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PubMed2006

Management of venous thromboembolism in the elderly.

In this review the authors discuss the use of oral and parenteral anticoagulants for the prevention and treatment of venous thromboembolism (VTE) in the elderly. The use of anticoagulant agents in VTE prophylaxis and treatment in the elderly is complicated by an increase with age in the presence of multiple risk factors and co-morbidities that may increase the risk of both VTE and bleeding. Age itself is identified as an independent risk factor for thromboembolism. VTE is underdiagnosed in the elderly population, and routine prophylaxis frequently falls short of the levels required according to level of risk. Although appropriate anticoagulation of at-risk patients offers a means of reducing the significant VTE burden in this population, concerns have been raised over the use of anticoagulants in a patient group in whom multiple risk factors are common. Bleeding in the elderly can be exacerbated by reduced renal clearance and hypersensitivity to oral anticoagulants that may lead to over-anticoagulation. Although bleeding due to anticoagulant therapy is a serious issue in the elderly, it is often overemphasized, given the therapeutic value otherwise observed in treating this patient group. Warfarin is still used in VTE prophylaxis after orthopaedic surgery and for long-term VTE treatment. Unfractionated and low-molecular-weight heparins (LMWHs) have been shown to be safe and effective in the prophylaxis of VTE, and are now being shown to be as effective as warfarin in the initial and long-term treatment of VTE. LMWHs confer the advantage over unfractionated heparin of subcutaneous once-daily administration with no requirement for laboratory monitoring of their anticoagulant effect, which allows for the convenience of outpatient therapy. New anticoagulants that may be of potential benefit in this patient population include fondaparinux sodium, but clinical experience of this drug in the elderly remains limited.

Adult↗
PubMed1996

Unresolved issues in the prevention of venous thromboembolism.

Venous thromboembolism is a potentially fatal complication of surgery. The use of graded pressure stockings in combination with unfractionated heparin (UFH) or a low molecular weight heparin (LMWH) appears to be the safest and most effective method of prevention. With some LMWHs, the risk of venous thromboembolism appears to be lower than that associated with the use of standard UFH. A comparison of heparin given before versus after surgery (with all patients receiving graded pressure stockings) is justified. More information on the benefit-risk ratio of minidose warfarin is also required. The risk of pulmonary embolism (PE) following discharge from hospital after general surgery is relatively low and the extended use of heparin may not be justified. The value of graded pressure stockings and minidose warfarin for the prevention of PE should be determined. The risk of late PE after orthopaedic surgery is unknown and also needs to be determined.

Anticoagulants↗
PubMed1996

The risk of thromboembolism in patients undergoing colorectal surgery.

Patients undergoing colorectal surgical procedures are at a moderately high risk for the development of thromboembolic events. Possible reasons may be that the procedures tend to be long in duration, patients are often placed in the lithotomy position, a pelvic dissection may be performed, and the indication is often inflammatory bowel disease or cancer. While prophylaxis with low dose heparin is effective at reducing this risk, approximately 10% of patients may still develop a thromboembolic event. Results on the effectiveness of low molecular weight heparin in this cohort of patients are pending.

Anticoagulants↗
PubMed1996

The postdischarge risk of venous thromboembolism after hip replacement. The role of prolonged prophylaxis.

This review deals with the problems of delayed thrombosis after hip arthroplasty and the possible need for prolonged prophylaxis. These problems have been considered key questions in the European Consensus Statement on venous thromboembolism. There are several factors, such as long immobilisation, venous trauma and decreased venous emptying, which all may contribute to the development of late postoperative thrombosis. There are data on frequencies of venous thromboembolism supporting the occurrence of such late complications. In 4 recent studies on prolonged prophylaxis, it was consistently shown that prophylaxis with low molecular weight heparins for 1 month significantly reduced the frequency of deep venous thrombosis compared with conventional prophylaxis during hospitalisation in patients undergoing elective hip arthroplasty.

Anticoagulants↗
PubMed2000

Dalteparin: an update of its pharmacological properties and clinical efficacy in the prophylaxis and treatment of thromboembolic disease.

