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VTE Prophylaxis in Gynecologic Surgery

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VTE Prophylaxis in Gynecologic Surgery ClinicalProviding Information Evidence-based for 25 Years AHC Media LLC Home Page—www.ahcmedia.com CME for Physicians—www.cmeweb.com EDITOR VTE Prophylaxis in Gynecologic Jeffrey T. Jensen, MD, MPH Leon Speroff Professor and Vice Chair for Research Surgery: Quo Vadis? Department of Obstetrics and Gynecology ABSTRACT & COMMENTARY Oregon Health & Science University InsIde Portland Oligohydram- By Robert L. Coleman, MD ASSOCIATE EDITORS nios: A reason Sarah L. Berga, MD Professor and Chair to deliver? Professor, University of Texas; M.D. Anderson Cancer Center, Houston Department of Obstetrics and page 59 Gynecology Vice President for Women’s Dr. Coleman reports no financial relationships relevant to this field of study. Health Services Wake Forest Baptist Health, Winston-Salem, NC Which is Synopsis: Venous thromboembolism (VTE) prophylaxis better: Open, Robert L. Coleman, MD interventions in gynecologic surgery are meritorious, supported Professor, University of laparoscopic, by Level 1 evidence and the subject of multiple guidelines, including Texas; M.D. Anderson Cancer Center, Houston or robotic? those published by the American College of Obstetricians and Gynecologists. However, new evidence suggests nearly Alison Edelman, MD, MPH page 60 Associate Professor, one-third of women undergoing hysterectomy in this country Assistant Director of the still receive no VTE prophylaxis, placing thousands of women at Family Planning Fellowship Special Department of Obstetrics & unnecessary risk for preventable morbidity. Gynecology, Oregon Health feature: & Science University, Portland Do we have a Source: Wright JD, et al. Quality of perioperative venous thromboembolism John C. Hobbins, MD problem? prophylaxis in gynecologic surgery. Obstet Gynecol 2011;118:978-986. Professor, Department of Obstetrics and Gynecology, Obesity and University of Colorado Health contraception he objective of this study was to estimate the use of vte pro- Sciences Center, Denver page 61 Tphylaxis in women undergoing major gynecologic surgery and to Frank W. Ling, MD estimate the patient, physician, and hospital characteristics associated Clinical Professor, Departments of Obstetrics with their use. To examine these factors, a validated and regularly au- and Gynecology, ® Vanderbilt University dited national commercial database (Perspective ) of inpatient hospi- School of Medicine, and Financial Disclosure: tal admissions was interrogated for VTE prophylaxis use over an 11- Meharry Medical College, OB/GYN Clinical Alert’s Nashville editor, Jeffrey T. Jensen, MD, MPH, receives year period (2000 to 2010). VTE prophylaxis was classified as none, research support from, is a mechanical, pharmacologic, or a combination. A total of 738,150 VICE PRESIDENT/GROUP consultant to, and serves PUBLISHER on the speakers bureau of women who underwent major gynecologic surgery were identified. In Donald R. Johnston Bayer Healthcare/Bayer Schering; he also receives this study, only abdominal or vaginal hysterectomy with or without EXECUTIVE EDITOR research support from Leslie G. Coplin Merck Abbott Laboratories, salpingo-oophorectomy for benign disease were included. In addition, Wyeth and Warner-Chilcott MANAGING EDITOR and is a consultant to laparoscopic/robotic procedures were excluded. No prophylaxis was Neill L. Kimball Schering Plough. Peer given to 292,034 (40%) women, whereas 344,068 (47%) received me- reviewer Catherine Leclair, MD; executive editor Leslie chanical prophylaxis, 40,268 (6%) pharmacologic prophylaxis, and PEER REVIEWER Coplin, and managing editor Catherine Leclair, MD Neill Kimball report no 61,780 (8%) combination prophylaxis. VTE prophylaxis use increased Associate Professor, financial relationship to this Department of OB/GYN, field of study. from 54% to 68% over the observation period and was more com- Oregon Health & Science University Portland Volume 28 • Number 8 • December 2011 • Pages 57-64 OB/GYN CLINICAL ALERT IS AVAILABLE ONLINE www.ahcmedia.com monly used in older women, those with Medicare and chanical devices, such as graded compression stockings more comorbidities, Caucasian women, patients treated and intermittent pneumatic compression devices.2,3 In ad- at rural hospitals, patients treated at teaching facilities, dition, risk stratification of patients and procedures (types and patients treated by high-volume surgeons and at high- and lengths) where VTE prophylaxis might be optimized volume centers. Factors associated with use of pharma- led to well-publicized guidelines in gynecologic surgery cologic prophylaxis included advanced age, white race, by American College of Obstetricians and Gynecologists noncommercial