Stratifying the risk of venous thromboembolism in otolaryngology

Venous Thromboembolism Prophylaxis in Otolaryngologic Patients Using Caprini Assessment

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.

Incidence of venous thromboembolism following head and neck surgery

PURPOSE

Venous thromboembolism (VTE) is associated with significant morbidity and mortality in patients undergoing surgery, but conflicting data exist on VTE risk in patients undergoing head and neck surgery for malignant and non-malignant conditions. Our aim was to examine the risk of VTE among patients with and without cancer undergoing head and neck surgery.

METHODS

We conducted a nationwide cohort study to examine the risk of VTE among patients with an otolaryngological diagnosis using data from the Danish National Patient Register between 2010 and 2018. Analyses were stratified by cancer and anatomical areas of the surgical procedure.

RESULTS

In total, 116,953 patients were included of whom 10% (n = 12,083) had active cancer. After 3 months, 1.2% of the patients with cancer and 0.3% of the patients without cancer experienced VTE, respectively. For patients undergoing mouth/throat surgery, 0.8% with cancer and 0.2% without cancer had VTE, respectively. After nose/sinuses surgery 0.7% and 0.2%, respectively. No patients experienced VTE after ear surgery; and after endoscopies the numbers were 1.3% and 0.6% respectively.

CONCLUSIONS

While the minority of patients undergoing head and neck surgery develop VTE postoperatively, the risk increases among those with cancer. To support clinical decision making on anticoagulation, risk stratification tools could be further developed to recognize this hazard in patients with cancer undergoing head and neck surgery.

Can Risk-Based Thromboprophylaxis Practice Guidelines be Safely Used in Esophagectomy Cases? Experience of an Academic Health System

BACKGROUND

Venous thromboembolism (VTE) occurs in 3-11% of esophagectomy patients and is associated with increased mortality and morbidity. The use of validated VTE risk assessment tools and compliance with recommended practice guidelines remains unclear. In this study, we seek to determine the use of Caprini guideline indicated VTE prophylaxis and its effect on VTE and bleeding complications following esophagectomy.

METHODS

Esophagectomy cases were identified from the Mayo Clinic electronic health records. Caprini score and VTE prophylaxis regimen received were determined retrospectively. VTE prophylaxis was identified as appropriate or inappropriate based on the Caprini score and prophylaxis received preoperative, during hospitalization, and after hospital discharge. Study cohorts were compared by Pearson Chi-square test, Fisher's Exact test, Kruskal-Wallis test, and logistic regression models. Stata/MP 16.1 was used for analysis. Odds ratios and 95% confidence intervals were reported for logistic regression models. A p-value < 0.05 was considered significant.

RESULTS

Four hundred and fifty-six esophagectomy cases were analyzed. The median Caprini score was thirteen. Appropriate prophylaxis resulted in a 6.9-fold reduction in inpatient VTE. All 30- and 90-day post-discharge VTEs occurred in those not receiving Caprini guideline-indicated VTE prophylaxis. Inpatient, 30- and 90-day post-discharge bleeding rates were 7.68%, 0.91%, and 2.11%, respectively; however, bleeding was not increased with receipt of appropriate prophylaxis.

CONCLUSION

In this esophagectomy cohort, Caprini guideline indicated VTE prophylaxis resulted in reduced inpatient VTE events without increasing bleeding complications. Risk-based VTE prevention measures should be considered in this patient cohort known to be at heightened risk for postoperative VTE.

Venous thromboembolism and bleeding after hepatectomy: role and impact of risk adjusted prophylaxis

Venous thromboembolism (VTE) occurs in 2-6% of post-hepatectomy patients and is associated with increased mortality and morbidity. The use of VTE risk assessment models in hepatectomy cases remains unclear. Our study aimed to determine the use and impact of Caprini guideline indicated VTE prophylaxis following hepatectomy. Hepatectomy cases performed during 2016-2021 were included. Caprini score and VTE prophylaxis were determined retroactively, and VTE prophylaxis was categorized as appropriate or inappropriate. The primary outcome was the receipt of appropriate prophylaxis, and secondary outcomes were postoperative VTE and bleeding. Statistical analyses included Fisher Exact test, Kruskal-Wallis, Pearson Chi-Square test, and multivariate regression models. R Statistical software was used for analysis. A p-value < 0.05 or 95% Confidence Interval (CI) excluding 1 was considered significant. A total of 1955 hepatectomy cases were analyzed. Patient demographics were similar between study cohorts. Inpatient, 30- and 90-day VTE rates were 1.28%, 0.56%, and 1.24%, respectively. By Caprini guidelines, 59% and 4.3% received appropriate in-hospital and discharged VTE prophylaxis, respectively. Inpatient VTE (4.5-fold) and mortality (9.5-fold) were lower in patients receiving appropriate prophylaxis. All discharged VTE and mortality occurred in patients not receiving appropriate prophylaxis. Inpatient, 30- and 90-day bleeding rates were 8.4%, 0.62%, and 0.68%, respectively. Appropriate prophylaxis did not increase postoperative bleeding. Increasing Caprini score inversely correlated with receiving appropriate prophylaxis (OR 0.38, CI 0.31-0.46) at discharge, and appropriate prophylaxis did not correlate with bleeding risk (OR 0.79, CI 0.57-1.12). Caprini guideline indicated prophylaxis resulted in reduced VTE complications without increasing bleeding risk.

Postoperative venous thromboembolism risk-prediction in foot and ankle fracture surgery

BACKGROUND

Venous thromboembolism (VTE) are rare but serious complications after foot and ankle fracture surgery. A consensus definition of a high-risk patient has not been reached, leading to significant variability in the use of pharmacologic agents for VTE prophylaxis. The aim of this study was to develop a model for predicting VTE risk in patients undergoing surgery for foot and ankle fractures that is usable and scalable in clinical practice.

METHODS

A retrospective review of 15,342 patients, within the ACS-NSQIP database, who had undergone surgical repair of foot and ankle fractures from 2015 to 2019 was performed. Univariate analysis evaluated differences in demographics and comorbidities. Stepwise multivariate logistic regression was generated based on a 60 % development cohort to evaluate risk factors for VTE. A receiver operator curve based on the 40 % test cohort calculated area under the curve (AUC) to measure the accuracy of the model in predicting VTE within the 30-day postoperative period.

RESULTS

Of the 15,342 patients, 1.2 % patients experienced VTE, and 98.8 % patients did not. Patients who experienced VTE were significantly older and had an overall higher comorbidity burden. Those who had VTE spent on average 10.5 more minutes in the operating room. In the final model, age over 65, diabetes, dyspnea, CHF, dialysis, wound infection and bleeding disorders were all found to be significant predictors of VTE after controlling for all other factors. The model generated an AUC of 0.731, indicating good predictive accuracy. The predictive model is publicly available at https://shinyapps.io/VTE_Prediction/.

CONCLUSIONS

In alignment with previous studies, we identified increased age and bleeding disorders as independent risk factors for VTE after foot and ankle fracture surgery. This is one of the first studies to generate and test a model for identifying patients at risk for VTE in this population. This evidence-based model may help surgeons prospectively identify high-risk patients who may benefit from pharmacologic VTE prophylaxis.

Thromboembolic outcomes are decreased with the use of a standardized venous thromboembolism risk assessment and prophylaxis protocol for patients undergoing superficial venous procedures

OBJECTIVE

Patients with venous insufficiency can be treated with ablation or phlebectomy, or both. Patients undergoing superficial venous procedures have an elevated risk of deep vein thrombosis (DVT) and pulmonary embolism (PE). At our institution, we initiated a standardized protocol in which patients with a Caprini score (2005 version) of ≥8 are treated with 1 week of prophylactic anticoagulation after the procedure. Duplex ultrasound was performed at 1 week and then within 90 days after the procedure. This aim of the present study was to determine the thrombotic and clinical outcomes after superficial vein procedures using a standardized protocol for DVT/PE risk assessment and prophylaxis.

