Thoracic surgery for patients with deep vein thrombosis

Deep vein thrombosis (DVT) is a main cause of pulmonary thromboembolism (PTE), and therefore both diseases are categorized as a serial pathophysiology of venous thromboembolism (VTE). Treatment goals for DVT include stopping clot propagation and preventing the recurrence of thrombus, the occurrence of PTE, and the development of pulmonary hypertension, which can be a complication of multiple recurrent pulmonary emboli. Clinical guidelines stratify the risk of VTE to 4 levels and recommend the treatment options. In high or extremely high risk patients for VTE, the use of low-dose heparin is recommended. The prevention against VTE, such as elastic compression stockings and intermittent sequential pneumatic leg compression( ISPC), is the most important prophylactic treatment against perioperative PTE by reducing thrombotic risk in low or moderate high risk patients for VET. Since there is no clear evidence that screening all or even selected patients for thrombophilias improves long-term outcomes, the physician's clinical judgment, and consultation with appropriate subspecialists should guide management perioperatively. Once PTE is suspected, immediate and accurate diagnosis and appropriate treatment are mandatory.     

A Systematic Review of Deep Venous Thrombosis Prophylaxis in Cancer Patients: Implications for Improving Quality

Introduction Deep venous thrombosis (DVT) prophylaxis is particularly important for surgical oncologists given the high rate of DVT in patients with malignancy. Additionally, DVT prophylaxis may soon be implemented by some payers as a “pay for performance” quality measure. This is a systematic review of randomized controlled trial (RCT) evidence for DVT prophylaxis in cancer patients undergoing surgery. We examine overall rates of DVT, the efficacy of high versus low-dose heparin prophylaxis, and the rate of bleeding complications. Methods The Medline database was searched for English language RCTs using key words DVT, venous thromboembolism, prophylaxis, and general surgery. Inclusion criteria were RCTs evaluating surgical oncology patients. Results Fifty-five RCTs studied DVT prophylaxis in surgery (nonorthopedic) patients. Twenty-six RCTs evaluated 7,639 cancer patients. The overall DVT rate was 12.7% for pharmacologic prophylaxis and 35.2% for controls. High-dose low-molecular weight heparin (LMWH) was more effective than low dose, lowering the DVT rate from 14.5% to 7.9% (P < 0.01). Heparin decreased the rate of proximal DVTs. Bleeding complications requiring discontinuation of prophylaxis occurred in 3% of the patients. There was no difference between LMWH and unfractionated heparin in efficacy, DVT location, or bleeding complications. Conclusion Using RCT data, this study demonstrates a greatly reduced DVT rate with pharmacologic prophylaxis in cancer patients, and higher doses appear more effective. Complication rates are low and should not prevent the use of prophylaxis in most patients. Finally, we found no difference between LMWH and unfractionated heparin in these RCTs. These results highlight the importance of routine pharmacologic prophylaxis in surgical patients with malignancy. Presented at 2006 Society of Surgical Oncology Annual Meeting, San Diego, CA.     

The incidence of thromboembolism in the surgical intensive care unit

The clinical diagnosis of deep venous thrombosis (DVT) is unreliable. Studies have been performed examining the utility of frequent duplex scans. However, these studies included patients outside of the intensive care unit. The incidence of venous thromboembolism and the effect of a less intense surveillance protocol was prospectively examined at a level-1 urban trauma center for a 6 month period. During the study period there were 726 admission to the surgical intensive care unit. Sequential compression devices (SCDs) were used for DVT prophylaxis in 93 per cent of the admissions. A total of 114 duplex scans were ordered: 42 per cent for surveillance and the rest for evaluation of a clinical indication. Twelve DVTs were discovered (11% overall DVT rate). No patient on subcutaneous heparin or low-molecular-weight heparin developed a DVT or pulmonary embolism (PE). Four patients suffered a PE; however, none were found to have a lower extremity DVT on duplex ultrasound and all received SCD prophylaxis. Overall, proper use of DVT prophylaxis for intensive care unit days 1-14 was 77 per cent. The incidence of venous thromboembolism in a group of patients at overall high risk was low. A program of DVT surveillance with duplex ultrasound was not cost-effective.     

