Screening and Diagnosis of VTE: The More You Look, The More You Find?

Thin air, thick blood: High altitude trauma centers have increased deep venous thrombosis rates

BACKGROUND

Patients undergoing elective procedures at altitudes >4000 ​ft have higher deep venous thrombosis (DVT) rates compared to those performed at ​≤ ​1000 ​ft.

DESIGN

We reviewed the American College of Surgeons Trauma Quality Improvement Program (TQIP) database from 2014 to 2019. Adults are divided into LOW (<1001 ​ft) or HIGH (>4000 ​ft) altitude treatment with DVT rates compared by multivariable regression analysis as well as using a 2:1 propensity matched model.

RESULTS

Risk-adjusted odds ratio (OR) for DVT at high altitude was 1.53 [95 ​% CI 1.42-1.64]. In patients with an Injury Severity Score (ISS) ​≥ ​16, the DVT rate was 1.10 ​% (LOW) vs 1.59 ​% (HIGH); risk-adjusted OR for DVT at high altitude with ISS ​≥ ​16 was 1.67 [1.53-1.83]. Under the propensity matched model, DVT rates at higher altitude had an OR of 1.59 [1.46-1.74].

CONCLUSION

Following traumatic injury, DVT rates are increased in higher altitude treatment facilities compared to their low elevation peers.

Screening ultrasound for deep vein thrombosis detection in high-risk pediatric trauma

PURPOSE

Venous thromboembolism (VTE) is a rare but significant complication among high-risk pediatric trauma patients. The NO CLOT study's primary aim was to evaluate the safety of chemical prophylaxis against VTE in high-risk pediatric trauma patients with a secondary aim of evaluating the use of screening venous duplex ultrasound (sUS) to identify deep vein thrombosis (DVT). We hypothesized that sUS would detect asymptomatic DVT at a high rate in high-risk patients.

METHODS

A prospective multi-institutional study was performed at eight level one pediatric trauma centers from 2019 to 2022. sUS was recommended 7 days after admission for all high-risk trauma patients. Univariate and multivariate analyses were performed.

RESULTS

Of 460 high-risk trauma patients, 64/341 (18.8%) remained admitted on day 7 and underwent sUS. Ten of 64 (15.6%) had a DVT identified on sUS (median of 6.5 [IQR 5.2, 7.0] days after trauma). In 277 patients still admitted on day 7 without sUS performed, 15 (5.4%) developed symptomatic DVT (median of 6.0 [IQR 3.0, 8.0] days after trauma. For the sUS cohort, 9/10 (90%) DVTs were associated with an indwelling central venous line (CVL) and occurred either without chemical prophylaxis use at all in 4/10 (40%) or when initiated more than 24-h post-trauma in 6/10 (60%).

CONCLUSIONS

In this high-risk cohort, most DVTs were identified in the first week following injury; however, the majority were asymptomatic. Use of sUS at 1-week post-injury increases DVT detection; however, the clinical consequences of asymptomatic detection of DVT remain unknown.

LEVEL OF EVIDENCE

III.

VTE rates and risk factors in major trauma patients

BACKGROUND

Venous thromboembolism (VTE) is a common and in some instances life-threatening complication following severe traumatic injury. Owing to a lack of high-quality evidence in VTE risk prediction and prevention in this cohort, major trauma patients receive variable VTE preventative care. The aim of this systematic review was to determine the reported rates of VTE in major trauma patients, and associated risk factors.

METHODS

A comprehensive database search was conducted using EBSCO/MEDLINE, EMBASE, CINAHL, Cochrane and Scopus to identify studies published between 1990 and 2023. Original Studies quantifying the occurrence of and/or evaluating risk factors for VTE, PE and DVT in a defined population were eligible for inclusion. Five reviewers screened, appraised, and extracted data from the selected studies.

