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Herring B, Lowen D, Ho P, Hodgson R. A systematic review of venous thromboembolism mechanical prophylaxis devices during surgery. Langenbecks Arch Surg 2023; 408:410. [PMID: 37851108 PMCID: PMC10584699 DOI: 10.1007/s00423-023-03142-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 10/04/2023] [Indexed: 10/19/2023]
Abstract
PURPOSE Hospitalisation and surgery are major risk factors for venous thromboembolism (VTE). Intermittent pneumatic compression (IPC) and graduated compression stockings (GCS) are common mechanical prophylaxis devices used to prevent VTE. This review compares the safety and efficacy of IPC and GCS used singularly and in combination for surgical patients. METHODS Ovid Medline and Pubmed were searched in a systematic review of the literature, and relevant articles were assessed against eligibility criteria for inclusion along PRISMA guidelines. RESULTS This review is a narrative description and critical analysis of available evidence. Fourteen articles were included in this review after meeting the criteria. Results of seven studies comparing the efficacy of IPC versus GCS had high heterogeneity but overall suggested IPC was superior to GCS. A further seven studies compared the combination of IPC and GCS versus GCS alone, the results of which suggest that combination mechanical prophylaxis may be superior to GCS alone in high-risk patients. No studies compared combination therapy to IPC alone. IPC appeared to have a superior safety profile, although it had a worse compliance rate and the quality of evidence was poor. The addition of pharmacological prophylaxis may make mechanical prophylaxis superfluous in the post-operative setting. CONCLUSION IPC may be superior to GCS when used as a single prophylactic device. A combination of IPC and GCS may be more efficacious than GCS alone for high-risk patients. Further high-quality research is needed focusing on clinical relevance, safety and comparing combination mechanical prophylaxis to IPC alone, particularly in high-risk surgical settings when pharmacological prophylaxis is contraindicated.
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Affiliation(s)
- Brianna Herring
- Department of Surgery, University of Melbourne, Epping, Australia
| | - Darren Lowen
- Department of Anaesthesia & Perioperative Medicine, Northern Health, Epping, VIC, 3076, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Parkville, Australia
| | - Prahlad Ho
- Department of Haematology, Northern Health, Epping, VIC, 3076, Australia
- Australian Centre for Blood Diseases, Monash University, Melbourne, Australia
- Department of Medicine, Northern Health, University of Melbourne, Heidelberg, Australia
| | - Russell Hodgson
- Department of Surgery, University of Melbourne, Epping, Australia.
- Department of Surgery, Northern Health, Epping, VIC, 3076, Australia.
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2
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Shargall Y, Wiercioch W, Brunelli A, Murthy S, Hofstetter W, Lin J, Li H, Linkins LA, Crowther M, Davis R, Rocco G, Morgano GP, Schünemann F, Muti-Schünemann G, Douketis J, Schünemann HJ, Litle VR. Joint 2022 European Society of Thoracic Surgeons and The American Association for Thoracic Surgery guidelines for the prevention of cancer-associated venous thromboembolism in thoracic surgery. J Thorac Cardiovasc Surg 2023; 165:794-824.e6. [PMID: 36895083 DOI: 10.1016/j.jtcvs.2022.05.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 04/21/2022] [Accepted: 05/09/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE), which includes deep vein thrombosis and pulmonary embolism, is a potentially fatal but preventable postoperative complication. Thoracic oncology patients undergoing surgical resection, often after multimodality induction therapy, represent among the highest risk groups for postoperative VTE. Currently there are no VTE prophylaxis guidelines specific to these thoracic surgery patients. Evidenced-based recommendations will help clinicians manage and mitigate risk of VTE in the postoperative period and inform best practice. OBJECTIVE These joint evidence-based guidelines from The American Association for Thoracic Surgery and the European Society of Thoracic Surgeons aim to inform clinicians and patients in decisions about prophylaxis to prevent VTE in patients undergoing surgical resection for lung or esophageal cancer. METHODS The American Association for Thoracic Surgery and the European Society of Thoracic Surgeons formed a multidisciplinary guideline panel that included broad membership to minimize potential bias when formulating recommendations. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used, including GRADE Evidence-to-Decision frameworks, which were subject to public comment. RESULTS The panel agreed on 24 recommendations focused on pharmacological and mechanical methods for prophylaxis in patients undergoing lobectomy and segmentectomy, pneumonectomy, and esophagectomy, as well as extended resections for lung cancer. CONCLUSIONS The certainty of the supporting evidence for the majority of recommendations was judged as low or very low, largely due to a lack of direct evidence for thoracic surgery. The panel made conditional recommendations for use of parenteral anticoagulation for VTE prevention, in combination with mechanical methods, over no prophylaxis for cancer patients undergoing anatomic lung resection or esophagectomy. Other key recommendations include: conditional recommendations for using parenteral anticoagulants over direct oral anticoagulants, with use of direct oral anticoagulants suggested only in the context of clinical trials; conditional recommendation for using extended prophylaxis for 28 to 35 days over in-hospital prophylaxis only for patients at moderate or high risk of thrombosis; and conditional recommendations for VTE screening in patients undergoing pneumonectomy and esophagectomy. Future research priorities include the role of preoperative thromboprophylaxis and the role of risk stratification to guide use of extended prophylaxis.
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Affiliation(s)
- Yaron Shargall
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada.
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Alessandro Brunelli
- Department of Thoracic Surgery, St. James's University Hospital, Leeds, United Kingdom
| | - Sudish Murthy
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Wayne Hofstetter
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Jules Lin
- Section of Thoracic Surgery, University of Michigan, Ann Arbor, Mich
| | - Hui Li
- Department of Thoracic Surgery, Capital Medical University, Beijing, China
| | - Lori-Ann Linkins
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Marc Crowther
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Roger Davis
- Patient Representative, Burlington, Ontario, Canada
| | - Gaetano Rocco
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Gian Paolo Morgano
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Finn Schünemann
- Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Germany
| | - Giovanna Muti-Schünemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - James Douketis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Holger J Schünemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Virginia R Litle
- Department of Surgery, Boston University School of Medicine, Boston, Mass
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3
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Shargall Y, Wiercioch W, Brunelli A, Murthy S, Hofstetter W, Lin J, Li H, Linkins LA, Crowther M, Davis R, Rocco G, Morgano GP, Schünemann F, Muti-Schünemann G, Douketis J, Schünemann HJ, Litle VR. Joint 2022 European Society of Thoracic Surgeons and The American Association for Thoracic Surgery guidelines for the prevention of cancer-associated venous thromboembolism in thoracic surgery. EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY : OFFICIAL JOURNAL OF THE EUROPEAN ASSOCIATION FOR CARDIO-THORACIC SURGERY 2022; 63:6889652. [PMID: 36519935 DOI: 10.1093/ejcts/ezac488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 04/21/2022] [Accepted: 05/09/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE), which includes deep vein thrombosis and pulmonary embolism, is a potentially fatal but preventable postoperative complication. Thoracic oncology patients undergoing surgical resection, often after multimodality induction therapy, represent among the highest risk groups for postoperative VTE. Currently there are no VTE prophylaxis guidelines specific to these thoracic surgery patients. Evidenced-based recommendations will help clinicians manage and mitigate risk of VTE in the postoperative period and inform best practice. OBJECTIVE These joint evidence-based guidelines from The American Association for Thoracic Surgery and the European Society of Thoracic Surgeons aim to inform clinicians and patients in decisions about prophylaxis to prevent VTE in patients undergoing surgical resection for lung or esophageal cancer. METHODS The American Association for Thoracic Surgery and the European Society of Thoracic Surgeons formed a multidisciplinary guideline panel that included broad membership to minimize potential bias when formulating recommendations. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used, including GRADE Evidence-to-Decision frameworks, which were subject to public comment. RESULTS The panel agreed on 24 recommendations focused on pharmacological and mechanical methods for prophylaxis in patients undergoing lobectomy and segmentectomy, pneumonectomy, and esophagectomy, as well as extended resections for lung cancer. CONCLUSIONS The certainty of the supporting evidence for the majority of recommendations was judged as low or very low, largely due to a lack of direct evidence for thoracic surgery. The panel made conditional recommendations for use of parenteral anticoagulation for VTE prevention, in combination with mechanical methods, over no prophylaxis for cancer patients undergoing anatomic lung resection or esophagectomy. Other key recommendations include: conditional recommendations for using parenteral anticoagulants over direct oral anticoagulants, with use of direct oral anticoagulants suggested only in the context of clinical trials; conditional recommendation for using extended prophylaxis for 28 to 35 days over in-hospital prophylaxis only for patients at moderate or high risk of thrombosis; and conditional recommendations for VTE screening in patients undergoing pneumonectomy and esophagectomy. Future research priorities include the role of preoperative thromboprophylaxis and the role of risk stratification to guide use of extended prophylaxis. (J Thorac Cardiovasc Surg 2022;▪:1-31).
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Affiliation(s)
- Yaron Shargall
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Alessandro Brunelli
- Department of Thoracic Surgery, St. James's University Hospital, Leeds, United Kingdom
| | - Sudish Murthy
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Wayne Hofstetter
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jules Lin
- Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Hui Li
- Department of Thoracic Surgery, Capital Medical University, Beijing, China
| | - Lori-Ann Linkins
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Marc Crowther
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Roger Davis
- Patient Representative, Burlington, Ontario, Canada
| | - Gaetano Rocco
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Gian Paolo Morgano
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Finn Schünemann
- Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Germany
| | - Giovanna Muti-Schünemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - James Douketis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Holger J Schünemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Virginia R Litle
- Department of Surgery, Boston University School of Medicine, Boston, Massachusetts, USA
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4
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Maradei-Pereira JAR, Sauma ML, Demange MK. Thromboprophylaxis with unilateral pneumatic device led to less edema and blood loss compared to enoxaparin after knee arthroplasty: randomized trial. BMC Musculoskelet Disord 2022; 23:984. [PMCID: PMC9664627 DOI: 10.1186/s12891-022-05910-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/25/2022] [Indexed: 11/16/2022] Open
Abstract
Abstract
Background
Pharmacological and mechanical thromboprophylaxis are frequently used together after total knee arthroplasty (TKA). Most studies in this context compare anticoagulants versus a combination of these drugs with an intermittent pneumatic compression device (IPCD). However, there is uncertainty about the need for the combination of both and whether a unilateral IPCD would alone affect other important clinical outcomes: edema and blood loss. We compared the effects of enoxaparin versus unilateral portable IPCD after TKA on edema and blood loss. We hypothesised that unilateral IPCD would cause the same level of edema and the same blood loss as enoxaparin.
Methods
In this open, randomized trial (1:1), adults with no history of coagulation disorders, anticoagulant use, venous thromboembolism, liver or malignant diseases underwent TKA. For 10 days, participants received the IPCD, used 24 h/day on the operated leg from the end of surgery, or 40 mg of enoxaparin, starting 12 h after surgery. All underwent the same rehabilitation and were encouraged to walk on the same day of surgery. We measured edema (thigh, leg and ankle circumference) before and on the third postoperative day. Blood loss (volume accumulated in the suction drain and drop of hemoglobin and hematocrit in 48 h) was a secondary outcome.
Results
We randomized 150 patients and lost 3 to follow-up with enoxaparin and 2 with IPCD. There was no case of symptomatic venous thromboembolism. Four patients needed transfusions (three receiving enoxaparin), one had infection and one hemarthrosis (both in the enoxaparin group). Leg circumference increased by approximately 2 cm for enoxaparin group and 1.5 cm in IPCD (p < 0.001). The increase in ankle circumference was about 1.5 cm in the enoxaparin group (p < 0.001), and almost zero in IPCD (p = 0.447). Enoxaparin group lost 566.1 ml (standard deviation, SD, 174.5) of blood in the first 48 h, versus 420.8 ml (SD 142.5) in the IPCD.