UNLABELLED: Dalteparin is a low molecular weight heparin (LMWH) with a mean molecular weight of 5000. Compared with unfractionated heparin (UFH), the drug has markedly improved bioavailability and increased plasma elimination half-life, and exerts a greater inhibitory effect on plasma activity of coagulation factor Xa relative to its effects on other coagulation parameters. Dalteparin also has less lipolytic activity than UFH. Dalteparin 2500U once daily subcutaneously is of similar antithrombotic efficacy to UFH 5000IU twice daily, and 2 studies have shown superiority over UFH 2 or 3 times daily of dalteparin 5000U once daily in patients requiring surgical thromboprophylaxis. After total hip arthroplasty, dalteparin was superior to adjusted-dosage warfarin and was of greater thromboprophylactic efficacy when given for 35 than for 7 days. Intravenous or subcutaneous dalteparin is as effective as intravenous UFH when given once or twice daily in the initial management of established deep vein thrombosis (DVT). The drug is also effective in long term home treatment. Dalteparin has been shown to be effective in combination with aspirin in the management of unstable coronary artery disease (CAD), with composite end-point data from 1 study suggesting benefit for up to 3 months. Current data indicate potential of the drug in the management of acute myocardial infarction (MI). Dalteparin is also of similar efficacy to UFH, with a single bolus dose being sufficient in some patients, in the prevention of clotting in haemodialysis and haemofiltration circuits. Pharmacoeconomic data indicate that overall costs relative to UFH from a hospital perspective can be reduced through the use of dalteparin in patients receiving treatment for venous thromboembolism. Dalteparin has also been shown to be cost effective when used for surgical thromboprophylaxis. Overall, rates of haemorrhagic complications in patients receiving dalteparin are low and are similar to those seen with UFH. CONCLUSIONS: Dalteparin is effective and well tolerated when given subcutaneously once daily in the prophylaxis and treatment of thromboembolic disease. The simplicity of the administration regimens used and the lack of necessity for laboratory monitoring facilitate home or outpatient treatment and appear to translate into cost advantages from a hospital perspective over UFH or warfarin. Dalteparin also maintains the patency of haemodialysis and haemofiltration circuits, with beneficial effects on blood lipid profiles and the potential for prophylaxis with a single bolus injection in some patients. Data are also accumulating to show dalteparin to be an effective and easily administered alternative to UFH in patients with CAD.

Blood Coagulation↗
PubMed1996

Enoxaparin. A pharmacoeconomic appraisal of its use in thromboembolic prophylaxis after total hip arthroplasty.