Heparin and graduated compression stockings in patients undergoing fractured hip surgery.

Despite evidence that effective regimens are available for the prevention of venous thrombosis in fractured hip patients, many centers do not use prophylaxis. In order to evaluate the efficacy and safety of heparin and graduated compression stockings, we conducted a cohort study of 55 consecutive fractures hip patients treated postoperatively with heparin, 5,000 U every 12 h, and graduated compression stockings. The rates of venous thromboembolism and bleeding were compared with an historical cohort from Hamilton. Before discharge, 51 patients underwent bilateral venography. Deep venous thrombosis (DVT) occurred in 10 of the 51 patients (incidence of 20%); three had proximal DVT (incidence of proximal DVT was 6%). DVT was seen in 29 of the 63 control patients (incidence 46%); 19 had proximal DVT (incidence of proximal DVT was 30%). The differences in the rates of DVT and proximal DVT are statistically significant (p less than 0.01). Bleeding occurred in one patient in the treatment group (incidence 2%) and five patients in the control group (incidence 8%). This study confirms that therapy with heparin and graduated compression stockings is effective, inexpensive, and convenient for the prevention of venous thrombosis in fractured hip patients and is associated with a low bleeding risk.     

Antithrombosis routines and hemorrhagic complications: a seven year survey comparing vascular and general surgical operations

Prospective monitoring of the occurrence of venous thromboembolism (VTE) and bleeding complications was carried out during a seven year period in a department of general and vascular surgery. Low dose heparin was given by pre-determined criteria to over 1200 patients undergoing general surgical operations, and to almost 700 patients having vascular surgical operations. Over 450 vascular patients received full dose anticoagulation and 3400 patients from both groups received no antithrombotic treatment. Clinically significant major VTE occurred in one percent of all patients. Nine patients died of pulmonary emboli (0.15%). There were 130 patients with bleeding complications (2.2%) half of them severe. Both VTE and bleeding were more common in the vascular patients (1.4 and 3.1% respectively) as compared with general surgery (0.7 and 1.6%). Patients receiving low dose heparin had a 3.4 percent incidence of bleeding but in one half of these cases a technical factor or a breach of the treatment protocol could have contributed to the bleeding. Possible modifications of antithrombosis routines are suggested.     

利伐沙班与低分子肝素在预防人工全膝关节置换术后深静脉血栓形成的分析

[目的]观察利伐沙班与低分子肝素在预防人工全膝关节置换深静脉血栓的疗效性和安全性.[方法]回顾性分析2009年5月～2011年2月行人工全膝关节置换术的患者200例,将其分为两组,利伐沙班组100例,给予利伐沙班10mg/d口服,连续14d;低分子肝素组的100例,术后给予低分子肝素5000IU/d皮下注射,连续14d.术后14d行双下肢静脉彩超检查有无深静脉血栓形成,并观察两组用药期间有无肺动脉栓塞和严重出血事件的发生.[结果]利伐沙班组深静脉血栓形成的发生率5％,显著低于低分子肝素组的9％,两组均末发生肺动脉栓塞和严重出血事件.[结论]应用利伐沙班较低分子肝素更有效预防膝关节置换术后下肢深静脉血栓的形成,出现严重出血事件很少,二者均较安全.     

Venous thromboembolism in morbid obesity and trauma. A review of literature

Deep venous thromboembolism (DVT) is common and leads to disability, economic loss and even death. The aims of this paper are to start from the basic knowledge that we have about DVT and to tailor our knowledge to the treatment and diagnosis of thromboembolism in obese patients and trauma patients, which are among the patients who have a high risk of developing DVT and pulmonary embolism. Venous thromboembolism is a common complication in patients with major trauma, and effective, safe prophylactic regimens are needed. The patients are treated effectively with heparin and low molecular weight heparins, which are shown to be safe and effective. Morbid obesity is a disease that affects 10% of Americans and increases the incidence of DVT. Forty mg of enoxaparin subcutaneously twice a day seems to be a better DVT prophylaxis than the 30 mg twice a day. Many patients admitted to the hospital are morbidly obese; therefore, we suggest they start on low molecular heparin. The high morbidity of these patients is because most of them are bedridden, which increases the chance of DVT and death from pulmonary embolism. Trauma increases the chance of having DVT. Low molecular weight heparin or heparin is a safe and extremely effective method of preventing DVT in high-risk trauma patients.     

