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PubMed2006

Usefulness of arterial blood gas analysis and D-dimer measurement in the assessment of pulmonary embolism after orthopedic surgery.

BACKGROUND: Deep venous thrombosis (DVT) and pulmonary embolism (PE) after spinal or lower extremity surgery are well recognized as common complications. Since 1995 we have investigated the incidence of PE after orthopedic surgery using ventilation-perfusion (V/Q) lung scans, and the prevalence of PE was about 10%. With a view to detecting early-stage PE by simple examinations, we evaluated the use of both the blood gas analysis and the D-dimer measurement after spinal or lower extremity surgery. METHODS: Altogether, 85 patients who underwent spinal or lower extremity surgery were eligible for the study. Pneumatic sequential leg compression devices (PSLCDs) were utilized continuously both intra- and postoperatively. Arterial blood gas analysis and D-dimer measurement were performed pre- and postoperatively on days 3 and 7. We set lung scan criteria as follows: postoperative decrease in Pa(O2) (deltaPa(O2) by > or = 10 torr (group G), postoperative D-dimer of > or = 1 microg/ml (group D), or both. Patients with the criteria went on to undergo lung scans, and PE was diagnosed by the existence of any mismatch between ventilation-perfusion (V/Q) lung scans. RESULTS: A total of 44 (51.8%) patients met the lung scan criteria and underwent perfusion lung scans, 10 (11.7%) of whom were diagnosed as PE. In groups G and D, about 30% showed PE. Moreover, six (85.7%) of the seven patients with both criteria showed a significant increase (83.7%) in the prevalence of PE. CONCLUSIONS: Patients with the above criteria showed a high prevalence of PE. Moreover, 10 (11.7%) of the 85 patients were diagnosed as having PE, which corresponded to the prevalence in our former studies where lung scans were performed in all patients. The blood gas analysis and the D-dimer measurement may be utilized as the first screening examinations.

Adolescent↗
PubMed1999

Pulmonary embolism in Veterans Affairs Medical Centers: is vena cava interruption underutilized?

Veterans with venous thrombosis or pulmonary embolism (PE) were evaluated using Veterans Affairs patient treatment file (PTF) data from fiscal years 1990-1995, inclusive, to define outcomes for those with PE. The specific aims of the study were to define how often those with PE underwent vena cava interruption (VCI) and whether VCI affected in-hospital mortality rates. Outcomes were defined using PTF data and Patient Management Category (PMC) software for 26,132 veterans discharged from all Veterans Affairs Medical Centers (VAMCs) with venous thromboembolism, which included a subset of 4,882 patients identified by both PTF data and PMC software to have PE. PMC software also generated measures of illness severity, patient complexity (PMC count), and resource utilization (called resource intensity scale) for each hospital admission. The in-hospital mortality rate for those with PE was 15.9 per cent (775 of 4882). Only 157 VCIs were performed in those with PE which constituted 3.2 per cent of the latter group. Those with PE who had VCI experienced a 13.4 per cent unadjusted in-hospital mortality rate (21 of 157) versus a 16 per cent unadjusted mortality rate without VCI (754/4725; not significant). In a logistic regression model of in-hospital mortality in those with PE, increasing age and illness severity were directly related to mortality, whereas VCI was independently associated with reduced mortality. The odds of death were reduced by 0.482 (0.287-0.807, 95% limits) for patients with PE who underwent VCI (P<0.005). Utilization of VCI varied among VAMCs: the hospital rates that VCI were performed in those with PE ranged from 0 to 16.7 per cent. Mortality associated with PE was substantial in VAMCs, and VCI was independently associated with reduced in-hospital mortality. The low percentage of veterans with pulmonary embolism who underwent VCI was surprising. VCI may be underutilized in veterans with PE.

Age Factors↗
PubMed2006

A comparison of neuraxial block versus general anesthesia for elective total hip replacement: a meta-analysis.