METHODS

We performed a retrospective analysis of prospectively collected data of superficial vein procedures from 2015 to 2021 at a single center. The patient demographics, CEAP (Clinical-Etiology-Anatomy-Pathophysiology) clinical class, venous clinical severity score, patient-reported outcomes, treatment type, Caprini scores, pre- and postoperative anticoagulation use, and outcomes were collected. Descriptive statistics were used for the patient demographics, procedure details, and unadjusted surgical outcomes. Multivariable logistic regression was used to evaluate the relationship between procedure type and DVT and PE after adjusting for patient characteristics, disease severity, periprocedural anticoagulation, and Caprini score.

RESULTS

A total of 1738 limbs were treated with ablation (n = 820), phlebectomy (n = 181), or ablation and phlebectomy (n = 737). More patients were women (67.1%) and White (90.9%). The overall incidence of DVT/PE was 1.4%. Patients undergoing ablation with phlebectomy had higher rates of DVT/PE (2.7%) than those undergoing ablation (0.2%) or phlebectomy alone (1.7%; P < .01). However, only 30% of DVTs were above the knee. On multivariate analysis, only the procedure type predicted for DVT/PE. However, patients undergoing ablation and phlebectomy achieved better patient-reported outcomes (Caprini score, 5.9) compared with those undergoing ablation (Caprini score, 7.2) or phlebectomy (Caprini score, 7.9) alone (P < .01). The best improvement in the venous clinical severity score was seen with phlebectomy alone.

CONCLUSIONS

The expected difference in the DVT/PE rates between high- and low-risk groups did not materialize in our patients, perhaps secondary to the additional chemoprophylaxis prescribed for the high-risk cohort (Caprini score, ≥8). These results call for a randomized trial to assess the efficacy of a standardized protocol in the reduction of DVT/PE after superficial vein procedures.

Enhanced Recovery After Surgery for Head and Neck Oncologic Surgery Requiring Microvascular Reconstruction

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.

A nomogram to predict postoperative deep vein thrombosis in patients with femoral fracture: a retrospective study

OBJECTIVE

The implementation of more active anticoagulant prevention and treatment measures has indeed led to a significant reduction in the incidence of perioperative deep vein thrombosis (DVT) among patients with bone trauma. However, it is important to note that despite these efforts, the incidence of DVT still remains relatively high. According to the Caprini score, all patients undergoing major orthopedic surgery were defined as the high-risk group for DVT. Stratifying the risk further within high-risk groups for DVT continues to present challenges. As a result, the commonly used Caprini score during the perioperative period is not applicable to orthopedic patients. We attempt to establish a specialized model to predict postoperative DVT risk in patients with femoral fracture.

METHODS

We collected the clinical data of 513 patients undergoing femoral fracture surgery in our hospital from May 2018 to December 2019. According to the independent risk factors of DVT obtained by univariate and multivariate logistic regression analysis, the corresponding nomogram model was established and verified internally. The discriminative capacity of nomogram was evaluated by receiver operating characteristic (ROC) curve and area under the curve (AUC). The calibration curve used to verify model consistency was the fitted line between predicted and actual incidences. The clinical validity of the nomogram model was assessed using decision curve analysis (DCA) which could quantify the net benefit of different risk threshold probabilities. Bootstrap method was applied to the internal validation of the nomogram model. Furthermore, a comparison was made between the Caprini score and the developed nomogram model.

RESULTS

The Caprini scores of subjects ranged from 5 to 17 points. The incidence of DVT was not positively correlated with the Caprini score. The predictors of the nomogram model included 10 risk factors such as age, hypoalbuminemia, multiple trauma, perioperative red blood cell infusion, etc. Compared with the Caprini scale (AUC = 0.571, 95% CI 0.479-0.623), the calibration accuracy and identification ability of nomogram were higher (AUC = 0.865,95% CI 0.780-0.935). The decision curve analysis (DCA) indicated the clinical effectiveness of nomogram was higher than the Caprini score.

CONCLUSIONS

The nomogram was established to effectively predict postoperative DVT in patients with femoral fracture. To further reduce the incidence, more specialized risk assessment models for DVT should take into account the unique risk factors and characteristics associated with specific patient populations.

The Thresholds of Caprini Score Associated With Increased Risk of Venous Thromboembolism Across Different Specialties: A Systematic Review

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.

Prior COVID-19 Infection Predisposes to Worse Outcomes After Autologous Breast Reconstruction: A Propensity Score-Matched Analysis

BACKGROUND

Major shifts in health care systems worldwide have occurred because of coronavirus disease 2019 (COVID-19). With nearly half of all Americans now having a history of COVID-19 infection, there is a pressing need to better understand the importance of prior COVID-19 infection as a potential surgical risk factor. The aim of this study was to investigate the impact of a history of prior COVID-19 infection on patient outcomes after autologous breast reconstruction.

METHODS

We performed a retrospective study using the TriNetX research database, which contains deidentified patient records from 58 participating international health care organizations. All patients who underwent autologous breast reconstruction between March 1, 2020, and April 9, 2022, were included and were grouped based on history of a prior COVID-19 infection. Demographic, preoperative risk factors, and 90-day postoperative complication data were compared. Data were analyzed by propensity score-matched analysis on TriNetX. Statistical analyses were performed by Fisher exact, χ2, and Mann-Whitney U tests as appropriate. Significance was set at P values of <0.05.

RESULTS

Patients with a history of autologous breast reconstruction within our temporal study window (N = 3215) were divided into groups with (n = 281) and without (n = 3603) a prior COVID-19 diagnosis. Nonmatched patients with prior COVID-19 had increased rates of select 90-day postoperative complications, including wound dehiscence, contour deformities, thrombotic events, any surgical site complications, and any complications overall. Use of anticoagulant, antimicrobial, and opioid medications was also found to be higher in those with prior COVID-19.After performing propensity-score matching, each cohort consisted of 281 patients without statistically significant differences between any baseline characteristics. When comparing outcomes between matched cohorts, patients with a history of COVID-19 had increased rates of wound dehiscence (odds ratio [OR], 1.90; P = 0.030), thrombotic events (OR, 2.83; P = 0.0031), and any complications (OR, 1.52; P = 0.037).

CONCLUSIONS

Our results suggest that prior COVID-19 infection is a significant risk factor for adverse outcomes after autologous breast reconstruction. Patients with a history of COVID-19 have 183% higher odds of postoperative thromboembolic events, warranting careful patient selection and postoperative management.

Stratifying the risks of venous thromboembolism in the lateral skull base surgery using Caprini risk assessment model

PURPOSE

To analyze and stratify the possible risk factors of venous thromboembolism (VTE) in lateral skull base surgery (LSBS) using the Caprini risk assessment model.

METHODS

In a single center, a retrospective study was conducted with patients who underwent LSBS from June 2016 to August 2021. The clinical characteristics and blood chemistry tests were collected. The incidence of VTE within 30 days of surgery was recorded. The Caprini risk score was calculated to assess the postoperative VTE risk.

RESULTS

Among the 123 patients in this study, the VTE incidence within 30 postoperative days was 8.9%. The total Caprini risk score in VTE patients (5.6 ± 1.9 points) was significantly higher than that of non-VTE patients (4.6 ± 1.4 points; p = 0.028). The binary logistic regression showed the total Caprini score as the only independent indicator of postoperative VTE. The receiver operating characteristic curve analysis showed that the Caprini score at 6.5 points had low sensitivity (36.4%) but high specificity (91.1%), with the largest area under the curve being 0.659. The VTE rate was significantly higher in patients with a total Caprini score ≥ 7 points (28.6%) compared to those with a total Caprini score ≤ 6 points (7.3%; p = 0.022).

CONCLUSION

LSBS patients have a high risk of developing postoperative VTE. Patients with a Caprini score ≥ 7 points had a significantly higher risk of developing VTE after LSBS. The Caprini risk system was useful in assessing the VTE risk in LSBS. However, more data, calibration, and validation are necessary to establish an exclusive Caprini risk system for LSBS.

Venous Thromboembolism Rates After Free Flap Reconstruction of the Head and Neck Region

BACKGROUND

Venous thromboembolism (VTE) is a major concern for the postoperative hospitalized patient, especially after long and complex procedures. Cancer itself also contributes to the hypercoagulable state, further complicating the management of patients. Despite prophylaxis, breakthrough events can occur. We aimed to assess our institutional VTE and bleeding rates after free flap reconstruction of the head and neck (H&N) region and the factors associated with VTE events.