Study on postoperative deep venous thrombosis with reference to prevention

Preventive effect of intermittent sequential pneumatic compression of the legs (ISPC) on the postoperative deep venous thrombosis (DVT) was studied by 125I-fibrinogen uptake test in 64 surgical patients. Furthermore the mechanism of preventive effect by ISPC was analysed from the point of view of coagulation and fibrinolytic activity in 78 patients. Following results were obtained. 1) The incidence of DVT in control group was 18.0 percent, while it was 6.3 percent in ISPC group (p less than 0.01). 2) The euglobulin lysis time in ISPC group was significantly shorter than that of control group on the first postoperative day (p less than 0.01). 3) There were no definite changes in plasminogen and B beta 15-42 peptide between control group and ISPC group. 4) There were no complications in using of ISPC. This study demonstrates that ISPC has a dual action; (1) mechanical prevention of venous stasis and (2) fibrinolytic acceleration. ISPC are effective for prevention of postoperative DVT.     

Randomized,pilot study of intermittent pneumatic compression devices plus dalteparin versus intermittent pneumatic compression devices plus heparin for prevention of venous thromboembolism in patients undergoing craniotomy

BACKGROUND: Unfractionated heparin and the low molecular weight heparin, dalteparin, are used for prophylaxis against venous thromboembolism in patients undergoing craniotomy. These drugs were compared in a randomized, prospective pilot study comparing intermittent pneumatic compression devices plus dalteparin to intermittent pneumatic compression devices plus heparin. METHODS: One hundred patients undergoing craniotomy were randomly allocated to receive perioperative prophylaxis with subcutaneous (SC heparin, 5000 units every 12 hours, or dalteparin, 2,500 units once a day, begun at induction of anesthesia and continued for 7 days or until the patient was ambulating. Entry criteria were age over 18 years, no deep vein thrombosis (DVT) preoperatively as judged by lower limb duplex ultrasound and no clinical evidence of pulmonary embolism preoperatively. Patients with hypersensitivity to heparin, penetrating head injury or who refused informed consent were excluded. Patients underwent a duplex study 1 week after surgery and 1 month clinical follow-up. All patients were treated with lower limb intermittent pneumatic compression devices. RESULTS: There were no differences between groups in age, gender, and risk factors for venous thromboembolism. There were no differences between groups in intraoperative blood loss, transfusion requirements or postoperative platelet counts. Two patients receiving dalteparin developed DVT (one symptomatic and one asymptomatic). No patient treated with heparin developed DVT and no patient in either group developed pulmonary embolism. There were two hemorrhages that did not require repeat craniotomy in patients receiving dalteparin and one that did require surgical evacuation in a patient treated with heparin. Drug was stopped in two patients treated with dalteparin because of thrombocytopenia. None of these differences were statistically significant. CONCLUSION: There was no significant difference in postoperative hemorrhage, venous thromboembolism or thrombocytopenia between heparin and dalteparin. The results suggest that, given the small sample size of this trial, both drugs appear to be safe and the incidence of venous thromboembolism by postoperative screening duplex ultrasound appears to be low when these agents are used in combination with intermittent pneumatic compression devices.     