BACKGROUND: A recent meta-analysis showed that compared with general anesthesia (GA), neuraxial block reduced many serious complications in patients undergoing various types of surgeries. It is not known whether this finding from studying heterogeneous patient groups is applicable to a particular surgical patient population. We performed the present meta-analysis to determine whether anesthesia choice affected the outcome after elective total hip replacement (THR). METHODS: Medline (1966 to August 2005), MD Consult (1966 to August 2005), BIOSIS (1969 to August 2005), and EMBASE (1969 to August 2005) databases were searched. Randomized and quasi randomized studies comparing GA and neuraxial (spinal or epidural) block for elective THR were included in this analysis. RESULTS: Ten independent trials, involving 330 patients under GA and 348 patients under neuraxial block, were identified and analyzed. Pooled results from five trials showed that neuraxial block significantly decreased the incidence of radiographically diagnosed deep venous thrombosis or pulmonary embolism. The odds ratio (OR) for deep venous thrombosis was 0.27 with 95% confidence interval (CI) 0.17-0.42. The OR for pulmonary embolism was 0.26 with 95% CI 0.12-0.56. Neuraxial block also decreased the operative time by 7.1 min/case (95% CI 2.3-11.9 min) and intraoperative blood loss by 275 mL/case (95% CI 180-371 mL). Data from three trials showed that patients under neuraxial block for THR were less likely to require blood transfusion than were patients under GA (21/177 = 12% vs 62/188 = 33% of patients transfused, P < 0.001 by z-test). The OR for this comparison was 0.26. However, the CIs were wide and compatible with both no effect and a nine-tenths reduction (95% CI 0.06-1.05). CONCLUSIONS: Patients undergoing elective THR under neuraxial anesthesia seem to have better outcomes than those under GA.

Anesthesia, Epidural↗
PubMed2000

Systematic lung scans reveal a high frequency of silent pulmonary embolism in patients with proximal deep venous thrombosis.

BACKGROUND: A high frequency of asymptomatic pulmonary embolism (PE) has been reported in patients with deep venous thrombosis (DVT) in studies of a limited number of patients using varying criteria for lung scan assessment. OBJECTIVES: To estimate the frequency of PE using systematic lung scans in a large group of outpatients with DVT and to compare the results using varying lung scan assessment criteria. METHODS: An international multicenter study comparing 2 different regimens of low-molecular-weight heparin nadroparin in DVT: perfusion lung scans were performed in 622 outpatients with no clinical indication of PE and with proximal DVT confirmed by venography. Three hundred seventy-nine of these patients underwent ventilation lung scans. High-probability (HP) scans for PE were assessed separately using either ventilation scans or chest radiographs to define mismatched perfusion defects. RESULTS: Perfusion scans showed abnormalities in 82% of the patients; 59% had segmental defects and 30% had normal scans or scans with a very low probability of PE. Depending on the criteria used, 32% to 45% had HP scans for PE; these percentages were higher in young patients. No relationship was found between extent of thrombosis and HP scans. The estimated frequency of silent PE was 39.5% to 49.5%. During a 3-month follow-up period during which the patients received therapy, the rate of PE recurrence was low (1.3%) and did not differ between patients with baseline HP scans and those with normal scans. CONCLUSIONS: Regardless of what interpretative criteria are used for assessing lung scans in PE, the frequency of silent PE is 40% to 50% in patients with DVT. A baseline lung scan may easily detect PE in these patients but is not useful for predicting early thromboembolic recurrences that may occur during therapy.

Adolescent↗
PubMedDate not supplied

Traveler's thrombosis: a systematic review.