METHODS

A retrospective review of the patients who underwent H&N free flap reconstruction at an academic center from 2012 to 2021 was performed from a prospectively maintained database. Data regarding patient demographics, medical history, surgical details, and overall outcomes were collected. Outcomes studied included postoperative 30-day VTE rates and major bleeding events. Patients who had a VTE event were compared with the rest of the cohort to identify factors associated with VTE.

RESULTS

Free flap reconstruction of the H&N region was performed in 949 patients. Reconstruction after cancer extirpation for squamous cell carcinoma was the most common etiology (79%). The most common flap was thigh based (50%), followed by the fibula (29%). The most common postoperative VTE chemoprophylaxis regimen was enoxaparin 30 mg twice daily (83%). The VTE and bleeding rates over the 10-year period were 4.6% (n = 44) and 8.7% (n = 83), respectively. Body mass index (28.7 ± 5.8 vs 26.2 ± 6.6, P = 0.013) and pulmonary comorbidities were found to be significantly higher in patients who had a VTE event (43% vs 27%, P = 0.017). Patients with a VTE event had a prolonged hospital stay of 8 more days (19.2 ± 17.4 vs 11 ± 7, P = 0.003) and a higher incidence of bleeding events (27% vs 8%, P < 0.001).

CONCLUSIONS

Postoperative VTE is a significant complication associated with increased length of hospitalization in patients undergoing free flap reconstruction of the H&N region. Institutional measures should be implemented on an individualized basis based on patient comorbidities to improve the postoperative VTE rates, while balancing the bleeding events.

Preoperative low-molecular weight heparin chemoprophylaxis in head and neck free flap reconstruction

BACKGROUND

The safety of presurgical thromboprophylaxis using low molecular weight heparin (LMWH) has not been well described in head and neck oncologic surgery with free tissue transfer (HNS-FTT).

METHODS

Retrospective chart review of HNS-FTT patients receiving versus not receiving presurgical subcutaneous enoxaparin (Px-LMWH) was performed. Outcomes included estimated blood loss (EBL), hematoma, flap compromise, DVT or pulmonary embolus (PE). Fisher's exact test and Wilcoxon Rank Sum test were performed to compare groups. Odds ratios and associated 95 % confidence intervals were provided as appropriate.

RESULTS

43 of 128 patients (34 %) received Px-LMWH. There was no significant difference in EBL, hematoma, or flap complications between groups. Patients without Px-LMWH had higher rates of DVT and PE, although the difference did not reach statistical significance (p = 1.00, 0.095, respectively).

CONCLUSION

Presurgical Px-LMWH can be used in major head and neck reconstructive surgery without increased intraoperative blood loss or postoperative complications. Larger studies will need to be done to determine the impact of Px-LMWH on DVT and PE in this patient population.

LEVEL OF EVIDENCE: 3

Are IBD Patients Underscored when Determining Postoperative VTE Risk?

BACKGROUND

Patients with inflammatory bowel disease (IBD) have an increased risk of venous thromboembolism (VTE) following colorectal surgery and there is currently no consensus on post-surgical VTE prevention or specific VTE risk assessment tools. We sought to evaluate VTE risk after colorectal surgery and determine if known risk factors used in risk assessment tools adequate correlate with VTE risk in IBD patients.

METHODS

Retrospective cohort study using the National Surgical Quality Improvement Project (NSQIP) Participant User File from 2010 to 2018.

RESULTS

A total of 27,679 patients were included; 19,015 (68.7%) had Crohn's disease (CD) and 8664 (31.3%) ulcerative colitis (UC). Of these, 16,749 (60.5%) underwent abdominopelvic procedures, 10,178 (36.8%) complex pelvic procedures, and 752 (2.7%) small bowel operations. The overall VTE rate was 2.3%. The VTE rate in patients with CD and UC was 1.8% and 3.6% (p < 0.001) respectively. Overall median time to VTE was 9 days after surgery. VTE rate was highest in patients who underwent complex pelvic procedures (3.6%; 361/10,178). A risk score was calculated using 16/40 available variables from the Caprini VTE Risk Assessment tool; risk score ranged from 3 to 12 points. Most patients that developed a VTE had a score between 3 and 5 points (75.6%), and only 24.5% had a score of 6 or higher. Patients with higher risk scores did not have a higher VTE incidence.

CONCLUSION

Post-surgical VTE rates are high in IBD patients. Over half of the events occurred following discharge and in patients with an apparent low-risk score. Additional studies are warranted to define a recommended postoperative VTE prophylaxis regimen for patients with IBD.

Postoperative protocols following endoscopic skull base surgery: An evidence-based review with recommendations

BACKGROUND

Postoperative management strategies for endoscopic skull base surgery (ESBS) vary widely because of limited evidence-based guidance.

METHODS

The PubMed, EMBASE, and Cochrane databases were systematically reviewed from January 1990 through February 2022 to examine 18 postoperative considerations for ESBS. Nonhuman studies, articles written in a language other than English, and case reports were excluded. Studies were assessed for levels of evidence, and each topic's aggregate grade of evidence was evaluated.

RESULTS

A total of 74 studies reporting on 18 postoperative practices were reviewed. Postoperative pain management, prophylactic antibiotics, and lumbar drain use had the highest grades of evidence (B). The literature currently lacks high quality evidence for a majority of the reviewed ESBS precautions. There were no relevant studies to address postoperative urinary catheter use and medical intracranial pressure reduction.

CONCLUSION

The evidence for postoperative ESBS precautions is heterogeneous, scarce, and generally of low quality. Although this review identified the best evidence available in the literature, it suggests the urgent need for more robust evidence. Therefore, additional high-quality studies are needed in order to devise optimal postoperative ESBS protocols.

Extended‐duration thromboprophylaxis for abdominopelvic surgery: Development and evaluation of a risk‐stratified patient decision aid to facilitate shared decision making

Background

Extended-duration thromboprophylaxis is used to decrease risk of venous thromboembolism (VTE) after surgery but may increase the risk of bleeding. The decision to complete a course of extended-duration thromboprophylaxis can be challenging.

Objective

The objective of this study was to develop an acceptable patient decision aid (PtDA) to facilitate shared decision making for the use of extended-duration thromboprophylaxis following major abdominal surgery.

Methods

An evidence-based, risk-stratified PtDA was created. The evidence on benefits and harms of a 28-day postoperative course of low-molecular-weight heparin (LMWH) versus in-hospital prophylaxis only were synthesized. Outcomes included minor bleeding, major bleeding, clinically significant VTE, and fatal VTE. Risks were calculated and reported by Caprini score. Alpha testing of the PtDA draft with various stakeholders was performed using a 10-question survey to assess acceptability of the PtDA with patients, thrombosis experts, and surgeons. The primary outcome was the acceptability of the PtDA.

Results

Acceptability testing was performed with 11 patients, 11 thrombosis experts, and 11 surgeons. Most responders felt the language on the PtDA was easy to follow (28/33, 85%), and that the information was well balanced between management options (9/11 [82%] patients; 17/21 [80%] clinicians). Most patients (9/11, 82%) and clinicians (18/22, 82%) believed it would be a useful clinical tool, and were satisfied with the overall quality of the PtDA (27/33, 82%).

Conclusions

A risk-stratified, evidence-based PtDA was created to facilitate shared decision making for the use of extended-duration LMWH following major abdominal surgery. This clinical tool was acceptable with patients and physicians and is available at https://decisionaid.ohri.ca/decaids.html.

Systematic review of venous thromboembolism risk categories derived from Caprini score

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.

Assessment of BMI and Venous Thromboembolism Rates in Patients on Standard Chemoprophylaxis Regimens After Undergoing Free Tissue Transfer to the Head and Neck

Importance

Venous thromboembolism (VTE) is a severe complication after free tissue transfer to the head and neck (H&N). Enoxaparin 30 mg twice daily (BID) is a common regimen for chemoprophylaxis. However, differences in enoxaparin metabolism based on body weight may influence its efficacy and safety profile.

Objective

To assess the association between BMI and postoperative VTE and hematoma rates in patients treated with prophylactic enoxaparin 30 mg BID.

