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Deep Venous Thrombosis and Venous Thromboembolism Prophylaxis

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Deep Venous Thrombosis and Venous Thromboembolism Prophylaxis Deep Venous Thrombosis and Venous Thromboembolism Prophylaxis Keely L. Buesing, MD*, Barghava Mullapudi, MD, Kristin A. Flowers, MD KEYWORDS Venous thromboembolism Deep venous thrombosis Risk factors Management strategies Prophylaxis KEY POINTS Venous thromboembolism (VTE) affects up to 25% of hospitalized patients, with up to 30% of those experiencing complications. Risk stratification is important in choosing therapy for prevention and management of VTE. Management of VTE depends on precipitating factors and future risk of VTE progression versus bleeding. Low-molecular-weight heparin is the preferred anticoagulant for initial treatment of VTE. Venous thromboembolism (VTE), which includes deep venous thrombosis (DVT) and pulmonary embolism (PE), remains an all too familiar risk for surgical patients, occurring in up to 25% of those hospitalized.1 These patients are a unique population who possess all 3 components of Virchow triad (stasis, hypercoagulability, and endothelial injury), completing the triad known to be the cause of thrombus formation. Despite validated guidelines, the problem is frequently left inappropriately addressed, leaving patients at risk for a process that can lead to significant morbidity and mortality. Fifty percent of all DVTs are asymptomatic, but approximately 30% will have additional complications.2 For some patients, a DVT is a transient episode (ie, the symptoms resolve once the disease is successfully treated). For others, it can lead to a PE, which occurs in more than one-third of patients with DVT.1,2 PE causes sudden death in up to 34% of patients,3 particularly when one or more of the larger pulmonary arteries are completely blocked by clot. Most of those who survive do not have any lasting effects; however, if the embolus in the lung fails to completely dissolve, chronic pulmonary Disclosure statement: The authors have nothing to disclose. Division of Trauma & Surgical Critical Care, Department of General Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE 68198-3280, USA * Corresponding author. E-mail address: [email protected] Surg Clin N Am 95 (2015) 285–300 http://dx.doi.org/10.1016/j.suc.2014.11.005 surgical.theclinics.com 0039-6109/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved. 286 Buesing et al hypertension may eventually occur, causing chronic shortness of breath and varying degrees of heart failure. The Surgeon General’s First Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism came in 2008 and estimated 350,000 to 600,000 Americans each year have a DVT and/or PE. Furthermore, at least 100,000 deaths are attributed to DVT/PE each year.3 Of those who survive, many go on to have complications with serious and negative impacts on quality of life. DVT and PE are estimated to be the number one preventable cause of death in hospitalized patients. To offset this risk, the Surgical Care Improvement Project states in its guidelines that all surgical patients should have thromboprophylaxis ordered and administered within 24 hours of an operation. The Joint Commission also requires that all surgical patients receive anti- coagulation, reflecting measures adopted by the Centers for Medicare and Medicaid Services, starting May 1st, 2009.4 Despite initiatives and mandates, VTE prophylaxis is underutilized in the United States. A 2009 analysis by Franklin Michota,5 citing data from a study by Brigham and Women’s Hospital in 2000, revealed that only 34% of high-risk patients receive appropriate prophylaxis. An article published in 2014 by the Journal of the American College of Surgeons about adopting mandatory VTE risk stratification and administra- tion similarly revealed that only 58.5% of surgical patients at risk received VTE prophy- laxis.4 Why? The reasons cited are as follows: 1. There is a fear of anticoagulant-associated bleeding. 2. There is a lack of awareness regarding VTE. 3. It is thought that guidelines are based on risks and benefits of prophylaxis in clinical trials that exclude recommendations for certain subsets of patients. 