Spinal subdural bleeding after attempted epidural and subsequent spinal anaesthesia in a patient on thromboprophylaxis with low molecular weight heparin

Despite the extensive use of low molecular weight heparins (LMWH) for thromboprophylaxis, only two serious complications have thus far been reported where spinal haematomas were incurred after epidural and spinal blocks in patients on such treatment. In our patient, who was on thromboprophylaxis with the LMWH drug enoxaparin, catheter epidural anaesthesia was abandoned due to a bloody tap and superseded by spinal anaesthesia. More than 40 hours later she had developed a paraparesis and complete sensory loss in the lower extremities. The MRT image showed haematomas epi- and subdurally, as well as subarachnoidally, but no epidural bleeding was seen at laminectomy.     

Investment in prolonged thromboprophylaxis with dalteparin improves clinical outcomes after hip replacement

Summary. Clinical guidelines recommend the use of extended out‐of‐hospital thromboprophylaxis in patients who have had major arthroplasty. However, the cost‐effectiveness of prolonging pharmacological thromboprophylaxis into the out‐of‐hospital phase following hip replacement surgery remains the subject of considerable debate. This debate centers on the clinical relevance of the ‘surrogate’ venographic endpoints that have been used in most clinical trials and used to generate some of the cost analyses of thromboprophylaxis. The objective of this study was to estimate, from the payer perspective, the direct medical costs of prolonging the duration of thromboprophylaxis with dalteparin from 1 week to 28–35 days in patients undergoing hip replacement, and to compare these to the costs associated with using ‘standard’ in‐hospital thromboprophylaxis with low‐molecular‐weight heparin (LMWH) or warfarin. To derive ‘best’ estimates for rates of clinically and economically relevant thromboembolism associated with hip replacement surgery (i.e. those that would in reality incur management costs), we used data on the prevalence of both symptomatic and asymptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE). These estimates were used in conjunction with diagnostic‐related groups (DRG) reimbursement rates and a dalteparin cost model, which assumed home‐based self‐administration for prolonged thromboprophylaxis, to calculate overall direct medical costs of prolonged vs. in‐hospital thromboprophylaxis. The management costs of the strategies evaluated were, to the nearest 1000 Euros: 465 000 Euros for in‐hospital prophylaxis with LMWH; 339 000 Euros for in‐hospital prophylaxis with warfarin; and 368 000 Euros for prolonged prophylaxis with dalteparin. For every 1000 patients treated, prolonging thromboprophylaxis with dalteparin from 1 to 4–5 weeks will avoid 30 clinical DVTs and 18 PEs at a saving of 2000 Euros per clinical event. Compared with in‐hospital warfarin, prolonged thromboprophylaxis with dalteparin will avoid 28 DVTs and four PEs at an incremental cost‐effectiveness ratio of 900 Euros per clinical event avoided. We consider that investment in prolonged thromboprophylaxis with dalteparin is justified for the improvement in clinical outcomes produced.     

Wound Discharge After Pharmacological Thromboprophylaxis in Lower Limb Arthroplasty

Background

The benefits vs risk of pharmacological prophylaxis for thromboembolic disease in orthopedic patients remain controversial. Pharmacological thromboprophylaxis regimes are commonly used in this patient group. Few studies specifically examine wound complications attributable to this therapy. In this prospective trial, we investigated the effect of various regimens on postoperative wounds.

Sustained prothrombotic profile after hip replacement surgery: the influence of prolonged prophylaxis with dalteparin

Summary.  In a randomized trial on the effect of dalteparin for 5 weeks after HRS we evaluated hemostatic variables in plasma sampled before and 1, 6 and 35 days postoperatively. In 218 patients we found that prothrombin fragment 1 + 2 (F1 + 2), thrombin–antithrombin complexes (TAT), d -dimer and fibrinogen were significantly higher on day 35 as compared with baseline values in the placebo group ( P  < 0.001 for all). The same pattern was found in the dalteparin group, but with significantly lower values for F1 + 2, TAT and d -dimer. In patients in the placebo group with venographically proven deep vein thrombosis (DVT) on day 35 (33%), significantly higher values were found for F1 + 2, TAT and d -dimer than in patients without DVT. Patients in the highest quartile of d -dimer (>2850 ng mL⁻¹) had an odds ratio for the presence of DVT of 24.0 when compared with patients in the lowest quartile (<1625 ng mL⁻¹). It is concluded that a substantial hypercoagulability is sustained until day 35 after HRS, significantly reduced with prolonged administration of dalteparin.     

Clinical predictors of prophylaxis use prior to the onset of acute venous thromboembolism in hospitalized patients SWIss Venous ThromboEmbolism Registry (SWIVTER)

Summary. Background: We investigated clinical predictors of appropriate prophylaxis prior to the onset of venous thromboembolism (VTE). Methods: In 14 Swiss hospitals, 567 consecutive patients (306 medical, 261 surgical) with acute VTE and hospitalization < 30 days prior to the VTE event were enrolled. Results: Prophylaxis was used in 329 (58%) patients within 30 days prior to the VTE event. Among the medical patients, 146 (48%) received prophylaxis, and among the surgical patients, 183 (70%) received prophylaxis (P < 0.001). The indication for prophylaxis was present in 262 (86%) medical patients and in 217 (83%) surgical patients. Among the patients with an indication for prophylaxis, 135 (52%) of the medical patients and 165 (76%) of the surgical patients received prophylaxis (P < 0.001). Admission to the intensive care unit [odds ratio (OR) 3.28, 95% confidence interval (CI) 1.94–5.57], recent surgery (OR 2.28, 95% CI  1.51–3.44), bed rest > 3 days (OR 2.12, 95% CI  1.45–3.09), obesity (OR 2.01, 95% CI  1.03–3.90), prior deep vein thrombosis (OR 1.71, 95% CI  1.31–2.24) and prior pulmonary embolism (OR 1.54, 95% CI  1.05–2.26) were independent predictors of prophylaxis. In contrast, cancer (OR 1.06, 95% CI  0.89–1.25), age (OR 0.99, 95% CI  0.98–1.01), acute heart failure (OR 1.13, 95% CI  0.79–1.63) and acute respiratory failure (OR 1.19, 95% CI  0.89–1.59) were not predictive of prophylaxis. Conclusions: Although an indication for prophylaxis was present in most patients who suffered acute VTE, almost half did not receive any form of prophylaxis. Future efforts should focus on the improvement of prophylaxis for hospitalized patients, particularly in patients with cancer, acute heart or respiratory failure, and in the elderly.     

Prevention of perioperative venous thromboembolism in pediatric patients: Guidelines from the Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI)

The Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI) Guidelines Working Group on Thromboprophylaxis in Children has reviewed the literature and where possible provided advice on the care of children in the perioperative period. Areas reviewed include the incidence of perioperative venous thromboembolism (VTE), risk factors, evidence for mechanical and chemical prophylaxis, and complications. Safe practice of regional anesthesia with anticoagulant prophylaxis is detailed. In summary, there are few areas of strong evidence. Routine prophylaxis cannot be recommended for young children. Postpubertal adolescents (approximately 13 years and over) are at a slightly increased risk of VTE and should be assessed for prophylaxis and may warrant intervention if other risk factors are present. However, the incidence of VTE is significantly lower than in the adult population. This special interest review presents a summary and discussion of the key recommendations, a decision‐making algorithm and a risk assessment chart. For the full guideline, go to www.apagbi.org.uk/publications/apa-guidelines .