Conclusions
Exclusively mechanical prophylaxis after TKA with portable IPCD only on the operated leg reduces leg and ankle swelling and post-operative blood loss compared to exclusively pharmacological prophylaxis with enoxaparin. Portable devices that can prevent deep vein thrombosis and pulmonary embolism without increasing blood loss or other risks should be further investigated.
Trial registration
REBEC RBR-8k2vpx. Registration date: 06/04/2019.
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Wong SYW, Ler FLS, Sultana R, Bin Abd Razak HR. What is the best prophylaxis against venous thromboembolism in Asians following total knee arthroplasty? A systematic review and network meta-analysis. Knee Surg Relat Res 2022; 34:37. [PMID: 35964142 PMCID: PMC9375282 DOI: 10.1186/s43019-022-00166-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 07/27/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Purpose
Asians have a low venous thromboembolism (VTE) incidence following total knee arthroplasty (TKA). This systematic review and network meta-analysis was conducted to evaluate the best prophylaxis against VTE in Asians following total knee arthroplasty in current literature.
Materials and Methods
A systematic search of PubMed, Embase and CINAHL was conducted in adherence with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Prophylaxis types were separated into low-molecular-weight heparin (LMWH), novel oral anti-coagulants (NOAC), mechanical-only prophylaxis (MOP) and no prophylaxis (NP). The primary outcome was VTE incidence, grouped according to diagnosis modality (ultrasound, venography, clinical). The secondary outcome was bleeding incidence, grouped into minor and major bleeding.
Results
Fourteen eligible articles, totalling 4259 patients, were pooled with the following significant results: NOACs had lower venography-diagnosed VTE incidence than LMWH (12.77%, p = 0.02) and NP (20.64, p < 0.001). MOP had lower venography-diagnosed VTE incidence than LMWH (23.72%, p < 0.001), NOACs (10.95%, p < 0.001) and NP (31.59%, p < 0.001) but, interestingly, a statistically higher ultrasound-diagnosed VTE incidence than LMWH (6.56%, p = 0.024) and NP (4.88%, p = 0.026). No significant differences were observed between prophylaxis types for symptomatic VTE, pulmonary embolism (PE) or death. LMWH and NOACs had a higher minor bleeding incidence than NP (11.71%, p < 0.001 and 6.33%, p < 0.02, respectively). No significant differences were observed between prophylaxis types for major bleeding incidence.
Conclusion
NOACs are a superior form of chemoprophylaxis, compared with LMWH, in reducing venography-diagnosed VTE incidence with no added bleeding incidence. However, routine chemoprophylaxis may not be required as LMWH and NOACs do not appear to reduce symptomatic VTE incidence compared with MOP and NP with an increased minor bleeding incidence. Mechanical prophylaxis in the form of graduated compression stockings or intermittent pneumatic compression should be routinely considered with significantly lower rates of venography-diagnosed VTE compared with NP. On the basis of current evidence, we recommend an individualised approach to select the most appropriate prophylaxis type.
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6
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7
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8
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Huang H, Bernstein JL, Otterburn DM. Prolonged Venous Thromboembolism Prophylaxis May Not Be Necessary for DIEP Flap Breast Reconstruction: A Tertiary Center's 10-Year Experience. J Reconstr Microsurg 2022; 38:647-653. [PMID: 35213926 DOI: 10.1055/s-0042-1742734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Based on the 2005 Caprini Risk Assessment Model for venous thromboembolism, the American Society of Plastic Surgeons prevention guidelines would result in prolonged chemoprophylaxis (1 week or more) for the majority of patients undergoing deep inferior epigastric perforator flap breast reconstruction. We aim to assess the necessity of prolonged prophylaxis by describing our institutional experience in thromboembolism prevention and evaluating the incidence of symptomatic VTE in our patient cohort. METHODS Women who underwent DIEP flap reconstruction from August 2011 to March 2020 at a tertiary care center were included. Charts were retrospectively reviewed for patient characteristics, VTE prophylaxis regimens, and development of deep vein thrombosis and pulmonary embolism within 60 days of surgery. Caprini scores were calculated for all patients. RESULTS Out of the 249 patients included in the study, 245 patients received chemoprophylaxis only during hospitalization, while four patients additionally received anticoagulant for at least 2 weeks after discharge for prophylactic or therapeutic indications. The cohort's average Caprini score was 6.0, with 72.7% of scores between 3 and 6 and 26.5% at 7 or higher. One patient (0.4%), who scored a 7 and received prophylaxis only while hospitalized, developed deep vein thrombosis. There were no cases of pulmonary embolism. There was no significant difference in VTE rate between patients who received chemoprophylaxis consistent with ASPS guidelines and those who did not (p = 1.000). CONCLUSION Despite our limited chemoprophylaxis use in DIEP flap patients, our VTE incidence is low. This current work suggests that the blanket application of prolonged prophylaxis is not warranted, and it further serves as impetus to re-evaluate the 2005 Caprini RAM in this patient population.
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Affiliation(s)
- Hao Huang
- NewYork-Presbyterian, Weill Cornell Medical Center, New York, New York
| | - Jaime L Bernstein
- NewYork-Presbyterian, Weill Cornell Medical Center, New York, New York.,NewYork-Presbyterian, Columbia University Irving Medical Center, New York, New York
| | - David M Otterburn
- NewYork-Presbyterian, Weill Cornell Medical Center, New York, New York
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9
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Deep vein thrombosis after major orthopedic surgery in Taiwan: A prospective cross-sectional study and literature review. J Formos Med Assoc 2022; 121:1541-1549. [PMID: 35033412 DOI: 10.1016/j.jfma.2021.12.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/25/2021] [Accepted: 12/28/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND/PURPOSE Postoperative venous thromboembolism is an important complication in Taiwan. We prospectively investigated the occurrence of deep vein thrombosis (DVT) after major orthopedic surgery without pharmacologic thromboprophylaxis in a cohort of 120 patients (46 males, 74 females, median age 71 years) at our institute. METHODS Color duplex compression ultrasonography (CUS) was used to detect DVT before and after the operation, while contrast venography was performed postoperatively for comparison and validation. RESULTS Total knee arthroplasty (TKA, 57 cases) and total hip arthroplasty (23 cases) were the most commonly performed operations. The rate of postoperative DVT was 7.5% (9/120), including five with proximal DVT and four with distal DVT. All were detected in the limbs on the operated side. Four of them were symptomatic DVT cases. Venography was performed in 19 patients and confirmed most findings of CUS, indicating the effectiveness of CUS for detecting DVT. The type of surgery (TKA) was significantly correlated with postoperative DVT. No clinically symptomatic pulmonary embolism or sudden death events were noted. CONCLUSION Nine out of 120 (7.5%) orthopedic patients without pharmacologic thromboprophylaxis developed postoperative sonographic DVT in our study. The DVT rate is consistent with other reports from various Asian countries and evidence from meta-analyses.
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10
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Major Orthopedic Surgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00034-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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11
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Machin M, Younan HC, Smith S, Salim S, Davies AH, Shalhoub J. Systematic review on the benefit of graduated compression stockings in the prevention of venous thromboembolism in low-risk surgical patients. Phlebology 2020; 36:184-193. [PMID: 33016226 PMCID: PMC7941500 DOI: 10.1177/0268355520958590] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Objectives The aim of this systematic review is to assess the performance of graduated compression stockings (GCS) in comparison to no venous thromboembolism (VTE) prophylaxis in the prevention of hospital-acquired thrombosis in low-risk surgical patients undergoing short-stay procedures. Methods Aligning with PRISMA guidelines, online databases MEDLINE and EMBASE, Cochrane Library® and trial registries were searched. Eligible articles reported the VTE rate in low-risk surgical patients either receiving GCS or no VTE prophylaxis. Results Narrative synthesis was performed on a single eligible article. The included study arm consisted of participants undergoing knee arthroscopy with the use of GCS alone reporting a total of 29 VTE events (4.4%), 16 of which were asymptomatic DVTs (2.4%). Conclusion There is a complete lack of evidence to support the use of GCS in the prevention of HAT for low-risk surgical patients. An adequately powered trial is required to provide level-IA evidence to support this practice.
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Affiliation(s)
- M Machin
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK.,Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
| | - H C Younan
- School of Public Health, Imperial College London, London, UK
| | - S Smith
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Safa Salim
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - A H Davies
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK.,Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
| | - J Shalhoub
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK.,Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
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12
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Golz AG, Davis WJ, Perry MW, Tonino PM, Garbis NG, Salazar DH. Improving the safety of shoulder arthroscopy in the beach chair position: a prospective randomized trial investigating the effect of compression stockings on cerebral desaturation events in obese patients. J Shoulder Elbow Surg 2020; 29:2027-2035. [PMID: 32590064 DOI: 10.1016/j.jse.2020.05.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 05/20/2020] [Accepted: 05/24/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Devastating transient and permanent postoperative neurocognitive complications in previously healthy, low-risk patients have been observed after elective shoulder arthroscopy in the beach chair position (BCP). Continuous monitoring of cerebral oxygen saturation has been recommended to identify cerebral desaturation events (CDEs) and improve patient safety. However, the relatively high cost and limited availability of monitoring may not be cost-effective. More cost-effective and available measures, including the use of thigh-high compression stockings (CS), have been investigated. However, efficacy data of CS usage is limited, especially for obese patients, who have been shown to be at increased risk for CDEs. The purpose of this was study was to determine if the intraoperative addition of thigh-high compression stockings decreases the incidence, frequency, and magnitude of CDEs in obese patients undergoing shoulder arthroscopy in the BCP. METHODS Thirty-three patients in the treatment group wore both thigh-high compression stockings (CS) and sequential compression devices (SCDs), and the remaining 33 patients in the control group wore SCDs alone. Cerebral oximetry was monitored during surgery using near-infrared spectroscopy. RESULTS The incidence of CDEs was equal between groups, with 9 patients (27%) in each experiencing desaturation events. The median number of CDEs per patient was 3 for the control group and 1 for patients wearing CS (P = .29). There was no difference between groups in terms of median time from induction of anesthesia to onset of CDE (P = .79), median time from upright positioning to onset of CDE (P = .60), mean CDE duration per patient (P = .22), and median cumulative CDE duration (P = .19). The median maximal desaturation from baseline was also not different between groups: 27.6% in the control group and 24.3% in the treatment group (P = .35). CONCLUSION The combination of thigh-high CS and SCDs did not decrease the incidence, frequency, or magnitude of CDEs in patients undergoing shoulder arthroscopy in the BCP. Twenty-seven percent of patients undergoing shoulder arthroscopy in the BCP demonstrated CDEs with or without the use of CS. Therefore, further research is required to identify cost-effective, minimally invasive, and universally available methods of decreasing the incidence of CDEs during this common surgical procedure.
