported in 68 studies that enrolled 4,207,895 patients. In all specialties, a significant increase in VTE incidence was observed in patients with a CRS of ≥5. In most specialties thresholds of ≥7, ≥9, and ≥11 to 12 were associated with dramatically increased incidences of VTE. In COVID-19, cancer, trauma, vascular, general, head and neck, and thoracic surgery patients with ≥9 and ≥11 to 12 scores the VTE incidence was extremely high (ranging from 13% to 47%). CONCLUSION The Caprini score is being used increasingly to predict VTE in many medical and surgical specialties. In most cases, the VTE risk for individual patients increases dramatically at a threshold CRS of 7 to 11.
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Affiliation(s)
- Kirill Lobastov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | | | - Eugeniy Stepanov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - Brajesh K Lal
- University of Maryland School of Medicine, Baltimore, MD
| | | | - Eugene S Krauss
- Department of Orthopaedic Surgery, Syosset Hospital, Northwell Health, Syosset, NY
| | - MaryAnne Cronin
- Department of Orthopaedic Surgery, Syosset Hospital, Northwell Health, Syosset, NY
| | - Nancy Dengler
- Department of Orthopaedic Surgery, Syosset Hospital, Northwell Health, Syosset, NY
| | - Ayal Segal
- Department of Orthopaedic Surgery, Syosset Hospital, Northwell Health, Syosset, NY
| | - Harold J Welch
- Division of Vascular Surgery, Lahey Hospital and Medical Center, Burlington, MA
| | | | - Xiaolan Chen
- Department of Respiratory and Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
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5
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Hayssen H, Cires-Drouet R, Englum B, Nguyen P, Sahoo S, Mayorga-Carlin M, Siddiqui T, Turner D, Yesha Y, Sorkin JD, Lal BK. Systematic review of venous thromboembolism risk categories derived from Caprini score. J Vasc Surg Venous Lymphat Disord 2022; 10:1401-1409.e7. [PMID: 35926802 PMCID: PMC9783939 DOI: 10.1016/j.jvsv.2022.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 04/11/2022] [Accepted: 05/03/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Hospital-acquired venous thromboembolism (VTE, including pulmonary embolism [PE] and deep vein thrombosis [DVT]) is a preventable cause of hospital death. The Caprini risk assessment model (RAM) is one of the most commonly used tools to assess VTE risk. The RAM is operationalized in clinical practice by grouping several risk scores into VTE risk categories that drive decisions on prophylaxis. A correlation between increasing Caprini scores and rising VTE risk is well-established. We assessed whether the increasing VTE risk categories assigned on the basis of recommended score ranges also correlate with increasing VTE risk. METHODS We conducted a systematic review of articles that used the Caprini RAM to assign VTE risk categories and that reported corresponding VTE rates. A Medline and EMBASE search retrieved 895 articles, of which 57 fulfilled inclusion criteria. RESULTS Forty-eight (84%) of the articles were cohort studies, 7 (12%) were case-control studies, and 2 (4%) were cross-sectional studies. The populations varied from postsurgical to medical patients. There was variability in the number of VTE risk categories assigned by individual studies (6 used 5 risk categories, 37 used 4, 11 used 3, and 3 used 2), and in the cutoff scores defining the risk categories (scores from 0 alone to 0-10 for the low-risk category; from ≥5 to ≥10 for high risk). The VTE rates reported for similar risk categories also varied across studies (0%-12.3% in the low-risk category; 0%-40% for high risk). The Caprini RAM is designed to assess composite VTE risk; however, two studies reported PE or DVT rates alone, and many of the other studies did not specify the types of DVTs analyzed. The Caprini RAM predicts VTE at 30 days after assessment; however, only 17 studies measured outcomes at 30 days; the remaining studies had either shorter or longer follow-ups (0-180 days). CONCLUSIONS The usefulness of the Caprini RAM is limited by heterogeneity in its implementation across centers. The score-derived VTE risk categorization has significant variability in the number of risk categories being used, the cutpoints used to define the risk categories, the outcome being measured, and the follow-up duration. This factor leads to similar risk categories being associated with different VTE rates, which impacts the clinical and research implications of the results. To enhance generalizability, there is a need for studies that validate the RAM in a broad population of medical and surgical patients, identify standardized risk categories, define risk of DVT and PE as distinct end points, and measure outcomes at standardized follow-up time points.
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Affiliation(s)
- Hilary Hayssen
- Department of Vascular Surgery, University of Maryland, Baltimore, MD; Surgery Service, VA Medical Center, Baltimore, MD
| | | | - Brian Englum
- Department of Vascular Surgery, University of Maryland, Baltimore, MD
| | - Phuong Nguyen
- Department of Computer Science and Electrical Engineering, University of Maryland, Baltimore County, MD
| | - Shalini Sahoo
- Department of Vascular Surgery, University of Maryland, Baltimore, MD; Surgery Service, VA Medical Center, Baltimore, MD
| | - Minerva Mayorga-Carlin
- Department of Vascular Surgery, University of Maryland, Baltimore, MD; Surgery Service, VA Medical Center, Baltimore, MD
| | | | | | - Yelena Yesha
- Department of Computer Science and Electrical Engineering, University of Maryland, Baltimore County, MD; Department of Computer Science, University of Miami, Miami, FL
| | - John D Sorkin
- Department of Medicine, Division of Gerontology and Palliative Care, University of Maryland School of Medicine, Baltimore, MD; Baltimore VA Geriatric Research, Education, and Clinical Center, Baltimore, MD
| | - Brajesh K Lal
- Department of Vascular Surgery, University of Maryland, Baltimore, MD; Surgery Service, VA Medical Center, Baltimore, MD.