Heparin Thromboprophylaxis in Gastric Bypass Surgery

Background: Patients undergoing gastric bypass surgery are at risk for postoperative venous thromboembolism. Thromboprophylaxis often includes fixed doses of some type of heparin. However, it is unlikely that the same dose of subcutaneous heparin will be optimal for all patients, because heparin pharmacokinetics depend on a number of patient variables, including thickness of the adipose layer. Methods: An adjusted-dose, unfractionated heparin protocol was developed using pharmacokinetic data from 245 medical and surgical patients. Heparin doses were adjusted to achieve subtherapeutic peak anti-factor Xa heparin activity levels of 0.11-0.25 units/mL. This protocol was then applied to a prospective series of 700 patients undergoing laparoscopic Roux-en-Y gastric bypass who had no history of thromboembolism. Heparin prophylaxis was begun the evening of the day of surgery. Results: No patients were diagnosed with a deep venous thrombosis, but 3 (0.4%) were diagnosed with a non-fatal pulmonary embolism. Heparin therapy was halted because of bleeding in 2.3% of patients but only half of these required blood transfusions (1% of total). No patient required reoperation. Minor wound hematomas occurred in 0.6%. There were no deaths from any cause in this series. Conclusion: Use of a monitored, adjusted-dose unfractionated heparin prophylactic protocol in a laparoscopic gastric bypass patient population resulted in doses greater than those used in traditional fixed-dose protocols. However, bleeding and thromboembolism rates were very low and no patients died.     

Les déficits constitutionnels en antithrombine III, protéine C et protéine S. Etude de 31 sujets appartenant à huit familles non apparentées

The families of eight unrelated patients were studied with regard to a hereditary deficiency in antithrombin III (ATIII), protein C, or protein S. These deficiencies were recognized in the course of investigations for deep-vein thrombosis (DVT) in the eight patients. A group of 31 individuals (patients and family members), mostly less then 40-year-old was explored. Two cases of AT III deficiency were discovered, as well as 21 of protein C deficiency, and seven of protein S. Ten of the 30 have had recurrent venous thrombosis at the time of bedrest, trauma, surgery, pregnancy, postpartum or during oral contraceptive treatment. Spontaneous DVT occurred in three cases. Seventeen patients had remained asymptomatic till then. Such patients need antithrombotic treatment during surgery or pregnancy. Prophylactic treatment with enoxaparin in one patient (deficiency in protein C) during her second pregnancy is discussed. It seems that low molecular weight heparin may be a safe alternative to unfractionated heparin. Oral anticoagulants are efficient in preventing recurring venous thromboembolism in patients with AT III deficiency. The questions of whether oral anticoagulants should be continued in the long-term in patients with protein C or protein S deficiency who have had a DVT, and whether asymptomatic deficient patients should be given any antithrombotic treatment outside circumstances likely to induce a DVT, remain as yet unanswered.     

Hereditary deficiency of antithrombin III, protein C and protein S. A study of 31 patients from 8 unrelated families

The families of eight unrelated patients were studied with regard to a hereditary deficiency in antithrombin III (ATIII), protein C, or protein S. These deficiencies were recognized in the course of investigations for deep-vein thrombosis (DVT) in the eight patients. A group of 31 individuals (patients and family members), mostly less than 40-year-old was explored. Two cases of AT III deficiency were discovered, as well as 21 of protein C deficiency, and seven of protein S. Ten of the 30 have had recurrent venous thrombosis at the time of bedrest, trauma, surgery, pregnancy, postpartum or during oral contraceptive treatment. Spontaneous DVT occurred in three cases. Seventeen patients had remained asymptomatic till then. Such patients need antithrombotic treatment during surgery or pregnancy. Prophylactic treatment with enoxaparin in one patient (deficiency in protein C) during her second pregnancy is discussed. It seems that low molecular weight heparin may be a safe alternative to unfractionated heparin. Oral anticoagulants are efficient in preventing reoccurring venous thromboembolism in patients with AT III deficiency. The questions of whether oral anticoagulants should be continued in the long-term in patients with protein C or protein S deficiency who have had a DVT, and whether asymptomatic deficient patients should be given any antithrombotic treatment outside circumstances likely to induce a DVT, remain as yet unanswered.     