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Affiliation(s)
- Andrew G Golz
- Loyola University Medical Center, Stritch School of Medicine, Department of Orthopaedic Surgery and Rehabilitation, Maywood, IL, USA.
| | - William J Davis
- Loyola University Medical Center, Stritch School of Medicine, Department of Orthopaedic Surgery and Rehabilitation, Maywood, IL, USA
| | - Michael W Perry
- Loyola University Medical Center, Stritch School of Medicine, Department of Orthopaedic Surgery and Rehabilitation, Maywood, IL, USA
| | - Pietro M Tonino
- Loyola University Medical Center, Stritch School of Medicine, Department of Orthopaedic Surgery and Rehabilitation, Maywood, IL, USA
| | - Nickolas G Garbis
- Loyola University Medical Center, Stritch School of Medicine, Department of Orthopaedic Surgery and Rehabilitation, Maywood, IL, USA
| | - Dane H Salazar
- Loyola University Medical Center, Stritch School of Medicine, Department of Orthopaedic Surgery and Rehabilitation, Maywood, IL, USA
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13
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Kakkos SK, Nicolaides AN, Caprini JA. Interpretation of the PREVENT study findings on the adjunctive role of intermittent pneumatic compression to prevent venous thromboembolism. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:725. [PMID: 32617345 PMCID: PMC7327361 DOI: 10.21037/atm.2020.01.68] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Andrew N Nicolaides
- Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus
| | - Joseph A Caprini
- NorthShore University Health System, Evanston, Ill and Pritzker School of Medicine, Chicago, IL, USA
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Dietz MJ, Ray JJ, Witten BG, Frye BM, Klein AE, Lindsey BA. Portable compression devices in total joint arthroplasty: poor outpatient compliance. Arthroplast Today 2020; 6:118-122. [PMID: 32211487 PMCID: PMC7083727 DOI: 10.1016/j.artd.2019.12.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 11/26/2019] [Accepted: 12/08/2019] [Indexed: 11/02/2022] Open
Abstract
Background Aspirin and mechanical compression devices are approved means of venous thromboembolism (VTE) prophylaxis after total joint arthroplasty. Prior studies of mechanical compression pumps after joint arthroplasty have been limited to the inpatient setting. The purpose of this study was to evaluate outpatient compliance and utilization factors in a rural population after elective hip or knee arthroplasty. Methods Utilization for portable pneumatic compression pumps after joint arthroplasty was prospectively recorded (hours). Compliance was defined as the recommended 20 hours per day. A questionnaire 2 weeks postoperatively assessed factors that may contribute to noncompliance. Patients were followed up for 90 days postoperatively to record VTE events. Results Data were collected for 115 joint arthroplasty patients (50 hips, 65 knees). Postdischarge day one had the highest average usage at 13.2 hours/day (66.0%, range 0%-100%), but this number fell to 4.8 hours/day (24.0, range 0%-100%) by day 14. Patient compliance (>20 hours use/day) was highest on postdischarge day one at 40 patients (34.7%). By postdischarge day 14, patient compliance fell to 17 patients (14.8%). Difficulty using the pumps (P = .027) and pump-associated heat (P = .009) were significantly associated with patient compliance. A deep vein thrombosis and nonfatal pulmonary embolism were recorded in 2 separate patients. Conclusions This study demonstrated poor outpatient compliance with portable pneumatic compression devices. Poor compliance was related to pump heat and difficulty with pump use. Even with poor compliance, a low incidence of VTE events was observed.
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Affiliation(s)
- Matthew J Dietz
- Department of Orthopaedics, West Virginia University, Morgantown, WV, USA
| | - Justin J Ray
- Department of Orthopaedics, West Virginia University, Morgantown, WV, USA
| | - Brent G Witten
- Aurora Orthopedics, Aurora Sinai Medical Center of Aurora Health Care Metro, Milwaukee, WI, USA
| | - Benjamin M Frye
- Department of Orthopaedics, West Virginia University, Morgantown, WV, USA
| | - Adam E Klein
- Department of Orthopaedics, West Virginia University, Morgantown, WV, USA
| | - Brock A Lindsey
- Department of Orthopaedics, West Virginia University, Morgantown, WV, USA
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Anderson DR, Morgano GP, Bennett C, Dentali F, Francis CW, Garcia DA, Kahn SR, Rahman M, Rajasekhar A, Rogers FB, Smythe MA, Tikkinen KAO, Yates AJ, Baldeh T, Balduzzi S, Brożek JL, Ikobaltzeta IE, Johal H, Neumann I, Wiercioch W, Yepes-Nuñez JJ, Schünemann HJ, Dahm P. American Society of Hematology 2019 guidelines for management of venous thromboembolism: prevention of venous thromboembolism in surgical hospitalized patients. Blood Adv 2019; 3:3898-3944. [PMID: 31794602 PMCID: PMC6963238 DOI: 10.1182/bloodadvances.2019000975] [Citation(s) in RCA: 270] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 10/22/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a common source of perioperative morbidity and mortality. OBJECTIVE These evidence-based guidelines from the American Society of Hematology (ASH) intend to support decision making about preventing VTE in patients undergoing surgery. METHODS ASH formed a multidisciplinary guideline panel balanced to minimize bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline-development process, including performing systematic reviews. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 30 recommendations, including for major surgery in general (n = 8), orthopedic surgery (n = 7), major general surgery (n = 3), major neurosurgical procedures (n = 2), urological surgery (n = 4), cardiac surgery and major vascular surgery (n = 2), major trauma (n = 2), and major gynecological surgery (n = 2). CONCLUSIONS For patients undergoing major surgery in general, the panel made conditional recommendations for mechanical prophylaxis over no prophylaxis, for pneumatic compression prophylaxis over graduated compression stockings, and against inferior vena cava filters. In patients undergoing total hip or total knee arthroplasty, conditional recommendations included using either aspirin or anticoagulants, as well as for a direct oral anticoagulant over low-molecular-weight heparin (LMWH). For major general surgery, the panel suggested pharmacological prophylaxis over no prophylaxis, using LMWH or unfractionated heparin. For major neurosurgery, transurethral resection of the prostate, or radical prostatectomy, the panel suggested against pharmacological prophylaxis. For major trauma surgery or major gynecological surgery, the panel suggested pharmacological prophylaxis over no prophylaxis.
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Affiliation(s)
- David R Anderson
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Gian Paolo Morgano
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Francesco Dentali
- Department of Medicine and Surgery, Insubria University, Varese, Italy
| | - Charles W Francis
- Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY
| | - David A Garcia
- Division of Hematology, Department of Medicine, University of Washington Medical Center, University of Washington School of Medicine, Seattle, WA
| | - Susan R Kahn
- Department of Medicine, McGill University and Lady Davis Institute, Montreal, QC, Canada
| | | | - Anita Rajasekhar
- Division of Hematology and Oncology, Department of Medicine, University of Florida, Gainesville, FL
| | - Frederick B Rogers
- Trauma and Acute Care Surgery, Penn Medicine Lancaster General Health, Lancaster, PA
| | - Maureen A Smythe
- Department of Pharmaceutical Services, Beaumont Hospital, Royal Oak, MI
- Department of Pharmacy Practice, Wayne State University, Detroit, MI
| | - Kari A O Tikkinen
- Department of Urology and
- Department of Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Adolph J Yates
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Tejan Baldeh
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Sara Balduzzi
- Department of Diagnostic, Clinical, and Public Health Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Jan L Brożek
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine and
| | | | - Herman Johal
- Center for Evidence-Based Orthopaedics, Division of Orthopaedic Surgery, McMaster University, Hamilton, ON, Canada
| | - Ignacio Neumann
- Department of Internal Medicine, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Holger J Schünemann
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine and
| | - Philipp Dahm
- Urology Section, Minneapolis VA Health Care System, Minneapolis, MN; and
- Department of Urology, University of Minnesota, Minneapolis, MN
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Venous thromboembolism prophylaxis strategies for people undergoing elective total knee replacement: a systematic review and network meta-analysis. LANCET HAEMATOLOGY 2019; 6:e530-e539. [DOI: 10.1016/s2352-3026(19)30155-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 06/10/2019] [Accepted: 06/14/2019] [Indexed: 02/06/2023]
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17
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Nadi S, Vreugdenburg TD, Atukorale Y, Ma N, Maddern G, Rovers M. Safety and effectiveness of aspirin and enoxaparin for venous thromboembolism prophylaxis after total hip and knee arthroplasty: a systematic review. ANZ J Surg 2019; 89:1204-1210. [PMID: 30989803 DOI: 10.1111/ans.15122] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/22/2019] [Accepted: 01/30/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) are at risk of venous thromboembolism (VTE). Australian orthopaedic guidelines recommend aspirin and low-molecular-weight heparin (e.g. enoxaparin) for VTE prophylaxis; however, there is debate in the international literature around the use of aspirin as VTE prophylaxis. This review assesses the risks and benefits of aspirin compared to enoxaparin as VTE prophylaxis for patients undergoing THA or TKA. METHODS A systematic review was conducted to identify relevant randomized controlled trials. Studies comparing enoxaparin, aspirin and/or placebo for VTE prophylaxis in THA or TKA patients were included. Network meta-analysis (NMA) was performed to calculate risk ratios (RRs) and confidence intervals (CIs). Quality appraisal was conducted by assessing risk of bias and the strength of the evidence. RESULTS Nine randomized controlled trials were eligible for inclusion. The NMA found no statistically significant differences for the investigated outcomes: total DVT rates (RR = 1.21, 95% CI 0.86, 1.72), symptomatic pulmonary embolism (PE) rates (RR = 1.02, 95% CI 0.02, 50.86), major haemorrhage (RR = 0.97, 95% CI 0.02, 50.99) and wound complication (RR = 0.73, 95% CI 0.17, 3.20). The occurrence of PE was rare. Due to limited data, sub-group analysis was not possible. The overall quality of evidence in the NMA is considered to be very low. CONCLUSION This review did not find statistically significant differences between aspirin and enoxaparin. Future studies should identify more evidence, particularly for rare outcomes such as PE, as this might help decision-makers to get consensus on the use of aspirin as VTE prophylaxis.
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Affiliation(s)
- Sinan Nadi
- Research and Evaluation, Incorporating ASERNIP-S, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia.,Department of Epidemiology, Biostatistics and HTA, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Thomas D Vreugdenburg
- Research and Evaluation, Incorporating ASERNIP-S, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Yasoba Atukorale
- Research and Evaluation, Incorporating ASERNIP-S, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Ning Ma
- Research and Evaluation, Incorporating ASERNIP-S, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Guy Maddern
- Research and Evaluation, Incorporating ASERNIP-S, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia.,Discipline of Surgery, The University of Adelaide and The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Maroeska Rovers
- Department of Epidemiology, Biostatistics and HTA, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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Factor Xa Inhibitors and Direct Thrombin Inhibitors Versus Low-Molecular-Weight Heparin for Thromboprophylaxis After Total Hip or Total Knee Arthroplasty: A Systematic Review and Meta-Analysis. J Arthroplasty 2019; 34:789-800.e6. [PMID: 30685261 DOI: 10.1016/j.arth.2018.11.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 10/31/2018] [Accepted: 11/26/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The purpose of this study is to perform a meta-analysis to compare outcomes of venous thromboembolism (VTE) prophylaxis with low-molecular-weight heparin (LMWH) vs other anticoagulants in patients who received total knee (TKA) or total hip arthroplasty (THA). METHODS MEDLINE, Cochrane, EMBASE, and Google Scholar databases were searched until June 30, 2017 for eligible randomized controlled studies. RESULTS Thirty-two randomized controlled studies were included. LMWH provided better protection against VTE than placebo. In both TKA and THA patients, the rates of VTE were lower with factor Xa inhibitors than LMWH. In THA patients, the rate of deep vein thrombosis (DVT) was lower with factor Xa inhibitors than LMWH. In TKA patients, the rates of VTE and DVT were similar between LMWH and direct thrombin inhibitors. In THA patients, the rate of VTE was lower with direct thrombin inhibitors than with LMWH, while the DVT rates were similar. The pulmonary embolism rates were similar between all 3 classes of drugs in TKA and THR patients, as were the major bleeding rates. Nonmajor and minor bleeding rates were also similar between the 3 drug classes. CONCLUSION LMWH is associated with a higher rate of VTE than factor Xa inhibitors in TKA and THA patients. Direct thrombin inhibitors are associated with a lower rate of VTE in THA patients, but their effectiveness with respect to DVT and pulmonary embolism prophylaxis is similar to that of LMWH in TKA and THA patients.