Design, Setting, and Participants

This was a retrospective review of a prospectively collected cohort from 2012 to 2022. Postoperative VTE, hematoma, and free flap pedicle thrombosis were recorded within 30 days of index surgery. The setting was a tertiary academic referral center. Participants included patients undergoing H&N reconstruction with free flaps that received fixed-dose subcutaneous enoxaparin 30 mg BID postoperatively. Statistical analysis was conducted from April to May 2022.

Main Outcomes and Measures

Outcomes include incidence of VTE, hematoma, and flap pedicle thrombosis events within 30 days of the surgery. Univariate and multivariable regression models were used to evaluate associations between BMI and other patient factors with these outcomes.

Results

Among the 765 patients included, 262 (34.24%) were female; mean (SD) age was 60.85 (12.64) years; and mean (SD) BMI was 26.36 (6.29). The rates of VTE and hematoma in the cohort were 3.92% (30 patients) and 5.09% (39 patients), respectively. After adjusting for patient factors, BMI was the only factor associated with VTE (OR, 1.07; 95% CI, 1.015-1.129). Obesity (BMI >30) was associated with increased odds of VTE (OR, 2.782; 95% CI, 1.197-6.564). Hematoma was not associated with BMI (OR, 0.988; 95% CI, 0.937-1.041). Caprini score of at least 9 was not associated with VTE (OR, 1.259; 95% CI, 0.428-3.701).

Conclusions and Relevance

This cohort study found that obesity was associated with an increased risk of VTE in patients after microvascular H&N reconstruction and while on standard postoperative chemoprophylaxis regimens. This association may suggest insufficient VTE prophylaxis in this group and a potential indication for weight-based dosing.

Provider Response to a Venous Thromboembolism Risk Assessment and Prophylaxis Ordering Tool: Observational Study

OBJECTIVES

Our health system launched an initiative to regulate venous thromboembolism (VTE) risk assessment and prophylaxis with electronically embedded risk assessment models based on validated clinical prediction rules. Prior to system-wide implementation, usability testing was conducted on the VTE clinical decision support system (CDSS) to assess provider perceptions, facilitate adoption, and usage of the tool. The objective of this study was to conduct usability testing with end users on the CDSS' risk assessment model and prophylaxis ordering components.

METHODS

This laboratory usability testing study was conducted with 24 health care providers. Participants were given two case scenarios that mirrored real-world scenarios to assess likelihood of use and adoption. During each case scenario, participants engaged in a think-aloud session, verbalizing their decision-making process while interacting with the tool. Following each case scenario, participants completed the System Usability Scale (SUS) and a posttask interview. Participants' comments and interactions with the VTE CDSS were placed into coding categories and analyzed for generalizable themes by three independent coders.

RESULTS

Of the 24 participants, 50% were female and the mean age of all participants was 32.76 years. The average SUS across the different services lines was 72.39 (C grade). Each participant's comments were grouped into three overarching themes: functionality, visibility/navigation, and content. Comments included personalizing workflow for each service line, minimizing the number of clicks, clearly defining risk models, including background on risk scores, and providing treatment guidelines for order sets.

CONCLUSION

An important step toward providing quality health care to patients at risk of developing a VTE event is providing user-friendly tools to providers. Following usability testing, our study revealed opportunities to positively impact provider behavior and acceptance. The rigor and breadth of this usability testing study and adoption of the optimizations should increase provider adoption and retention of the VTE CDSS.

Using an Institute Model to Reduce the Incidence of Venous Thromboembolism Within a Large Hospital System

Internal benchmarking showed that the Orthopedic Institute had an above average rate of venous thromboembolism (VTE) along with other institutes. The Orthopedic VTE Quality Team was assigned to investigate opportunities for improvement to share with other institutes. To investigate the issues and barriers to the administration of chemical and mechanical VTE prophylaxis, data collection included real-time point prevalence study, physician and nursing surveys, and electronic medical record audits. The results of the data collection indicated inconsistencies in nursing and patient care. Therefore a VTE policy and VTE educational poster was developed. In conjunction, nursing education will be completed to describe the best practice for sequential compression devices and anticoagulant therapies and documentation. The physician will be notified for refusals on either mechanical or chemical prophylaxis.

Evaluation of In-Hospital Venous Thromboembolism Prevention and Management System Using Hospital-Level Metrics: A Nationwide Cross-Sectional Survey in China

BACKGROUND

Countries in the world have taken actions to prevent venous thromboembolism (VTE) in hospitals. We have conducted a study in China to assess the establishment of hospital-based systems for VTE prevention and management.

METHODS

A nationwide hospital survey was conducted in China to collect hospital-level metrics on their system for VTE prevention between 2019 and 2020. We analyzed hospital-level metrics potentially influencing the implementation of thromboprophylaxis using a multivariable regression model. Characteristics of the hospital, organizational structure, quality control, and staff training were analyzed.

RESULTS

Among 435 hospitals responding to the survey, 328 (75.4%) were able to implement thromboprophylaxis. They performed VTE and bleeding risk assessments and had prophylactic interventions. Institutional VTE steering committee and unit-based working group were set up in 317 (72.9%) and 339 (77.9%) hospitals, respectively. More than 80% of the hospitals performed quality control and staff training. In contrast, digitalization of risk assessment was only accomplished in 196 (45.1%) hospitals. Proportions of the aforementioned metrics were consistently higher in tertiary hospitals than secondary hospitals (P < 0.01) except for quality control. There were geographical disparities in the establishment of VTE steering committees (P = 0.0004). In multivariable analysis, VTE steering committee was an independent factor for the implementation of thromboprophylaxis (odds ratio, 2.22, 95% confidence interval, 1.17-4.23). Working group, quality control, and training on VTE were also positively associated with the implementation of thromboprophylaxis.

CONCLUSIONS

In-hospital VTE prevention has been undertaken in China, but system establishment remains suboptimal. Implementation of VTE prevention programs was associated with a decrease in thrombolytic events. Hospitals with VTE steering committees performed better on implementing preventive strategies. Suboptimal adoption of information digitization was identified, and the implementation of computer supporting techniques would be expected to improve the implementation of thromoboprophylaxis.

[The new algorithm for stratification of the risk of venous thromboembolic events in elective neurosurgery and its prognostic significance]

Early identification of risk groups is essential for effective and target prevention of venous thromboembolic events (VTE) in all areas of surgery. For this purpose, the authors has developed and put into practice an algorithm distinguishing the groups of low, moderate and high risk of VTE among neurosurgical patients.

OBJECTIVE

To assess predictive value of the developed algorithm for elective neurosurgical interventions.

MATERIAL AND METHODS

The study included 7914 patients who underwent surgery between January 2018 and December 2019. According to the algorithm, we identified the groups of low (1536 (19%) patients), moderate (4554 (58%) patients) and high risk (1824 (23%) patients). Moreover, patients were divided into subgroups depending on surgical procedure. We analyzed the incidence of VTE and mortality in all groups.

RESULTS. INCIDENCE

Of VTE with a 95% confidence interval in the low-risk group was 0.65% [0.26; 1.04], in the moderate risk group - 1.82% [1.47; 2.24], in the high-risk group - 12.61% [11.02; 14.09]. When comparing various surgical interventions, we revealed more common VTE after vascular microsurgery (15.62%), in patients with brain tumors (12.63%) and spinal cord tumors (6.52%).

CONCLUSION

The risk stratification algorithm has demonstrated its convenience and significant predictive value for determining the risk of VTE among elective neurosurgical patients. In addition, different incidence of VTE was demonstrated in patients with various neurosurgical diseases.

Guideline No. 417: Prevention of Venous Thromboembolic Disease in Gynaecological Surgery

OBJECTIVE

The primary objective of this clinical practice guideline is to provide gynaecologists with an algorithm and evidence to guide the use of thromboprophylaxis in gynaecological surgery.

TARGET POPULATION

All patients undergoing gynaecological surgery for benign or malignant indications.

BENEFITS, HARMS, AND COSTS

The implementation of this guideline will benefit patients undergoing gynaecological surgery and provide physicians with a standard algorithm for the use of perioperative thromboprophylaxis.