Therapy of acute pulmonary thromboembolism from the physician's standpoint

The therapy of acute pulmonary thromboembolism (APTE) is based on the clinical grade and ranges from ambulant therapy with anticoagulation, to thrombolysis, inferior vena cava (IVC) filtration, and catheter thrombectomy. In the absence of contraindications, initial treatment of APTE should consist of parenteral anticoagulation with unfractionated heparin. Long-term anticoagulation therapy, usually with warfarin, should be administered according to the individual risk profile of the patient. Thrombolytic therapy may be appropriate for patients with massive APTE with cardiac shock, syncope, etc. Similarly, thrombolysis has been reported to be effective in submassive APTE with right ventricular overload on echocardiography. IVC filters should be reserved for APTE with deep vein thrombosis (DVT) in which there are absolute contraindications to anticoagulation, recurrent thromboemboli despite therapeutic anticoagulation, and status after surgical thrombectomy. Relative indications for IVC filters that require individualized decision making include proximal DVT, especially with free-floating thrombi or in patients with limited cardiopulmonary reserve. For patients with massive APTE with contraindications to anticoagulation or in whom anticoagulation is uneffective, transcatheter aspiration with catheterization or fragmentation using a guidewire and rotating pig-tail catheter can be used. In addition, cardiopulmonary management such as supplemental oxygen, catecholamine administration, percutaneous cardiopulmonary support, etc. may be necessary for individual patients.     

Prevention of venous thromboembolism in patients with spinal cord injury: effects of sequential pneumatic compression and heparin

OBJECTIVE: To estimate the incidence of and risk factors for venous thromboembolism in patients with acute traumatic spinal cord injury (SCI) and evaluate the effectiveness of sequential pneumatic compression devices (SCD), gradient elastic stockings (GES), and heparin in preventing thromboembolism. DESIGN: Prentice's case-cohort design. SETTING: All patients admitted to our hospital between 1976 and 1995 with acute traumatic SCI. MAIN OUTCOME MEASURES: Demographic characteristics, venous thromboembolism risk factors, methods of surveillance and prophylaxis, and thromboembolic events during the first 6 weeks following injury. RESULTS: Venous thromboembolism occurred in 84 of 428 patients (19.6%). Venous thromboembolism increased from 21% between 1976 and 1979 to 31% between 1980 and 1984, then decreased to 16% between 1985 and 1989 and to 8% between 1990 and 1995. Routine surveillance for venous thromboembolism increased through 1983, and SCD/GES use increased after 1983, with a concurrent decline in incidence of thromboembolism. Multivariate analysis showed that SCD/GES reduced the risk of deep venous thrombosis (DVT) or pulmonary embolism (relative risk, 0.5; 95% CI, 0.28 to 0.90). Multivariate analysis suggested a reduced risk of DVT in patients receiving heparin therapy within the first 14 to 42 days after injury, but estimates of reduced risk were not statistically significant (p = .064 for first 14 days, p = .13 for heparin anytime). CONCLUSION: The SCD/GES combination and heparin are each effective in preventing venous thromboembolism in individuals' acute traumatic SCI. Effectiveness of heparin prophylaxis may be greatest during the first 14 days after injury, whereas benefit from SCD continues to 6 weeks after injury.     

多模式预防措施对老年关节置换术后静脉血栓栓塞症发生及转归的影响

目的分析采用多模式血栓预防措施后,老年初次髋、膝关节置换术后静脉血栓栓塞症（VTE）的发生和转归情况。 方法回顾性收集2015年1月至2017年6月行初次单侧髋、膝关节置换的老年患者375例（年龄≥60岁）,所有患者均接受抗凝药物、足底小腿静脉气压泵、加强踝泵和早期下地等康复预防以及减少围手术期脱水等多模式血栓预防措施,术后采用彩色多普勒超声检查双侧下肢深静脉血栓（DVT）的发生情况,对有症状患者行肺动脉CT造影排查肺动脉栓塞（PE）。 结果共349名患者获完整随访,随访率92.5%。随访期间无症状性PE,DVT共38例,总发生率为10.9%,均为远端DVT。手术同侧DVT 38例,双侧3例。症状性DVT共27例（27/38,71.1%）,无症状性DVT 11例（11/38,29.0%）。单纯腓肠肌间静脉血栓29例,单条小腿静脉血栓3例,混合静脉血栓6例。接受不同手术方式的患者DVT发生率差别有统计学意义（χ²=0.000,P<0.001）,其中接受全膝关节置换手术患者DVT的发生率为16.3%,显著高于单髁关节置换手术组的4.7%。单纯腓肠肌间静脉血栓未予药物治疗,其他DVT口服利伐沙班抗凝治疗4 w。术后8 w,有26例（26/38,68.4%）血栓完全消融,12例（12/38,31.6%）血栓未完全消融,但所有DVT相关临床表现均消失,无残留血栓后遗症,且无血栓进展或新发PE。 结论采取多模式预防措施后,老年关节置换术后VTE发生率低,且均为远端DVT,经观察或短程抗凝治疗,症状消失并无后遗症。     