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Kim KI, Kim DK, Song SJ, Hong SJ, Bae DK. Pneumatic compression device does not show effective thromboprophylaxis following total knee arthroplasty in a low incidence population. Orthop Traumatol Surg Res 2019; 105:71-75. [PMID: 30555017 DOI: 10.1016/j.otsr.2018.11.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 07/25/2018] [Accepted: 11/14/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Purpose of this study was to assess whether the intermittent pneumatic compression (IPC) device would be an effective prophylaxis for deep vein thrombosis (DVT) following total knee arthroplasty (TKA) in a low incidence population. HYPOTHESIS The mechanical thromboprophylaxis could reduce the incidence of DVT compared to non-prophylaxis group and would have similar efficacy as the chemoprophylaxis following TKA in a low DVT incidence population. MATERIALS AND METHODS From January 2009 to June 2016, 1259 elective primary TKA with preoperative diagnosis of primary osteoarthritis in a single institute were enrolled. Patients were divided into three groups: those who were managed with chemoprophylaxis (CPX group, 414 cases), with mechanical prophylaxis (IPC group, 425 cases), or without pharmacological and mechanical prophylaxis (control group, 420 cases). All patients underwent preoperative ultrasonography and computed tomographic venography on postoperative day 6 to assess development of DVT. The incidence of overall, proximal, symptomatic DVT and symptomatic pulmonary embolism (PE) were compared among the groups. Major and minor bleeding complications were also evaluated. RESULTS The incidence of overall DVT was 14.8% in control group, 6.3% in CPX group and 11.3% in IPC group respectively and CPX group showed significantly lower incidence than other two groups (p<0.001). The incidence of proximal DVT was 1.9% in control group, 0.7% in CPX group and 0.9% in IPC group respectively (p>0.05). The incidence of symptomatic DVT was 0.7% in control group, 0% in CPX group and 0.7% in IPC group respectively (p>0.05). There was no case of symptomatic PE diagnosed during hospital stay in all patients. DISCUSSION Single use of IPC device could not reach significant level of DVT prophylaxis compared to control group and only chemoprophylaxis showed significantly reduce the incidence of overall DVT following TKA. Single use of IPC device does not show effective thromboprophylaxis in a low DVT incidence population. LEVEL OF EVIDENCE III, case control study.
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Affiliation(s)
- Kang-Il Kim
- Department of Orthopaedic Surgery, Center for Joint Diseases and Rheumatism, Kyung Hee University Hospital at Gangdong, 892, Dongnam-ro, Gangdong-gu, Seoul, Republic of Korea; Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University Seoul, Seoul, Republic of Korea
| | - Dong-Kyoon Kim
- Department of Orthopaedic Surgery, Center for Joint Diseases and Rheumatism, Kyung Hee University Hospital at Gangdong, 892, Dongnam-ro, Gangdong-gu, Seoul, Republic of Korea.
| | - Sang-Jun Song
- Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University Seoul, Seoul, Republic of Korea
| | - Se-Jung Hong
- Department of Orthopaedic Surgery, Center for Joint Diseases and Rheumatism, Kyung Hee University Hospital at Gangdong, 892, Dongnam-ro, Gangdong-gu, Seoul, Republic of Korea
| | - Dae-Kyung Bae
- Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University Seoul, Seoul, Republic of Korea
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20
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Abstract
BACKGROUND Hospitalised patients are at increased risk of developing deep vein thrombosis (DVT) in the lower limb and pelvic veins, on a background of prolonged immobilisation associated with their medical or surgical illness. Patients with DVT are at increased risk of developing a pulmonary embolism (PE). The use of graduated compression stockings (GCS) in hospitalised patients has been proposed to decrease the risk of DVT. This is an update of a Cochrane Review first published in 2000, and last updated in 2014. OBJECTIVES To evaluate the effectiveness and safety of graduated compression stockings in preventing deep vein thrombosis in various groups of hospitalised patients. SEARCH METHODS For this review the Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), and trials registries on 21 March 2017; and the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE Ovid, Embase Ovid, CINAHL Ebsco, AMED Ovid , and trials registries on 12 June 2018. SELECTION CRITERIA Randomised controlled trials (RCTs) involving GCS alone, or GCS used on a background of any other DVT prophylactic method. We combined results from both of these groups of trials. DATA COLLECTION AND ANALYSIS Two review authors (AS, MD) assessed potentially eligible trials for inclusion. One review author (AS) extracted the data, which a second review author (MD) cross-checked and authenticated. Two review authors (AS, MD) assessed the methodological quality of trials with the Cochrane 'Risk of bias' tool. Any disagreements were resolved by discussion with the senior review author (TL). For dichotomous outcomes, we calculated the Peto odds ratio and corresponding 95% confidence interval. We pooled data using a fixed-effect model. We used the GRADE system to evaluate the overall quality of the evidence supporting the outcomes assessed in this review. MAIN RESULTS We included 20 RCTs involving a total of 1681 individual participants and 1172 individual legs (2853 analytic units). Of these 20 trials, 10 included patients undergoing general surgery; six included patients undergoing orthopaedic surgery; three individual trials included patients undergoing neurosurgery, cardiac surgery, and gynaecological surgery, respectively; and only one trial included medical patients. Graduated compression stockings were applied on the day before surgery or on the day of surgery and were worn up until discharge or until the participants were fully mobile. In the majority of the included studies DVT was identified by the radioactive I125 uptake test. Duration of follow-up ranged from seven to 14 days. The included studies were at an overall low risk of bias.We were able to pool the data from 20 studies reporting the incidence of DVT. In the GCS group, 134 of 1445 units developed DVT (9%) in comparison to the control group (without GCS), in which 290 of 1408 units developed DVT (21%). The Peto odds ratio (OR) was 0.35 (95% confidence interval (CI) 0.28 to 0.43; 20 studies; 2853 units; high-quality evidence), showing an overall effect favouring treatment with GCS (P < 0.001).Based on results from eight included studies, the incidence of proximal DVT was 7 of 517 (1%) units in the GCS group and 28 of 518 (5%) units in the control group. The Peto OR was 0.26 (95% CI 0.13 to 0.53; 8 studies; 1035 units; moderate-quality evidence) with an overall effect favouring treatment with GCS (P < 0.001). Combining results from five studies, all based on surgical patients, the incidence of PE was 5 of 283 (2%) participants in the GCS group and 14 of 286 (5%) in the control group. The Peto OR was 0.38 (95% CI 0.15 to 0.96; 5 studies; 569 participants; low-quality evidence) with an overall effect favouring treatment with GCS (P = 0.04). We downgraded the quality of the evidence for proximal DVT and PE due to low event rate (imprecision) and lack of routine screening for PE (inconsistency).We carried out subgroup analysis by speciality (surgical or medical patients). Combining results from 19 trials focusing on surgical patients, 134 of 1365 (9.8%) units developed DVT in the GCS group compared to 282 of 1328 (21.2%) units in the control group. The Peto OR was 0.35 (95% CI 0.28 to 0.44; high-quality evidence), with an overall effect favouring treatment with GCS (P < 0.001). Based on results from seven included studies, the incidence of proximal DVT was 7 of 437 units (1.6%) in the GCS group and 28 of 438 (6.4%) in the control group. The Peto OR was 0.26 (95% CI 0.13 to 0.53; 875 units; moderate-quality evidence) with an overall effect favouring treatment with GCS (P < 0.001). We downgraded the evidence for proximal DVT due to low event rate (imprecision).Based on the results from one trial focusing on medical patients admitted following acute myocardial infarction, 0 of 80 (0%) legs developed DVT in the GCS group and 8 of 80 (10%) legs developed DVT in the control group. The Peto OR was 0.12 (95% CI 0.03 to 0.51; low-quality evidence) with an overall effect favouring treatment with GCS (P = 0.004). None of the medical patients in either group developed a proximal DVT, and the incidence of PE was not reported.Limited data were available to accurately assess the incidence of adverse effects and complications with the use of GCS as these were not routinely quantitatively reported in the included studies. AUTHORS' CONCLUSIONS There is high-quality evidence that GCS are effective in reducing the risk of DVT in hospitalised patients who have undergone general and orthopaedic surgery, with or without other methods of background thromboprophylaxis, where clinically appropriate. There is moderate-quality evidence that GCS probably reduce the risk of proximal DVT, and low-quality evidence that GCS may reduce the risk of PE. However, there remains a paucity of evidence to assess the effectiveness of GCS in diminishing the risk of DVT in medical patients.
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Affiliation(s)
- Ashwin Sachdeva
- Newcastle UniversityWellcome Centre for Mitochondrial Research4th floor, Cookson Building, Medical SchoolFramlington PlaceNewcastle upon TyneUKNE2 4HH
| | - Mark Dalton
- Royal Victoria InfirmaryDepartment of AnaestheticsQueen Victoria RoadNewcastle upon TyneTyne and WearUKNE1 4LP
| | - Timothy Lees
- NMC Royal HospitalKhalifa CityAbu DhabiUnited Arab Emirates
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Xia ZN, Zhou Q, Zhu W, Weng XS. Low molecular weight heparin for the prevention of deep venous thrombosis after total knee arthroplasty: A systematic review and meta-analysis. Int J Surg 2018; 54:265-275. [DOI: 10.1016/j.ijsu.2018.04.059] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 03/23/2018] [Accepted: 04/28/2018] [Indexed: 11/26/2022]
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Rabe E, Partsch H, Hafner J, Lattimer C, Mosti G, Neumann M, Urbanek T, Huebner M, Gaillard S, Carpentier P. Indications for medical compression stockings in venous and lymphatic disorders: An evidence-based consensus statement. Phlebology 2018; 33:163-184. [PMID: 28549402 PMCID: PMC5846867 DOI: 10.1177/0268355516689631] [Citation(s) in RCA: 115] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Objective Medical compression stockings are a standard, non-invasive treatment option for all venous and lymphatic diseases. The aim of this consensus document is to provide up-to-date recommendations and evidence grading on the indications for treatment, based on evidence accumulated during the past decade, under the auspices of the International Compression Club. Methods A systematic literature review was conducted and, using PRISMA guidelines, 51 relevant publications were selected for an evidence-based analysis of an initial 2407 unrefined results. Key search terms included: 'acute', CEAP', 'chronic', 'compression stockings', 'compression therapy', 'lymph', 'lymphatic disease', 'vein' and 'venous disease'. Evidence extracted from the publications was graded initially by the panel members individually and then refined at the consensus meeting. Results Based on the current evidence, 25 recommendations for chronic and acute venous disorders were made. Of these, 24 recommendations were graded as: Grade 1A (n = 4), 1B (n = 13), 1C (n = 2), 2B (n = 4) and 2C (n = 1). The panel members found moderately robust evidence for medical compression stockings in patients with venous symptoms and prevention and treatment of venous oedema. Robust evidence was found for prevention and treatment of venous leg ulcers. Recommendations for stocking-use after great saphenous vein interventions were limited to the first post-interventional week. No randomised clinical trials are available that document a prophylactic effect of medical compression stockings on the progression of chronic venous disease (CVD). In acute deep vein thrombosis, immediate compression is recommended to reduce pain and swelling. Despite conflicting results from a recent study to prevent post-thrombotic syndrome, medical compression stockings are still recommended. In thromboprophylaxis, the role of stockings in addition to anticoagulation is limited. For the maintenance phase of lymphoedema management, compression stockings are the most important intervention. Conclusion The beneficial value of applying compression stockings in the treatment of venous and lymphatic disease is supported by this document, with 19/25 recommendations rated as Grade 1 evidence. For recommendations rated with Grade 2 level of evidence, further studies are needed.
