DVT Prophylaxis – Two Articles

Updated 3/2017 -- all links removed (except to my own posts) as many no longer active.


There were two articles regarding deep venous thrombosis prevention in the November 2011 issue of the Plastic and Reconstructive Surgery Journal.  Both are worth reading.  I have supplied the full references below with links.

From the second article:

Between 1 and 7 percent of surgeons have personally experienced a venous thromboembolism–related patient death after high-risk plastic surgery.  Plastic surgeons' self-reported practice patterns indicate a disparity between clinical understanding and clinical practice. The majority of surgeons can identify patients at high risk for postoperative venous thromboembolism. However, examination of their self-reported practice patterns indicates that a substantial proportion of surgeons (>50 percent) provide inadequate levels of venous thromboembolism prophylaxis for high-risk patients.  In addition, surgeons recognize modifiable venous thromboembolism risk factors (such as oral contraceptive use) but may fail to modify those factors before surgery. 

“Never event” is a poor descriptor for venous thromboembolism, as it implies that all events are potentially preventable. Breakthrough venous thromboembolism events routinely occur in the face of rigorous protocols and criterion-standard prophylaxis, as has been reported in the plastic surgery, orthopedic surgery, and general surgery literature. We observed multiple breakthrough events in the Venous Thromboembolism Prevention Study enoxaparin group, although the distinct causes of these events remain unclear. Unrecognized hypercoagulability has been identified as a major contributor to venous thromboembolism risk.  Venous Thromboembolism Prevention Study data support the belief that a prior personal history of venous thromboembolism is an important risk factor as well (Table 3).

Venous thromboembolism represents a financial burden for patients and payers. The mean cost of hospitalization for an index deep venous thrombosis event is over $20,000.   Previous work has shown that enoxaparin is a cost-effective method of venous thromboembolism prevention.  In July of 2010, the U.S. Food and Drug Administration approved production of enoxaparin in generic form, which should result in substantially decreased costs to patients.

For a complete overview of venous thromboembolism in plastic surgery, we refer readers to two excellent reviews that have recently been published by Miszkiewicz and colleagues and Venturi and colleagues. These reviews built on the foundation of several outstanding reviews and consensus statements published previously.

I added the references mentioned in the last paragraph to the section below.  DVT prevention is important.  It can be done safely.  It needs to be done.


Related Posts:
Deep Venous Thrombosis Prevention  (June 19, 2007)
DVT Prevention (June 4, 2008)
Prevent Pulmonary Thromboembolism – an Article Review (February 23, 2009)
DVT Screening and Prevention (February 3, 2010)

REFERENCES

1.  Changing Practice: Implementation of a Venous Thromboembolism Prophylaxis Protocol at an Academic Medical Center; Pannucci, Christopher J.; Jaber, Reda M.; Zumsteg, Justin M.; Golgotiu, Vlad; Spratke, Lisa M.; Wilkins, Edwin G.; Plastic & Reconstructive Surgery. 128(5):1085-1092, November 2011; doi: 10.1097/PRS.0b013e31822b67ff

2.  Postoperative Enoxaparin Prevents Symptomatic Venous Thromboembolism in High-Risk Plastic Surgery Patients; Pannucci, Christopher J.; Dreszer, George; Wachtman, Christine Fisher; Bailey, Steven H.; Portschy, Pamela R.; Hamill, Jennifer B.; Hume, Keith M.; Hoxworth, Ronald E.; Rubin, J. Peter; Kalliainen, Loree K.; Pusic, Andrea L.; Wilkins, Edwin G.; Plastic & Reconstructive Surgery. 128(5):1093-1103, November 2011; doi: 10.1097/PRS.0b013e31822b6817

3.  Miszkiewicz K, Perreault I, Landes G, et al.. Venous thromboembolism in plastic surgery: Incidence, current practice and recommendations. J Plast Reconstr Aesthet Surg. 2009;62:580–588.

4.  Venturi ML, Davison SP, Caprini JA. Prevention of venous thromboembolism in the plastic surgery patient: Current guidelines and recommendations. Aesthet Surg J. 2009;29:421–428.

5.  McDevitt NB. Deep vein thrombosis prophylaxis. American Society of Plastic and Reconstructive Surgeons. Plast Reconstr Surg. 1999;104:1923–1928.

6. Davison SP, Venturi ML, Attinger CE, Baker SB, Spear SL. Prevention of venous thromboembolism in the plastic surgery patient. Plast Reconstr Surg. 2004;114:43E–51E.

7. Young VL, Watson ME. The need for venous thromboembolism (VTE) prophylaxis in plastic surgery. Aesthet Surg J. 2006;26:157–175.

Fitness to Fly

Updated 3/2017 -- all links (except to my own posts) removed as many no longer active.

I noticed this tweet from @doc2doc

In Flight Emergencies http://bit.ly/9N55iG

Enclosed in the link article was the pdf file link for the paper by the working group of the British Medical Cardiovascular Society:   Fitness to fly for passengers with cardiovascular disease.

The portion of the paper I found most interesting was the advise to patients regarding travel, DVT risk, and recent surgery:

Advice to long-distance (air) travelers (>6 h)
1. Low risk
< No history of DVT/VTE.
< No recent surgery (4 weeks).
< No other known risk factor.
It is common sense, given the foregoing, that encouragement be given to keep mobile in so far as is possible, adopt regular flexion and extension exercises of the lower limbs and extremities with the avoidance of dehydration.