EVIDENCE

The following search terms were entered into MEDLINE, Google Scholar, and Cochrane in 2017 and 2018: VTE, PE, DVT, thromboprophylaxis, gynaecological surgery, heparin, graduated compression stocking, intermittent pneumatic stocking, obesity, pediatrics, minimally invasive surgery, heparin induced thrombocytopenia, regional anesthesia). Articles included were randomized controlled trials, meta-analyses, systematic reviews, and observational studies. Additional publications were identified from the reference lists of these articles. There were no date limits, but search results were limited to English language articles only. Searches were updated and incorporated into the guideline up to September 2018.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

INTENDED USERS

Gynaecologists and other members of the surgical team. RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

Venous thromboembolism rates and risk factors following endoscopic skull base surgery

BACKGROUND

Venous thromboembolism (VTE) is a potentially fatal perioperative complication. The objective of this study was to assess the rate and risk factors for VTE in endoscopic skull base surgery (ESBS).

METHODS

This was a retrospective review of adults undergoing ESBS at a tertiary academic center. Incidence of VTE in the 30-day postoperative period was recorded. Logistic regression analyses identified factors associated with VTE.

RESULTS

1122 ESBS cases between 2009 and 2019 were studied. Almost no cases (96.1%) employed perioperative VTE chemoprophylaxis. The overall incidence of VTE was 2.3% (26/1122). Malignant pathologies had a higher rate of VTE compared to nonmalignant pathologies (4.5% vs 2.0%, OR 2.85, 95%CI 1.22-6.66). Factors associated with an increased risk of VTE included a Caprini score greater than 5 (OR 1.53, 95% CI 1.28-1.83); multiple preoperative endocrinopathies such as the syndrome of inappropriate antidiuretic hormone secretion (SIADH) (OR 22.48, 95% CI 3.93-128.70), adrenal insufficiency (OR 5.24, 95% CI 1.82-15.03), hypercortisolism (OR 4.46, 95% CI 1.47-13.56), and hypothyroidism (OR 3.69, 95% CI 1.66-8.20), each 10-hour increment of lumbar drain duration (OR 1.16, 95%CI 1.08-1.25), and each 10-hour increment for duration of hospitalization (OR 1.05, 95% CI 1.03-1.06).

CONCLUSIONS

The incidence of VTE following ESBS is relatively low. Factors with a higher association with VTE include malignancy, preoperative endocrinopathies, higher Caprini score, prolonged lumbar drain duration, and prolonged hospitalization. Further study is needed to validate these findings and to refine clinical decision making around perioperative VTE prophylaxis. This article is protected by copyright. All rights reserved.

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.

Rate of Development of Venous Thromboembolism in Lateral Skull Base Surgery

OBJECTIVES

Venous thromboembolism (VTE) is a major cause of morbidity and mortality for surgical patients. This article aims to determine factors that may have contributed to the development of VTE in patients undergoing lateral skull base surgery, to assess the validity of the Caprini Risk Assessment Model (RAM) score in this subset of patients, and to determine the efficacy of mechanical DVT prophylaxis alone in preventing VTE.

STUDY DESIGN

Retrospective chart review.

METHODS

A retrospective chart review was conducted of patients who underwent skull base surgery for vestibular schwannoma, and the rate of VTE was assessed. Patient demographics, comorbidities, and treatment factors were examined to determine risk factors associated with the development of a postoperative thrombotic event. Caprini RAM scores were compared for patients who developed a VTE.

RESULTS

Among 197 patients, the rate of VTE formation was 3.5%. No individual risk factor independently contributed to the development of a thrombotic event. The mean Caprini RAM score was 4.06 in patients who did not develop a VTE and 5.14 in the patients that did develop a VTE (P = .005). The Caprini score was significant for the risk of VTE formation, with an odds ratio of 2.8 (P = .009, 95% CI = 1.3-6.2).

CONCLUSION

Venous thromboembolism rates are relatively low following lateral skull base surgery. While there is no individual risk factor associated with increased VTE risk, the Caprini RAM score appears to be a useful predictor of risk. The Caprini score may be useful in identifying high-risk patients who may benefit from chemoprophylaxis for VTE prevention.

LEVEL OF EVIDENCE

Level III-This is a retrospective chart review study Laryngoscope, 2021.

A Review of Current and Future Antithrombotic Strategies in Surgical Patients-Leaving the Graduated Compression Stockings Behind?

Venous thromboembolism (VTE) remains an important consideration within surgery, with recent evidence looking to refine clinical guidance. This review provides a contemporary update of existing clinical evidence for antithrombotic regimens for surgical patients, providing future directions for prophylaxis regimens and research. For moderate to high VTE risk patients, existing evidence supports the use of heparins for prophylaxis. Direct oral anticoagulants (DOACs) have been validated within orthopaedic surgery, although there remain few completed randomised controlled trials in other surgical specialties. Recent trials have also cast doubt on the efficacy of mechanical prophylaxis, especially when adjuvant to pharmacological prophylaxis. Despite the ongoing uncertainty in higher VTE risk patients, there remains a lack of evidence for mechanical prophylaxis in low VTE risk patients, with a recent systematic search failing to identify high-quality evidence. Future research on rigorously developed and validated risk assessment models will allow the better stratification of patients for clinical and academic use. Mechanical prophylaxis' role in modern practice remains uncertain, requiring high-quality trials to investigate select populations in which it may hold benefit and to explore whether intermittent pneumatic compression is more effective. The validation of DOACs and aspirin in wider specialties may permit pharmacological thromboprophylactic regimens that are easier to administer.

Evaluating post-operative venous thromboembolism risk in urology patients using a validated risk assessment model

Background

Venous thromboembolism (VTE) is an important cause of post-surgical morbidity and mortality. This study aimed to apply a validated risk assessment model to evaluate the risk of post-operative VTE in urology patients.

Methods

This prospective descriptive observational study used the Caprini risk assessment model to evaluate VTE risk in patients planned for elective urology surgery at a tertiary Johannesburg hospital from January to June 2020.

Results

Two hundred and twenty-six patients with a mean age of 52 years were evaluated for post-operative VTE risk. The population was generally overweight, with a mean BMI of 26.3 kg/m2. The mean Caprini score was 4.42, reflecting a population at high risk for post-operative VTE. There was no statistically significant difference between males and females in this regard. On average, participants had three risk factors for post-operative VTE. Fifteen per cent of all patients were at low risk for VTE, while 40.3% of participants were categorised as moderate risk. The category with the highest percentage of participants (44.7%) was the high-risk category (Caprini score ≥ 5). High-risk patients undergoing oncology surgery comprised 16.8% of the population, and these patients may require extended duration pharmacological thromboprophylaxis to prevent VTE. The most clinically significant risk factors for post-operative VTE included age, obesity, malignancy and HIV infection.

Conclusion

Venous thromboembolism may be difficult to diagnose, and clinicians may underestimate the risk for it to develop. Risk assessment models, such as the Caprini score, are objective and a practical tool to guide the application of thromboprophylaxis. The application of the Caprini RAM in the elective urological surgery population at Chris Hani Baragwanath Academic Hospital yields similar results to studies performed elsewhere on similar surgical populations. Further research is required to evaluate whether the actual incidence of VTE correlates with the risk assessment in this population. Clinician compliance with the use of RAMs as well as the corresponding recommendations for prophylaxis may need to be evaluated. A validated risk assessment model which accounts for procedure-specific risks in urology may be useful.

Incidence of Venous Thromboembolism and Safety of Perioperative Subcutaneous Heparin During Inflatable Penile Prosthesis Surgery

OBJECTIVE

To identify the incidence of venous thromboembolism (VTE) risk factors, postoperative VTE, and to assess the morbidity of perioperative pharmacologic VTE prophylaxis in men undergoing inflatable penile prosthesis (IPP) surgery.

METHODS

We retrospectively reviewed 215 patients undergoing IPP surgery between July 2017 and June 2019. Univariate and multivariate statistical analyzes were performed to assess pre-operative Caprini risk score and compare post-operative day 0 scrotal drain output, scrotal hematoma formation, and VTE in men who received subcutaneous heparin (SqH) vs those who did not receive SqH.