RESULTS

A total of 22 studies fulfilled the inclusion criteria. Most studies were conducted in Northern America (72 %), followed by Asia (18 %), and Europe (9 %). Of the 22 studies, 17 were retrospective, 4 were prospective and 1 was the control arm of an RCT. The reported rates in included studies ranged from 0.39 % to 32 % (VTE), 0.59 % to 57.60 % (DVT) and 0.35 % to 24.0 % (PE). Operative procedure was the most consistently reported associated variable for DVT followed by delays to prophylaxis and pelvic injury. Lower extremity injury was the most frequently reported associated variable for PE followed by male sex and increased age. Age was the most frequently reported variable for both DVT and PE.

CONCLUSION

There exists significant variation in the reported rates of VTE in major trauma patients globally. Operative procedure, delays to prophylaxis and pelvic injury were the most consistently reported associated variables for DVT. Lower extremity injury followed by male sex and increased age were the most frequently reported associated variables for PE. Although studies indicate possible differences in risk factors for DVT and PE, heterogeneity in study characteristics and outcome reporting impedes any meaningful conclusions. Reconciliation of VTE rates in major trauma patients is necessary when comparing populations.

Venous thromboembolism testing practices after orthopaedic trauma: prophylaxis regimen does not influence testing patterns

Objectives

To determine venous thromboembolism (VTE) testing patterns in an orthopaedic trauma population and to evaluate for differences in VTE surveillance by prophylaxis regimen through a secondary analysis of the ADAPT trial.

Design

Prospective randomized trial.

Setting

Level I trauma center.

Patients

Three hundred twenty-nine adult (18 years and older) trauma patients presenting with an operative extremity fracture proximal to the metatarsals/carpals or any pelvic or acetabular fracture requiring VTE prophylaxis.

Intervention

VTE imaging studies recorded within 90 days post injury.

Main Outcome Measurements

Percentage of patients tested for VTE were compared between treatment groups using Fisher's exact test. Subsequently, multivariable regression was used to determine patient factors significantly associated with risk of receiving a VTE imaging study.

Results

Sixty-seven patients (20.4%) had VTE tests ordered during the study period. Twenty (29.9%) of these 67 patients with ordered VTE imaging tests had a positive finding. No difference in proportion of patients tested for VTE by prophylaxis regimen (18.8% on aspirin vs. 22.0% on LMWH, P = 0.50) was observed. Factors associated with increased likelihood of VTE testing included White race (adjusted odds ratio [aOR]: 2.61, 95% CI: 1.26-5.42), increased Injury Severity Score (aOR for every 1-point increase: 1.10, 95% CI: 1.05-1.15), and lower socioeconomic status based on the Area Deprivation Index (aOR for every 10-point increase: 1.14, 95% CI: 1.00-1.30).

Conclusions

VTE surveillance did not significantly differ by prophylaxis regimen. Patient demographic factors including race, injury severity, and socioeconomic status were associated with differences in VTE surveillance.

Level of Evidence

Level I, Therapeutic.

A comparative analysis of tranexamic acid dosing strategies in traumatic major hemorrhage

INTRODUCTION

Tranexamic acid (TXA) is a life-saving treatment for traumatic hemorrhage, but the optimal dosing regimen remains unknown. Different doses and treatment strategies have been proposed, including single bolus, repeated bolus, or bolus plus infusion. The aim of this study was to determine the effect of different TXA dosing strategies on clinical outcomes in bleeding trauma patients.

METHODS

Secondary analysis of a perpetual cohort study from a UK Level I trauma center. Adult patients who activated the local major hemorrhage protocol and received TXA were included. The primary outcome was 28-day mortality. Secondary outcomes were 24-hour mortality, multiple organ dysfunction syndrome, venous thromboembolism, and rotational thromboelastometry fibrinolysis.