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Affiliation(s)
- Eberhard Rabe
- Department of Dermatology, University of Bonn, Bonn, Germany
| | - Hugo Partsch
- Department of Dermatology, Medical University of Vienna, Austria
| | - Juerg Hafner
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland
| | - Christopher Lattimer
- Josef Pflug Vascular Laboratory, West London Vascular and Interventional Centre, Ealing Hospital & Imperial College, London, UK
| | - Giovanni Mosti
- Angiology Department, Clinica MD Barbantini, Lucca, Italy
| | - Martino Neumann
- Department of Dermatology, Erasmus University Hospital, Rotterdam, The Netherlands
| | - Tomasz Urbanek
- Medical University of Silesia Department of General Surgery, Vascular Surgery, Angiology and Phlebology, Katowice, Poland
| | | | | | - Patrick Carpentier
- Centre de Recherche Universitaire de La Léchère, Equipe THEMAS, Université Joseph Fourier, Grenoble, France
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Impact of anesthesia modality and mechanical venous thromboembolism prophylaxis on the incidence of symptomatic deep venous thrombosis after TKA. J Clin Orthop Trauma 2018; 9:142-145. [PMID: 29896017 PMCID: PMC5995002 DOI: 10.1016/j.jcot.2016.10.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 10/15/2016] [Accepted: 10/29/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Venous thromboembolic events (VTE) are a common complication of total knee arthroplasty (TKA). Prior studies have discussed the utility of mechanical VTE prophylaxis as a monotherapy for low-risk TKA patients. We assess the incidence of clinically significant deep venous thrombosis (DVT) or pulmonary embolism (PE) in low-risk TKA patients who receive mechanical VTE prophylaxis and undergo spinal, epidural, or general anesthesia for their surgery. METHODS A retrospective study was performed on consecutive low-risk patients who received a TKA between July 2002 and June 2015 with spinal anesthesia (n = 65), epidural and general anesthesia (n = 154), or general anesthesia alone (n = 152). Patients with spinal anesthesia had mechanical VTE prophylaxis until 15 h postoperatively, when remobilization was permitted. Patients who received epidural or general anesthesia had mechanical VTE prophylaxis for 2 h postoperatively. Notable outcomes included development of clinically symptomatic DVT or PE, patient demographics, and perioperative lab values. Statistical analysis was performed using SPSS 22, with chi-squared and Fisher's exact tests for categorical variables and the Kruskal-Wallis test with Scheffe's method for continuous variables. RESULTS No clinically symptomatic DVT or PE was diagnosed. Patient demographics were equivocal. A statistically significant decrease in prothrombin and activated partial thromboplastin times were noted in the general anesthesia group, but all measurements were within the normal range. CONCLUSIONS A short course of mechanical VTE prophylaxis may be appropriate for low-risk patients who can immediately mobilize.
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Zan P, Mol MO, Yao JJ, Fan L, Yang D, Liu K, Li G. Release of the tourniquet immediately after the implantation of the components reduces the incidence of deep vein thrombosis after primary total knee arthroplasty. Bone Joint Res 2017; 6:535-541. [PMID: 28899856 PMCID: PMC5630995 DOI: 10.1302/2046-3758.69.bjr-2017-0149.r2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 08/09/2017] [Indexed: 11/21/2022] Open
Abstract
Objectives The length of the tourniquet time during total knee arthroplasty (TKA) is related to the incidence of post-operative deep vein thrombosis (DVT). Our aim in this study was to investigate the effect of the early release of the tourniquet on the incidence of DVT in patients undergoing TKA. Methods A total of 200 patients who underwent TKA between November 2015 and November 2016 were prospectively enrolled. The tourniquet was inflated before surgery and released immediately after the introduction of the components (early release group). This group was compared with a retrospective cohort of 200 primary TKAs, in which the tourniquet was released after the dressings had been applied (late release group). The presence of a DVT was detected using bilateral lower limb ultrasonography. Peri-operative clinical and follow-up data were collected for analysis. Results The incidence of DVT in the early release group (9 of 196, 4.6%) was significantly lower compared with the late release group (24 of 200, 12%; odds ratio (OR) 0.35, 95% confidence interval (CI) 0.16 to 0.78, p = 0.008). The incidence of proximal DVT in the early release group (1 of 196 (0.5%)) was significantly lower than in the late release group (8 of 196, 4%; OR 0.12, 95% CI 0.02 to 0.99, p = 0.020). Although the mean intra-operative blood loss was higher in the early release group, the mean post-operative drainage, total blood loss, transfusion requirements and complications were not significantly different in the two groups. Conclusion In patients who undergo TKA, releasing the tourniquet early is associated with a decreased incidence of DVT, without increasing the rate of complications. Cite this article: Bone Joint Res 2017;6:535–541.
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Affiliation(s)
- P Zan
- Department of Orthopaedic Surgery, Tongji University, Shanghai Tenth People's Hospital, Zhabei Qu, Shanghai 200085, China
| | - M O Mol
- Academic Medical Centre (AMC), University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam-Zuidoost, The Netherlands
| | - J J Yao
- Department of Orthopedic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas, USA
| | - L Fan
- Department of Orthopaedic Surgery, Tongji University, Shanghai Tenth People's Hospital, Zhabei Qu, Shanghai 200085, China
| | - D Yang
- Department of Orthopaedic Surgery, Tongji University, Shanghai Tenth People's Hospital, Zhabei Qu, Shanghai 200085, China
| | - K Liu
- Department of Orthopaedic Surgery, Tongji University, Shanghai Tenth People's Hospital, Zhabei Qu, Shanghai 200085, China
| | - G Li
- Department of Orthopaedic Surgery, Tongji University, Shanghai Tenth People's Hospital, Zhabei Qu, Shanghai 200085, China
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Bin Abd Razak HR, Binte Abd Razak NF, Tan HCA. Prevalence of Venous Thromboembolic Events Is Low in Asians After Total Knee Arthroplasty Without Chemoprophylaxis. J Arthroplasty 2017; 32:974-979. [PMID: 27776904 DOI: 10.1016/j.arth.2016.09.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 08/01/2016] [Accepted: 09/08/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND This retrospective cohort study was designed to establish the prevalence of clinically significant venous thromboembolic events (VTE) in our patients undergoing total knee arthroplasty (TKA) without chemoprophylaxis. METHODS A single-surgeon cohort of patients who underwent TKA from 2006 to 2014 were included. All patients had a pneumatic tourniquet applied and a drain inserted postoperatively. Tranexamic acid was not used perioperatively. All patients were under a standardized postoperative protocol with routine mechanical prophylaxis against VTE. None of the patients received prophylactic anticoagulation. All patients ambulated on the second postoperative day. Only symptomatic patients were referred for radiological examination to exclude VTE. We evaluated the patient demographics and calculated the prevalence of VTE in our cohort. RESULTS A total of 966 patients were reviewed. Mean age was 66.1 ± 7.8 years. Mean body mass index was 28.2 ± 4.7 kg/m2. Mean tourniquet time was 53 ± 23 minutes. Patients stayed in hospital for a mean of 5.4 ± 3.1 days. There was 100% compliance to mechanical prophylaxis. And 11.1% of our patients were on concomitant antiplatelet or anticoagulant use. There were 8 patients with clinically significant VTE. This translates to a prevalence of 0.82%. Seven patients developed deep vein thrombosis and 1 patient died from massive pulmonary embolism. CONCLUSION The prevalence of clinically significant VTE in our patients who underwent TKA without routine chemoprophylaxis is 0.82%. With proper patient selection, risk stratification, and stringent perioperative protocols, routine chemoprophylaxis may not be necessary in Asians undergoing TKA.
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Tay K, Bin Abd Razak HR, Tan AHC. Obesity and Venous Thromboembolism in Total Knee Arthroplasty Patients in an Asian Population. J Arthroplasty 2016; 31:2880-2883. [PMID: 27369301 DOI: 10.1016/j.arth.2016.05.061] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 05/10/2016] [Accepted: 05/25/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a known complication of total knee arthroplasty (TKA). In addition, obesity has been implicated as a risk factor and justification for chemoprophylaxis for VTE. We wanted to review the prevalence of VTE among our patients and evaluate the incidence rates of VTE among nonobese and obese patients. METHODS We reviewed 894 patients who underwent elective unilateral total knee arthroplasty by a single surgeon from March 2003 to November 2014 in our center. Any patients with clinically significant symptoms or signs of VTE such as deep venous thrombosis (DVT) or pulmonary embolism (PE) were diagnosed radiologically. The patient demographics analyzed included age, gender, body mass index, the number of comorbid diseases, and a history of hyperlipidemia. RESULTS We found the incidence of VTE of 0.67% in our patients (6 patients of 894). Four of the 6 patients (66.7%) who developed DVT and PE belonged to nonobese group. The frequency of VTE in nonobese patients was 0.65% and 0.73% in the obese patients. There were no significant differences in age, number of comorbidities, and a history of hyperlipidemia between those who developed DVT and PE and those who did not. CONCLUSION With the low prevalence of VTE among our study population, including patients with obesity, advanced age, multiple comorbidities, or hyperlipidemia, the practice of routine chemoprophylaxis should be reviewed.
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Affiliation(s)
- Kenny Tay
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore, Singapore
| | | | - Andrew Hwee Chye Tan
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore, Singapore
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Radzak KN, Wages JJ, Hall KE, Nakasone CK. Rate of Transfusions After Total Knee Arthroplasty in Patients Receiving Lovenox or High-Dose Aspirin. J Arthroplasty 2016; 31:2447-2451. [PMID: 27554782 DOI: 10.1016/j.arth.2015.10.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 10/12/2015] [Accepted: 10/19/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Controversy continues regarding the use of powerful anticoagulants for venous thromboembolism prophylaxis in patients undergoing total knee arthroplasty (TKA). To comply with institution-mandated guidelines and pressure from hospitalist intent on complying with conventionally recommended anticoagulation guidelines, we singularly changed our chemoprophylaxis practice from using aspirin to Lovenox and noted that transfusion rates increased substantially. METHODS A retrospective case review was performed to evaluate transfusion requirement differences in primary TKA patients receiving Lovenox (unilateral TKA: n = 135, bilateral TKA: n = 44) or aspirin (unilateral TKA: n = 153, bilateral TKA: n = 45) for venous thromboembolism prophylaxis. Pearson's chi-square tests were used to evaluate surgical complications and the rate of transfusions between aspirin and Lovenox groups. Independent t tests were used to evaluate the units of packed red blood cells transfused, hemoglobin drop, and hematocrit drop between aspirin and Lovenox groups. RESULTS Lovenox was found to significantly increase (P < .01) the rate of transfusion, units of packed red blood cells, hemoglobin drop, and hematocrit drop compared to aspirin in both unilateral and bilateral TKA patients, without significantly decreasing venous thromboembolism events (aspirin: 3 pulmonary embolisms and 4 deep venous thrombosis; Lovenox: 3 pulmonary embolisms and 2 deep venous thrombosis). CONCLUSION Our findings suggest that aspirin is as effective as Lovenox in preventing venous thromboembolism and that the use of Lovenox significantly increases the likelihood of requiring transfusions after surgery.