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Wilson S, Chen X, Cronin M, Dengler N, Enker P, Krauss ES, Laberko L, Lobastov K, Obi AT, Powell CA, Schastlivtsev I, Segal A, Simonson B, Siracuse J, Wakefield TW, McAneny D, Caprini JA, Caprini JA. Thrombosis prophylaxis in surgical patients using the Caprini Risk Score. Curr Probl Surg 2022; 59:101221. [PMID: 36372452 DOI: 10.1016/j.cpsurg.2022.101221] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
| | - Xialan Chen
- Beijing Shijitan Hospital, Capital Medical University, Beijing, P.R. China
| | - MaryAnne Cronin
- Department of Orthopedic Surgery, Syosset Hospital, Syosset, NY
| | - Nancy Dengler
- Department of Orthopedic Surgery, Syosset Hospital, Syosset, NY
| | - Paul Enker
- Zucker School of Medicine, Hofstra University, Uniondale, NY
| | - Eugene S Krauss
- Department of Orthopedic Surgery, Syosset Hospital, Syosset, NY
| | - Leonid Laberko
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - Kirill Lobastov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - Andrea T Obi
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Chloé A Powell
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | | | - Ayal Segal
- Department of Orthopedic Surgery, Syosset Hospital, Syosset, NY
| | - Barry Simonson
- Zucker School of Medicine, Hofstra University, Uniondale, NY
| | | | | | - David McAneny
- Boston University School of Medicine, Boston Medical Center, Boston, MA
| | - Joseph A Caprini
- Emeritus, NorthShore University Health System, University of Chicago Pritzker School of Medicine, Chicago, IL
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7
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Chen Q, Cai Y, Zhang Z, Dong H, Miao J, Li H, Hu B. Prevalence of venous thromboembolism and evaluation of a modified caprini risk assessment model: a single-centre, prospective cohort study involving patients undergoing lung resections for bronchiectasis. Thromb J 2022; 20:43. [PMID: 35915486 PMCID: PMC9341115 DOI: 10.1186/s12959-022-00402-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 07/24/2022] [Indexed: 11/29/2022] Open
Abstract
Background Venous thromboembolism (VTE) is a common postoperative complication in general thoracic surgery, but the incidence of patients undergoing surgery for bronchiectasis was not known. The purpose of our study was to investigate the incidence of VTE in bronchiectasis patients undergoing lung resection and to evaluate the risk stratification effect of the modified caprini risk assessment model (RAM). Methods We prospectively enrolled patients with bronchiectasis who underwent lung resection surgery between July 2016 and July 2020.The postoperative duplex lower-extremity ultrasonography or(and) computed tomographic pulmonary angiography (CTPA) was performed to detect VTE. The clinical characteristics and caprini scores of VTE patients and non-VTE patients would be compared and analyzed. Univariate logistic regression was performed to evaluate whether higher Caprini scores were associated with postoperative VTE risk.In addition, We explored the optimal cutoff for caprini score in patients with bronchiectasis by using the receiver operating characteristic (ROC) curve. Results One hundred and seventeen patients were eligible based on the prospective study criteria. The postoperative VTE incidence was 8.5% (10/117). By comparing the clinical characteristics and Caprini scores of VTE and non-VTE patients, the median preoperative hospitalization (7 vs 5 days, P = 0.028) and Caprini score (6.5 vs 3,P < 0.001) were significantly higher in VTE patients. In univariate logistic regression, a higher Caprini score was associated with higher odds ratio (OR) for VTE of 1.7, 95% confidence interval (CI) was from 1.2 to 2.5 (P = 0.001), C-statistics was 0.815 in the modified caprini RAM for predicting VTE. In a multivariable analysis adjusting for preoperative hospitalization, a higher Caprini score was associated with higher odds OR for VTE of 1.8 (95%CI: 1.2–2.6, P = 0.002), C-statistics was 0.893 in the caprini RAM for predicting VTE. When taking the Caprini score as 5 points as the diagnostic threshold, the Youden index is the largest. Conclusions The postoperative VTE incidence in patients undergoing lung resection for bronchiectasis was 8.5%.The modified caprini RAM effectively stratified bronchiectasis surgery patients for risk of VTE and showed excellent predictive power for VTE. The patients with postoperative caprini scores = 5, should be recommended to take positive measures to prevent postoperative VTE. Trial Registration Chinese Clinical Trial Register: ChiCTR-EOC-17010577.
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Affiliation(s)
- Qingshan Chen
- Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - YongSheng Cai
- Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Zhirong Zhang
- Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Honghong Dong
- Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jinbai Miao
- Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China.
| | - Hui Li
- Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Bin Hu
- Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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8
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Ke L, Cui S, Yang M, Chen J, Xu S, Jiang G, Zhang Y, Chen S, Zheng E, Zhao H, Fan X, Li Y, Zhi X, Hu B, Li H. Validation of a modified Caprini risk assessment model in lung cancer patients undergoing surgery: Results of a multicenter cross-sectional observational study. J Surg Oncol 2022; 125:933-942. [PMID: 35041203 DOI: 10.1002/jso.26794] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/24/2021] [Accepted: 01/01/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND OBJECTIVES Lung cancer patients slated for surgery are at high risk of venous thromboembolism (VTE). Precise risk assessment is necessary for providing proper thromboprophylaxis and reducing morbidity and mortality of VTE. METHODS A multicenter, observational, cross-sectional cohort study, involving patients with primary lung cancer undergoing surgery, was carried out from August 2016 to December 2019. All patients were assessed according to the Caprini risk assessment model (RAM) and a modified scoring system incorporating elevated D-dimer and new stratification of surgical time. The endpoint was confirmed VTE or patient discharge. RESULTS Out of 1205 patients, 87 (7.2%) were diagnosed with VTE. The area under the curve of modified scores for VTE was 0.759, which was larger than that of the original one (0.589) (p < 0.05). By modified Caprini scoring system, a higher score was associated with increased VTE risk (odds ratio [OR], 1.345; 95% confidence interval [CI], 1.197-1.512; p < 0.001), and there was an increased OR of 4.090 (95% CI, 2.472-6.768, p < 0.001) for VTE in high-risk category patients. CONCLUSION Modified Caprini RAM showed an improved prediction of high-risk patients with an elevated likelihood of postoperative VTE compared to the original one.
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Affiliation(s)
- Lihui Ke
- Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Songping Cui
- Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Mei Yang
- Department of Thoracic Surgery, West China Hospital, West China School of Nursing, Sichuan University, Chengdu, Sichuan, China
| | - Jun Chen
- Department of Lung Cancer Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Shun Xu
- Department of Thoracic Surgery, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Gening Jiang
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yi Zhang
- Department of Thoracic Surgery, Beijing Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shuo Chen
- Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - E Zheng
- Department of Thoracic Surgery, West China Hospital, West China School of Nursing, Sichuan University, Chengdu, Sichuan, China
| | - Honglin Zhao
- Department of Lung Cancer Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiaoxi Fan
- Department of Thoracic Surgery, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Yuping Li
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiuyi Zhi
- Department of Thoracic Surgery, Beijing Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Bin Hu
- Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Hui Li
- Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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9
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Levi L, Spectre G, Nesichi O, Leader A, Raanani P, Reuven Y, Schindel H, Shpitzer T, Reifen E, Bachar G, Mizrachi A. Implementation of a Novel Protocol for Preventing Venous Thromboembolism in Otolaryngology Patients. Otolaryngol Head Neck Surg 2021; 166:297-304. [PMID: 34255600 DOI: 10.1177/01945998211024923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Venous thromboembolism (VTE) is a preventable cause of postoperative morbidity and mortality. The Caprini risk assessment model (CRAM) is a validated tool for estimating the risk for postoperative VTE. Previous studies demonstrated a low risk of VTE among otorhinolaryngology-head and neck surgery (ORL-HNS). Hence, our objective was to modify the CRAM-based protocol to be applicable for otolaryngology patients and assess protocol efficacy and safety. STUDY DESIGN Observational pilot study conducted on ORL-HNS patients undergoing surgery. SETTING University-affiliated tertiary care center. METHODS We constructed a modified protocol based on the CRAM and previous reports in the ORL-HNS literature using a reduced postoperative anticoagulation regimen. Primary end point was symptomatic VTE up to 3 months after surgery. Main secondary outcome was postoperative bleeding. RESULTS A total of 508 patients were enrolled. Of them, 48% underwent head and neck surgery, 18% direct laryngoscopy and transoral robotic surgery, 15% endoscopic sinus surgery, and 11% otology surgery. Adherence to the protocol was 79%. Mean follow-up time was 115 days (range, 30-448 days). Only 1 patient developed deep vein thrombosis, and none developed pulmonary embolism. Two patients had major bleeding not related to the use of anticoagulation. CONCLUSIONS Our novel CRAM-based protocol appears to be efficacious and safe for VTE prevention in otolaryngology. A larger-scale study is required to validate these findings. LEVEL OF EVIDENCE Level 2b.