Total hip arthroplasty (THA) is a major orthopaedic procedure with a high risk of postoperative thromboembolism. Increasing demand for this type of surgery, together with its high cost, has led to examination of means by which the cost of THA may be minimised. Current clinical opinion favours the use of suitable pharmacological thromboprophylaxis in patients undergoing THA; such prophylaxis may be provided with subcutaneous standard unfractionated heparin (UFH), oral warfarin or subcutaneous low molecular weight heparin (LMWH). Traditionally, LMWHs have been perceived as being more expensive to use than UFH or warfarin because of their relatively high acquisition cost. However, recent pharmacoeconomic data have shown that cost savings are possible when LMWHs are used. This is attributed mainly to reduced frequency of administration, reductions in costs associated with diagnosis and treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE), and the lack of need for laboratory monitoring of blood coagulation parameters. LMWHs have proportionally less anti-factor IIa (antithrombin) activity relative to anti-factor Xa activity than UFH. Enoxaparin, a LMWH with a mean molecular weight of 4 to 5kD, is reported to have approximately 5 times less activity against thrombin than UFH, for equivalent anti-factor Xa activity. Randomised clinical trials in patients undergoing THA have shown enoxaparin to be at least as effective as UFH in the prevention of DVT and PE, with consistent trends towards a lower incidence of DVT with enoxaparin than with UFH. Similar rates of haemorrhagic complications were reported for enoxaparin and UFH in most trials, although a significantly higher total transfusion requirement was reported for UFH than for enoxaparin in a double-blind study. A significantly higher incidence of bleeding was observed with UFH than with enoxaparin in another study, with similar transfusion requirements for both treatment groups. Cost comparisons in which costs were assigned retrospectively to clinical data have shown cost advantages for LMWHs in general over UFH when costs of administration, hospital bed occupancy and laboratory/radiology procedures are calculated. Cost savings with LMWHs were attributed mainly to reductions in the cost of managing thromboembolic complications in patients receiving these drugs. One meta-analysis showed a saving of $US50 000 (1993 figures) for LMWH over UFH (both subcutaneously twice daily) for every 1000 patients. Subcutaneous enoxaparin at a dosage of 30mg twice daily was shown to be more cost effective than oral warfarin in the prophylaxis of DVT and PE in 2 North American studies in which costs were related to outcomes. One study comprised the application of a decision analysis to a hypothetical group of 10 000 patients; an incremental cost effectiveness of $US12 288 (1993 figures) per death averted was reported for enoxaparin. Enoxaparin was also associated with an overall incremental cost effectiveness of $Can29 140 (1992 figures) per year of life saved (YLS) in the other study, in which costs were applied to clinical data obtained retrospectively from 10 randomised trials. Although no cost-effectiveness analyses have been carried out to compare enoxaparin with UFH, a UK cost comparison reported an overall cost saving of pounds 20 per patient (figures from 1989 to 1990) with enoxaparin 40mg once daily subcutaneously over subcutaneous UFH 5000IU 3 times daily. It has also been suggested that the use of once- or twice-daily enoxaparin in preference to UFH may reduce the overall length of hospital stay; a significant difference emerged in 1 analysis (9.9 or 9.5 vs 11.3 days). Pharmacoeconomic data therefore support the use of enoxaparin as an effective thromboprophylactic treatment with potential cost advantages over warfarin and UFH. Cost-effecti

Anticoagulants↗
PubMed2002

Enoxaparin: a pharmacoeconomic review of its use in the prevention and treatment of venous thromboembolism and in acute coronary syndromes.

The pharmacoeconomics of the low molecular weight heparin (LMWH) enoxaparin in the prophylaxis and treatment of venous thromboembolism have mostly been investigated in cost-effectiveness studies that estimated direct costs associated with treatment, using decision analyses and clinical outcome data from randomised controlled trials. These studies have shown enoxaparin to be cost effective compared with unfractionated heparin (UFH) and warfarin in short-term thromboprophylaxis for hospital inpatients undergoing orthopaedic surgery and in thromboprophylaxis following trauma. Outpatient treatment of acute proximal deep vein thrombosis with enoxaparin has also been shown to be cost effective compared with inpatient treatment using UFH. In general surgery, however, it remains to be determined whether enoxaparin is a cost-effective alternative to UFH. The cost effectiveness of enoxaparin compared with UFH in the treatment of unstable angina and non-Q-wave myocardial infarction has also been investigated in several countries using clinical outcomes data from the Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-wave Coronary Events (ESSENCE) randomised trial. ESSENCE demonstrated that enoxaparin was superior to UFH in terms of tolerability and efficacy, and cost saving at both 30-day and 1-year follow-ups. An increasing number of studies indicate enoxaparin to be of economic benefit when used for prevention and treatment of venous thromboembolism and treatment of acute coronary symdromes.

Coronary Disease↗
PubMed2004

Warfarin in the secondary prevention of thromboembolism in atrial fibrillation: impact of bioavailability on costs and outcomes.