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Affiliation(s)
- Kara N Radzak
- Department of Kinesiology and Rehabilitation Science, University of Hawaii, Honolulu, Hawaii
| | | | - Kimberly E Hall
- John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
| | - Cass K Nakasone
- Department of Orthopedic Surgery, Straub Bone and Joint Center, Honolulu, Hawaii
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The Use of Intermittent Pneumatic Compression in Orthopedic and Neurosurgical Postoperative Patients: A Systematic Review and Meta-analysis. Ann Surg 2016; 263:888-9. [PMID: 26720432 DOI: 10.1097/sla.0000000000001530] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this systematic review and meta-analysis was to carry out an up-to-date evaluation on the use of compression devices as deep vein thrombosis (DVT) prophylaxis methods in orthopedic and neurological patients. SUMMARY OF BACKGROUND DATA There is an increased risk of DVT with surgery, particularly in patients who are not expected to mobilize soon after their procedures, such as orthopedic and neurosurgical patients. Compression devices are often employed for DVT prophylaxis in these patients. However, the true efficacy of these devices and the standardization of use with these devices are yet to be established. METHODS Medline, CINAHL, Embase, Google Scholar, and the Cochrane library electronic databases were searched to identify randomized controlled trials and observational studies reporting on the use of compression devices for DVT prevention. RESULTS Nine studies were included for review and meta-analysis. Use of an intermittent pneumatic compression device alone is neither superior nor inferior to chemoprophylaxis. CONCLUSIONS In the absence of large randomized multicenter trials comparing the use of intermittent pneumatic compression or chemoprophylaxis alone to a combination of both treatments, the current evidence supports the use of a combined approach in high-risk surgical patients.
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Schramm D, Bach AG, Meyer HJ, Surov A. Thrombotic events as incidental finding on computed tomography in intensive care unit patients. Thromb Res 2016; 141:171-4. [PMID: 27058274 DOI: 10.1016/j.thromres.2016.03.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 03/20/2016] [Accepted: 03/27/2016] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Intensive care unit (ICU) patients are a risk group to develop thrombosis and/or thromboembolism. The purpose of this study was to analyze the frequency and localization of clinically silent thrombotic events (TE) detected on CT. MATERIALS AND METHODS From 2006 to 2013 a total of 370 patients from the ICU of our university clinic were investigated by postcontrast CT. In all cases CT was performed for detecting septic foci. There were 135 women and 235 men. CT scans included cervical, thoracic, abdominal, and pelvic regions. CT images of all patients were re-interpreted by 2 radiologists by consensus. Only thromboses detected for the first time on CT were included into the analysis. Collected data were evaluated by means of descriptive statistics. Frequencies and localizations of TE in surgical and non surgical patients were analyzed by Chi-square test. Significance level was p<0.05. RESULTS In 31.9% several TE were diagnosed. There were venous thrombosis (89.8%), cardiac thrombus (2.6%), and pulmonary embolism (7.6%). More often jugular veins were affected followed by brachiocephalic veins, and iliac veins. The frequency of TE in surgical patients was 31.1%, and 32.1% in non surgical patients. Patients after surgery had more often thrombosis of extremities veins in comparison to non surgical patients. In 61.9% of all TE the identified thrombotic complications were not diagnosed at the time of CT investigations. CONCLUSION TE can be identified in 31.9% of ICU patients as incidental finding on CT. There were venous thromboses, pulmonary embolism, and cardiac thrombus. Most frequently neck and thoracic veins were affected. 61.9% of all TE were not diagnosed at the time of CT investigations. Radiologists should check carefully CT scans for presence of different TE.
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Affiliation(s)
- Dominik Schramm
- Department of Diagnostic Radiology, Martin Luther University Halle-Wittenberg, Germany
| | - Andreas Gunter Bach
- Department of Diagnostic Radiology, Martin Luther University Halle-Wittenberg, Germany
| | - Hans Jonas Meyer
- Department of Diagnostic Radiology, Martin Luther University Halle-Wittenberg, Germany
| | - Alexey Surov
- Department of Diagnostic Radiology, Martin Luther University Halle-Wittenberg, Germany.
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Pavon JM, Adam SS, Razouki ZA, McDuffie JR, Lachiewicz PF, Kosinski AS, Beadles CA, Ortel TL, Nagi A, Williams JW. Effectiveness of Intermittent Pneumatic Compression Devices for Venous Thromboembolism Prophylaxis in High-Risk Surgical Patients: A Systematic Review. J Arthroplasty 2016; 31:524-32. [PMID: 26525487 DOI: 10.1016/j.arth.2015.09.043] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 09/21/2015] [Accepted: 09/25/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Thromboprophylaxis regimens include pharmacologic and mechanical options such as intermittent pneumatic compression devices (IPCDs). There are a wide variety of IPCDs available, but it is uncertain if they vary in effectiveness or ease of use. This is a systematic review of the comparative effectiveness of IPCDs for selected outcomes (mortality, venous thromboembolism [VTE], symptomatic or asymptomatic deep vein thrombosis, major bleeding, ease of use, and adherence) in postoperative surgical patients. METHODS We searched MEDLINE (via PubMed), Embase, CINAHL, and Cochrane CENTRAL from January 1, 1995, to October 30, 2014, for randomized controlled trials, as well as relevant observational studies on ease of use and adherence. RESULTS We identified 14 eligible randomized controlled trials (2633 subjects) and 3 eligible observational studies (1724 subjects); most were conducted in joint arthroplasty patients. Intermittent pneumatic compression devices were comparable to anticoagulation for major clinical outcomes (VTE: risk ratio, 1.39; 95% confidence interval, 0.73-2.64). Limited data suggest that concurrent use of anticoagulation with IPCD may lower VTE risk compared with anticoagulation alone, and that IPCD compared with anticoagulation may lower major bleeding risk. Subgroup analyses did not show significant differences by device location, mode of inflation, or risk of bias elements. There were no consistent associations between IPCDs and ease of use or adherence. CONCLUSIONS Intermittent pneumatic compression devices are appropriate for VTE thromboprophylaxis when used in accordance with current clinical guidelines. The current evidence base to guide selection of a specific device or type of device is limited.
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Affiliation(s)
- Juliessa M Pavon
- Division of Geriatrics, Duke University Medical Center, Durham, North Carolina; Durham Veterans Affairs Medical Center, GRECC, Durham, North Carolina
| | - Soheir S Adam
- Division of Hematology/Oncology, Duke University Medical Center, Durham, North Carolina
| | - Zayd A Razouki
- Center for Health Services Research in Primary Care, Durham VAMC, Durham, North Carolina
| | - Jennifer R McDuffie
- Center for Health Services Research in Primary Care, Durham VAMC, Durham, North Carolina; Division of General Internal Medicine, Duke University Medical Center, Durham, North Carolina
| | - Paul F Lachiewicz
- Orthopaedics, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Andrzej S Kosinski
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | | | - Thomas L Ortel
- Division of Hematology/Oncology, Duke University Medical Center, Durham, North Carolina
| | - Avishek Nagi
- Center for Health Services Research in Primary Care, Durham VAMC, Durham, North Carolina
| | - John W Williams
- Center for Health Services Research in Primary Care, Durham VAMC, Durham, North Carolina; Division of General Internal Medicine, Duke University Medical Center, Durham, North Carolina
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Pierce TP, Cherian JJ, Jauregui JJ, Elmallah RK, Lieberman JR, Mont MA. A Current Review of Mechanical Compression and Its Role in Venous Thromboembolic Prophylaxis in Total Knee and Total Hip Arthroplasty. J Arthroplasty 2015; 30:2279-84. [PMID: 26048728 DOI: 10.1016/j.arth.2015.05.045] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 05/19/2015] [Accepted: 05/20/2015] [Indexed: 02/01/2023] Open
Abstract
Interest in mechanical compression for venous thromboembolic disease prophylaxis has increased over the last several years because of concerns related to bleeding complications associated with chemoprophylaxis. However, the research evaluating compression is clearly not definitive. Therefore, this review aims to: (1) summarize methods of compression; (2) compare AAOS, ACCP, and SCIP guidelines; and (3) make recommendations regarding usage. Below-the-knee devices have demonstrated the most efficacy with multiple guidelines recommending usage. Efficacy and compliance may be improved with the use of mobile devices.
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Affiliation(s)
- Todd P Pierce
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Jeffrey J Cherian
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Julio J Jauregui
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Randa K Elmallah
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Jay R Lieberman
- Keck Medical Center of University of Southern California, Suite 2000, Los Angeles, California
| | - Michael A Mont
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
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Sachdeva A, Dalton M, Amaragiri SV, Lees T. Graduated compression stockings for prevention of deep vein thrombosis. Cochrane Database Syst Rev 2014:CD001484. [PMID: 25517473 DOI: 10.1002/14651858.cd001484.pub3] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND One of the settings where deep vein thrombosis (DVT) in the lower limb and pelvic veins occurs is in hospital with prolonged immobilisation of patients for various surgical and medical illnesses. Using graduated compression stockings (GCS) in these patients has been proposed to decrease the risk of DVT. This is an update of a Cochrane review first published in 2000 and updated in 2010. OBJECTIVES To evaluate the effectiveness and safety of graduated compression stockings in preventing DVT in various groups of hospitalised patients. SEARCH METHODS For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched March 2014) and CENTRAL (2014, Issue 2). SELECTION CRITERIA Randomised controlled trials (RCTs) involving GCS alone; or GCS used on a background of any other DVT prophylactic method. Results from both these groups of trials were combined in this update. DATA COLLECTION AND ANALYSIS For this update one review author (AS) extracted the data. These were cross-checked and authenticated by a second author (MJD). Two review authors (AS and MJD) assessed the quality of trials. Disagreements were resolved by discussion. MAIN RESULTS Nineteen RCTs were identified involving 1681 individual patients and 1064 individual legs (2745 analytic units). Of these 19 trials, nine included patients undergoing general surgery, six included patients undergoing orthopaedic surgery, and only one trial included medical patients. Graduated compression stockings were applied on the day before surgery or on the day of surgery and were worn up until discharge or until the patients were fully mobile. In the majority of the included studies DVT was identified by the radioactive I(125) uptake test. Overall, included studies were of good quality.In the treatment group (GCS) of 1391 units 126 developed DVT (9%) in comparison to the control group (without GCS) of 1354 units where 282 (21%) developed DVT. The Peto odds ratio (OR) was 0.33 (95% confidence interval (CI) 0.26 to 0.41) with an overall effect favouring treatment with GCS (P < 0.00001).Based on results from eight included studies, the incidence of proximal DVT was 7 of 517 (1%) units in the treatment group and 28 of 518 (5%) units in the control group. The Peto OR was 0.26 (95% CI 0.13 to 0.53) with an overall effect favouring treatment with GCS (P = 0.0002). Based on results from five included studies, the incidence of PE was 5 of 283 (2%) participants in the treatment group and 14 of 286 (5%) in the control group. The Peto OR was 0.38 (95% CI 0.15 to 0.96) with an overall effect favouring treatment with GCS (P = 0.04). Limited data were available to accurately assess the incidence of adverse effects and complications with the use of GCS. AUTHORS' CONCLUSIONS GCS are effective in diminishing the risk of DVT in hospitalised patients, with strong evidence favouring their use in general and orthopaedic surgery. However, evidence for their effectiveness in medical patients is limited to one trial.