BACKGROUND: Anecdotal evidence suggests a possible link between travel and venous thromboembolism (VTE). We systematically evaluated the evidence from observational studies. METHODS: We searched studies evaluating the risk of venous thrombosis in relation to traveling from MEDLINE and EMBASE up tp March 2004, together with a hand search of reference lists from retrieved literature, and we contacted some of the experts. Observational studies estimating the risks of VTE and isolated calf vein thrombosis were eligible. Methodologic quality was assessed based on prior criteria, and meta-analysis was considered where applicable. RESULTS: A total of 194 English-language publications were initially identified. Sixteen studies were included: 9 case-control, 2 prospective controlled, and 5 other observational studies. They differed drastically in study designs, selection of controls where applicable, mode and duration of travel, and subtypes of VTE under consideration. Ten studies concluded that travel, mostly through air and of prolonged duration, is a risk factor for venous thrombosis and/or pulmonary embolism, and the risk increases for passengers with preexisting venous thrombosis risk factors. Outcomes examined ranged from asymptomatic isolated calf muscle vein thrombosis to severe fatal pulmonary embolism. CONCLUSIONS: Current literature is controversial over any association between travel and VTE, and although the quality and power of these studies have been variable, studies of higher quality have shown a strong and significant association between prolonged air travel and VTE. No conclusions could be drawn about other modes of transportation. Since VTE is a disease of multifactorial causation, those with preexisting VTE risk factors are most vulnerable.

Aerospace Medicine↗
PubMed1975

Platelet 5-hydroxy-tryptamine in thrombotic and non-thrombotic diseases.

It is generally accepted that platelets from the main constituent of a thrombus. Experimental work has shown that 5-hydroxy-tryptamine (5 HT) in a concentration of 0.06 mg/ml produces clumping of the platelets. In view of this it was decided to estimate platelet 5 HT in thrombotic and non-thrombotic diseases. Thirty-five patients were investigated. Estimations of 5 HT were made on washed platelets rather than platelet-rich plasma which has been used in previous studies. Three groups were recognized on the basis of platelet 5 HT values. The first group consisted of five subjects who were clinically asymptomatic at the time of investigation but died 24 to 48 hours later and were shown at autopsy to have deep-vein thrombosis and pulmonary embolism; they had the highest level of platelet 5 HT. The second group comprised eight patients with cerebral thrombosis whose platelet 5 HT ranged between 1529 and 2183 ng/10-9. There were 22 subjects in the third group (11 apparently normal and 11 with different pathologies). Their platelet 5 HT ranged from 611 to 877 ng/10-9 and did not vary in the different pathological conditions studied. Since the highest level of platelet 5 HT was observed in patients prior to the formation or embolization of a thrombus, it is suggested that this may have some role in initiating thrombus formation.

Age Factors↗
PubMed1986

Pulmonary embolism. Guide to diagnosis, treatment, and prevention.

While more remains to be learned about the natural history of deep vein thrombosis and pulmonary embolism, better information is now available on which to base decisions about diagnosis and treatment. Several retrospective and prospective studies have placed the value of lung scanning, venography, and pulmonary angiography in better perspective. Newer diagnostic techniques for deep vein thrombosis, such as 125I-labeled fibrinogen scanning and impedance plethysmography, are valuable and should be more widely used. Other diagnostic techniques for pulmonary embolism, such as computed tomography and nuclear magnetic resonance imaging, may be of value but are still untested. More effective therapies are now available. Moderate-dose subcutaneous heparin and lower-dose warfarin for long-term therapy of deep vein thrombosis are attractive alternatives to standard warfarin therapy. Thrombolytic therapy has not replaced standard intravenous heparin therapy, although it should be considered in treatment of a massive pulmonary embolus. Perhaps most important, prevention of deep vein thrombosis in most patients at high risk is possible with minidose heparin therapy or intermittent pneumatic compression. One of these methods of prophylaxis should be used in all high-risk patients as the only current effective way to decrease the mortality of pulmonary embolism.

Angiography↗
PubMed1999

High prevalence of detectable deep venous thrombosis in patients with acute pulmonary embolism.