BACKGROUND: The bioavailability of warfarin is an important factor affecting the achievement of therapeutic anticoagulation. It is uncertain whether less expensive generic preparations of warfarin would compromise prevention of thromboembolism or increase bleeding risk in patients with atrial fibrillation. OBJECTIVE: To compare the cost effectiveness of strategies using warfarin products with variable bioavailability in patients with a prior stroke or transient ischaemic attack related to atrial fibrillation. DESIGN: A Markov decision-analytic model simulating health and economic outcomes over 1 year using the perspective of a government provincial payer was created. Four strategies were compared (where F = 1 is the assumed bioavailability of the branded/reference product): (i) warfarin F = 1; (ii) warfarin F = 1.25; (iii) warfarin F = 0.80; and (iv) alternating warfarin F = 1.25 and 0.80 every other month. Direct medical costs for drugs, physician fees, laboratory testing and hospitalisation for morbid events were obtained from a government payer, a local accounting system and the medical literature. The cost of warfarin F = 1 was equivalent to the cost of the brand name warfarin and the cost of warfarin F not equal 1 was equivalent to generic warfarin. RESULTS: In our institution, warfarin F = 1 was similar in cost to the other three strategies (Can dollars 1361 vs Can dollars 1334-1613) and may be more effective than switching between generic preparations which have bioavailabilities at the extremes of acceptable limits (thromboembolism and bleeds 7. 1% vs 9.3%). CONCLUSIONS: In patients with atrial fibrillation and a prior ischaemic stroke or transient ischaemic attack, the use of one warfarin agent within the range of acceptable bioavailability can be considered economically attractive from the healthcare perspective.

Anticoagulants↗
PubMed2005

Cost effectiveness of dalteparin for preventing venous thromboembolism in abdominal surgery.

INTRODUCTION: Patients undergoing abdominal surgeries face substantial risk of experiencing venous thromboembolic events in the perioperative period. The low-molecular-weight heparin dalteparin sodium is clinically effective in reducing the incidence of venous thromboembolism (VTE) in these patients. Dalteparin may be used in low (2500 units [U]) and high (5000 U) once-daily doses for this indication. However, the cost effectiveness of dalteparin 5000 U compared with dalteparin 2500 U and unfractionated heparin (UFH) for this indication has not been studied. OBJECTIVE: To conduct a cost-utility analysis to evaluate the cost effectiveness of dalteparin compared with UFH for preventing VTE in patients undergoing elective abdominal surgery. METHODS: A Markov model, from a healthcare perspective, was constructed to evaluate the cost effectiveness of dalteparin 5000 U and dalteparin 2500 U compared with UFH. A 69-year-old mixed sex patient population was studied using pooled probabilities of clinical outcomes from randomised, controlled trials. Cost data were mostly derived from Medicare reimbursement, in year 2002-03 values. Cost effectiveness was measured as cost per QALY gained over the patient's lifetime. RESULTS: Total costs for patients given UFH, dalteparin 2500 U and dalteparin 5000 U were US45,855 dollars, US45,882 dollars and US46,308 dollars, respectively, while QALYs were 9.5603, 9.5632 and 9.5811, respectively. Hence, the incremental cost effectiveness of dalteparin 5000 U over dalteparin 2500 U and UFH was US23,799 dollars/QALY and US21,779 dollars/QALY gained, respectively. Similarly, cost effectiveness for dalteparin 2500 U over UFH was US9310 dollars/QALY gained. Univariate sensitivity analysis showed that dalteparin 5000 U maintained its cost effectiveness (incremental cost-effectiveness ratio [ICER] or =90% patients receive the benefit of the medication, policy makers would need to commit substantially more resources than suggested by the baseline ICERs.

Abdomen↗
PubMed2006

Cost effectiveness of enoxaparin as prophylaxis against venous thromboembolic complications in acutely ill medical inpatients: modelling study from the hospital perspective in Germany.