RESULTS

Of 215 IPP patients, 84% were classified as high or highest risk for VTE utilizing the Caprini risk score. A total of 119 (55%) received perioperative SqH with or without additional anti-thrombotics. Post-operative day 0 scrotal drain output was higher in those who received SqH compared to those who did not receive SqH, 99.9 mL vs 75.6 mL, respectively (P = .001). Minor scrotal hematomas occurred in similar rates in patients who received perioperative SqH vs those who did not, 3.8% vs 6.3%, respectively (P = .38). Similar results were found on subgroup analysis when eliminating patients who received SqH concurrently with other anti-thrombotics. The overall rate of postoperative VTE was 0.9%. No post-operative infections occurred.

CONCLUSION

Patients undergoing IPP surgery are at elevated risk for VTE. To our knowledge, this is the first study showing SqH use in the perioperative IPP surgery setting is safe when used in conjunction with a scrotal drain. Preoperative VTE risk stratification may be performed and can be used to guide clinical decision making regarding pharmacologic prophylaxis.

Implementation of a Novel Protocol for Preventing Venous Thromboembolism in Otolaryngology Patients

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.

Risk of Venous Thromboembolism Following Rhinoplasty

BACKGROUND

Although prior studies have identified a low risk of venous thromboembolism (VTE) in rhinoplasty, these studies are limited by small samples and associated risk factors remain unknown.

OBJECTIVES

The aim of this study was to discern the incidence of VTE following rhinoplasty in a large patient population through analysis of a nationwide insurance claims database.

METHODS

This study involved a population-based retrospective analysis of insurance claims made by patients who underwent rhinoplasty between 2007 and 2016. Established risk factors for VTE, demographic data, procedural details, and absolute incidence of VTE were collected.

RESULTS

We identified a total of 55,287 patients who underwent rhinoplasty from 2007 to 2016. Mean age [standard error of the mean] was 38.74 [0.06] years (range, 18-74 years), and 54% were female. The overall incidence of VTE was 111, of which 70 were DVT and 41 were PE. From multivariate regression analysis, previous VTE (odds ratio [OR], 52.8; 95% confidence interval [CI], 35.2-78.6; P < 0.0001), peripherally inserted central catheter (PICC)/central line placement (OR, 19.6; 95% CI, 9.8-153; P < 0.05), rib graft (OR, 4.6; 95% CI, 2.3-8.5; P < 0.0001), age 41 to 60 years (OR, 2.65; 95% CI, 1.7-4.3; P < 0.01), inflammatory bowel disease (IBD) (OR, 2.6; 95% CI, 1.0-5.5; P < 0.05), and age 61 to 74 years (OR, 2.4; 95% CI, 1.2-4.8; P < 0.05) were associated with an increased risk of VTE.

CONCLUSIONS

We demonstrate a low overall incidence of VTE in rhinoplasty patients. Previous VTE, PICC/central line, advancing age, IBD, and intraoperative rib graft harvest were most strongly associated with VTE in this population cohort.

LEVEL OF EVIDENCE: 4

Association of Prolonged-Duration Chemoprophylaxis With Venous Thromboembolism in High-risk Patients With Head and Neck Cancer

Importance

Venous thromboembolism (VTE) is associated with substantial morbidity and is the most common factor associated with preventable death among hospitalized patients. Data from otolaryngologic studies suggest that the risk of VTE may be underestimated among high-risk patients, particularly among those undergoing oncologic procedures. The incorporation of prolonged-duration chemoprophylaxis (PDC) into preventive therapy has been associated with substantial decreases in VTE incidence among patients undergoing oncologic surgery. However, bleeding remains a major concern among otolaryngologists, and substantial variation exists in the use of thromboprophylaxis.

Objective

To assess the association between PDC and VTE in high-risk patients with head and neck cancer undergoing oncologic procedures.

Design, Setting, and Participants

This retrospective cohort study identified 750 patients with biopsy-confirmed head and neck cancer and a Caprini risk score of 8 or higher who underwent inpatient oncologic surgery at a tertiary care referral center between January 1, 2014, and February 1, 2020. After exclusions, 247 patients were included in the study; patients were divided into 2 cohorts, traditional and PDC, based on the duration of prophylaxis. Univariate and multivariate analyses were performed to examine the development of VTE and bleeding-associated complications during the 30-day postoperative period. Data were analyzed from April 1 to April 30, 2020.

Exposures

PDC, defined as 7 or more postoperative days of chemoprophylaxis.

Main Outcomes and Measures

VTE and bleeding events during the 30-day postoperative period.

Results

Among 247 patients (mean [SD] age, 63.1 [11.1] years; 180 men [72.9%]) included in the study, 106 patients (42.9%) received traditional prophylaxis, and 141 patients (57.1%) received PDC. The incidence of VTE was 5 of 106 patients (4.7%) in the traditional cohort and 1 of 141 patients (0.7%) in the PDC cohort (odds ratio [OR], 0.15; 95% CI, 0.003-1.33). In the multivariate logistic regression analysis, PDC was independently associated with reductions in the risk of VTE (OR, 0.04; 95% CI, 0.001-0.46). The incidence of bleeding events was 1 of 106 patients (0.9%) in the traditional cohort and 6 of 141 patients (4.3%) in the PDC cohort (OR, 4.64; 95% CI, 0.55-217.00).

Conclusions and Relevance

The use of chemoprophylaxis for high-risk patients with head and neck cancer remains a high-priority topic. The results of this study suggest that PDC may be associated with reductions in VTE among this patient population. However, the associated increase in nonfatal bleeding events warrants careful consideration and further highlights the need to determine an optimal duration for chemoprophylaxis among this distinct cohort.

Prognostic Value of Venous Thromboembolism Risk Assessment Models in Patients with Severe COVID-19

Introduction  Severe novel corona virus disease 2019 (COVID-19) causes dysregulation of the coagulation system with arterial and venous thromboembolism (VTE). We hypothesize that validated VTE risk scores would have prognostic ability in this population. Methods  Retrospective observational cohort with severe COVID-19 performed in NorthShore University Health System. Patients were >18 years of age and met criteria for inpatient or intensive care unit (ICU) care. The International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) and Caprini scores were calculated and patients were stratified. Results  This study includes 184 patients, mostly men (63.6%), Caucasian (54.3%), 63 years old (interquartile range [IQR]: 24-101), and 57.1% of them required ICU care. Twenty-seven (14.7%) thrombotic events occurred: 12 (6.5%) cases of disseminated intravascular coagulation (DIC), 9 (4.9%) of pulmonary embolism, 5 (2.7%) of deep vein thrombosis, and 1 (0.5%) stroke. Among them, 86 patients (46.7%) died, 95 (51.6%) were discharged, and 3 (1.6%) were still hospitalized. "Moderate risk for VTE" and "High risk for VTE" by IMPROVE score had significant mortality association: (hazard ratio [HR]: 5.68; 95% confidence interval [CI]: 2.93-11.03; p  < 0.001) and (HR = 6.22; 95% CI: 3.04-12.71; p  < 0.001), respectively, with 87% sensitivity and 63% specificity (area under the curve [AUC] = 0.752, p  < 0.001). "High Risk for VTE" by Caprini score had significant mortality association (HR = 17.6; 95% CI: 5.56-55.96; p  < 0.001) with 96% sensitivity and 55% specificity (AUC = 0.843, p  < 0.001). Both scores were associated with thrombotic events when classified as "High risk for VTE" by IMPROVE (HR = 6.50; 95% CI: 2.72-15.53; p  < 0.001) and Caprini scores (HR = 11.507; 95% CI: 2.697-49.104; p  = 0.001). Conclusion  The IMPROVE and Caprini risk scores were independent predictors of mortality and thrombotic events in severe COVID-19. With larger validation, this can be useful prognostic information.