RESULTS

Over an 11-year period, 525 patients were included. Three dosing groups were identified: 1 g bolus only (n = 317), 1 g bolus +1 g infusion over 8 hours (n = 80), and 2 g bolus (n = 128). Demographics and admission physiology were similar, but there were differences in injury severity (median Injury Severity Score, 25, 29, and 25); and admission systolic blood pressure (median Systolic Blood Pressure, 99, 108, 99 mm Hg) across the 1-g, 1 g + 1 g, and 2-g groups. 28-day mortality was 21% in each treatment group. The incidence of multiple organ dysfunction syndrome was significantly higher in the bolus plus infusion group (84%) vs. 1 g bolus (64%) and 2 g bolus (62%) group, p = 0.002, but on multivariable analysis was nonsignificant. Venous thromboembolism rates were similar in the 1-g bolus (4%), 2 g bolus (8%) and bolus plus infusion groups (7%). There was no difference in rotational thromboelastometry maximum lysis at 24 hours: 5% in both the 1-g and 2-g bolus groups vs. 4% in bolus plus infusion group.

CONCLUSION

Clinical outcomes and 24-hour fibrinolysis state were equivalent across three different dosing strategies of TXA. Single bolus administration is likely preferable to a bolus plus infusion regimen.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Unfractionated heparin versus enoxaparin for venous thromboembolism prophylaxis in intensive care units: a propensity score adjusted analysis

Venous thromboembolism (VTE) is a common complication in hospitalized patients. Pharmacologic prophylaxis is used in order to reduce the risk of VTE events. The main purpose of this study is to compare the prevalence of deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients admitted to the intensive care unit (ICU) who received unfractionated heparin (UFH) versus enoxaparin as VTE prophylaxis. Mortality was evaluated as a secondary outcome. This was a Propensity Score Adjusted Analysis. Patients admitted to neurology, surgical, or medical ICUs and screened with venous doppler ultrasonography or computed tomography angiography for detection of VTE were included in the analysis. We identified 2228 patients in the cohort, 1836 (82.4%) patients received UFH and 392 (17.6%) patients received enoxaparin. Propensity score matching yielded a well-balanced cohort of 950 (74% UFH, 26% enoxaparin) patients. After matching, there was no difference in prevalence of DVT (RR 1.05; 95% CI 0.67-1.64, p = 0.85) and PE (RR 0.76; 95% CI, 0.44-1.30, p = 0.31). No significant differences in location and severity of DVT and PE between the two groups were detected. Hospital and intensive care unit stay was similar between the two groups. Unfractionated heparin was associated with a higher rate of mortality, (HR 2.04; 95% CI, 1.13-3.70; p = 0.019). The use of UFH as VTE prophylaxis in ICU patients was associated with a similar prevalence of DVT and PE compared with enoxaparin, and the site and degree of occlusion were similar. However, a higher mortality rate was seen in the UFH group.

Venous thromboembolic screening in pediatric trauma: A prospective cohort study of risk-stratified ultrasonography

BACKGROUND

This prospective observational cohort study evaluates risk-stratified venous thromboembolism (VTE) screening in injured children. While the reported incidence of VTE is 6% to 10% among critically injured children, there is no standard for screening. Venous thromboembolism may have long-term sequelae in children, including postthrombotic syndrome.

METHODS

Patients admitted to a level 1 pediatric trauma center were risk stratified for VTE using a validated prediction algorithm. Children at high risk (risk scores ≥523; i.e., ≥1% risk) received screening duplex ultrasonography. Children at moderate risk (risk scores 410-522; i.e., 0.3-0.99% risk) were screened as a comparison/control.

RESULTS

Three-hundred fifty-five children were consecutively risk stratified from October 2019 to May 2021. Forty-seven children received screening duplex ultrasounds: 21 from a high-risk cohort and 26 from a moderate-risk cohort. Four children were diagnosed with VTE in the high-risk cohort compared with seven in the moderate-risk cohort ( p = 0.53). Total incidence of VTE among screened children was 23.4% (11 of 47). Asymptomatic VTE accounted for 81.8% of all events (9 of 11). Fifty-four percent (6 of 11) of VTE were central venous catheter associated. Venous thromboembolism in surviving children resolved by 3 to 6 months with no symptoms of postthrombotic syndrome after 1 year. No cases of VTE were identified in unscreened children, yielding an institutional VTE incidence of 3.1% (11 of 355).