OBJECTIVE: To estimate, from the hospital perspective in Germany, the cost effectiveness of the low-molecular-weight heparin (LMWH) subcutaneous enoxaparin sodium 40 mg once daily (ENOX) relative to no pharmacological prophylaxis (NPP) and relative to subcutaneous unfractionated heparin (UFH) 5,000 IU three times daily (low-dose UFH [LDUFH]). Each is used in addition to elastic bandages/compression stockings and physiotherapy in the prevention of venous thromboembolic events (VTE) in immobilised acutely ill medical inpatients without impaired renal function or extremes of body weight. METHODS: The incremental cost-effectiveness ratios (ICERs) of the 'additional cost for ENOX per clinical VTE avoided versus NPP' and 'additional cost for ENOX per episode of major bleeding avoided versus LDUFH' were chosen as target variables. The target variables were quantified using a modelling approach based on the decision-tree technique. Resource use during thromboprophylaxis, diagnosis and treatment of VTEs, episode of major bleeding and secondary pneumonia after pulmonary embolism (PE) was collected from a hospital survey. Costs were exclusively those to hospitals incurred by staff expenses, drugs, devices, disposables, laboratory tests and equipment for diagnostic procedures. These costs were determined by multiplying utilised resource items by the price or tariff of each item as of the first quarter of 2003. Safety and efficacy values of the comparators were taken from the MEDENOX (prophylaxis in MEDical patients with ENOXaparin) and the THE-PRINCE (THromboEmbolism-PRevention IN Cardiac or respiratory disease with Enoxaparin) trials and from a meta-analysis. The evaluation encompassed 8 (6-14) days of thromboprophylaxis plus time to treat VTE and episode of major bleeding in hospital. Point estimates of all model parameters were applied exclusively in the base-case analysis. RESULTS: There were incremental costs of euro 1,106 for ENOX per clinical VTE avoided versus NPP (1 euro approximately equals 1.07 US dollars; average of the first quarter of 2003). ENOX dominated LDUFH: cost savings of euro 55,825 were obtained and 7.7 episodes of major bleeding were avoided by ENOX compared with LDUFH, each per 1000 patients. In comprehensive sensitivity analyses, the robustness of the model and its results was shown. CONCLUSIONS: Results of this evaluation suggest that, in immobilised acutely ill medical inpatients, ENOX may offer hospitals in Germany a very cost-effective option for thromboprophylaxis compared with NPP and a cost-saving alternative compared with LDUFH.

Anticoagulants↗
PubMed2006

Dalteparin versus warfarin for the prevention of recurrent venous thromboembolic events in cancer patients: a pharmacoeconomic analysis.

OBJECTIVE: In a recent randomised trial (CLOT [Comparison of Low molecular weight heparin versus Oral anticoagulant Therapy for long term anticoagulation in cancer patients with venous thromboembolism]), which evaluated secondary prophylaxis of venous thromboembolism (VTE) in cancer patients, dalteparin reduced the relative risk of recurrent VTEs by 52% compared with oral anticoagulation therapy (p = 0.002). A Canadian pharmacoeconomic analysis was conducted to measure the economic value of dalteparin for this indication. DESIGN: The study was conducted from the Canadian healthcare system. The first part of this study utilised the CLOT trial database, from which resource utilisation data were converted into Canadian cost estimates (Can dollars, year 2005 values). Univariate and multivariate regression analyses were conducted to compare the total cost of therapy between patients randomised to treatment with dalteparin or oral therapy. Health state utilities and treatment preferences were then measured in 24 oncology care providers using the time trade-off technique. RESULTS: When all of the cost components were combined for the entire population (n = 676), patients in the dalteparin group had significantly higher overall costs than the control group (Can dollars 4162 vs Can dollars 2003; p < 0.001). The preference assessment revealed that 23 of 24 respondents (96%) selected dalteparin over warfarin, with an associated gain of 0.157 QALYs. When the incremental cost of dalteparin (Can dollars 2159 per patient) was combined with the QALY gain, the findings revealed that dalteparin was associated with a cost of approximately Can dollars 13,800 (95% CI 12,400, 15,100) per QALY gained. CONCLUSIONS: Given the practical advantages of dalteparin in terms of convenience, improved efficacy and the acceptable economic value, this analysis suggests that long-term dalteparin therapy is a sound alternative to warfarin for the prevention of recurrent VTEs in patients with cancer.

Adult↗
PubMed1988

Frequency of thromboembolic complications in patients with acute pneumonia and pyelonephritis.

