Lack of extended venous thromboembolism prophylaxis in high-risk patients undergoing major orthopaedic or major cancer surgery

 

 Buy Article Permissions and Reprints

Summary

Extended pharmacological venous thromboembolism (VTE) prophylaxis beyond discharge is recommended for patients undergoing high-risk surgery. We prospectively investigated prophylaxis in 1,046 consecutive patients undergoing major orthopaedic (70%) or major cancer surgery (30%) in 14 Swiss hospitals. Appropriate in-hospital prophylaxis was used in 1,003 (96%) patients. At discharge, 638 (61%) patients received prescription for extended pharmacological prophylaxis: 564 (77%) after orthopaedic surgery, and 74 (23%) after cancer surgery (p <0.001). Patients with knee replacement (94%), hip replacement (81%), major trauma (80%), and curative arthroscopy (73%) had the highest prescription rates for extended VTE prophylaxis; the lowest rates were found in patients undergoing major surgery for thoracic (7%),gastrointestinal (19%),and hepatobiliary (33%) cancer. The median duration of prescribed extended prophylax is was longer in patients with orthopaedic surgery (32 days, interquartile range 14–40 days) than in patients with cancer surgery (23 days, interquartile range 11–30 days; p<0.001).Among the 278 patients with an extended prophylaxis order after hip replacement, knee replacement, or hip fracture surgery, 120 (43%) received a prescription for at least 35 days, and among the 74 patients with an extended prophylaxis order after major cancer surgery, 20 (27%) received a prescription for at least 28 days. In conclusion, approximately one quarter of the patients with major orthopaedic surgery and more than three quarters of the patients with major cancer surgery did not receive prescription for extended VTE prophylaxis. Future effort should focus on the improvement of extended VTE prophylaxis, particularly in patients undergoing major cancer surgery.

Both authors contributed equally to the study.