老年股骨颈骨折全髋关节置换术围手术期下肢深静脉血栓形成的特点

目的探讨老年股骨颈骨折行人工全髋关节置换术及规范化预防性抗凝治疗下围手术期下肢深静脉血栓形成的特点。 方法回顾性分析2015年1月~2017年6月华中科技大学同济医学院附属普爱医院骨科行人工全髋关节置换的老年患者363例,年龄（66±5）岁,男性114例（31.4%）,女性249例（68.6%）。将患者分为股骨颈骨折组（n=187）和非股骨颈骨折组（n=176）。按照《中国骨科大手术静脉血栓栓塞症预防指南》进行规范化血栓预防,对围手术期出现下肢深静脉血栓的患者进行回顾性分析,对比两组患者围手术期深静脉血栓形成的特点。 结果骨折组患者中8例出现下肢深静脉血栓,其中2例并发肺栓塞;非骨折组中6例出现下肢深静脉血栓,其中1例并发肺栓塞,差异无统计学意义（χ²=0.185,P>0.05）。骨折组下肢深静脉血栓5例发生于术前,3例发生于术后;非骨折组6例患者均发生于术后,两组比较差异有统计学意义（P<0.05）。 结论老年股骨颈骨折全髋关节置换患者术前和术后均易形成下肢深静脉血栓,对于这类特殊的群体,术前血栓防治也应引起足够的重视。     

Low Thrombotest Values in Active Thrombosis

Four patients with postoperative venous thromboembolism, in the presence of unusual and unexpected Thrombotestr` (TT) patterns, are reported. At the time of the diagnosis, 3 patients had lower TT values than a control series of uncomplicated postoperative cases. Two had a marked progression of thrombosis when TT was less than 5%, and 1 died with massive pulmonary embolism. A paradoxical rise in TT occurred during the initial stage of heparin treatment in 2 patients. The diagnostic and therapeutic implications of low TT values during active thrombosis are discussed.     

The role of low molecular weight heparin in total knee arthroplasty

Low-molecular-weight heparin prophylaxis is an acceptable, if not superior, alternative to heparin and warfarin prophylaxis in TKA. Considering the current popularity of pharmacologic prophylaxis after total hip and total knee arthroplasty and the advantages of low-molecular-weight heparins over traditional pharmacologic agents, these agents have the potential to become the prophylactic agent of choice against DVT in TKA. There are several practical differences between low molecular weight heparins and warfarin. Low molecular weight heparins are administered by subcutaneous injection and do not require drug-level or blood monitoring. Warfarin, although administered orally, must be maintained within an appropriate international normalized ratio (INR=2-3) with daily dose adjustments and takes 36 hours to produce a measurable effect, which may leave patients relatively unprotected during the early postoperative period. Comparative trials have demonstrated that low molecular weight heparins are more efficacious than warfarin in producing a greater overall reduction in the incidence and risk of DVT, but show similar rates of PE. Some studies suggest that bleeding may be a greater problem with low molecular weight heparin. Despite the superior efficacy of low molecular weight heparin, the prevalence of venous thromboembolism after TKA continues to be substantial compared with total hip arthroplasty, with at least a quarter of patients still affected. Additional prophylaxis strategies for this indication are needed and could include combining mechanical prophylaxis (eg, external pneumatic compression) with low molecular weight heparin. An appropriate management strategy should be established for all patients undergoing TKA. This should include identification of high-risk patients, cautious transfusion of blood products, pharmacologic prophylaxis with an acceptable agent for TKA, early mobilization, postoperative screening in high-risk patients, and continuing pharmacologic prophylaxis for an appropriate period postoperatively.     