DISCUSSION

Risk-stratified screening demonstrates a significant incidence of asymptomatic VTE in injured children. These results may guide reevaluation of prediction algorithms developed from symptomatic VTE risk and longitudinal study of the sequelae of asymptomatic VTE.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Trauma-related electrolyte disturbances: From resuscitation to rhabdomyolysis

Traumatic injury results in drastic changes to a patient's normal physiology. The hormonal stress response, as well as some treatment strategies, lead to significant disruptions in electrolyte homeostasis that are important for clinicians to understand. In addition, advances in fluid resuscitation and modern transfusion practices have led to their own unique set of consequences, which we are just beginning to appreciate. Special attention is placed on rhabdomyolysis, as this distinct entity represents an extreme example of injury induced electrolyte derangements. This review describes the physiologic response to trauma and highlights some of the important electrolyte abnormalities that can be encountered while caring for the injured patient.

Fourteen years of pancreatic surgery for malignancy among ACS-NSQIP centers: Trends in major morbidity and mortality

BACKGROUND

The American College of Surgeons National Surgical Quality Improvement Program was established to help participating hospitals track and report surgical complications with the goal of improving surgical care. We sought to determine whether this has led to improvements in surgical outcomes for pancreatic malignancies.

METHODS

Patients with pancreatic malignancies who underwent surgical resection were identified from the American College of Surgeons National Surgical Quality Improvement Program database (2006-2019). Thirty-day postoperative major morbidity and mortality were analyzed by year. Major morbidity included organ and deep surgical site infection, venous thromboembolism, cardiac event, pneumonia, acute renal failure, sepsis, and respiratory failure.

RESULTS

Of the 28,888 patients identified, 51% were male, the median age was 68, 74.3% underwent a pancreaticoduodenectomy, and 25.7% underwent a distal pancreatectomy. Among patients who underwent a pancreaticoduodenectomy, there was a significant increase in major morbidity (annual percent change 0.77, P = .012) driven by increases in organ space surgical site infection (annual percent change 3.52, P < .001) and venous thromboembolism (annual percent change 4.72, P = .005). However, there was a decrease in postoperative mortality (annual percent change -4.58, P = .001). For distal pancreatectomy patients, there was no change in rates of overall major morbidity (annual percent change -1.35, P = .08) or mortality (annual percent change -3.21, P = .25).

CONCLUSION

Although major morbidity and mortality have not significantly changed for distal pancreatectomy patients, mortality has steadily decreased for patients undergoing pancreaticoduodenectomy, despite an increase in major morbidity. Whether this trend reflects a change in patient selection, an increase in detection of postoperative morbidities and/or an improvement in mitigation of these morbidities warrants further study.

An abbreviated Caprini model for VTE risk assessment in trauma

The Caprini risk assessment model (RAM) is widely used to assess risk of venous thromboembolism (VTE). However, it is cumbersome with 31 variables and poses challenges with inter-rater reliability. This study aimed to determine if an abbreviated model could perform similarly in VTE risk assessment. We performed a retrospective review of trauma patients ≥ 18 years old and admitted for over 24 h at a Level I trauma center from January 1, 2018, to December 31, 2018. Demographic and clinical data were analyzed to generate Caprini scores. Using a p-value cutoff of < 0.05, the individual components of the original Caprini RAM most highly associated with VTE were identified and used to calculate an abbreviated Caprini score. Logistic regression assessed odds of inpatient VTE with the original or abbreviated Caprini RAMs. Receiver operating characteristic curves and c-statistics were generated to assess discriminatory ability. The study sample included 1279 patients. Ten risk factors were included in the abbreviated model (recent major surgery, length of surgery > 2 h, transfusion, restricted mobility > 72 h, central venous catheter, current major surgery, age, history of VTE, hip or leg fracture, and serious trauma). Compared to the original, the abbreviated model had a similar odds ratio (1.17 vs 1.07, both p-values < 0.001), c-statistic (0.747 vs 0.753), sensitivity (0.73 vs 0.76) and specificity (0.62 vs 0.61). An abbreviated Caprini RAM performs similarly to the original, may streamline workflow and allow for automation in electronic health records, potentially enhancing its use in resource limited settings.