Rationalizing post-operative prophylactic anticoagulation in reconstructive head and neck cancer patients: a review

Microsurgical reconstructive head and neck cancer patients are at high risk of venous thromboembolism. The use of anticoagulation can reduce their risk; however, this also increases their bleeding risk. It is not clear whether the benefits of treatment outweigh the risks, and whether a specific post-operative anticoagulation regime is superior. The aim of this review is to evaluate the evidence pertaining to the risks and benefits of post-operative anticoagulation and to provide a rationale for its use in head and neck cancer patients receiving free flaps. The secondary aim was to determine the optimal post-operative anticoagulation regimen. A search was conducted in the PubMed and EMBASE databases identifying studies reporting venous thromboembolism rates in reconstructive head and neck cancer patients undergoing free flaps. These studies were reviewed for their eligibility. Outcomes measured were rates of venous thromboembolism, bleeding-related and microsurgical complications. A total of 306 studies were found from the search with another seven studies identified from citations of key articles. After assessment, nine studies were included. Venous thromboembolism rates ranged from 0.5% to 7% and the rates of bleeding-related complications ranged from 2.4% up to 29%. Anticoagulation appears to lower the risk of venous thromboembolism in this patient group, but also increases the bleeding risk. Risk stratification using the Caprini risk assessment model can help surgeons make decisions. For patients with cancer, low molecular weight heparin appears to be superior to heparin given twice daily but equal to heparin given three times daily and the bleeding risk of each medication appears similar.

[Prevention of thromboembolic complications in otorhinolaryngological surgery]

The article reviews current clinical guidelines and recent publications on the perioperative prophylaxis of venous thromboembolism (VTE) in ENT-HNS patients. The literature review is descriptive and includes foreign sources and national guidelines on diagnosis, treatment, and prevention of VTE. The average risk of VTE in otorhinolaryngology - head and neck surgery is lower than in the other surgical specialties, not reaching 1% in total. Major oncologic head and neck surgery carries higher risk of VTE. When prescribing anticoagulants after ENT-HNS surgery, one should predict and compare the risk of postoperative bleeding with the risk of VTE.

Perioperative Venous Thromboembolism Prophylaxis

Venous thromboembolism (VTE) is a preventable cause of postoperative morbidity and mortality; however, audits suggest that the use of thromboprophylaxis is underused. In this review, we describe our approach to prevention of postoperative VTE and provide guidance on how to formulate an optimal VTE prophylaxis plan. We recommend that all patients undergo thrombosis- and bleeding-risk assessment as part of their preoperative evaluation. The risk of thrombosis can be estimated based on patient- and procedure-specific factors, using validated risk-assessment models such as the Caprini score. There are no validated models to predict perioperative bleeding; however, several risk factors have been proposed. Patients should ambulate early and frequently after surgery. We recommend no additional prophylaxis in patients at very low risk of VTE (Caprini score 0). Patients at low risk of VTE (Caprini 1 to 2) are recommended to receive either mechanical or pharmacological prophylaxis. Patients at moderate (Caprini 3 to 4) to high risk of VTE (Caprini ≥5) are recommended pharmacological prophylaxis either alone or combined with mechanical prophylaxis. Patients at high risk of bleeding should receive mechanical prophylaxis until their risk of bleeding is reduced and pharmacological prophylaxis can be reconsidered. Populations for which the Caprini score has not been validated (such as orthopedic surgery) are recommended prophylaxis based on individual and procedure-specific risk factors. Prophylaxis is typically continued until the patient is ambulatory or until hospital dismissal; however, longer durations can be considered in certain circumstances (high-risk patients undergoing malignant abdominopelvic operations, bariatric operations, and certain orthopedic operations).

Is Preoperative Plate-Lymphocyte Ratio a Predictor of Deep Vein Thrombosis in Patients With Oral Cancer During Surgery?

PURPOSE

Detecting deep vein thrombosis (DVT) is necessary to reduce the morbidity of venous thromboembolism, and platelet-lymphocyte ratio (PLR) is a novel marker for predicting DVT. This study aimed to investigate the association between preoperative PLR and risk of developing DVT in patients receiving surgical treatment of oral cancer.

PATIENTS AND METHODS

We designed a retrospective cohort study, and the source of study sample was patients with oral cancer and who underwent surgery between 2015 and 2019. Patients were excluded if they did not undergo surgical treatment and had preoperative DVT and history of hypercoagulable disorders. The primary predictor variable was PLR. We calculated the receiver operating characteristic curve and area under the curve to determine the best-defined risk groups. The best cutoff value for PLR was 187.4 (area under the curve, 0.772; sensitivity, 75.0%; specificity, 74.2%; P = .002). The primary outcome variable was DVT, and the other variables were patient characteristics, blood examination data, and therapeutic data. A logistic regression analysis was used to adjust the effects of potential confounders.

RESULTS

A total of 101 patients were included in this study, and DVT was observed in 12 (11.9%) patients. Free flap reconstructive surgery was performed in 8 of the 12 (66.7%) patients in the DVT group. Statistical analyses showed that DVT was significantly associated with PLR (≤187.4 vs >187.4; P = .001). Logistic multivariate analysis of the preoperative parameters identified the following 2 independent predictive factors for DVT: PLR (≤187.4 vs >187.4) (odds ratio, 13.735; 95% confidence interval, 2.950 to 63.944; P = .001) and free flap reconstructive surgery (odds ratio, 6.584; 95% confidence interval, 1.504 to 28.822; P = .012).

CONCLUSIONS

High PLR (>187.4) and free flap reconstructive surgery, considered as preoperative predictive factors, were associated with DVT.

Prophylaxis of Venous Thromboembolism in Ankle and Foot Surgeries

Venous thromboembolism (VTE) is among the most feared complications by orthopedists both for due to its potentially lethal outcome and the uncertainties related to its prevention. Despite the vast literature on VTE prevention in major orthopedic surgeries, little is known about it in ankle and foot procedures. In orthopedics, adequate thromboprophylaxis requires a careful assessment of the thrombotic and hemorrhagic risks based on the procedure to be performed, as well as and knowledge on anticoagulant agents. The presentis review has the goal of assessing the risk of developingdiscusses VTE risk assessment, the modalities of thromboprophylaxis modalities, and the drugs used, with an emphasis on foot and ankle surgeries.

Call to Action to Prevent Venous Thromboembolism in Hospitalized Patients: A Policy Statement From the American Heart Association

Venous thromboembolism (VTE) is a major preventable disease that affects hospitalized inpatients. Risk stratification and prophylactic measures have good evidence supporting their use, but multiple reasons exist that prevent full adoption, compliance, and efficacy that may underlie the persistence of VTE over the past several decades. This policy statement provides a focused review of VTE, risk scoring systems, prophylaxis, and tracking methods. From this summary, 5 major areas of policy guidance are presented that the American Heart Association believes will lead to better implementation, tracking, and prevention of VTE events. They include performing VTE risk assessment and reporting the level of VTE risk in all hospitalized patients, integrating preventable VTE as a benchmark for hospital comparison and pay-for-performance programs, supporting appropriations to improve public awareness of VTE, tracking VTE nationwide with the use of standardized definitions, and developing a centralized data steward for data tracking on VTE risk assessment, prophylaxis, and rates.

Extended Venous Thromboembolism Prophylaxis in Medically Ill Patients: An NATF Anticoagulation Action Initiative

Hospitalized patients with acute medical illnesses are at risk for venous thromboembolism (VTE) during and after a hospital stay. Risk factors include physical immobilization and underlying pathophysiologic processes that activate the coagulation pathway and are still present after discharge. Strategies for optimal pharmacologic VTE thromboprophylaxis are evolving, and recommendations for VTE prophylaxis can be further refined to protect high-risk patients after hospital discharge. An early study of extended VTE prophylaxis with a parenteral agent in medically ill patients yielded inconclusive results with regard to efficacy and bleeding. In the Acute Medically Ill VTE Prevention with Extended Duration Betrixaban (APEX) trial, extended use of betrixaban halved symptomatic VTE, decreased hospital readmission, and reduced stroke and major adverse cardiovascular events compared with standard enoxaparin prophylaxis. Based on findings from APEX, the Food and Drug Administration approved betrixaban in 2017 for extended VTE prophylaxis in acute medically ill patients. In the Reducing Post-Discharge Venous Thrombo-Embolism Risk (MARINER) study, extended use of rivaroxaban halved symptomatic VTE in high-risk medical patients compared with placebo. In 2019, rivaroxaban was approved for extended thromboprophylaxis in high-risk medical patients, thus making available a new strategy for in-hospital and post-discharge VTE prevention. To address the critical unmet need for VTE prophylaxis in medically ill patients at the time of hospital discharge, the North American Thrombosis Forum (NATF) is launching the Anticoagulation Action Initiative, a comprehensive consensus document that provides practical guidance and straightforward, patient-centered recommendations for VTE prevention during hospitalization and after discharge.

