A combination of heparin and an intermittent pneumatic compression device may be more effective to prevent deep-vein thrombosis in the lower extremities after laparoscopic cholecystectomy

Advancements in the interventional therapy and nursing care on deep vein thrombosis in the lower extremities

This review examines recent advancements in interventional treatments and nursing care for lower extremity deep vein thrombosis (DVT), highlighting significant innovations and their clinical applications. It discusses the transition to novel anticoagulants such as Direct Oral Anticoagulants, which offer a safer profile and simplified management compared to traditional therapies. Mechanical interventions, including balloon angioplasty and venous stenting, are detailed for their roles in improving immediate and long-term vascular function in acute DVT cases. Furthermore, the use of image-guided techniques is presented as essential for enhancing the accuracy and safety of DVT interventions. Additionally, this study outlines advances in nursing care strategies, emphasizing comprehensive preoperative and postoperative evaluations to optimize patient outcomes. These evaluations facilitate tailored treatment plans, crucial for managing the complex needs of DVT patients. Long-term care strategies are also discussed, with a focus on patient education to ensure adherence to treatment protocols and to prevent recurrence. The synthesis aims to inform healthcare professionals about cutting-edge practices in DVT management, promoting a deeper understanding of how these advancements can be integrated into clinical practice. It also underscores the necessity for ongoing research to address challenges such as cost-effectiveness and patient compliance, ensuring that future treatments are both accessible and effective.

Is there any effect of pneumoperitoneum pressure on coagulation and fibrinolysis during laparoscopic cholecystectomy?

BACKGROUND

Laparoscopic cholecystectomies (LC) are generally performed in a 12 mmHg-pressured pneumoperitoneum in a slight sitting position. Considerable thromboembolism risk arises in this operation due to pneumoperitoneum, operation position and risk factors of patients. We aim to investigate the effect of pneumoperitoneum pressure on coagulation and fibrinolysis under general anesthesia.

MATERIAL AND METHODS

Fifty American Society of Anesthesiologist (ASA) I-III patients who underwent elective LC without thromboprophlaxis were enrolled in this prospective study. The patients were randomly divided into two groups according to the pneumoperitoneum pressure during LC: the 10 mmHg group (n = 25) and the 14 mmHg group. Prothrombin time (PT), thrombin time (TT), International Normalized Ratio (INR), activated partial thromboplastin time (aPTT) and blood levels of d-dimer and fibrinogen were measured preoperatively (pre), one hour (post1) and 24 h (post24) after the surgery. Moreover, alanine amino transferase, aspartate amino transferase and lactate dehydrogenase were measured before and after the surgery. These parameters were compared between and within the groups.

RESULTS

PT, TT, aPTT, INR, and D-dimer and fibrinogen levels significantly increased after the surgery in both of the groups. D-dimer level was significantly higher in 14-mmHg group at post24.

CONCLUSION

Both the 10-mmHg and 14-mmHg pressure of pneumoperitoneum may lead to affect coagulation tests and fibrinogen and D-dimer levels without any occurrence of deep vein thrombosis, but 14-mmHg pressure of pneumoperitoneum has a greater effect on D-dimer. However, lower pneumoperitoneum pressure may be useful for the prevention of deep vein thrombosis.

Evidence-Based Practice in Laparoscopic Surgery: Perioperative Care

Best practices for reducing risks of postoperative infection, venous thromboembolism, and nausea and vomiting in patients undergoing laparoscopic surgery are uncertain. As a result, perioperative care varies widely. We reviewed evidence from randomized clinical trials on the effectiveness of interventions for postoperative infection, venous thromboembolism, and nausea and vomiting Data sources were the Cochrane Central Register of Clinical Trials, reference lists of published trials, and randomized clinical trials published in English since 1990. Trials were also limited to those focused on patients undergoing laparoscopic surgery. Data from 98 randomized clinical trials were included in the final analysis. Routine antibiotic use in laparoscopic cholecystectomy, and possibly other clean procedures not involving placement of prostheses, is likely unnecessary. Similarly, venous thromboembolism prophylaxis is probably unnecessary for low-risk patients undergoing brief procedures. Of a wide variety of methods for reducing postoperative nausea and vomiting, serotonin receptor antagonists appear the most effective and should be considered for routine prophylaxis.