insurance, later year of diagnosis, greater and the American College of Chest Physicians.4 With this comorbidity, treatment at large hospitals and urban facili- proviso, it is hard to imagine that in 2010, nearly a third of ties, and treatment by a high-volume surgeon. The survey patients undergoing major gynecologic surgery still were data highlight that VTE prophylaxis use is substantially not given any form of VTE prophylaxis. underutilized in women undergoing major gynecological A second paper in this issue of Obstetrics & Gynecolo- surgery, despite clear recommendations from evidence- gy suggests the quality of data among benign gynecology based guidelines. Hospital, physician, and patient factors cohorts in their meta-analysis is not as strong as in others influence use. (e.g., oncology patients) and opines that the guidelines are viewed with tepid regard.5 Nevertheless, it is estimated n COMMENTARY that VTE occurs in up to 3% of patients following benign There are many things in surgery we can’t control: age, gynecologic procedures, which translates into hundreds preexisting anatomy, preexisting comorbidities, charac- of preventable cases every year. In the current study, it teristics of disease, and patient compliance, just to name was reassuring that the proportion has significantly in- a few. However, there are those factors under our con- creased in the last decade, and that it is practiced more trol that should be as automatic as getting informed con- often in urban training centers with high-volume surgeons sent. VTE prophylaxis is one of them! For more than 35 and hospitals, as this holds promise that the practice will years, Level 1 evidence from randomized clinical trials continue to increase as more residents and operating room has clearly demonstrated, in nearly every surgical dis- staff trainees are exposed to Best Practices and Quality cipline (including 15 randomized trials in gynecology/ Improvement projects around this topic. Data like these gynecologic oncology), that fatal VTE can be prevented are hard to come by, and as with any voluntary national by intervention.1 Initially, unfractionated heparin given registry, true compliance with guidelines (dose, duration, before and after surgery was advocated, but concerns and timing of pharmacological prophylaxis and patient for intraoperative and postoperative bleeding ushered in compliance with compression devices) is difficult to ad- evaluation of alternative pharmacological agents and me- judicate. However, this should serve as a wake-up call to review the guidelines and our compliance in order to pro- OB/GYN Clinical Alert, ISSN 0743-8354, is published vide the best care to our patients. n monthly by AHC Media, a division of Thompson Media Group LLC, 3525 Piedmont Rd., NE, Bldg. 6, Suite 400, Atlanta, GA Subscriber Information 30305. Customer Service: 1-800-688-2421. References Editorial E-Mail: [email protected] EXECUTIVE EDITOR: Leslie G. Coplin Customer Service E-Mail: [email protected] MANAGING EDITOR: Neill L. Kimball Subscription Prices 1. No authors listed. Prevention of fatal postoperative pul- GST Registration Number: R128870672. United States Periodicals Postage Paid at Atlanta, GA 30304 and at additional 1 year with free AMA Category 1 credits: $319 monary embolism by low doses of heparin. An interna- mailing offices. Add $17.95 for shipping & handling. (Student/Resident rate: $125) tional multicentre trial. Lancet 1975;2:45-51. POSTMASTER: Send Multiple Copies Discounts are available for group subscriptions, multiple copies, 2. Clarke-Pearson DL, et al. Perioperative external pneu- address changes to site-licenses or electronic distribution. For pricing information, call Tria Kreutzer at 404-262-5482. matic calf compression as thromboembolism prophylaxis OB/GYN Clinical Alert, Canada in gynecologic oncology: Report of a randomized con- P.O. Box 105109, Add 7% GST and $30 shipping. trolled trial. Gynecol Oncol 1984;18:226-232. Atlanta, GA 30348. Elsewhere Add $30 shipping. Copyright © 2011 by AHC Media. All rights reserved. No 3. Clarke-Pearson DL, et al. Venous thromboembolism part of this newsletter may be reproduced in any form or Accreditation incorporated into any information-retrieval system without the prophylaxis in gynecologic oncology: A prospective, con- written permission of the copyright owner. AHC Media is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for trolled trial of low-dose heparin. Am J Obstet Gynecol Back Issues: $42. physicians. 1983;145:606-613. Missing issues will be fulfilled by customer service free of AHC Media designates this enduring material for a maximum of 25 charge when contacted within one month of the missing AMA PRA Category 1 Credits™. Physicians should claim only the issue’s date. 4. ACOG Practice Bulletin
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