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Affiliation(s)
- Ashwin Sachdeva
- Department of Urology, Freeman Hospital, Newcastle upon Tyne, UK
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Low MH, Yeo SJ, Chin PL, Chia SL, Lo NN, Tay KJ. A Singapore perspective on the use of a short course of chemothromboprophylaxis in patients who underwent total knee arthroplasty. Singapore Med J 2014; 54:560-3. [PMID: 24154580 DOI: 10.11622/smedj.2013200] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION There is considerable controversy regarding the best method to prevent venous thromboembolism. In 2008, the American College of Chest Physicians (ACCP) published specific guidelines recommending the use of ow-molecular-weight heparin or warfarin, and a target international normalised ratio of 2.0-3.0 for a duration of at least 7-10 days, after elective knee arthroplasties. Many orthopaedic surgeons believe that these recommendations are biased toward reducing deep venous thrombosis (DVT), but neglect the implicated possibility of a higher incidence of wound complications. In order to enable an objective evaluation of the fit of the ACCP recommendations to the needs of our local cohort of patients, we aimed to look at the incidence of DVT in our local population. METHODS This study was a prospective observational study involving existing local patients in Singapore General Hospital, Singapore, who underwent total knee arthroplasty (TKA) and were on a short course of chemothromboprophylaxis (< 7 days) after the operation. The incidence of DVT in patients was evaluated using DVT imaging 4-6 days after the operation and at one month after the operation. RESULTS In our study cohort, the prevalence of DVT during the period between postoperative Days 4 and 6 was 12% (11% were distal DVT and 1% was proximal DVT). Only 9% of the patients had DVT one month after the operation. Using chi-square analysis, we found that there was no significant increase in the number of DVT and pulmonary embolism cases 4-6 days and 1 month after the operation (p > 0.05). CONCLUSION Contrary to the ACCP guidelines, a short course of chemothromboprophylaxis post TKA, lasting no more than 7 days, is safe and adequate in the low-risk Asian population.
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Affiliation(s)
- Mun Hon Low
- Department of Orthopaedic Surgery, Singapore General Hospital, Outram Road, Singapore 169608.
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Chen A, Haddad F, Lachiewicz P, Bolognesi M, Cortes LE, Franceschini M, Gallo J, Glynn A, Gonzalez Della Valle A, Gahramanov A, Khatod M, Lazarinis S, Lob G, Nana A, Ochsner P, Tuncay I, Winkler T, Zeng Y. Prevention of late PJI. J Arthroplasty 2014; 29:119-28. [PMID: 24370487 DOI: 10.1016/j.arth.2013.09.051] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Choi JS, Han HS, Choi YH, Kwon JH, Ahn HY. Comparison of Simultaneous and Alternate Bilateral Pneumatic Compression in Hemodynamic Effects and Thromboprophylaxis After Total Knee Arthroplasty. Clin Appl Thromb Hemost 2014; 21:653-60. [PMID: 24408881 DOI: 10.1177/1076029613518366] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
In this randomized trial, we compared the hemodynamic effects of 2 different methods of bilateral sequential pneumatic compression (Simultaneous compression with Fixed cycling rate [SF] vs Alternate compression with Adjusted cycling rate [AA]) and investigated whether venous flow augmentation influenced deep vein thrombosis (DVT) development in patients undergoing total knee arthroplasty. Pneumatic compression was started on the operation day and applied to discharge. A total of 108 limbs was evaluated by computed tomographic angiography and duplex ultrasound. Augmented peak volume flow (P = .008), expelled total volume (P < .001), and expelled peak volume (P < .001) were significantly larger in group SF. The DVT developed in 35 (32.4%) limbs, and they were neither symptomatic nor ileofemoral in location. The enhanced hemodynamic parameters did not influence the DVT development. In conclusion, group SF showed superior hemodynamic efficacy, but this superiority may not be a surrogate for better thromboprophylaxis.
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Affiliation(s)
- Jae-Sung Choi
- Department of Thoracic and Cardiovascular Surgery, Seoul Metropolitan Government-Seoul National University Boramae Hospital, Seoul, Korea
| | - Hyuk-Soo Han
- Department of Orthopedic Surgery, Seoul Metropolitan Government-Seoul National University Boramae Hospital, Seoul, Korea
| | - Young Ho Choi
- Department of Radiology, Seoul Metropolitan Government-Seoul National University Boramae Hospital, Seoul, Korea
| | - Jae Hyun Kwon
- Division of Interventional Radiology, Department of Radiology, Dongguk University Ilsan Hospital, Dongguk University, Gyeonggi-do, Korea
| | - Hong-Yup Ahn
- Department of Statistics, Dongguk University-Seoul, Seoul, Korea
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Chen A, Haddad F, Lachiewicz P, Bolognesi M, Cortes LE, Franceschini M, Gallo J, Glynn A, Della Valle AG, Gahramanov A, Khatod M, Lazarinis S, Lob G, Nana A, Ochsner P, Tuncay I, Winkler T, Zeng Y. Prevention of late PJI. J Orthop Res 2014; 32 Suppl 1:S158-71. [PMID: 24464891 DOI: 10.1002/jor.22561] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Qin J, Xu Z, Shi D, Chen D, Dai J, Teng H, Jiang Q. Deep Vein Thrombosis After Total Hip Arthroplasty and Total Knee Arthroplasty in Patients With Previous Ischemic Stroke. INT J LOW EXTR WOUND 2013; 12:316-9. [PMID: 24043672 DOI: 10.1177/1534734613493291] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The present study evaluated the prevalence and therapy of deep vein thrombosis (DVT) after total hip arthroplasty (THA) and total knee arthroplasty (TKA) in 57 patients with previous ischemic stroke. Postoperative anticoagulants were used for DVT prophylaxis, and batroxobin and prolonged anticoagulants were used for thrombolysis in DVT subjects. The incidence of DVT after THA and TKA in patients with previous ischemic stroke was 16.2% and 20%, respectively. No bleeding complications were observed and no new ischemic stroke occurred during the following 3 months. The prevalence DVT after THA and TKA in patients with previous ischemic stroke was not specific, and the treatment of DVT with batroxobin and anticoagulants was effective and safe.
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Affiliation(s)
- Jizheng Qin
- Drum Tower Hospital Affiliated to Medical School of Nanjing University, Jiangsu, People’s Republic of China
- Nanjing University, Jiangsu, People’s Republic of China
| | - Zhihong Xu
- Drum Tower Hospital Affiliated to Medical School of Nanjing University, Jiangsu, People’s Republic of China
- Nanjing University, Jiangsu, People’s Republic of China
| | - Dongquan Shi
- Drum Tower Hospital Affiliated to Medical School of Nanjing University, Jiangsu, People’s Republic of China
- Nanjing University, Jiangsu, People’s Republic of China
| | - Dongyang Chen
- Drum Tower Hospital Affiliated to Medical School of Nanjing University, Jiangsu, People’s Republic of China
- Nanjing University, Jiangsu, People’s Republic of China
| | - Jin Dai
- Drum Tower Hospital Affiliated to Medical School of Nanjing University, Jiangsu, People’s Republic of China
- Nanjing University, Jiangsu, People’s Republic of China
| | - Huajian Teng
- Nanjing University, Jiangsu, People’s Republic of China
| | - Qing Jiang
- Drum Tower Hospital Affiliated to Medical School of Nanjing University, Jiangsu, People’s Republic of China
- Nanjing University, Jiangsu, People’s Republic of China
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Abstract
Venous thromboembolism (VTE) is a serious risk after major orthopedic surgery (MOS) including total knee replacement, total hip replacement and hip fracture surgery. This risk can be reduced with several pharmacologic and mechanical prophylactic approaches, and the choice among them depends on their ability to reduce VTE with an acceptable increase in adverse events, especially major bleeding complications. Improvements in medical and surgical care have led to a progressive decrease in the risk of VTE after MOS with an estimated baseline risk with contemporary practice of approximately 4.3 % up to day 39 after surgery. Low-molecular-weight heparin is the most thoroughly studied thromboprophylactic agent following MOS and demonstrates good effectiveness with an acceptable rate of bleeding complications. Warfarin, rivaroxaban, dabigatran, and apixaban have all been studied in large trials in comparison with low-molecular-weight heparin and also show an acceptable benefit: risk ratio. Mechanical approaches including graduated compression stockings, intermittent pneumatic compression and venous foot pump also offer protection against VTE, but there is less evidence is available regarding their effectiveness and risks. Combination therapy consisting of an antithrombotic agent and mechanical device is probably more effective than either alone. The appropriate use of thromboprophylaxis after MOS results in reduced VTE with acceptable bleeding risks.
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Ho KM, Tan JA. Stratified meta-analysis of intermittent pneumatic compression of the lower limbs to prevent venous thromboembolism in hospitalized patients. Circulation 2013; 128:1003-20. [PMID: 23852609 DOI: 10.1161/circulationaha.113.002690] [Citation(s) in RCA: 134] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Optimal thromboprophylaxis for patients at risk of bleeding remains uncertain. This meta-analysis assessed whether intermittent pneumatic compression (IPC) of the lower limbs was effective in reducing venous thromboembolism and whether combining pharmacological thromboprophylaxis with IPC would enhance its effectiveness. METHODS AND RESULTS Two reviewers searched MEDLINE, EMBASE, and the Cochrane controlled trial register (1966-February 2013) for randomized, controlled trials and assessed the outcomes and quality of the trials independently. Trials comparing IPC with pharmacological thromboprophylaxis, thromboembolic deterrent stockings, no prophylaxis, and a combination of IPC and pharmacological thromboprophylaxis were considered. Trials that used IPC <24 hours or compared different types of IPC were excluded. A total of 16 164 hospitalized patients from 70 trials met the inclusion criteria and were subjected to meta-analysis. IPC was more effective than no IPC prophylaxis in reducing deep vein thrombosis (7.3% versus 16.7%; absolute risk reduction, 9.4%; 95% confidence interval [CI], 7.9-10.9; relative risk, 0.43; 95% CI, 0.36-0.52; P<0.01; I(2)=34%) and pulmonary embolism (1.2% versus 2.8%; absolute risk reduction, 1.6%; 95% CI, 0.9-2.3; relative risk, 0.48; 95% CI, 0.33-0.69; P<0.01; I(2)=0%). IPC was also more effective than thromboembolic deterrent stockings in reducing deep vein thrombosis and appeared to be as effective as pharmacological thromboprophylaxis but with a reduced risk of bleeding (relative risk, 0.41; 95% CI, 0.25-0.65; P<0.01; I(2)=0%). Adding pharmacological thromboprophylaxis to IPC further reduced the risk of deep vein thrombosis (relative risk, 0.54; 95% CI, 0.32-0.91; P=0.02; I(2)=0%) compared with IPC alone. CONCLUSIONS IPC was effective in reducing venous thromboembolism, and combining pharmacological thromboprophylaxis with IPC was more effective than using IPC alone.
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Affiliation(s)
- Kwok M Ho
- Department of Intensive Care, Royal Perth Hospital, University of Western Australia, Wellington Street, Perth, WA 6000, Australia.
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41
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Kim KI, Kang DG, Khurana SS, Lee SH, Cho YJ, Bae DK. Thromboprophylaxis for deep vein thrombosis and pulmonary embolism after total joint arthroplasty in a low incidence population. Knee Surg Relat Res 2013; 25:43-53. [PMID: 23741698 PMCID: PMC3671115 DOI: 10.5792/ksrr.2013.25.2.43] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 04/10/2013] [Indexed: 12/31/2022] Open
Abstract
Postoperative venous thromboembolism is one of the most serious complications following total joint arthroplasty. Pharmacological and mechanical prophylaxis methods are used to reduce the risk of postoperative symptomatic deep vein thrombosis and pulmonary embolism. Use of pharmacological prophylaxis requires a fine balance between the efficacy of the drug in preventing deep vein thrombosis and the adverse effects associated with the use of these drugs. In regions with a low prevalence of deep vein thrombosis such as Korea, there might be a question whether the benefits of using pharmacological prophylaxis outweigh the risks involved. The current article reviews the need for thromboprophylaxis, guidelines, problems with the guidelines, pharmacological prophylaxis use, and the current scenario of deep vein thrombosis, and discusses whether the use of pharmacological prophylaxis should be mandatory in low incidence populations.