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Affiliation(s)
- Lirit Levi
- Department of Otorhinolaryngology-Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Galia Spectre
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute for Hematology, Rabin Medical Center, Petah Tikva, Israel
| | - Ofir Nesichi
- Department of Otorhinolaryngology-Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avi Leader
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute for Hematology, Rabin Medical Center, Petah Tikva, Israel
| | - Pia Raanani
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute for Hematology, Rabin Medical Center, Petah Tikva, Israel
| | - Yonatan Reuven
- Department of Otorhinolaryngology-Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hilla Schindel
- Department of Otorhinolaryngology-Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Thomas Shpitzer
- Department of Otorhinolaryngology-Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ella Reifen
- Department of Otorhinolaryngology-Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gideon Bachar
- Department of Otorhinolaryngology-Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aviram Mizrachi
- Department of Otorhinolaryngology-Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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10
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Yang X, Yu L, Yu T, Li F, Zhang Y, Yu Z, Zhang B, Ke J, Li H. Venous thromboembolism after adult thymus or thymic tumor resection: A single-center experience. Thorac Cancer 2020; 11:2291-2296. [PMID: 32558357 PMCID: PMC7396359 DOI: 10.1111/1759-7714.13543] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 05/29/2020] [Accepted: 05/30/2020] [Indexed: 12/27/2022] Open
Abstract
Background Venous thromboembolism (VTE) is a common postoperative complication. Previous studies have shown that the VTE incidence after major thoracic surgery is high. However, there have been no exclusive data after thymectomy thus far. To investigate the incidence of postoperative VTE, we conducted a single‐center, prospective cohort study. Methods Patients who underwent thymectomy between December 2017 and January 2020 were enrolled. None of the patients received any prophylaxis perioperatively. Subjects were risk stratified into groups of low risk (0–4), moderate risk (5–8), and high risk (≥9). Occurrence of VTE events, including deep vein thrombosis (DVT) and pulmonary embolism (PE), were identified by imaging. Results There were 192 patients who underwent thymectomy enrolled into the study. The overall VTE incidence was 8.9%. All the patients were diagnosed with DVT, and none were diagnosed with PE. The VTE incidence was 4.6% in patients with benign thymic diseases and 14.5% with malignant diseases. The VTE incidence was 4.7% in patients undergoing thoracoscopic surgery and 22.7% undergoing median sternotomy. The VTE incidence increased with Caprini score. Scores in the low, moderate, and high risk groups were associated with a VTE incidence of 0%, 10.3% and 37.5%, respectively. In patients with thymic malignancy, the VTE incidence in the moderate and high risk groups were 8.8% and 31.8%, respectively. Conclusions VTE occurred frequently in patients after thymectomy without VTE prophylaxis. The median sternotomy procedure and malignant tumor may be the major risk factors for the development of VTE. Aggressive VTE screening/treatment protocols should be implemented in patents after thymectomy.
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Affiliation(s)
- Xingguo Yang
- Department of Thoracic Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Lei Yu
- Department of Thoracic Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Tao Yu
- Department of Thoracic Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Fei Li
- Department of Thoracic Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Yunfeng Zhang
- Department of Thoracic Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Zhen Yu
- Department of Thoracic Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Baoxun Zhang
- Department of Thoracic Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Ji Ke
- Department of Thoracic Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Hui Li
- Department of Thoracic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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11
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Kim NE, Conway-Pearson L, Kavanah M, Mendez J, Sachs TF, Drake FT, Ko NY, McAneny D, Cassidy MR. Standardized Risk Assessment and Risk-Stratified Venous Thromboembolism Prophylaxis for Patients Undergoing Breast Operation. J Am Coll Surg 2020; 230:947-955. [DOI: 10.1016/j.jamcollsurg.2019.11.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 11/11/2019] [Accepted: 11/12/2019] [Indexed: 10/25/2022]
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12
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Venkatesh KP, Ambani SW, Arakelians AR, Johnson JT, Solari MG. Head and Neck Microsurgeon Practice Patterns and Perceptions Regarding Venous Thromboembolism Prophylaxis. J Reconstr Microsurg 2020; 36:549-555. [DOI: 10.1055/s-0040-1710553] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Abstract
Background Patients undergoing head and neck (H&N) microvascular reconstruction comprise a population at high risk for venous thromboembolism (VTE). Free flap and VTE thromboprophylaxis may coincide but tend to vary from surgeon to surgeon. This study identifies VTE prophylaxis patterns and perceptions among H&N microsurgeons in the United States.
Methods An online survey on VTE prophylaxis practice patterns and perceptions was emailed to 172 H&N microsurgeons in the United States using an anonymous link.
Results There were 74 respondents (43% response rate). These surgeons completed residencies in otolaryngology (59%), plastic surgery (31%), and oral maxillofacial surgery (7%). Most underwent fellowship training (95%) and have practiced at an academic center (97%) for at least 6 years (58%), performing an average of 42 ± 31 H&N free flap cases per year (range = 1–190). Most adhered to general VTE prophylaxis guidelines (69%) while 11% did not and 20% were unsure. Nearly all surgeons (99%) would provide prophylactic anticoagulation, mostly in the form of subcutaneous heparin (51%) or enoxaparin (44%); 64% additionally used aspirin, while 4% used aspirin alone. The majority of surgeons (68%) reported having postoperative VTE complications, with six surgeons (8%) reporting patient deaths due to pulmonary embolism. A third of the surgeons have encountered VTE prophylaxis-related adverse bleeding events, but most still believe that chemoprophylaxis is important for VTE prevention (92%). While 35% of surgeons were satisfied with their current practice, most would find it helpful to have official prophylactic anticoagulation guidelines specific to H&N free flap cases.
Conclusion The majority of microsurgeons experienced postoperative VTE complications after H&N free flap reconstruction despite the routine use of prophylactic anticoagulation. Though bleeding events are a concern, most surgeons believe chemoprophylaxis is important for VTE prevention and would welcome official guidelines specific to this high-risk population.
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Affiliation(s)
- Kaushik P. Venkatesh
- Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Shoshana W. Ambani
- Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Department of Plastic Surgery, Henry Ford Allegiance Health System, Jackson, Michigan
| | - Aris R.L. Arakelians
- Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jonas T. Johnson
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mario G. Solari
- Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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13
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Ali NES, Alyono JC, Song Y, Kouhi A, Blevins NH. Postoperative Venous Thromboembolism after Neurotologic Surgery. J Neurol Surg B Skull Base 2019; 82:378-382. [PMID: 34026416 DOI: 10.1055/s-0039-3400223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 09/28/2019] [Indexed: 10/25/2022] Open
Abstract
Objective This study aimed to determine the incidence of postoperative venous thromboembolism (VTE) in adults undergoing neurotologic surgery at a single center. Methods The records of adults undergoing neurotologic surgery from August 2009 to December 2016 at a tertiary care hospital were reviewed for VTE within 30 postoperative days. Particular attention was focused on postoperative diagnosis codes, imaging, and a keyword search of postoperative notes. Caprini risk scores were calculated. Results Among 387 patients, 5 experienced postoperative VTE including 3 cases of pulmonary embolism (PE) and 2 cases of isolated deep vein thrombosis (DVT). All patients were given sequential compression devices perioperatively, and none received preoperative chemoprophylaxis. Patients with Caprini score > 8 had a significantly higher rate of VTE compared with those < 8 (12.5 vs. 1%, p = 0.004). Receiver operating characteristic analysis revealed the Caprini risk assessment model to be a fair predictor of VTE, with a C-statistic of 0.70 (95% confidence interval [CI]: 0.49-0.92). Conclusion While no specific validated VTE risk stratification scheme has been widely accepted for patients undergoing neurotologic surgery, the Caprini score appears to be a useful predictor of risk. The benefits of chemoprophylaxis should be balanced with the risks of intraoperative bleeding, as well as the potential for postoperative intracranial hemorrhage.