Venous thromboembolism risk stratification in trauma using the Caprini risk assessment model

INTRODUCTION

The Caprini risk assessment model is widely used for venous thromboembolism (VTE) but has limited data in trauma. The study objective was to determine if the Caprini risk assessment model could effectively risk stratify trauma patients.

MATERIALS AND METHODS

We performed a retrospective review of trauma patients aged ≥18 years, admitted for greater than 24 h at a level one trauma center from January 1, 2018, to December 31, 2018. Demographic and clinical data were analyzed to generate Caprini scores. Multiple logistic regression assessed odds of inpatient VTE.

RESULTS

A total of 1279 patients met study eligibility, with a total of 33 VTE (2.6%). When comparing those with VTE to those without, the mean age was lower (52.5 vs 59.5, p = 0.06, respectively), sex distribution was similar, but mean body mass index was higher (30.2 vs 27.4, p = 0.019, respectively). The mean Caprini score was 9.9, and 75.5% had a score >4, the traditional Caprini high-risk cutoff. The VTE group had a higher mean Injury Severity Score (17.8 vs 12.6, p = 0.011), and mean Caprini score (16.4 vs 9.8, p < 0.001). Multiple logistic regression found Caprini score, not Injury Severity Score, was associated with higher odds of VTE (adjusted odds ratio 1.06, 95% confidence interval 1.02-1.10), after adjusting for Injury Severity Score, any missed doses of VTE chemoprophylaxis, and VTE prophylaxis type.

CONCLUSIONS

Higher Caprini scores are associated with elevated odds of inpatient VTE within hospitalized trauma patients. These data support using the Caprini risk assessment model in the trauma population, which may aid in risk stratification.

Incidence of VTE and Bleeding Among Hospitalized Patients With Coronavirus Disease 2019: A Systematic Review and Meta-analysis

BACKGROUND

Individual studies have reported widely variable rates for VTE and bleeding among hospitalized patients with coronavirus disease 2019 (COVID-19).

RESEARCH QUESTION

What is the incidence of VTE and bleeding among hospitalized patients with COVID-19?

METHODS

In this systematic review and meta-analysis, 15 standard sources and COVID-19-specific sources were searched between January 1, 2020, and July 31, 2020, with no restriction according to language. Incidence estimates were pooled by using random effects meta-analyses. Heterogeneity was evaluated by using the I² statistic, and publication bias was assessed by using the Begg and Egger tests.

RESULTS

The pooled incidence was 17.0% (95% CI, 13.4-20.9) for VTE, 12.1% (95% CI, 8.4-16.4) for DVT, 7.1% (95% CI, 5.3-9.1) for pulmonary embolism (PE), 7.8% (95% CI, 2.6-15.3) for bleeding, and 3.9% (95% CI, 1.2-7.9) for major bleeding. In subgroup meta-analyses, the incidence of VTE was higher when assessed according to screening (33.1% vs 9.8% by clinical diagnosis), among patients in the ICU (27.9% vs 7.1% in the ward), in prospective studies (25.5% vs 12.4% in retrospective studies), and with the inclusion of catheter-associated thrombosis/isolated distal DVTs and isolated subsegmental PEs. The highest pooled incidence estimate of bleeding was reported for patients receiving intermediate- or full-dose anticoagulation (21.4%) and the lowest in the only prospective study that assessed bleeding events (2.7%).