Effect of various pneumoperitoneum pressures on femoral vein hemodynamics during laparoscopic cholecystectomy

High intra-abdominal pressure and reverse Trendelenburg position during laparoscopic cholecystectomy (LC) are risk factors for venous stasis in lower extremity. Lower limb venous stasis is one of the major pathophysiological elements involved in the development of peri-operative deep vein thrombosis. Low pressure pneumoperitoneum (7-10 mmHg) has been recommended in patients with limited cardiac, pulmonary or renal reserve. The purpose of this study was to observe the effect of various pneumoperitoneum pressures on femoral vein (FV) hemodynamics during LC. A total of 50 patients undergoing elective LC were enrolled and they were prospectively randomized into two groups containing 25 patients each. In group A high pressure pneumoperitoneum (14 mmHg) and in group B low pressure pneumoperitoneum (8 mmHg) was maintained. Comparison of pre-operative and post-operative coagulation profile was done. Preoperative and intraoperative change in femoral vein diameter (FVD) (AP and LAT), cross-sectional area (CSA) and peak systolic flow (PSF) during varying pneumoperitoneum pressure was recorded in FV by ultrasound Doppler. First measurement (pre-operative) was carried out just after the induction of anesthesia before creation of pneumoperitoneum and second measurement (intra-operative) was taken just before completion of surgery with pneumoperitoneum maintained. Changes in coagulation parameters were less significant at low pressure pneumoperitoneum. There was statistical significant difference in the pre-operative and intra-operative values of FVD, CSA and PSF in both groups when analyzed independently (P = 0.00). There was no significant difference in pre-operative values of FVD, CSA and PSF (P > 0.05) among two groups but when the comparison was made between the intra-operative values, there was significant increase in FVD (AP) (P = 0.016), CSA (P = 0.00) and decrease in PSF (P = 0.00) at high pressure pneumoperitoneum. This study provides evidence of using low pressure pneumoperitoneum during LC as changes in FV hemodynamics and coagulation parameters were less pronounced at low pressure pneumoperitoneum.

Subclinical activation of coagulation and fibrinolysis in laparoscopic cholecystectomy: do risk factors exist?

PURPOSES

This study examines whether inherent patient-related risk factors (age, gender) modify the effect of laparoscopic cholecystectomy (LC) upon the coagulation and fibrinolysis cascades.

METHODS

This observational study included 119 low-risk for deep vein thrombosis (DVT) patients undergoing elective LC, without thromboprophylaxis. Pre-operatively and 24 h post-operatively we measured PT-INR, aPTT, FDP, d-dimer, and fibrinogen. Color Doppler scan of the lower extremity was performed the 1st post-operative day. Differences before and after surgery were analyzed with respect to risk factors.

RESULTS

No clinically or ultrasound evident DVT was observed. INR (1.04 ± 0.06 vs. 1.12 ± 0.11, p < 0.0001), d-dimer (0.38 ± 0.36 vs. 0.9 ± 0.64, p < 0.0001), plasma fibrinogen (380.8 ± 74.9 vs. 403.8 ± 78.8, p = 0.0001) and FDP positivity exhibited statistically significant increase after surgery. The levels of aPTT did not exhibit any significant change. Concerning d-dimer, older age was associated with higher pre-operative concentrations; older patients accordingly exhibited more intense increase in d-dimer and FDP positivity after surgery. Male sex was associated with higher PT-INR and aPTT before surgery, as well as with more pronounced increase in PT- INR postoperatively; similarly, older age was associated only with higher PT-INR before surgery.

CONCLUSIONS

Despite no DVT, significant increase in PT-INR, d-dimer, FDP and fibrinogen appeared after LC. This may be attributed to surgical trauma and pneumoperitoneum effects on the portal vein flow. Elderly subjects and males seem particularly vulnerable, demonstrating more sizeable changes.

Anesthesia for cosmetic surgery

Increasing numbers of plastic surgery procedures are performed in diverse environments, including traditional hospital operating rooms, outpatient surgery centers, and private offices. Just as plastic surgeons develop areas of specialization to better care for their patients, anesthesiologists have specialized in outpatient plastic surgery, both cosmetic and reconstructive. The methods they utilize are similar to those for other procedures but incorporate specific techniques that aim to better relieve preoperative anxiety, induce and awaken patients more smoothly, and minimize postoperative sequelae of anesthesia such as nausea and vomiting. It is important for plastic surgeons to understand these techniques since they are the ones who are ultimately responsible for their patients' care and are frequently called on to employ anesthesiologists for their practices, surgery centers, and hospitals. The following is a review of the specific considerations that should be given to ambulatory plastic surgery patients and the techniques used to safely administer agreeable and effective anesthesia.