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Affiliation(s)
- Noor-E-Seher Ali
- Department of Otolaryngology, Stanford University, Stanford, California, United States
| | - Jennifer C Alyono
- Department of Otolaryngology, Stanford University, Stanford, California, United States
| | - Yohan Song
- Department of Otolaryngology, Stanford University, Stanford, California, United States
| | - Ali Kouhi
- Department of Otolaryngology, Stanford University, Stanford, California, United States
| | - Nikolas H Blevins
- Department of Otolaryngology, Stanford University, Stanford, California, United States
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14
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Utilization of the Caprini score in conjunction with thrombodynamic testing reduces the number of unpredicted postoperative venous thromboembolism events in patients with colorectal cancer. J Vasc Surg Venous Lymphat Disord 2019; 8:31-41. [PMID: 31495765 DOI: 10.1016/j.jvsv.2019.06.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 06/09/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND The thrombodynamic test (TD) is a novel global test of hemostasis that allows to study the spatial-temporal characteristics of a clot formation in real time under conditions close to natural ones and demonstrates high sensitivity to detect the state of hypercoagulation. The main paraments of the test are the velocity of clot growth, clot's size, and clot density. The objective of this study was to compare the classic Caprini 2005 score and its modified version in association with the results of TD. The goal is to predict postoperative venous thromboembolism (VTE) in surgical patients undergoing surgery for colorectal cancer. METHODS This was a prospective observational clinical study involving 80 patients (33 men and 47 women; mean age, 73.9 ± 7.2 years) who underwent major (79 cases) or minor (1 case) surgery for colorectal cancer. Patients were at high risk for postoperative VTE (ie, a mean Caprini score of 9.9 ± 2.0) and received combined prophylaxis (ie, antiembolic compression stockings and enoxaparin 40 mg once daily) until discharge. Enoxaparin was administered at a fixed time of blood sampling for the TD test. Duplex ultrasound scan was performed to detect postoperative vein thrombosis before and 5 to 7 days after surgery. RESULTS Postoperative vein thrombosis was found in 21 of 80 patients (26.3%; 95% confidence interval, 17.9%-36.8%). Regression analysis and receiver operating characteristic (ROC) curve showed that Caprini scores significantly predicted VTE (P < .0001; area under the curve [AUC] = 0.839 ± 0.045). Analysis of ROC curve coordinates showed that a cutoff point of 11 scores had a sensitivity of 76.2% and a specificity of 74.6%. The results of the TD test showed significant hypercoagulation despite enoxaparin administration in patients with VTE. Regression analysis and ROC curves demonstrated that the following TD parameters had the greatest predictability for postoperative DVT: initial velocity of clot growth (Vin) and clot size (CS) measured at 12 hours after enoxaparin administration (AUC, 0.697 ± 0.063 and AUC, 0.790 ± 0.059, respectively), as well as Vin and CS measured 24 hours after the enoxaparin injection (S = 0.847 ± 0.059 and S = 0.803 ± 0.069, respectively). The cutoff points for VTE prediction at 12 and 24 hours seemed to be a Vin of greater than 62.5 and greater than 64.5 μm/minute (normal range, 35-56 μm/minute) as well as a CS of greater than 1351.5 and greater than 1333.5 μm (normal range, 800-1200 μm), respectively. Identified thresholds for TD parameters have been integrated into Caprini scores under the item "other congenital or acquired thrombophilia." The total Caprini scores were recalculated in patients where one or all TD parameters had exceeded the cutoff followed by reanalysis of the ROC curves. The best predictability was found for Caprini scores considering the elevation of all four TD parameters (AUC, 0.924 ± 0.029) with increased cutoff to a score of 12 with a sensitivity of 85.7% and a specificity of 81.4%. The use of cutoffs for the original and modified scores could be used to calculate the number of patients that were under cutoff but developed with VTE: 10.2% and 5.9%, respectively. CONCLUSIONS Integrating TD parameters into the Caprini score increases the ability to predict postoperative VTE.
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Hanh BM, Cuong LQ, Son NT, Duc DT, Hung TT, Hung DD, Giang TB, Hiep NH, Xuyen HTH, Nga NT, Chu DT. Determination of Risk Factors for Venous Thromboembolism by an Adapted Caprini Scoring System in Surgical Patients. J Pers Med 2019; 9:jpm9030036. [PMID: 31319527 PMCID: PMC6789529 DOI: 10.3390/jpm9030036] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 07/02/2019] [Accepted: 07/16/2019] [Indexed: 11/26/2022] Open
Abstract
Venous thromboembolism (VTE) is a frequent preventable complication among surgical patients. Precise risk assessment is a necessary step for providing appropriate thromboprophylaxis and reducing mortality as well as morbidity caused by VTE. We carried out this work to define the rate of VTE postoperatively, following a Caprini score, and to determine VTE risk factors through a modified Caprini risk scoring system. This multicenter, observational, cohort study involved 2,790,027 patients who underwent surgery in four Vietnamese hospitals from 01/2017 to 12/2018. All patients who were evaluated before surgery by using a Caprini risk assessment model (RAM) and monitored within 90 days after surgery. The endpoint of the study was ultrasound-confirmed VTE. Our data showed that the 90-day postoperative VTE was found in 3068 patients. Most of VTE (46.97%) cases were found in the highest risk group (Caprini score > 5). A total of 37.19% were observed in the high risk group, while the rest (15.84%) were from low to moderate risk groups. The likelihood of occurring VTE was heightened 2.83 times for patients with a Caprini score of 3–4, 4.83 times for a Caprini score of 5–6, 8.84 times for a score of 7–8, and 11.42 times for a score of >8, comparing to ones with a score of 0 to 2 (all p values < 0.05). Thus, the frequency of postoperative VTE rises substantially, according to the advanced Caprini score. Further categorizing patients among the highest risk group need delivering more appropriate thromboprophylaxis.
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Affiliation(s)
- Bui My Hanh
- Tuberculosis and Lung Disease Department, Hanoi Medical University, Hanoi 100000, Vietnam
| | - Le Quang Cuong
- Department of Neurology, Hanoi Medical University, Hanoi 100000, Vietnam
| | | | - Duong Tuan Duc
- Center for Health Insurance and Multilateral Payment in The Northern Region, Viet Nam Social Security, Hanoi 100000, Vietnam
| | - Tran Tien Hung
- Center for Health Insurance and Multilateral Payment in The Northern Region, Viet Nam Social Security, Hanoi 100000, Vietnam
| | - Duong Duc Hung
- Department of General Administration, Bach Mai Hospital, Hanoi 100000, Vietnam
| | | | - Nguyen Hoang Hiep
- Tuberculosis and Lung Disease Department, Hanoi Medical University, Hanoi 100000, Vietnam
| | - Hoang Thi Hong Xuyen
- Tuberculosis and Lung Disease Department, Hanoi Medical University, Hanoi 100000, Vietnam
| | - Nguyen Thi Nga
- Institute for Research and Development, Duy Tan University, 03 QuangTrung, Danang 550000, Vietnam
| | - Dinh-Toi Chu
- Faculty of Biology, Hanoi National University of Education, Hanoi Vietnam 100000, Vietnam.
- School of Odonto Stomatology, Hanoi Medical University, Hanoi Vietnam 100000, Vietnam.