INTERPRETATION

Among hospitalized patients with COVID-19, the overall estimated pooled incidence of VTE was 17.0%, with higher rates with routine screening, inclusion of distal DVT, and subsegmental PE, in critically ill patients and in prospective studies. Bleeding events were observed in 7.8% of patients and were sensitive to use of escalated doses of anticoagulants and nature of data collection. Additional studies are required to ascertain the significance of various thrombotic events and to identify strategies to improve patient outcomes.

TRIAL REGISTRY

PROSPERO; No.: CRD42020198864; URL: https://www.crd.york.ac.uk/prospero/.

Fondaparinux Sodium Compared With Low-Molecular-Weight Heparins for Perioperative Surgical Thromboprophylaxis: A Systematic Review and Meta-analysis

Background

Fondaparinux sodium has been compared with low‐molecular‐weight heparins (LMWH) in randomized controlled trials for perioperative surgical thromboprophylaxis. However, the results from these studies are inconsistent in terms of efficacy and safety to reach a clinical decision. The objective of this study was to systematically review the randomized controlled trials comparing the efficacy and safety of fondaparinux and LMWH for perioperative surgical thromboprophylaxis.

Methods and Results

Systematic search in various databases was done to identify randomized controlled trials comparing fondaparinux and LMWH published during the years 2000 to 2017. Outcomes of interest in this study included venous thromboembolism up to day 15, all‐cause mortality up to day 90, major bleeding, and minor bleeding during the treatment period. Analyses were performed with the relative odds based on a random‐effects model using Mantel‐Haenszel statistics. Results were presented as odds ratios with their 95% CIs. The assessment of study quality was performed as per Cochrane collaboration. After screening 10 644 articles, 12 randomized controlled trials including 14 906 patients were included in the final analyses. Pooled analyses showed the odds of venous thromboembolism in the fondaparinux group were 0.49 times the odds in LMWH group (OR=0.49 [0.38–0.64]). However, the odds of major bleeding in the fondaparinux group were 1.48 times the odds in the LMWH group (OR=1.48 [1.15–1.90]).

Conclusions

Fondaparinux was associated with a superior efficacy in terms of reduction of venous thromboembolism in this meta‐analysis. However, it was also associated with increased odds of major bleeding.

Routine surveillance for diagnosis of venous thromboembolism after pleurectomy for malignant pleural mesothelioma

OBJECTIVE

The purpose of this study was to determine the incidence of venous thromboembolism and utility of a routine surveillance program in patients undergoing surgery for mesothelioma.

METHODS

Patients undergoing pleurectomy from May 2016 to August 2018 were included. A standardized surveillance program to look for venous thromboembolism in this group included noninvasive studies every 7 days postoperatively or earlier if symptomatic. All patients received external pneumatic compression sleeves in addition to prophylactic heparin. If deep vein thrombosis or pulmonary embolus was discovered, heparin drip was initiated until conversion to therapeutic anticoagulation.

RESULTS

A total of 100 patients underwent pleurectomy for mesothelioma. Seven patients were found to have preoperative deep vein thrombosis, and as such only 93 patients were included for analysis. The median age of patients at surgery was 71 years (30-85 years). During the study, 30 patients (32%) developed evidence of thrombosis; 20 patients (22%) developed only deep vein thrombosis without embolism, 3 patients (3%) developed only pulmonary embolism, and 7 patients (7%) developed both deep vein thrombosis and pulmonary embolus. Of the 27 patients who developed deep vein thrombosis, 9 (33%) were asymptomatic at the time of diagnosis, and none of these developed a pulmonary embolus or other bleeding complications. There were 2 (2%) events of major postoperative bleeding related to therapeutic anticoagulation.

CONCLUSIONS

The incidence of venous thromboembolism is high (32%) among patients undergoing surveillance after pleurectomy for mesothelioma. Up to 33% of patients with deep vein thrombosis are asymptomatic at the time of diagnosis, and the incidence of complications related to anticoagulation is low. Routine surveillance may be useful to diagnose and treat deep vein thrombosis before it progresses to symptomatic or fatal pulmonary embolus.