Prevention of Venous Thromboembolism in Patients with Spinal Cord Injury: Effects of Sequential Pneumatic Compression and Heparin

Abstract

Objective: To estimate the incidence of and risk factors for venous thromboembolism in patients with acute traumatic spinal cord injury (SCI) and evaluate the effectiveness of sequential pneumatic compression devices (SCD), gradient elastic stockings (GES), and heparin in preventing thromboembolism. Design: Prentice’s case-cohort design.

Setting: All patients admitted to our hospital between 1976 and 1995 with acute traumatic SCI. Main outcome measures: Demographic characteristics, venous thromboembolism risk factors, methods of surveillance and prophylaxis, and thromboembolic events during the first 6 weeks following injury. Results: Venous thromboembolism occurred in 84 of 428 patients (19.6%). Venous thromboembolism increased from 21% between 1976 and 1979 to 31% between 1980 and 1984, then decreased to 16% between 1985 and 1989 and to 8% between 1990 and 1995. Routine surveillance for venous thromboembolism increased through 1983, and SCD/GES use increased after 1983, with a concurrent decline in incidence of thromboembolism. Multivariate analysis showed that SCD/GES reduced the risk of deep venous thrombosis (DVT) or pulmonary embolism (relative risk, 0.5; 95% CI, 0.28 to 0.90). Multivariate analysis suggested a reduced risk of DVT in patients receiving heparin therapy within the first 14 to 42 days after injury, but estimates of reduced risk were not statistically significant (p = .064 for first 14 days, p = .13 for heparin anytime).

Conclusion: The SCD/GES combination and heparin are each effective in preventing venous thromboembolism in individuals’ acute traumatic SCI. Effectiveness of heparin prophylaxis may be greatest during the first 14 days after injury, whereas benefit from SCD continues to 6 weeks after injury.     

Heparin-induced thrombocytopenia after elective hip joint replacement with postoperative prevention of thromboembolism with low-molecular-weight heparin

BACKGROUND: Heparin-induced thrombocytopenia (HIT) is a severe side effect of the prophylaxis of venous thromboembolism with unfractionated heparin. The aim of the present study is to gain more information on the incidence of HIT during prophylaxis of venous thromboembolism with low-molecular-weight heparin in elective hip surgery. METHODS: 586 consecutive patients were included into the prospective study, who were admitted to hospital for elective hip replacement. The incidence of thrombocytopenia, clinically manifest venous thromboembolism and of the heparin-induced IgG antibodies were analysed during prophylaxis with low molecular-weight heparin. Patients received once daily subcutaneously low molecular-weight heparin for a mean of 28 days postoperatively. Platelet counts and clinical examinations for the presence of venous thromboembolism were done at days 0, 2, 7 (+/- 1) and 12 (+/- 2). Heparin-induced IgG antibodies were determined before and after a 12 (+/- 2) days prophylaxis with low molecular-weight heparin in 265 of 586 patients randomly. Patients were reexamined for thromboembolic complications after 3 and 6 months. The clinical suspicion of thromboembolic complication was documented objectively. RESULTS: None of the patients developed a decrease of platelets of < 50% of the initial value. Ten of 265 patients had elevated IgG antibodies against heparin/platelet factor 4 before prophylaxis (3.8%). After the 12 (+/- 2) days prophylaxis 13 of 265 patients had elevated IgG antibodies (4.9%). C14 serotonin assay was positive in 0 of 10 patients before treatment and in 3 of 19 patients at day 12 (+/- 2). Ten patients developed venous thromboembolism postoperatively (8 x deep venous thrombosis, 2 x pulmonary embolism, no fatal embolism). Only 1/19 patients with elevated antiheparin IgG titres developed venous thromboembolism. The C14 serotonin assay was negative in this patient. Two patients died in the postoperative phase due to underlying cardiovascular diseases. CONCLUSIONS: In patients with elective hip replacement prophylaxis of venous thromboembolism with low molecular-weight heparin was associated with a very low incidence of HIT, and hence screening for HIT antibodies is not required.