• References

• 1 Cohen AT, Agnelli G, Anderson FA. et al. Venous thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality. Thromb Haemost 2007; 98: 756-764.
  Article in Thieme ConnectPubMedGoogle Scholar
• 2 Prandoni P, Villalta S, Bagatella P. et al. The clinical course of deep-vein thrombosis. Prospective long-term follow-up of 528 symptomatic patients. Haematologica 1997; 82: 423-428.
  PubMedGoogle Scholar
• 3 Pengo V, Lensing AW, Prins MH. et al. Thromboembolic Pulmonary Hypertension Study Group. Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism. N Engl J Med 2004; 350: 2257-2264.
  CrossrefPubMedGoogle Scholar
• 4 Geerts WH, Pineo GF, Heit JA. et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126 (03) Suppl 338S-400S.
  CrossrefPubMedGoogle Scholar
• 5 Anderson FA, Wheeler HB, Goldberg RJ. et al. A population-based perspective of the hospital incidence and case fatality rates of deep vein thrombosis and pulmonary embolism: the Worcester DVT Study. Arch Intern Med 1991; 151: 933-938.
  CrossrefPubMedGoogle Scholar
• 6 White RH, Romano PS, Zhou H. et al. Incidence and time course of thromboembolic outcomes following total hip or knee arthroplasty. Arch Intern Med 1998; 158: 1525-1531.
  CrossrefPubMedGoogle Scholar
• 7 Warwick D, Friedman RJ, Agnelli G. et al. Insufficient duration of venous thromboembolism prophylaxis after total hip or knee replacement when compared the time course of thromboembolic events: Findings from the global orthopaedic registry. J Bone Joint Surg (Br) 2007; 89-B: 799-807.
  CrossrefPubMedGoogle Scholar
• 8 Dahl OE, Aspelin T, Arnesen H. et al. Increased activation of coagulation and formation of late deep venous thrombosis following discontinuation of thromboprophylaxis after hip replacement surgery. Thromb Res 1995; 80: 299-306.
  CrossrefPubMedGoogle Scholar
• 9 Bergqvist D, Benoni G, Bjorgell O. et al. Low-molecular-weight heparin (enoxaparin) as prophylaxis against venous thromboembolism after total hip replacement. N Engl J Med 1996; 335: 696-700.
  CrossrefPubMedGoogle Scholar
• 10 Mismetti P, Laporte S, Darmon JY, Buchmuller A, Decousus H. Meta-analysis of low molecular weight heparin in the prevention of venous thromboembolism in general surgery. Br J Surg 2001; 88: 913-930.
  CrossrefPubMedGoogle Scholar
• 11 Douketis JD, Eikelboom JW, Quinlan DJ. et al. Shortduration prophylaxis against venous thromboembolism after total hip or knee replacement: a metaanalysis of prospective studies investigating symptomatic outcomes. Arch Intern Med 2002; 162: 1465-1471.
  CrossrefPubMedGoogle Scholar
• 12 Freedman KB, Brookenthal KR, Fitzgerald RH. et al. A meta-analysis of thromboembolic prophylaxis following elective total hip arthroplasty. J Bone Joint Surg Am 2000; 82: 929-938.
  CrossrefPubMedGoogle Scholar
• 13 Westrich GH, Haas SB, Mosca P. et al. Meta-analysis of thromboembolic prophylaxis after total knee arthroplasty. J Bone Joint Surg Br 2000; 82: 795-800.
  CrossrefPubMedGoogle Scholar
• 14 Bergqvist D, Agnelli G, Cohen AT. et al. Duration of prophylaxis against venous thromboembolism with enoxaparin after surgery for cancer. N Engl J Med 2002; 346: 975-980.
  CrossrefPubMedGoogle Scholar
• 15 Hull RD, Pineo GF, Stein PD. et al. Extended outof-hospital low-molecular-weight heparin prophylaxis against deep venous thrombosis in patients after elective hip arthroplasty: A systematic review. Ann Intern Med 2001; 135: 858-869.
  CrossrefPubMedGoogle Scholar
• 16 Eikelboom JW, Quinlan DJ, Douketis JD. Extended-duration prophylaxis against venous thromboembolism after total hip or knee replacement: a meta-analysis of the randomised trials. Lancet 2001; 358: 9-15.
  CrossrefPubMedGoogle Scholar
• 17 Geerts WH, Pineo GF, Heit JA. et al. Prevention of Venous Thromboembolism: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126: 338S-400S.
  CrossrefPubMedGoogle Scholar
• 18 Geerts WH, Bergqvist D, Pineo GF. et al. Prevention of venous thromboembolism: ACCP Evidence Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133: 381S-453S.
  CrossrefPubMedGoogle Scholar
• 19 Raskob GE, Hirsh J. Controversies in timing of the first dose of anticoagulant prophylaxis against venous thromboembolism after major orthopedic surgery. Chest 2003; 124: 379S-385S.
  CrossrefPubMedGoogle Scholar
• 20 Anderson FA, White K. bfor the Hip and Knee Registry Investigators. Prolonged prophylaxis in orthopedic surgery: insights from the United States. Semin Thromb Haemost 2002; 28 (Suppl. 03) 43-46.
  Article in Thieme ConnectPubMedGoogle Scholar
• 21 Kucher N, Koo S, Quiroz R. et al. Electronic alerts to prevent venous thromboembolism among hospitalized patients. N Engl J Med 2005; 352: 968-977.
  PubMedGoogle Scholar
• 22 Kucher N, Spirk D, Kalka C. et al. Clinical predictors of prophylaxis use prior to the onset of acute venous thromboembolism in hospitalized patients. J Thromb Haemost 2008; 06: 2082-2087.
  CrossrefPubMedGoogle Scholar
• 23 Eikelboom JW, Mehta SR, Anand SS. et al. Adverse impact of bleeding on prognosis in patients with acute coronary syndromes. Circulation 2006; 114: 774-782.
  CrossrefPubMedGoogle Scholar