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16
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Song Y, Alyono JC, Ali NES, Blevins NH. Postoperative Venous Thromboembolism after Extracranial Otologic Surgery. Otolaryngol Head Neck Surg 2019; 161:144-149. [PMID: 30857484 DOI: 10.1177/0194599819835743] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine the incidence of postoperative venous thromboembolism (VTE) in adults undergoing otologic surgery. STUDY DESIGN Cross-sectional retrospective study. SETTING Single tertiary academic center. SUBJECTS AND METHODS Adults undergoing nononcologic, extracranial otologic surgery from August 2009 to December 2016. Patients with postoperative diagnosis VTE codes were identified. Imaging and clinical documents were searched for VTE evidence within the first 30 postoperative days. Methods of thromboprophylaxis were documented, and Caprini risk scores were calculated. RESULTS In total, 1213 otologic surgeries were evaluated. No postoperative VTE events were identified (0/1268). Mean age was 51.0 ± 17.3 years (range, 18.1-93.4 years). Average length of surgery was 136.0 ± 79.0 minutes (range, 5-768 minutes). The average Caprini score in all patients was 4.0 ± 1.7 (range, 1-15). Eighty-five percent of patients had a Caprini score ≥3, the threshold at which chemoprophylaxis has been recommended in general surgery patients by the American College of Chest Physicians 2012 guidelines. Six patients had documented preoperative chemoprophylaxis and a Caprini score of 4.8 ± 1.7. This was not significantly different from that of patients who did not receive preoperative chemoprophylaxis (t test, P = .3). The literature would estimate a rate of 3.7% VTE in adults with similar Caprini scores undergoing general surgery procedures with no VTE prophylaxis. CONCLUSION The Caprini risk assessment model may overestimate VTE risk in patients undergoing extracranial otologic surgery. Postoperative VTE following otologic surgery is rare, even in patients traditionally considered moderate or high risk. Chemoprophylaxis guidelines in this group should be balanced against the potential risk of increased intraoperative bleeding and its associated effects on surgical visualization and morbidity.
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Affiliation(s)
- Yohan Song
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California, USA
| | - Jennifer C Alyono
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California, USA
| | - Noor-E-Seher Ali
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California, USA
| | - Nikolas H Blevins
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California, USA
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Tham T, Costantino P. Comparison of venous thromboembolism risk stratification models in a high risk otolaryngology patient cohort. J Perioper Pract 2019; 29:129-134. [PMID: 30672371 DOI: 10.1177/1750458919826794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Our objective was to compare the venous thromboembolism outcomes in two of the most commonly utilised venous thromboembolism assessment tools, the Caprini system and the University of Michigan system, in a high risk head and neck surgery population. Currently, there is a lack of data reporting the validation of well known scoring systems in this patient population. Established risk factors for venous thromboembolism were included in the data collection process. We retrospectively evaluated all patients with the Caprini Risk Assessment and the University of Michigan Health System (UMHS) Scores. Out of all the risk factors, only length of surgery was found to be associated with venous thromboembolism. The mean Caprini scores in those with and without venous thromboembolism were 8.00 ± 3.00 and 6.86 ± 1.45, respectively. The mean UMHS scores in those with and without venous thromboembolism were 6.85 ± 1.28 and 6.54 ± 1.20, respectively. Both scoring systems were not found to be associated with venous thromboembolism.
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Affiliation(s)
- Tristan Tham
- Department of Otolaryngology, New York Head and Neck Institute, Zucker School of Medicine at Hofstra Northwell, New York City, NY, USA
| | - Peter Costantino
- Department of Otolaryngology, New York Head and Neck Institute, Zucker School of Medicine at Hofstra Northwell, New York City, NY, USA
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Abstract
Venous thromboembolism (VTE) including pulmonary embolism (PE) and deep vein thrombosis (DVT) is one of the leading causes of preventable cardiovascular disease in the United States (US) and is the number one preventable cause of death following a surgical procedure. Post-operative VTE is associated with multiple short and long-term complications. We will focus on reviewing the many faces of VTE in detail as they represent common challenging scenarios in clinical practice.
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19
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Cramer JD, Shuman AG, Brenner MJ. Antithrombotic Therapy for Venous Thromboembolism and Prevention of Thrombosis in Otolaryngology–Head and Neck Surgery: State of the Art Review. Otolaryngol Head Neck Surg 2018; 158:627-636. [DOI: 10.1177/0194599818756599] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Objective The aim of this report is to present a cohesive evidence-based approach to reducing venous thromboembolism (VTE) in otolaryngology–head and neck surgery. VTE prevention includes deep venous thrombosis and pulmonary embolism. Despite national efforts in VTE prevention, guidelines do not exist for otolaryngology–head and neck surgery in the United States. Data Sources PubMed/MEDLINE. Review Methods A comprehensive review of literature pertaining to VTE in otolaryngology–head and neck surgery was performed, identifying data on incidence of thrombotic complications and the outcomes of regimens for thromboprophylaxis. Data were then synthesized and compared with other surgical specialties. Conclusions We identified 29 articles: 1 prospective cohort study and 28 retrospective studies. The overall prevalence of VTE in otolaryngology appears lower than that of most other surgical specialties. The Caprini system allows effective individualized risk stratification for VTE prevention in otolaryngology. Mechanical and chemoprophylaxis (“dual thromboprophylaxis”) is recommended for patients with a Caprini score ≥7 or patients with a Caprini score of 5 or 6 who undergo major head and neck surgery, when prolonged hospital stay is anticipated or mobility is limited. For patients with a Caprini score of 5 or 6, we recommend dual thromboprophylaxis or mechanical prophylaxis alone. Patients with a Caprini score ≤4 should receive mechanical prophylaxis alone. Implications for Practice Otolaryngologists should consider an individualized and risk-stratified plan for perioperative thromboprophylaxis in every patient. The risk of bleeding must be weighed against the risk of VTE when deciding on chemoprophylaxis.
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Affiliation(s)
- John D. Cramer
- Department of Otolaryngology–Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Andrew G. Shuman
- Department of Otolaryngology–Head and Neck Surgery, School of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael J. Brenner
- Department of Otolaryngology–Head and Neck Surgery, School of Medicine, University of Michigan, Ann Arbor, Michigan, USA
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20
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Beswick DM, Vaezeafshar R, Ma Y, Hwang PH, Nayak JV, Patel ZM. Risk Stratification for Postoperative Venous Thromboembolism after Endoscopic Sinus Surgery. Otolaryngol Head Neck Surg 2018; 158:767-773. [PMID: 29460675 DOI: 10.1177/0194599818755340] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives Venous thromboembolism (VTE) contributes to significant patient morbidity, yet the incidence of VTE following endoscopic sinus surgery (ESS) is unknown. Quality improvement criteria are prompting increased standardization of perioperative VTE prophylaxis. Risk stratification for VTE may better define best practice measures to balance limiting VTE development with avoiding unnecessary chemoprophylaxis. Study Design Retrospective cohort study. Setting Tertiary institution. Subjects and Methods Adult patients who underwent ESS without perioperative chemoprophylaxis from 2008 to 2016 were evaluated. Identification of VTE was performed via screening diagnosis and procedure codes and clinical records, with subsequent confirmation of true-positive VTE. Data for individual Caprini scores were abstracted from electronic medical records. The primary outcome was development of VTE within 30 days following ESS relative to the Caprini score. Results A total of 2369 ESS cases were evaluated. While initial screening identified multiple potential VTE events, in-depth medical record review confirmed only 4 true VTE (0.17%). The VTE rate among cases with a Caprini score of <8 (0.09%, 2/2278) was significantly less ( P = .008) than the rate with a score of ≥8 (2.2%, 2/91). Beyond overall score, specific risk factors associated with development of postoperative VTE included stroke, central venous access, sepsis, and inpatient status (all P < .025), while prior VTE and hypercoagulability were not associated with postoperative VTE (all P > .5). Conclusions In the absence of perioperative chemoprophylaxis, postoperative VTE following ESS is extremely rare, particularly for patients carrying low-to-moderate Caprini scores. Risk stratification based on these data can assist in the design of VTE prophylaxis guidelines for ESS patients.