STUDY OBJECTIVES: Because specific studies are unavailable, the exact prevalence of detectable "residual" deep venous thrombosis (DVT) in patients with acute pulmonary embolism (PE) is unknown. DESIGN: Review of clinical records and radiologic documents of consecutive patients. SETTING: Pulmonary diseases and radiology departments at a university hospital. PATIENTS: All patients hospitalized in the Department of Pulmonary Diseases with a diagnosis of acute PE during a 5-year period (1984 to 1988). During this period, the diagnosis of PE was based exclusively on pulmonary angiography, and bilateral lower limb venography was routine in patients with proven acute PE. MEASUREMENTS AND RESULTS: Among 228 consecutive patients with angiography-proven PE, 213 underwent bilateral lower limb venography within 48 h of the diagnosis. Venography demonstrated DVT in 174 patients (81.7%; 95% confidence interval, 76.5 to 86.9%), including 128 patients (60%) with proximal DVT. Signs or symptoms of DVT were present in only 72 patients (42%) with DVT. The prevalence of detectable DVT was significantly lower in patients with recent pelvic surgery or delivery (6 of 12, 50%) than in the other patients, whatever their individual risk factors (p < 0.05). The mean pulmonary vascular obstruction was significantly lower in patients with normal venography than in patients with detectable DVT (37.6 +/- 20.9% vs 48.4 +/- 21.7%; p = 0.007). CONCLUSIONS: Lower limb venography demonstrates a high prevalence (82%) of residual DVT in patients with angiography-proven PE. These data should be taken into account in the diagnostic and therapeutic management of patients with suspected or proven PE.

Adolescent↗
PubMed1976

Antithrombotic drugs: part I.

There are three categories of antithrombotic agents: drugs which prevent fibrin fromation (the anticoagulants and defibrinating enzymes), drugs which prevent platelet adhesion or aggregation (the antiplatelet drugs), and thrombolytic drugs which induce fibrin degradation. Clinical studies have now led to a better understanding of the relative value of these drugs in different thrombotic disorders. In addition, knowledge of the mechanism of action of some of these drugs has recently been much advanced. The anticoagulant drugs in clinical use are heparin and the oral anticoagulants. Heparin is a potent inhibitor of several steps on the intrinsic coagulation pathway through its effect on a plasma cofactor, antithrombin III. its action is immediate, but heparin must be given parenterally. Oral anticoagulants act more slowly, by reducing the hepatic synthesis of biologically active factors II, VII, IX and X, but can be given by mouth. Heparin is therefore most suitable for starting anticoagulant treatment, while oral anticoagulants are generally used for prolonged therapy. The value of the anticoagulants as antithrombotic agents has been best assessed by studying their effectiveness in preventing and treating venous thromboembolic disease. Oral anticoagulants have been repeatedly shown to prevent venous thrombosis and pulmonary embolism in patients at high risk of developing these complications. However, the increased risk of postoperative bleeding has prevented their widespread use for this purpose in surgical patients. Recently, the use of low doses of heparin, given subcutaneously before and after surgery, has been shown to markedly reduce the incidence of venous thrombosis and pulmonary embolism (including fatal pulmonary embolism) after major elective abdominal surgery, and to produce only a slight increase of postoperative bleeding. This represents a major advance in anticoagulant prophylaxis of venous thromboembolism insurgical patients. However, low dose heparin prophylasix is relatively ineffective in patients having hip surgery, and has not been evaluated in patients having other types of orthopaidic surgery. There is direct evidence that antocoagulant therapy prevents death and recurrent embolism in patients who have developed pulmonary embolism, and considerable indirect evidence that it prevents pulmonary embolism, and considerable indirect evidence that it prevents pulmonary embolism (and death from pulmonary embolism) in patients who have venous thrombosis. The incidence of further venous thromboembolism or bleeding during treatment appears to be minimised when heparin is given by continuous intravenous infusion in a dose sufficient to produce a moderate, but no excessive, prolongation of a heparin-sensitive, in vitro coagulation test. The tests most commonly used to monitor heparin therapy was based on either the whole blood clotting time or the activated partial thromboplastin time...

Anticoagulants↗