Venous thromboembolism chemoprophylaxis regimens in trauma and surgery patients with obesity: A systematic review (original) (raw)
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Venous Thromboembolism Prophylaxis in Obese Medical Patients: A Retrospective Cohort Study
Background: Obese patients are 2-3 times more likely to develop venous thromboembolism (VTE), and over 60% of VTE occurs in hospital. Our primary objective was to identify the incidence of objectively documented symptomatic VTE during hospitalization or up to ninety days post discharge. Our secondary objectives were to describe the prescribing patterns of VTE prophylaxis received in hospitalized obese medical patients (body mass index [BMI] ≥30 kg/m2) as well as risk factors for VTE in obese patients. Method: A retrospective design was used look at obese patients admitted to a general medicine service at three tertiary care academic teaching hospitals in Calgary, AB, Canada from January 1, 2012 to December 31, 2012. VTE was identified based on clinical diagnosis and incidence was calculated. Results: There were 443 patients included in the analysis. The average age and BMI were 58.5 years and 41 kg/m2 respectively, and 70.2% were males. The median length of stay in hospital was 7 days (IQR 4-13). A total of 122 patients (27.5%) of patients did not receive thromboprophylaxis during their hospitalization. Unfractionated heparin (UFH) was the most common agent prescribed (37.9%), and only seven patients received high-dose thromboprophylaxis. The median duration of prophylaxis was 6.5 days (IQR 4-12). Seven patients (1.6%) developed VTE (5 pulmonary embolism and 2 DVT) during the study period, and six of these patients received thromboprophylaxis. In terms of risk for VTE, the median Padua Prediction Score for the study group was 2 (IQR 1-3). Conclusion: There is very little literature on VTE prophylaxis and incidence of VTE in the obese medical patient. Given the low risk for and incidence of VTE in this study, particularly in the context of 27.5% of the study population not receiving thromboprophylaxis, there is a need for further research to evaluate the efficacy and safety of high dose thromboprophylaxis in the obese medical patient.
World Journal of Surgery, 2020
Background The risk of venous thromboembolism (VTE) persists beyond hospitalization in surgical patients, yet post-hospital discharge chemoprophylaxis regimens are not common. The purpose of this study is to systematically review the literature regarding extended-duration (post-hospital discharge) venous thromboembolism chemoprophylaxis and to determine whether it is warranted in high-risk surgical patients, as determined by its safety and efficacy. Method We searched four online databases for articles evaluating extended-duration (post-hospital discharge) VTE chemoprophylaxis regimens in surgical patients between the years January 2000 and February 2020. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were used. GRADE methodology and the Cochrane Risk of Bias Assessment Tool for Randomized Controlled Trials were used to grade the quality of evidence and assess risk of bias. Results Nineteen studies with 10,544 patients were analyzed. The duration for extended-duration VTE chemoprophylaxis ranged from 7 to 42 days. In our study cohort, high-risk patients not prescribed extended-duration VTE chemoprophylaxis had a mean VTE incidence rate of 12.23%, while patients receiving 28-30 days of chemoprophylaxis had a mean VTE incidence rate of 4.37% (p = 0.006). The risk of bleeding events did not correlate with the duration of chemoprophylaxis. Conclusion Extended-duration VTE chemoprophylaxis in high-risk surgical patients decreased the incidence of thrombotic complications without increasing the risk of bleeding events. Further research is needed to establish guidelines for the optimal duration of VTE chemoprophylaxis in high-risk surgical patients. Level of evidence III.
Journal of Thrombosis and Haemostasis, 2005
The influence of extreme body weight on clinical outcome of patients with venous thromboembolism: findings from a prospective registry (RIETE). J Thromb Haemost 2005; 3: 856-62. See also Spinler SA. The skinny on treatment of venous thromboembolism in obesity. This issue, pp 854-5; Nieto JA, De Tuesta AD, Marchena PJ, Tiberio G, Todoli JA, Samperiz AL, Monreal M for the RIETE Investigators. Clinical outcome of patients with venous thromboembolism and recent major bleeding: findings from a prospective registry (RIETE). J Thromb Haemost 2005; 3: 703-09.
Thrombosis research, 2017
Thromboprophylaxis is a mainstay of hospital care in patients at high risk of thrombosis. Fixed doses of low-molecular-weight heparin (LMWH) are recommended for thromboprophylaxis in patients admitted to hospital for an acute medical condition. However, the distribution of LMWH is weight-based, and the efficacy of standard doses in obese patients may be decreased. Data for obese patients are mainly available in bariatric surgery with extremely obese patients who are at greater risk of venous thromboembolism than those hospitalized for a medical condition. We conducted a randomized control trial in medically obese inpatients (BMI≥30kg/m(2)) assessing two regimens of enoxaparin (40mg and 60mg SQ daily) in order to determine whether a stronger dosage would achieve higher anti-Xa level suitable for thromboprophylaxis. Between September 2013 and April 2015, 91 patients were included in the study (mean (±standard deviation) age was 70.4±10.7years, average BMI 37.8±6.4kg/m(2)). Main indica...