Direct Oral Anticoagulants in the Prevention of Venous Thromboembolism Following Surgery for Hip Fracture in Older Adults: A Population-Based Cohort Study

Introduction

Direct oral anticoagulants (DOACs) decrease the risk of venous thromboembolism (VTE) without increasing the risk of hemorrhage in elective lower limb orthopedic surgery. However, the role of DOACs in preventing VTE following hip fracture surgery in the older adults remains unclear. This study aims to evaluate the efficacy and safety of DOACs in older adults undergoing surgery for hip fracture.

Materials and methods

Single-center, retrospective, population-based cohort study of patients receiving either a DOAC or low-molecular-weight heparin (LMWH) for VTE prophylaxis following hip fracture surgery. Data obtained included patient demographics, comorbidities, fracture classification, time to surgery, procedure performed, and length of stay. Main outcomes assessed were incidence of VTE, incidence of major hemorrhage, and death within 30 days of surgery.

Results

A total of 321 patients were included. Incidence of VTE was 0% in the DOAC group and 3.4% in the LMWH group (risk ratio [RR]:0.26, 95% confidence interval [CI]: 0.02-4.34, P = .35). Hemorrhage occurred in 7.4% and 3.0% of patients in the DOAC and LMWH groups, respectively (RR: 2.47, 95% CI: 0.77-7.91, P = .13). Mortality from VTE was 0% in the DOAC group and 0.7% in the LMWH group (RR: 0.97, 95% CI: 0.05-20.02, P = .99). Mortality from hemorrhage was 1.9% in the DOAC group and 0.7% in the LMWH group (RR: 2.47, 95% CI: 0.23-26.78, P = .46).

Discussion

The use of DOACs for VTE prophylaxis following surgery in older adults with hip fracture was associated with a similar rate of VTE compared to LMWH. However, there was a worrying trend toward an increased risk of hemorrhage.

Conclusion

In the present study of a carefully selected cohort of patients, the effect of DOACs in reducing the risk of VTE following surgery for hip fracture in the older adults was comparable to LMWH. However, a trend toward increased risk of hemorrhage was noted. Larger prospective studies will be required to identify patients who will benefit the most from treatment.

Analysis of venous thromboembolism in neurosurgical patients undergoing standard versus routine ultrasonography

Routine screening of high-risk asymptomatic trauma or surgical patients for venous thromboembolism (VTE) is controversial. Studies suggest against screening while others recognize that some patients at high risk may benefit. The purpose of this pilot study is to evaluate the benefit of routine screening using doppler ultrasonography for the early detection of deep venous thrombosis (DVT) in post-operative neurosurgical patients. This was a quasi-experimental study at a major academic tertiary care medical center. A total of 157 adults underwent cranial or spinal surgical interventions from March through August 2017 and received either standard screening (n = 104) versus routine ultrasonography screening (n = 53). There was no significant difference in incidence of DVT between the two groups: 11 (11%) in the standard screening group versus 5 (9%) in the routine screening group, p = 0.823. Upper and lower extremity ultrasonography was performed in 43 (41%) of the standard screening group versus 53 (100%) in the routine screening group, p < 0.001. DVT was identified in nearly one of every 6 ultrasonography screenings in the standard screening group versus 27 ultrasonography screenings required to identify one DVT in the routine screening group. There were the same number of screenings for upper extremity ultrasonography, but they did not yield or detect DVT; instead only superficial, untreatable, DVTs were reported. Total cost to diagnose one DVT, including screening and labor, averaged $13,664 in the standard group versus $56,525 in the routine group. Routine screening in neurosurgical patients who received VTE prophylaxis was not associated with lower incidence of VTE and mortality attributed to PE. Thus, routine screening may not be cost effective to prevent complications from DVT incidence.

Role of nurses in improving patient safety: Evidence from surgical complications in 21 countries

Objectives

To analyze the role of nurse staffing in improving patient safety due to reducing surgical complications in member countries of Organization for Economic Co-operation and Development (OECD).