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Affiliation(s)
- Kang-Il Kim
- Department of Orthopaedic Surgery, Center for Joint Diseases and Rheumatism, Kyung Hee University Hospital at Gangdong, Seoul, Korea
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The incidence of pulmonary embolism and deep vein thrombosis after knee arthroplasty in Asians remains low: a meta-analysis. Clin Orthop Relat Res 2013; 471:1523-32. [PMID: 23264001 PMCID: PMC3613515 DOI: 10.1007/s11999-012-2758-9] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND While Western literature has mostly reported the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) after TKA with chemoprophylaxis, the Asian literature still has mostly reported the incidence without chemoprophylaxis. This may reflect a low incidence of DVT and PE in Asian patients, although some recent studies suggest the incidence after TKA in Asian patients is increasing. Moreover, it is unclear whether the incidence of DVT and PE after TKA is similarly low among different Asian countries. QUESTIONS/PURPOSES We therefore determined the overall incidence of symptomatic PE and DVT without chemoprophylaxis after TKA in the Asian population, determined whether the incidence had a tendency to increase over time in Asia, and compared the incidence of symptomatic PE and DVT among Asian countries through a meta-analysis. METHODS We searched the PubMed, Embase, Cochrane Library, Web of Science, and Google Scholar websites for prospective studies published between 1996 and 2011. A total of 1947 patients from 18 studies were reviewed for meta-analysis. RESULTS The incidence of symptomatic PE was 0.01%. The incidences of overall DVT, proximal DVT, and symptomatic DVT were 40.4%, 5.8% and 1.9%, respectively. We found no difference in incidence of symptomatic PE among Asian countries and no trends in changes of the incidence over time. CONCLUSIONS The incidence of symptomatic PE and DVT after TKA without prophylaxis is low in Asian countries and has not changed over time, despite Westernizing lifestyles and an aging populace. Further investigation with large randomized studies is necessary to confirm our findings and identify risk factors predisposing to DVT.
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43
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[The new guidelines for deep venous thromboembolic disease prophylaxis in elective hip and knee replacement surgery. Are we nearer or further away from a consensus?]. Rev Esp Cir Ortop Traumatol (Engl Ed) 2013; 56:328-37. [PMID: 23594854 DOI: 10.1016/j.recot.2012.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Revised: 04/03/2012] [Accepted: 04/03/2012] [Indexed: 11/22/2022] Open
Abstract
Venous thromboembolism events (VTE) prophylaxis after elective hip or knee replacement surgery is a subject of controversy. Three sets of guidelines (NICE, ACCP and AAOS) on this topic have recently been updated. The guidelines have points in common: prophylaxis is necessary, it is recommended to combine mechanical and pharmacological prophylaxis in patients who have suffered a previous VTE, isolated mechanical measures and low molecular weight heparins are effective, the new oral anticoagulants and fondaparinux are effective drugs. There is some consensus in recommending regional anaesthesia, in advising against echography studies in asymptomatic patients, and in the promotion of early mobilisation of the patient. There is controversy over the most suitable pharmacological treatment and the time of starting, and the duration of this, as well as on vena cava filters, antiplatelet drugs, and VTE or bleeding risk factors.
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Hong KC, Kim H, Kim JY, Kwak KS, Cho OM, Cha HY, Lim SH, Song YJ. Risk factors and incidence of deep vein thrombosis in lower extremities among critically ill patients. J Clin Nurs 2012; 21:1840-6. [PMID: 22672452 DOI: 10.1111/j.1365-2702.2012.04112.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS AND OBJECTIVES To investigate how many critically ill patients developed deep vein thrombosis (DVT) during their admission to intensive care units (ICU) and to compare the characteristics of patients with and without deep vein thrombosis. BACKGROUND Critically ill patients are a high-risk group for deep vein thrombosis because they typically have multiple risk factors, such as prolonged immobility, mechanical ventilation and old age. DESIGN A prospective observational study was employed. METHODS The subjects were 90 patients who were older than 18 years of age, who were admitted to an intensive care unit for more than five days and were not provided any prophylactic measures. Data were collected at a university hospital for five months. A duplex scan was performed on day 2.4 on average and repeated between days 5-7 to diagnose deep vein thrombosis. The iliac, femoral, popliteal and tibial veins were examined by compression and colour Doppler methods of the duplex scan by one technician. RESULTS Age, gender and body mass index were significant factors for deep vein thrombosis development (p < 0.05). Ten patients (11.1%) developed deep vein thrombosis during their stay in the intensive care units. CONCLUSIONS The incidence was lower than in Western studies in which patients were not provided prophylaxis, but may increase with an extended observation period as in previous studies. RELEVANCE TO CLINICAL PRACTICE The results of this study could allow ICU nurses to recognise the DVT incidence in critically ill patients. This result could lead to more active prevention and monitoring of DVT by ICU nurses, especially for high-risk patients, such as older or obese patients.
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Affiliation(s)
- Kee Chun Hong
- College of Medicine, Inha University, Incheon, Korea
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45
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Ruiz-Iban M, Díaz-Heredia J, Elías-Martín M, Martos-Rodríguez L, Cebreiro-Martínez del Val I, Pascual-Martín-Gamero F. The new guides for deep venous thromboembolic event prophylaxis in elective hip and knee replacement surgery. Are we nearer or further away from a consensus? Rev Esp Cir Ortop Traumatol (Engl Ed) 2012. [DOI: 10.1016/j.recote.2012.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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46
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Incidence of clinically significant venous thromboembolic events in Asian patients undergoing total knee arthroplasty without anticoagulation. J Arthroplasty 2012; 27:1128-32. [PMID: 22088783 DOI: 10.1016/j.arth.2011.09.024] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Accepted: 09/23/2011] [Indexed: 02/01/2023] Open
Abstract
This study aimed to evaluate the incidence of clinically significant venous thromboembolic events (VTE) in Asian patients undergoing total knee arthroplasty (TKA) without anticoagulation. All patients who underwent TKA by a single surgeon from 2006 to 2010 in Singapore General Hospital were reviewed. Only symptomatic patients were referred for ultrasonography. Of the 531 patients reviewed, 3 patients developed symptoms of deep vein thrombosis with subsequent ultrasonographic confirmation, whereas 1 patient developed fatal pulmonary embolism without any clinical or radiologic evidence of deep vein thrombosis. Hence, the incidence of clinically significant VTE was 0.75%. Given the low incidence of clinically significant VTE, there is a need to review the current practice of routine chemoprophylaxis in Asian patients undergoing TKA.
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Falck-Ytter Y, Francis CW, Johanson NA, Curley C, Dahl OE, Schulman S, Ortel TL, Pauker SG, Colwell CW. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e278S-e325S. [PMID: 22315265 DOI: 10.1378/chest.11-2404] [Citation(s) in RCA: 1446] [Impact Index Per Article: 120.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND VTE is a serious, but decreasing complication following major orthopedic surgery. This guideline focuses on optimal prophylaxis to reduce postoperative pulmonary embolism and DVT. METHODS The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement. RESULTS In patients undergoing major orthopedic surgery, we recommend the use of one of the following rather than no antithrombotic prophylaxis: low-molecular-weight heparin; fondaparinux; dabigatran, apixaban, rivaroxaban (total hip arthroplasty or total knee arthroplasty but not hip fracture surgery); low-dose unfractionated heparin; adjusted-dose vitamin K antagonist; aspirin (all Grade 1B); or an intermittent pneumatic compression device (IPCD) (Grade 1C) for a minimum of 10 to 14 days. We suggest the use of low-molecular-weight heparin in preference to the other agents we have recommended as alternatives (Grade 2C/2B), and in patients receiving pharmacologic prophylaxis, we suggest adding an IPCD during the hospital stay (Grade 2C). We suggest extending thromboprophylaxis for up to 35 days (Grade 2B). In patients at increased bleeding risk, we suggest an IPCD or no prophylaxis (Grade 2C). In patients who decline injections, we recommend using apixaban or dabigatran (all Grade 1B). We suggest against using inferior vena cava filter placement for primary prevention in patients with contraindications to both pharmacologic and mechanical thromboprophylaxis (Grade 2C). We recommend against Doppler (or duplex) ultrasonography screening before hospital discharge (Grade 1B). For patients with isolated lower-extremity injuries requiring leg immobilization, we suggest no thromboprophylaxis (Grade 2B). For patients undergoing knee arthroscopy without a history of VTE, we suggest no thromboprophylaxis (Grade 2B). CONCLUSIONS Optimal strategies for thromboprophylaxis after major orthopedic surgery include pharmacologic and mechanical approaches.
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Affiliation(s)
- Yngve Falck-Ytter
- Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, OH.
| | - Charles W Francis
- Hematology/Oncology Unit, University of Rochester Medical Center, Rochester, NY
| | - Norman A Johanson
- Department of Orthopaedic Surgery, Drexel University College of Medicine, Philadelphia, PA
| | - Catherine Curley
- Division of Hospital Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
| | - Ola E Dahl
- Innlandet Hospitals, Brumunddal, Norway; Thrombosis Research Institute, Chelsea, London, England
| | - Sam Schulman
- Department of Medicine, Division of Hematology and Thromboembolism, McMaster University, Hamilton, ON, Canada
| | - Thomas L Ortel
- Hemostasis and Thrombosis Center, Duke University Health System, Durham, NC
| | | | - Clifford W Colwell
- Shiley Center for Orthopaedic Research and Education at Scripps Clinic, La Jolla, CA
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Kesieme E, Kesieme C, Jebbin N, Irekpita E, Dongo A. Deep vein thrombosis: a clinical review. J Blood Med 2011; 2:59-69. [PMID: 22287864 PMCID: PMC3262341 DOI: 10.2147/jbm.s19009] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Indexed: 01/01/2023] Open
Abstract
Background: Deep vein thrombosis (DVT) is the formation of blood clots (thrombi) in the deep veins. It commonly affects the deep leg veins (such as the calf veins, femoral vein, or popliteal vein) or the deep veins of the pelvis. It is a potentially dangerous condition that can lead to preventable morbidity and mortality. Aim: To present an update on the causes and management of DVT. Methods: A review of publications obtained from Medline search, medical libraries, and Google. Results: DVT affects 0.1% of persons per year. It is predominantly a disease of the elderly and has a slight male preponderance. The approach to making a diagnosis currently involves an algorithm combining pretest probability, D-dimer testing, and compression ultrasonography. This will guide further investigations if necessary. Prophylaxis is both mechanical and pharmacological. The goals of treatment are to prevent extension of thrombi, pulmonary embolism, recurrence of thrombi, and the development of complications such as pulmonary hypertension and post-thrombotic syndrome. Conclusion: DVT is a potentially dangerous condition with a myriad of risk factors. Prophylaxis is very important and can be mechanical and pharmacological. The mainstay of treatment is anticoagulant therapy. Low-molecular-weight heparin, unfractionated heparin, and vitamin K antagonists have been the treatment of choice. Currently anticoagulants specifically targeting components of the common pathway have been recommended for prophylaxis. These include fondaparinux, a selective indirect factor Xa inhibitor and the new oral selective direct thrombin inhibitors (dabigatran) and selective factor Xa inhibitors (rivaroxaban and apixaban). Others are currently undergoing trials. Thrombolytics and vena caval filters are very rarely indicated in special circumstances.
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Affiliation(s)
- Emeka Kesieme
- Department of Surgery, Irrua Specialist Teaching Hospital, Irrua, Nigeria
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