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Affiliation(s)
- Daniel M Beswick
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, USA.,2 Department of Otolaryngology, Oregon Health and Science University, Portland, Oregon, USA
| | - Reza Vaezeafshar
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Yifei Ma
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Peter H Hwang
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Jayakar V Nayak
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Zara M Patel
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, USA
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21
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Tham T, Rahman L, Persaud C, Olson C, Costantino P. Venous Thromboembolism Risk in Head and Neck Cancer: Significance of the Preoperative Platelet-to-Lymphocyte Ratio. Otolaryngol Head Neck Surg 2018; 159:85-91. [PMID: 29406795 DOI: 10.1177/0194599818756851] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objective We aimed to investigate the association between the preoperative platelet-to-lymphocyte ratio (PLR) and venous thromboembolism (VTE) in patients with head and neck cancer (HNC) undergoing major surgery. Study Design Retrospective cohort study. Setting Academic tertiary hospital from 2011 to 2017. Subjects and Methods Patients with confirmed HNC undergoing major surgery were included in this study. The preoperative PLR was recorded for all patients. Known VTE risk factors, including Caprini score, age, sex, smoking, body mass index, prior VTE, and anticoagulation, were also recorded. Risk factors were screened in univariate analysis using Wilcoxon's rank sum test and χ2 test (Bonferroni corrected). Significant covariates were included in a multivariate regression model. Bootstrap techniques were used to obtain credible confidence intervals (CIs). Results There were 306 patients enrolled with 7 cases of VTE (6 deep vein thromboses and 1 pulmonary embolism. On univariate analysis, length of stay ( P = .0026), length of surgery ( P = .0029), and PLR ( P = .0002) were found to have significant associations with VTE. A receiver operator characteristic (ROC) curve was constructed that yielded an area under the ROC of 0.905 (95% CI, 0.82-0.98). Using an optimized cutoff, the multivariate model showed that length of surgery (β 95% CI, 0.0001-0.0006; P = .0056) and PLR (β 95% CI, 5.3256-5.3868; P < .0001) were significant independent predictors of VTE. Conclusion This exploratory pilot study has shown that PLR offers a potentially accurate risk stratification measure as an adjunct to current tools in VTE risk prediction, without additional cost to health systems.
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Affiliation(s)
- Tristan Tham
- 1 Department of Otolaryngology, New York Head and Neck Institute, Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA
| | - Lauren Rahman
- 1 Department of Otolaryngology, New York Head and Neck Institute, Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA
| | - Christina Persaud
- 1 Department of Otolaryngology, New York Head and Neck Institute, Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA
| | - Caitlin Olson
- 1 Department of Otolaryngology, New York Head and Neck Institute, Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA
| | - Peter Costantino
- 1 Department of Otolaryngology, New York Head and Neck Institute, Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA
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22
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Mowery A, Light T, Clayburgh D. Venous thromboembolism incidence in head and neck surgery patients: Analysis of the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. Oral Oncol 2017; 77:22-28. [PMID: 29362122 DOI: 10.1016/j.oraloncology.2017.12.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 11/28/2017] [Accepted: 12/04/2017] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Venous thromboembolism (VTE) may cause significant postoperative morbidity and mortality; research in other surgical fields suggests an elevated VTE risk persists up to 30 days after surgery, beyond hospital discharge. We performed a review of the Veteran's Affairs Surgical Quality Improvement Project (VASQIP) database to determine the 30-day incidence of VTE following head and neck surgery and assess the proportion of VTE that occur post-discharge. MATERIALS AND METHODS A retrospective review was performed of all head and neck ablative procedures captured in the VASQIP database between 1991 and 2015. Post-operative VTE incidence was determined and the relationship of pre-operative data and post-operative mortality to VTE incidence was assessed. RESULTS 48,986 patients were included in the study; there were 152 VTE events (0.31%) and 39 (25.7%) occurred post-discharge. Lower VTE rates were found in parotidectomies (0.22%) and thyroid/parathyroid cases (0.23%), and higher rates in free flap (1.52%) and laryngectomy cases (0.69%). Age >70, recent weight loss, low serum albumin, and increased surgical time were all associated with increased VTE incidence on multivariate analysis. 90-day mortality in patients without VTE was 2.1% compared to 19.7% in patients who experienced a VTE. CONCLUSION While the documented rate of VTE in a national dataset is relatively low following head and neck surgeries, it is elevated with certain procedure categories and following long operations, and a significant proportion of VTE occur post-discharge. This study provides baseline data to better inform efforts to risk-stratify and customize thromboprophylaxis for patients undergoing head and neck procedures.
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Affiliation(s)
- Alia Mowery
- School of Medicine, Oregon Health and Science University, Portland, OR, United States
| | - Tyler Light
- School of Medicine, Oregon Health and Science University, Portland, OR, United States
| | - Daniel Clayburgh
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, OR, United States; Operative Care Division, Portland Veterans Affairs Health Care System, Portland, OR, United States.
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Cramer JD. Letter to the Editor regarding “Systematic review and meta-analysis of venous thromboembolism in otolaryngology-head and neck surgery”. Head Neck 2017; 40:447-448. [DOI: 10.1002/hed.25013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 10/09/2017] [Indexed: 11/09/2022] Open
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Cramer JD, Dilger AE, Schneider A, Smith SS, Samant S, Patel UA. Risk of Venous Thromboembolism Among Otolaryngology Patients vs General Surgery and Plastic Surgery Patients. JAMA Otolaryngol Head Neck Surg 2017; 144:9-17. [PMID: 29049530 DOI: 10.1001/jamaoto.2017.1768] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Importance Venous thromboembolism (VTE), which includes deep venous thrombosis or pulmonary embolism, is the number 1 cause of preventable death in surgical patients. Current guidelines from the American College of Chest Physicians provide VTE prevention recommendations that are specific to individual surgical subspecialties; however, no guidelines exist for otolaryngology. Objective To examine the rate of VTE for various otolaryngology procedures compared with an established average-risk field (general surgery) and low-risk field (plastic surgery). Design, Setting, and Participants This cohort study compared the rate of VTE after different otolaryngology procedures with those of general and plastic surgery in the American College of Surgeons National Surgical Quality Improvement Program from January 1, 2005, through December 31, 2013. We used univariate and multivariable logistic regression analysis of clinical characteristics, cancer status, and Caprini score to compare different risk stratification of patients. Data analysis was performed from May 1, 2016, to April 1, 2017. Exposure Surgery. Main Outcomes and Measures Thirty-day rate of VTE. Results A total of 1 295 291 patients, including 31 896 otolaryngology patients (mean [SD] age, 53.9 [16.7] years; 14 260 [44.7%] male; 21 603 [67.7%] white), 27 280 plastic surgery patients (mean [SD] age, 50.5 [13.9] years; 4835 [17.7%] male; 17 983 [65.9%] white), and 1 236 115 general surgery patients (mean [SD] age, 54.9 [17.2] years; 484 985 [39.2%] male; 867 913 [70.2%] white) were compared. The overall 30-day rate of VTE was 0.5% for otolaryngology compared with 0.7% for plastic surgery and 1.2% for general surgery. We identified a high-risk group for VTE in otolaryngology (n = 3625) that included free or regional tissue transfer, laryngectomy, composite resection, skull base surgery, and incision and drainage. High-risk otolaryngology patients experienced similar rates of VTE as general surgery patients across all Caprini risk levels. Low-risk otolaryngology patients (n = 28 271) experienced lower rates of VTE than plastic surgery patients across all Caprini risk levels. Malignant tumors were associated with VTE; however, the rates varied by cancer type and were 11-fold greater for cancers of the upper aerodigestive tract compared with thyroid cancers (odds ratio, 10.97; 95% CI, 7.38-16.31). Venous thromboembolism was associated with a 14-fold higher 30-day mortality among otolaryngology patients (5.1% mortality with VTE vs 0.4% mortality without VTE; difference, 4.7%; 95% CI of the difference, 2.2%-9.3%). Conclusions and Relevance Most patients undergoing otolaryngology procedures are at low risk of VTE, indicating that guidelines for a low-risk population could be adapted to otolaryngology. Patients undergoing high-risk otolaryngology procedures should be considered as candidates for more aggressive VTE prophylaxis.