[What kind of treatment are available in deep vein thrombosis prevention?]

In order to propose new recommendations concerning deep vein thrombosis prevention in surgery and obstetrics, we identified all the available tools. We performed a Medline search for ten years to review all the studies published in this field. This preliminary stage is mandatory in assessing guidelines able to work out strategies considering each patient in each particular surgical situation. There are no formal guidelines and we outlined a practical approach for the prevention of deep vein thrombosis. Data concerning all available treatment were not classified in an evidence-based strategy.

Video laparoscopic surgery: is out-of-hospital thromboprophylaxis necessary?

Despite widespread use of laparoscopic procedures, no adequate data are available to support specific recommendations for venous thromboprophylaxis in patients undergoing laparoscopic surgery. This prospective, randomized trial is the first to be designed to evaluate a regimen of out-of-hospital thromboprophylaxis after laparoscopic surgery. Consecutive patients admitted for laparoscopic surgery were considered for the study. The thromboprophylaxis regimen used for each patient was based on a risk score. Possible thromboprophylactic measures included elastic stockings and pre- and postoperative Dalteparin or early ambulation. At discharge, patients were randomly allocated either to continue Dalteparin for 1 week, or to receive no further prophylaxis. Patients judged to be at low risk were not randomized. Compression ultrasound of the leg veins was performed in all patients 4 weeks after hospital discharge. Fifty-three patients, all with acute appendicitis, were judged to be at low risk of deep vein thrombosis and were not included in the randomized study. The remaining 209 patients fell into two groups: 104 patients received postdischarge Dalteparin and 105 patients did not. The incidence of deep vein thrombosis was 0% (0 of 104) vs. 0.95% (one of 105), respectively (P = 1.00). The risk of postdischarge venous thromboembolism is low in patients undergoing laparoscopic surgery who receive in-hospital thromboprophylaxis. Given this low risk, a clinical trial powered to determine if extending prophylaxis in such patients reduces the risk of clinically apparent deep vein thrombosis would be unfeasibly large.

Tromboprofilaxia na colecistectomia videolaparoscópica

Inspirados no caso de um paciente que desenvolveu tromboembolia pulmonar três dias após a realização de uma colecistectomia videolaparoscópica, mesmo tendo feito uso de heparina não fracionada no pré e nas primeiras 24hs de pós-operatório.Os autores analisaram a ocorrência de tromboembolia venosa na colecistectomia videolaparoscópica , os fatores de risco, as medidas de tromboprofilaxia e sugerem a conduta a ser adotada neste tipo de procedimento.

Venous thromboembolism in laparoscopic surgery

Currently there are limited randomized data regarding thromboprophylaxis in laparoscopic surgery. The aim of this article is to identify principles to guide safe practice with regard to prevention of venous thromboembolism. With the exception of laparoscopic cholecystectomy, there are no prospective, randomized studies comparing the incidence of venous thromboembolism between a conventional procedure and a laparoscopic procedure for the same operation. Surveys of surgical practice indicate that policies for venous thromboembolism prophylaxis in laparoscopic surgery are generally the same as those for conventional surgery. The increasing use of a minimal access approach for a variety of abdominal, pelvic, and thoracic procedures demands further prospective, randomized studies in this area. Current guidelines endorsed by The Society of American Gastrointestinal Endoscopic Surgeons recommend following the adoption of protocols used in conventional surgery for the equivalent laparoscopic operation, and the European Association for Endoscopic Surgery has recommended the use of intraoperative intermittent pneumatic compression of the lower extremities for all prolonged laparoscopic procedures. There is only limited evidence to support these recommendations. Venous thromboembolism is an important and preventable complication in surgical patients. Evidence does not exist to consider laparoscopic surgery patients to be at a substantially lower risk for venous thromboembolism than those undergoing conventional procedures. Currently there is a lack of data regarding the prophylaxis against venous thromboembolism in laparoscopic surgery, and the practice is thus opinion based. The authors recommend that the use of standard prophylactic regimens tailored to specific patient populations for conventional operations be adopted for laparoscopic surgery until prospective data are available.