Methods

The number of practicing nurses' density per 1000 population and five surgical complications indicators including foreign body left in during procedure (FBL), postoperative pulmonary embolism (PPE) and deep vein thrombosis (DVT) after hip and knee replacement, postoperative sepsis after abdominal surgery (PSA) and postoperative wound dehiscence (PWD) were collected in crude rates per 100,000 hospital discharges for age group of 15 years old and over within 30 days after surgery based on surgical admission-related and all admission-related methods. The observations of 21 OECD countries were collected from OECD Health Statistics during 2010-2015 period. The statistical technique of panel data analysis including unit root test, co-integration test and dynamic long-run analysis were used to estimate the possible relationship between our panel series.

Results

There were significant relationships from nurse-staffing level to reducing FBL, PPE, DVT, PSA and PWD with long-run magnitudes of -2.91, -1.30, -1.69, -2.81 and -1.12 based on surgical admission method as well as -6.12, -14.57, -7.29, -1.41 and -0.88 based on all admission method, respectively.

Conclusions

A higher proportion of nurses is associated with higher patient safety resulting from lower surgical complications and adverse clinical outcomes in OECD countries. Hence, we alert policy makers about the risk of underestimating the impact of nurses on improving patient safety as well as the quality of health care services in OECD countries.

Systematic Review of Safety and Cost-Effectiveness of Venous Thromboembolism Prophylaxis Strategies in Patients Undergoing Craniotomy for Brain Tumor

BACKGROUND

Studies have evaluated various strategies to prevent venous thromboembolism (VTE) in neuro-oncology patients, without consensus.

OBJECTIVE

To perform a systematic review with cost-effectiveness analysis (CEA) of various prophylaxis strategies in tumor patients undergoing craniotomy to determine the safest and most cost-effective prophylaxis regimen.

METHODS

A literature search was conducted for VTE prophylaxis in brain tumor patients. Articles reporting the type of surgery, choice of VTE prophylaxis, and outcomes were included. Safety of prophylaxis strategies was determined by measuring rates of VTE and intracranial hemorrhage. Cost estimates were collected based on institutional data and existing literature. CEA was performed at 30 d after craniotomy, comparing the following strategies: mechanical prophylaxis (MP), low molecular weight heparin with MP (MP+LMWH), and unfractionated heparin with MP (MP+UFH) to prevent symptomatic VTE. All costs were reported in 2016 US dollars.

RESULTS

A total of 34 studies were reviewed (8 studies evaluated LMWH, 12 for MP, and 7 for UFH individually or in combination; 4 studies used LMWH and UFH preoperatively). Overall probability of VTE was 1.49% (95% confidence interval (CI) 0.42-3.72) for MP+UFH, 2.72% [95% CI 1.23-5.15] for MP+LMWH, and 2.59% (95% CI 1.31-4.58) for MP, which were not statistically significant. Compared to a control of MP alone, the number needed to treat for MP+UFH is 91 and 769 for MP+LMWH. The risk of intracranial hemorrhage was 0.26% (95% CI 0.01-1.34) for MP, 0.74% (95% CI 0.09-2.61) for MP+UFH, and 2.72% (95% CI 1.23-5.15) for MP+LMWH, which were also not statistically significant. Compared to MP, the number needed to harm for MP+UFH was 208 and for MP+LMWH was 41. Fifteen studies were included in the final CEA. The estimated cost of treatment was $127.47 for MP, $142.20 for MP+UFH, and $169.40 for MP+LMWH. The average cost per quality-adjusted life-year for different strategies was $284.14 for MP+UFH, $338.39 for MP, and $722.87 for MP+LMWH.

CONCLUSION

Although MP+LMWH is frequently considered the optimal prophylaxis for VTE risk reduction, our model suggests that MP+UFH is the safest and most cost-effective measure to balance VTE and hemorrhage risks in brain tumor patients at lower risk of hemorrhage. MP+LMWH may be more effective for patients at higher risk of VTE.