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Affiliation(s)
- John D Cramer
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Amanda E Dilger
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Alex Schneider
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Stephanie Shintani Smith
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sandeep Samant
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Urjeet A Patel
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Individualized Venous Thromboembolism Risk Stratification Using the 2005 Caprini Score to Identify the Benefits and Harms of Chemoprophylaxis in Surgical Patients: A Meta-analysis. Ann Surg 2017; 265:1094-1103. [PMID: 28106607 DOI: 10.1097/sla.0000000000002126] [Citation(s) in RCA: 166] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE We performed a meta-analysis to investigate benefits and harms of chemoprophylaxis among surgical patients individually risk stratified for venous thromboembolism (VTE) using Caprini scores. SUMMARY OF BACKGROUND DATA Individualized VTE risk stratification may identify high risk surgical patients who benefit from peri-operative chemoprophylaxis. METHODS MEDLINE, EMBASE, and the Cochrane Library (CENTRAL) databases were queried. Eligible studies contained data on postoperative VTE and/or bleeding events with and without chemoprophylaxis. Primary outcomes included rates of VTE and clinically relevant bleeding after surgical procedures, stratified by Caprini score. A meta-analysis was conducted using a random-effects model. RESULTS Among 13 included studies, 11 (n = 14,776) contained data for VTE events and 8 (n = 7590) contained data for clinically relevant bleeding with and without chemoprophylaxis. The majority of patients received mechanical prophylaxis. A 14-fold variation in VTE risk (from 0.7% to 10.7%) was identified among surgical patients who did not receive chemoprophylaxis, and patients at increased levels of Caprini risk were significantly more likely to have VTE. Patients with Caprini scores of 7 to 8 [odds ratio (OR) 0.60, 95% confidence interval (95% CI) 0.37-0.97] and >8 (OR 0.41, 95% CI 0.26-0.65) had significant VTE risk reduction after surgery with chemoprophylaxis. Patients with Caprini scores ≤6 comprised 75% of the overall population, and these patients did not have a significant VTE risk reduction with chemoprophylaxis. No association between postoperative bleeding risk and Caprini score was identified. CONCLUSIONS The benefit of peri-operative VTE chemoprophylaxis was only found among surgical patients with Caprini scores ≥7. Precision medicine using individualized VTE risk stratification helps ensure that chemoprophylaxis is used only in appropriate surgical patients and may minimize bleeding complications.
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[Prophylaxis of venous thromboembolic events in head and neck surgery]. HNO 2017; 65:894-900. [PMID: 28699039 DOI: 10.1007/s00106-017-0392-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Application of perioperative thrombosis prophylaxis in head and neck surgery lacks consistent standards in Germany. Due to sparse data, the latest German S3 guideline concerning prophylaxis of thromboembolic events recommends a restrictive handling of anticoagulants in head and neck surgery, with few specific recommendations. OBJECTIVE The aim of this paper is to provide concrete clinical recommendations based on a systematic literature review and the S3 guidelines. MATERIALS AND METHODS A keyword-based literature search was performed and the German S3 guideline "Prophylaxis of Venous Thromboembolic Events" was used to state the current level of evidence and provide a clinical algorithm. RESULTS Eight additional cohort studies dealing with the incidence of thromboembolic events in head and neck surgery were identified. There were no randomized controlled trials. In the proposed algorithm, a classification of dispositional (patient history) and expositional (operation time) risk into three groups enables preoperative risk evaluation indicating the individual demand for prophylaxis. In short operations without major tissue traumatization, routine drug-based thrombosis prophylaxis is not necessary, provided no third-grade risk factors (earlier thromboembolic event, coagulopathy, or malignant disease) are present. Low molecular weight heparins should be used as anticoagulants for drug-based prophylaxis. CONCLUSION Prophylaxis of thromboembolic events in head and neck surgery is of high clinical relevance but there is currently limited evidence regarding its implementation. This paper is based on a systematic literature review and provides a clinical algorithm for head and neck surgeons.
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Pannucci CJ, Obi AT, Timmins BH, Cochran AL. Venous Thromboembolism in Patients with Thermal Injury. Clin Plast Surg 2017; 44:573-581. [DOI: 10.1016/j.cps.2017.02.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Moubayed SP, Eskander A, Mourad MW, Most SP. Systematic review and meta-analysis of venous thromboembolism in otolaryngology-head and neck surgery. Head Neck 2017; 39:1249-1258. [DOI: 10.1002/hed.24758] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 01/04/2017] [Accepted: 02/02/2017] [Indexed: 11/12/2022] Open
Affiliation(s)
- Sami P. Moubayed
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology - Head and Neck Surgery; Stanford University School of Medicine; Stanford California
| | - Antoine Eskander
- Department of Otolaryngology - Head and Neck Surgery; University of Toronto; Toronto Ontario Canada
| | - Moustafa W. Mourad
- Department of Otolaryngology - Head and Neck Surgery; New York Eye and Ear Infirmary of Mount Sinai; New York New York
| | - Sam P. Most
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology - Head and Neck Surgery; Stanford University School of Medicine; Stanford California
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Ahmad FI, Clayburgh DR. Venous thromboembolism in head and neck cancer surgery. CANCERS OF THE HEAD & NECK 2016; 1:13. [PMID: 31093343 PMCID: PMC6460546 DOI: 10.1186/s41199-016-0014-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 10/03/2016] [Indexed: 11/30/2022]
Abstract
Background Venous thromboembolism (VTE) is a major cause of perioperative morbidity and mortality. Historically, otolaryngology surgery has been seen as very low risk of VTE, given the relatively short procedures and healthy patient population. However, head and neck surgery patients have multiple additional risk factors for VTE compared to general otolaryngology patients, and only recently has research been directed at examining this population of patients regarding VTE risk. Review VTE has long been recognized as a major issue in other surgical specialties, with VTE rates of 15–60 % in some specialties in the absence of prophylaxis with either mechanical compression or anticoagulation. Multiple large-scale retrospective studies have shown that the incidence of VTE in otolaryngology patients is quite low, ranging between 0.1 and 1.6 %. However, these studies indicated that head and neck cancer patients may have an increased risk of VTE. Further retrospective studies focusing on head and neck cancer patients found a VTE rate of approximately 2 %, but one study also found a suspected VTE rate of 5.6 % based on clinical symptoms, indicating that retrospective studies may underreport the true incidence. A single prospective study found a 13 % risk of VTE after major head and neck surgery. Furthermore, risk stratification using the Caprini risk assessment model demonstrates that the highest risk patients may have a VTE risk of 18.3 %, although this may be lowered (but not eliminated) through the use of appropriate prophylactic anticoagulation. Conclusion VTE is likely a more significant concern in head and neck surgery patients than previously realized. Appropriate prophylaxis with mechanical compression and anticoagulation is essential; risk stratification may serve as a useful tool to identify head and neck cancer patients at highest risk for VTE.