Postoperative Complications of Paramedian Forehead Flap Reconstruction

Importance

Paramedian forehead flaps are commonly used to reconstruct facial defects caused by skin cancers. Data are lacking on the complications from this procedure, postoperative outcomes, and association of cancer diagnosis with rate of deep venous thrombosis (DVT).

Objectives

The primary objective was to determine complication rates after paramedian forehead flap reconstruction for defects resulting from resection of facial cancers; and the secondary objective was to determine patient factors and complications that are associated with readmission.

Design, Setting, and Participants

Retrospective cohort study of patients who underwent paramedian forehead flap reconstruction for skin cancer reconstruction from January 1, 2007, through December 31, 2013. Data analysis took place between October 1, 2017, and June 1, 2018.

Main Outcomes and Measures

Complication rates including DVT, emergency department visits, and hospital readmissions.

Results

A total of 2175 patient were included in this study; mean (SD) age, 70.3 (13.4) years; 1153 (53.5%) were men. Postoperative DVT occurred in 10 or fewer patients (≤0.5%); postoperative bleeding in 30 (1.4%), and postoperative infection in 63 (2.9%). Most patients went home on the day of surgery (89.6%; n = 1949), while 10.4% stayed one or more days in the hospital (n = 226). Overnight admission was associated with tobacco use (odds ratio [OR], 1.65; 95% CI, 1.11-2.44), hypothyroidism (OR, 1.93; 95% CI, 1.10-3.39), hypertension (OR, 1.82; 95% CI, 1.29-2.57), ear cartilage graft (OR, 2.20; 95% CI, 1.51-3.21), and adjacent tissue transfer (OR, 1.88; 95% CI, 1.33-2.67). Risk factors strongly associated with immediate return to the emergency department or readmission within 48 hours of surgery included postoperative bleeding (OR, 13.05; 95% CI, 4.24-40.16), neurologic disorder (OR, 4.11; 95% CI, 1.12-15.09), and alcohol use (OR, 7.70; 95% CI, 1.55-38.21).

Conclusions and Relevance

In this study, the most common complication of paramedian forehead flap reconstruction was infection. Risk factors for readmission included development of postoperative bleeding, having a neurologic disorder, and alcohol use. Deep venous thrombosis was a rare complication. Because bleeding is a more common complication in this patient population, discretion should be used when deciding to administer anticoagulation medication to low- to medium-risk patients prior to surgery.

Level of Evidence

NA.

Caprini score and surgical times linked to the risk for venous thromboembolism after robotic-assisted radical prostatectomy

OBJECTIVE

To evaluate the Caprini score as an independent predictor of venous thromboembolism (VTE) in patients undergoing robotic-assisted radical prostatectomy (RARP) and to identify appropriate cut-points for clinical use.

MATERIAL AND METHODS

We performed a retrospective review of patients who underwent RARP for prostate cancer between December 2003 and February 2016. VTE cases developed the condition within 90 days of discharge. The control group was comprised of patients whose RARP most closely preceded and followed each VTE case in time and who were matched on lymph node dissection and surgeon. The Caprini score was calculated for each patient, and the groups were compared on a number of clinical variables. Multiple logistic regression was used to evaluate whether the Caprini score was an independent predictor of VTE. Receiver operating characteristics (ROC) curves were used to establish appropriate clinical cutpoints.

RESULTS

A total of 3719 patients underwent RARP during the study period. A total of 52 (1.4%) of patients met the criteria for cases. Data were available for 97 patients who met the criteria for controls. Multiple logistic regression indicated that the Caprini score and operative time were independently both significant predictors of VTE (p=0.005 and p=0.044, respectively). ROC indicated that the Caprini score showed a significant but moderate relationship to VTE (area under curve [AOC]=0.64; p=0.004). A Caprini score >6 was the best arithmetic balance for sensitivity (61.5; 95% confidence interval [CI]: 47.0-74.7) and specificity (59.8; 95% CI: 49.3-69.6).

CONCLUSION

The Caprini score predicts postoperative VTE in patients undergoing RARP.

Have Venous Thromboembolism Rates Decreased in Total Hip and Knee Arthroplasty?

BACKGROUND

Venous thromboembolism (VTE) is a major cause of morbidity, mortality, and healthcare costs in arthroplasty patients. In an effort to reduce VTEs, numerous strategies and guidelines have been implemented, but their impact remains unclear. The purpose of this study is to compare annual trends in 30-day VTE, deep vein thrombosis (DVT), pulmonary embolism (PE), and all-cause mortality in (1) total hip arthroplasty (THA) and (2) total knee arthroplasty (TKA).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database identified 363,530 patients who received a TKA or THA from 2008 to 2016. Bivariate analysis was performed to assess the association between the year in which surgery was performed and demographics and comorbidities. Bimodal multivariate logistic regression models for THA and TKA were developed for 2009-2016 using 2008 as a reference.

RESULTS

Overall incidence of VTE, DVT, PE, and mortality for THA were 0.6%, 0.4%, 0.3%, and 0.2%, respectively. Based off of multivariate regression VTE, DVT, PE, and mortality rates have shown no significant (P > .05) change from 2008 to 2016 in THA patients. Overall incidence of VTE, DVT, PE, and mortality for TKA were 1.4%, 0.9%, 0.6%, and 0.1%, respectively. Multivariate regression revealed reductions when compared to 2008 for VTEs and DVTs from 2009 to 2016 (P < .05) for TKA patients. A significant reduction in PEs (P = .002) was discovered for 2016, while no significant change was observed in mortality (P > .05).

CONCLUSION

Approximately 1 in 71 patient undergoing TKA, and 1 in 167 undergoing THA developed a VTE within 30 days after surgery. Our study demonstrated that VTE incidence rates have decreased in TKA, while remaining stable in THA over the past 8 years. Further research to determine the optimal prophylaxis algorithm that would allow for a personalized, efficacious, and safe thromboprophylaxis regimen is needed.

LEVEL OF EVIDENCE

III.

A Caprini Risk Score-Based Cost-Effectiveness Analysis of Enoxaparin for the Thromboprophylaxis of Patients After Nonorthopedic Surgery in a Chinese Healthcare Setting

BACKGROUND

Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is an important cause of post-surgery morbidity and mortality. However, it is unclear whether thromboprophylaxis with the low-molecular-weight heparin (LMWH) enoxaparin after non-orthopedic surgery could balance the cost and clinical outcomes or not.

OBJECTIVES

The purpose of this research was to evaluate the cost-effectiveness of enoxaparin for the universal prophylaxis of VTE and associated long-term complications in patients after non-orthopedic surgery compared with no prevention in a Chinese healthcare setting.

METHODS

A decision model, which included both acute VTE and long-term complications, was developed to assess the economic outcomes of the two strategies for patients after non-orthopedic surgery. Quality-adjusted life years (QALYs) and direct medical costs were measured over a 5-year horizon. Incremental cost-effectiveness ratios (ICERs) were calculated.

RESULTS

Compared with no prevention, patients under enoxaparin treatment with Caprini risk scores of 3-4, 5-6, 7-8, and ≥ 9 increased by 0.012, 0.017, 0.034, and 0.102 in QALYs, respectively. The results were either that ICERs of thromboprophylaxis with enoxaparin over no prevention were lower than the thresholds or that thromboprophylaxis with enoxaparin was dominant. For patients with a Caprini risk score ≥ 9, thromboprophylaxis with enoxaparin is dominant across the whole drug use duration range. The sensitivity analysis confirmed the results.

CONCLUSIONS

As the first analysis evaluating the economic outcomes of enoxaparin in patients undergoing general non-orthopedic surgery, this study suggests that thromboprophylaxis with enoxaparin is highly cost-effective compared with no prevention in patients with Caprini risk score ≥ 3.

Postoperative Venous Thromboembolism after Neurotologic Surgery

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.