Surgery for Obesity and Related Diseases, 2012
Background-Anticoagulation, the use of sequential compression devices on lower extremities peri-operatively, and early ambulation are thought to reduce venous thromboembolism (VTE) postoperatively and are recommended to reduce VTE risk. However, the evidence upon which this recommendation is based is not particularly strong. We demonstrate that even a large, multi-center cohort with carefully collected prospective data is inadequate to provide sufficient evidence to support, or refute, this recommendation. Methods-The Longitudinal Assessment of Bariatric Surgery (LABS) participants from 10 centers in the United States who underwent their first bariatric surgery between March, 2005 and December, 2007 comprise the study group. We examined the ability to address the question of whether anti-coagulation therapy, in addition to sequential compression, reduces the 30 day incidence of VTE or death sufficiently to recommend the use of prophylactic anticoagulation, a therapy that is not without risk. Results-Of 4416 patients, 396 (9.0%) received sequential compression alone, while the others also received anticoagulation therapy. The incidence of VTE within 30 days of surgery was small (0.25% among those receiving sequential compression alone, 0.47% when anticoagulation therapy was added), and the 30 days incidence of death was also small (0.25% vs. 0.34%, p = 0.76, for
Mandatory Risk Assessment Reduces Venous Thromboembolism in Bariatric Surgery Patients
Obesity surgery, 2017
Bariatric surgery patients are at high risk for venous thromboembolism (VTE), and chemoprophylaxis is recommended. Sheikh Khalifa Medical City (SKMC) is an American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) member since 2009. We report the rates of VTE in bariatric surgery patients from 2010 to 2016 compared to ACS NSQIP bariatric surgery programs before and after switching from heparin to low molecular weight heparin (LMWH), initiating mandatory risk assessment using Caprini scoring for VTE and adopting an aggressive strategy for high-risk patients regarding dosage of LMWH and chemoprophylaxis after discharge. During the study period, there were 1152 cases (laparoscopic Roux-en-Y gastric bypass (LRYGB) 625 and laparoscopic sleeve gastrectomy (LSG) 527) at Bariatric & Metabolic Institute (BMI) Abu Dhabi compared to 65,693 cases (LRYGB 32,130 and LSG 33,563) at ACS NSQIP bariatric surgery programs. VTE rates remained stable at ACS NSQIP bariatric s...
European guidelines on perioperative venous thromboembolism prophylaxis
European Journal of Anaesthesiology, 2018
A systematic literature search was performed and patients were selected as obese patients undergoing bariatric surgery or obese patients undergoing nonbariatric surgical procedures. In addition, patients were stratified according to low risk of venous thromboembolism and high risk of venous thromboembolism (age >55 years, BMI >55 kg m À2 , history of venous thromboembolism, venous disease, sleep apnoea, hypercoagulability or pulmonary hypertension). Prophylaxis of venous thromboembolism was analysed depending on the type of modality: compression devices of the lower extremities (including intermittent pneumatic compression and graduated compression stockings), pharmacological prophylaxis or inferior vena cava filters. Two prospective studies compared mechanical devices and pharmacological prophylaxis vs. a mechanical device alone without significant differences. A few randomised controlled studies and most of the prospective nonrandomised studies showed that low-dose low molecular weight heparin (3000 to 4000 anti-Xa IU 12 h À1 subcutaneously) was acceptable for obese patients with a lower risk of venous thromboembolism, but a higher dose of low molecular weight heparin (4000 to 6000 anti-Xa IU 12 h À1 subcutaneously) should be proposed for obese patients with a higher risk of venous thromboembolism. Extended prophylaxis for 10 to 15 days was well tolerated for obese patients with a high risk of venous thromboembolism in the postdischarge period. The safety and efficacy of inferior vena cava filters in bariatric surgical patients is highly heterogeneous. There were no randomised trials that analysed prophylaxis of venous thromboembolism in obese patients undergoing nonbariatric surgery. Higher doses of anticoagulants could be proposed for obese patients with a BMI more than 40 kg m À2. The lack of good quality randomised trials with a low risk of bias did not allow us to propose strong recommendations.
Need to improve thromboprophylaxis across the continuum of care for surgical patients
Advances in Therapy, 2010
Introduction: Prophylaxis for venous thromboembolism (VTE) is underused following major surgery and frequently stopped at hospital discharge despite short stays and high VTE risk for several weeks postsurgery. We evaluated inpatient and postdischarge prophylaxis in patients who underwent major abdominal or orthopedic surgery. Methods: Patient records were assessed for anticoagulant use by cross-matching