The passenger should be well hydrated the day before as well as on the day of the flight. 

Smoking (now generally banned on aircraft) should be avoided.  Also to be avoided are alcohol and/or caffeine, which contribute to dehydration, and hypnotics, particularly in a cramped environment.

2. Moderate risk
< Previous history of DVT/VTE.
< Recent surgery lasting >30 min in the past 2 months but not in the last 4 weeks.
< Known thrombophilia.
< Pregnancy.
< Obesity (BMI >30 kg/m2).

The guidance for low risk should be adopted with the addition of compression stockings which have been shown to reduce risk, although their use has given rise to adverse comment.

3. High risk
< Recent (within 4 weeks) surgery under general anesthesia lasting >30 min.
< Previous DVT with known additional risk factor(s) including known cancer.

The guidance for low and moderate risk should be adopted and low molecular weight heparin considered (ie, subcutaneous enoxoparin 40 mg on the morning of the flight and on the following day).  Although rare compared with unfractionated
heparin, complications including bleeding and thrombocytopenia can occur so it is only recommended in those at high risk.

Co-existent treatment with warfarin is protective and should be continued. Advice should be sought for patients with a plaster cast and consideration given towards a split cast to relieve limb compression.

Similarly, advice is needed following recent (<2 weeks) DVT/VTE. Aspirin had no effect in one study of the prevention of DVT during air travel and its use was associated with gastrointestinal symptoms in 13% of those who used it. It is not currently recommended in this context for DVT/VTE prophylaxis.

I often ask patients of if they have any travel plans when scheduling elective surgery, especially when the surgery is one that is longer than 1 hour.  This has become a routine part of my DVT assessment risk.

DVT Screening and Prevention

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Last week the National Institute for Health and Clinical Excellence (Nice) published it’s report calling for DVT screening of all patients admitted to the hospital in Great Britain.   You can read the Quick Reference Guide here (pdf file).  Seems like a good time to review the subject.

From the prevention side in surgical patients, here are a few things to remember. Patients are ranked into risk categories. These are:

• Low: Minor procedure, Patient less than 40 yrs old, No other risk factors
• Moderate: Minor procedure, Age between 40-60 yrs, No other risks factors
• High : Non-minor (major) procedure, More than 60 yrs, No other risks factors
  Or Age between 40-60 yrs with other risks factors
• Highest: Major procedure, Multiple risk factors, Hip/knee arthroplasty, Hip fracture surgery, Major trauma, Spinal cord injury

Other risks factors include: recent pregnancy (less than one month ago) [This is why, along with the recent blood loss of delivery, and often anemia of pregnancy that women should never have a tummy tuck at the time of their C-section. The risks are too high for complications.], varicose veins, overweight, personal or family history of blood clots, personal history of cancer, use of birth control or hormone replacement, recent travel (long flights or car rides without movement), etc. Recall the journalist who died after sitting in a tank for long hours with little to no movement.

 

Preventive Therapy consists of:
All surgical patients should have intermittent pneumatic compression devices used (unless the procedure will be less than 1 hour) during the surgical procedure.

• Low Risk (less than 2 %)
  Ambulate three times daily for 5 minutes minimum each time
  Flex and extend ankles often
  

• Moderate Risk (10-20%)
  1. Ambulate as above
  2. Flex and extend ankles often
  3. TED stockings
  
• High Risk (20-40%)
  1. Same as moderate (1-3)
  2. Lovenox (enoxaparin sodium) SQ for 7-14 days
  
• Highest Risk (40-80%)
  1. Same as high risk
  2. Lovenox, Fondaparinux SQ, Heparin or Warfarin (will depend on the procedure being done and on patient history)
  

REFERENCES

1.  Prevent DVT.org

2.  Prevention of Venous Thromboembolism in the Plastic Surgery Patient; Plastic and Reconstructive Surgery, Vol 114 (3) September 1, 2004, pp 43e-51e.

3.   Deep Venous Thrombosis Prophylaxis Practice and Treatment Strategies among Plastic Surgeons: Survey Results, Plastic and Reconstructive Surgery; Vol 119 (1) January 2007, pp 157-174.

4.   Current Diagnosis of Venous Thromboembolism in Primary Care: A Clinical Practice Guideline from the American Academy of Family Physicians and the American College of Physicians

5.   Current and Emerging Therapies in the Management of Venothromboembolism by Jack E. Ansell MD, Samuel Z. Goldhaber MD, Ajay K. Kakkar MBBS, Graham Turpie MD -- Medscape Article Dec 28, 2007

6.   The Efficacy of Prophylactic Low-Molecular-Weight Heparin to Prevent Pulmonary Thromboembolism in Immediate Breast Reconstruction Using the TRAM Flap; Plastic and Reconstructive Surgery:Volume 123(1)January 2009pp 9-12; Kim, Eun Key M.D.; Eom, Jin Sup M.D., Ph.D.; Ahn, Sei Hyun M.D., Ph.D.; Son, Byung Ho M.D., Ph.D.; Lee, Taik Jong M.D., Ph.D.

7.  Executive Summary: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition); Chest June 2008 133:71S-109S; doi:10.1378/chest.08-0693