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Affiliation(s)
- Faisal I Ahmad
- Department of Otolaryngology- Head & Neck Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, PV01, Portland, OR 97239 USA
| | - Daniel R Clayburgh
- Department of Otolaryngology- Head & Neck Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, PV01, Portland, OR 97239 USA
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Hachey KJ, Sterbling H, Choi DS, Pinjic E, Hewes PD, Munoz J, McAneny D, Tripodis Y, Fernando HC, Litle VR. Prevention of Postoperative Venous Thromboembolism in Thoracic Surgical Patients: Implementation and Evaluation of a Caprini Risk Assessment Protocol. J Am Coll Surg 2016; 222:1019-27. [DOI: 10.1016/j.jamcollsurg.2015.12.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Revised: 11/23/2015] [Accepted: 12/07/2015] [Indexed: 10/22/2022]
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Hachey KJ, Hewes PD, Porter LP, Ridyard DG, Rosenkranz P, McAneny D, Fernando HC, Litle VR. Caprini venous thromboembolism risk assessment permits selection for postdischarge prophylactic anticoagulation in patients with resectable lung cancer. J Thorac Cardiovasc Surg 2016; 151:37-44.e1. [DOI: 10.1016/j.jtcvs.2015.08.039] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 07/31/2015] [Accepted: 08/08/2015] [Indexed: 10/23/2022]
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Hewes PD, Hachey KJ, Zhang XW, Tripodis Y, Rosenkranz P, Ebright MI, McAneny D, Fernando HC, Litle VR. Evaluation of the Caprini Model for Venothromboembolism in Esophagectomy Patients. Ann Thorac Surg 2015; 100:2072-8. [DOI: 10.1016/j.athoracsur.2015.05.098] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 05/11/2015] [Accepted: 05/26/2015] [Indexed: 11/30/2022]
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Validation of the Caprini risk assessment model for venous thromboembolism in high-risk surgical patients in the background of standard prophylaxis. J Vasc Surg Venous Lymphat Disord 2015; 4:153-60. [PMID: 26993860 DOI: 10.1016/j.jvsv.2015.09.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 09/15/2015] [Indexed: 01/18/2023]
Abstract
OBJECTIVE We used the Caprini venous thromboembolism risk assessment score to prospectively evaluate if there was a correlation between the Caprini scores and the incidence of postoperative deep vein thrombosis (DVT) in high-risk surgical patients. A second objective was to determine whether patients at extremely high risk need a more effective prophylactic regimen. METHODS This prospective multicenter observational study involved 140 high-risk patients who underwent abdominal (48%) or cranial and/or spinal (52%) surgery. All patients were assessed using the Caprini model and had a mean score of 9.5 ± 2.7 (range, 5-15). Our standard prophylaxis for venous thromboembolism consisted of above-knee graduated compression stockings with 18 to 21 mm Hg pressure and subcutaneous low-dose unfractionated heparin three times per day, starting on the first or second through the fifth postoperative day depending on the risk of bleeding. We performed a duplex ultrasound examination at baseline during the first 12 to 24 hours after surgery and then every 3 to 5 days until discharge to assess the lower limb venous system up to the inferior vena cava. The end point of the study was ultrasound verification of fresh DVT or pulmonary embolism (PE). Verification of PE was made in all cases of DVT using echocardiography, lung scintigraphy, combined single-photon emission computed tomography and X-ray computed tomography, or autopsy. RESULTS Fresh postoperative DVT was found in 39 patients (28%). The incidence of DVT was 2% in patients with a Caprini score of 5 to 8, 26% in patients with scores of 9 to 11, and 65% in patients with scores of 12 to 15 (P for trend < .01). The risk for DVT was increased 18.7-fold for patients with scores of 9 to 11 and 98.4-fold for scores of 12 to 15 compared with patients with scores of 5 to 8. The area under the receiver operating characteristic curve was 0.87 (95% confidence interval, 0.81-0.94) and a Caprini score of 11 was the cutoff point that provided the highest sensitivity combined with highest specificity. In the 77 patients with a score of <11, DVT occurred in 2 patients (3%). In contrast, in the 63 patients with a score of ≥ 11, DVT occurred in 37 patients (59%; P < .01). PE was found in 13 patients (9%) and confirmed with autopsy. In all cases, verified fresh DVT was the source of embolism. CONCLUSIONS There was a significant correlation between Caprini scores and the incidence of postoperative DVT in high-risk surgical patients. A Caprini score of ≥ 11 can identify a subgroup of patients at extremely high risk. These patients need a more effective prophylactic regimen.
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Shah SP, Xu T, Hooker CM, Hulbert A, Battafarano RJ, Brock MV, Mungo B, Molena D, Yang SC. Why are patients being readmitted after surgery for esophageal cancer? J Thorac Cardiovasc Surg 2015; 149:1384-9; discussion 1389-91. [PMID: 25983251 DOI: 10.1016/j.jtcvs.2015.01.064] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 12/19/2014] [Accepted: 01/24/2015] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Readmission after surgery is an unwanted adverse event that is costly to the healthcare system. We sought to evaluate factors associated with increased risk of readmission and to characterize the nature of these readmissions in patients who have esophageal cancer. METHODS A retrospective cohort study was performed in 306 patients with esophageal carcinoma who underwent neoadjuvant chemoradiation followed by esophagectomy at Johns Hopkins Hospital between 1993 and 2011. Logistic regression was used to identify factors associated with 30-day readmission. Readmissions were defined as inpatient admissions to our institution within 30 days of discharge. RESULTS The median age at surgery was 61 years; the median postoperative length of stay was 9 days; and 48% of patients had ≥1 postoperative complication (POC). The 30-day readmission rate was 13.7% (42 of 306). In univariate analysis, length of stay and having ≥1 POC were significantly associated with readmission. In multivariate analysis, having ≥1 POC was significantly associated with a >2-fold increase in risk for 30-day readmission (odds ratio 2.35, with 95% confidence interval [1.08-5.09], P = .031) when controlling for age at diagnosis and length of stay. Of the 42 patients who were readmitted, 67% experienced POCs after surgery; 50% of patients who experienced POCs were readmitted for reasons related to their postoperative complication. The most common reasons for readmission were pulmonary issues (29%), anastomotic complications (20%), gastrointestinal concerns (17%), and venous thromboembolism (14%). CONCLUSIONS Complications not adequately managed before discharge may lead to readmission. Quality improvement efforts surrounding venous thromboembolism prophylaxis, and discharging patients nothing-by-mouth, may be warranted.
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Affiliation(s)
- Sneha P Shah
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Md
| | - Tim Xu
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Md
| | - Craig M Hooker
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Md
| | - Alicia Hulbert
- Division of Cancer Biology, Department of Oncology, Johns Hopkins School of Medicine, Baltimore, Md
| | - Richard J Battafarano
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Md
| | - Malcolm V Brock
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Md; Division of Cancer Biology, Department of Oncology, Johns Hopkins School of Medicine, Baltimore, Md
| | - Benedetto Mungo
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Md
| | - Daniela Molena
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Md
| | - Stephen C Yang
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Md.
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