4. Individual risk assessment is necessary, making a protocol difficult to reinforce. The following sections are intended to address each of these cited reasons individually. BLEEDING RISK The International Medical Prevention Registry on Venous Thromboembolism investi- gators developed a scoring system to calculate the risk of bleeding in medical pa- tients.6 Table 1 shows the bleeding risk factors identified for purposes of this study. Scores greater than or equal to 7.0 were associated with a 7.9% risk of any bleeding and a 4.1% risk of major bleeding.6 If the risk of bleeding is greater than the risk of VTE, then chemical prophylaxis can be avoided. The ninth edition of the American College of Chest Physicians’ (ACCP) guidelines, revised and published in 2012, includes a consideration of the bleeding risk in patients receiving anticoagulants. They did not assess how the risk of bleeding would influence every recommendation because it would be unlikely to change the recommendation, there are few data assessing outcomes in patients with differing risks of bleeding, and because of the lack of validated tools for stratifying bleeding risk. For extended- duration anticoagulation, recommendations are based on 4 primary risk groups for VTE and 3 risk groups for major bleeding (Table 2). The estimated total of recurrent VTE versus major bleeding for each of the 12 combinations is shown in Table 3.7 LACK OF AWARENESS REGARDING VENOUS THROMBOEMBOLISM Table 4 is a reproduction of the Venous Thromboembolism Update by Joseph Caprini, MD, and summarizes the incidence and percent of complications of VTE in an attempt to underscore the significance of VTE and associated complications.8 DVT and VTE Prophylaxis 287 Table 1 Factors at admission associated with bleeding risk Bleeding Risk Factors Points Moderate renal failure; GFR 30–59 vs >60 mL/min/m2 1 Male vs female 1 Age: 40–84 y vs <40 y old 1.5 Current cancer 2 Rheumatic disease 2 Central venous catheter 2 ICU/CCU 2.5 Severe renal failure; GFR <30 vs >60 mL/min/m2 2.5 Hepatic failure (INR >1.5) 2.5 Age: >85 y vs <40 y 3.5 Platelet count <50 Â 109 cells/L 4 Bleeding within 3 mo before admission 4 Active gastroduodenal ulcer 4.5 Scores greater than or equal to 7.0 were associated with 7.9% risk of any bleeding and a 4.1% risk of major bleeding. Abbreviations: CCU, critical care unit; GFR, glomerular filtration rate; ICU, intensive care unit; INR, international normalized ratio. From Decousus H, Tapson VF, Bergmann JF, et al. Factors at admission associated with bleeding risk in medical patients. Findings from the IMPROVE investigators. Chest 2011;139(1):75; with permission. Table 2 Rates of recurrent VTE and major bleeding events with long-term anticoagulation Outcomes After Risk of Bleeding 5 y of Treatment Low Intermediate High First VTE provoked Recurrent VTE 2.6 (2.2–2.9) 2.6 (2.2–2.9) 2.6 (2.2–2.9) by surgery reduction % (0.1 fatal) (0.1 fatal) (0.1 fatal) Major bleeding 2.4 (0–8.7) 4.9 (0.1–17.3) 19.6 (0.2–69.2) increase % (0.3 fatal) (0.5 fatal) (2.2 fatal) First VTE provoked Recurrent VTE 13.2 (11.3–14.2) 13.2 (11.3–14.2) 13.2 (11.3–14.2) by a nonsurgical reduction % (0.5 fatal) (0.5 fatal) (0.5 fatal) factor/first Major bleeding 2.4 (0–8.7) 4.9 (0.1–17.3) 19.6 (0.2–69.2) unprovoked distal increase % (0.3 fatal) (0.5 fatal) (2.2 fatal) DVT First unprovoked Recurrent VTE 26.4 (22.5–28.5) 26.4 (22.5–28.5) 26.4 (22.5–28.5) proximal DVT reduction % (1 fatal) (1 fatal) (1 fatal) or PE Major bleeding 2.4 (0–8.7) 4.9 (0.1–17.3) 19.6 (0.2–69.2) increase % (0.3 fatal) (0.5 fatal) (2.2 fatal) Second unprovoked Recurrent VTE 39.6 (33.7–42.7) 39.6 (33.7–42.7) 39.6 (33.7–42.7) VTE reduction % (1.4 fatal) (1.4 fatal) (1.4 fatal) Major bleeding 2.4 (0–8.7) 4.9 (0.1–17.3) 19.6 (0.2–69.2) increase% (0.3 fatal) (0.5 fatal) (2.2 fatal) Data from Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy and prevention of throm- bosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2012;141(2 Suppl):e419S–94S. 288 Buesing et al Table 3 Complications of VTE PE There is a 1%–5% incidence in patients with 4 or more risk factors for VTE. 16% mortality at 3 mo is caused by PE (30–80,000 patients); 34% of these patients present as sudden death. Pulmonary 4% of patients with a PE develop chronic pulmonary hypertension. hypertension Clinical VTE It involves drugs, testing, wearing hose, and changes in lifestyle. Risk of phlegmasia alba and cerulea dolens Risk of venous gangrene with limb loss Silent VTE Risk of subsequent event is 2 Â the control population; the greatest risk is in the following 2 y.9,11 Embolic stroke There is a 20%–30% patent foramen ovale rate. 50% of patients with embolic stroke are disabled. 20% of patients with embolic stroke die. 30% of patients with embolic stroke recover. Adapted from Caprini JA. Venous thromboembolism update. Available at: http://web2.facs.org/ download/Caprini.pdf. Symptomatic patients with a PE have a higher risk of recurrent VTE than those with symptomatic VTE alone. There is a higher recurrence rate of VTE in men than women (20% vs 6%, relative risk 3.6).2,9 Sometimes, lifestyle-altering vigilance is required to avoid and/or manage the potential impact of other risk factors (prolonged air travel, further surgery, trauma, and so forth).
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