Infectious complications increase the risk of postoperative thromboembolism. In order to assess the risk of deep vein thrombosis (DVT) in acute infections not associated with surgery, 36 patients with acute pneumonia or pyelonephritis were evaluated regarding development of DVT with the 125I-fibrinogen uptake test with confirmative phlebography. 1/15 patients with pyelonephritis and 1/21 patients with pneumonia developed DVT. No fatal pulmonary embolism was seen. The frequency of DVT was thus 6%. This low figure may be due to early mobilization of the patients and does not motivate routine anticoagulant prophylaxis against thromboembolic complications in patients with acute infections.

Acute Disease↗
PubMed1975

Serum lipid levels and thromboembolic complications during estrogen therapy of prostatic cancer.

The effect of diethylstilboestrol diphosphate (DES) and polyestradiol phosphate (PES) on the serum lipid levels of 40 prostatic cancer patients was investigated during a long-term follow-up. In patients treated with DES serum triglyceride levels elevated significantly whereas changes in serum cholesterol and total lipid contents were not significant. In patients treated with PES no significant changes in serum triglyceride, cholesterol and total lipid levels were found. Nineteen out of 40 (48%) of patients developed cardiovasculat complications during the trial; 11 had cerebrovascular attacks, 5 coronary occlusion and 3 thromboembolism in the leg. There was a significant increase in serum triglyceride levels in all patients who developed vascular disorders, whereas the changes in serum cholesterol and total lipids were not significant. The results suggest a possible association between the increase of serum triglycerides and the development of thromboembolic complications.

Aged↗
PubMedDate not supplied

Treatments with lead expedite hyperthermia-induced thromboembolism in mouse pial microvessels.

Three trials were carried out to study the influence of acute and chronic treatments with lead on hyperthermia-induced thromboembolic activity in pial microvessels of adult male mice. Each trial consisted of four groups, 10 mice (approximately 33 g) per group. Three groups were injected with lead acetate dissolved in a 5% glucose solution (vehicle) at doses of 0.1, 0.5 and 1.0 mg/kg and the control group received only the vehicle. Acute treatments were by a single injection made 1 h (i.p.) in one trial and 24 h (i.p.) in another, prior to the a hyperthermic exposure at 45 degrees C. In the third trial, a single injection was given daily (s.c.) for 7 days. Mice were anesthetized by urethane (1-2 mg/kg, i.p.), the trachea was intubated, a craniotomy was performed and the mouse was placed on the microscope stage of an intravital microscopy set-up. Core body and brain surface temperatures were raised first to 37 degrees C, the animal was stabilized for 30 min then only the brain surface temperature was raised to 45 degrees C by heating the irrigating artificial cerebrospinal fluid. The hyperthermic exposure lasted for 45 min. In all trials, lead at the three doses given (low, medium and high) significantly reduced (p < 0.001) the time of initial thromboembolic activity seen. Lead exerted its influence as quickly as in 1 h, even with the low dose administered. Neither the acute nor chronic treatments affected the degree of arteriolar constriction observed or caused venular diameter change. Arteriolar patency rate at the end of experiment was higher for control than for all lead-treated groups. Data evidenced the rapidity of the adverse influence of lead on the susceptibility to thrombosis, in vivo. The enhanced initiation of thrombotic activity may be attributed to facilitated damage to the microvascular endothelium caused by lead, when challenged by hyperthermia.

Animals↗
PubMed1987

Prevention of thromboembolism in total hip replacement. Aspirin versus dihydroergotamine-heparin.

In a prospective and controlled study, we compared the prophylactic effect of high-dose acetylsalicylic acid (ASA) and dihydroergotamine-heparin (DHEH) in 82 patients over 50 years of age undergoing total hip replacement. The patients were screened by pulmonary scan and 125I fibrinogen uptake. Phlebography was done if the 125 I fibrinogen test was positive. According to our criteria, thromboembolism developed in 9 of 40 receiving ASA and in 5 of 42 patients receiving DHEH. The effect of ASA was limited to men; in 16 men on this therapy, none had thromboembolism versus 9 of 24 women. Twenty-two patients showed wound hematomas, but none needed surgical intervention.

Aspirin↗
PubMed1991

Prevention of thromboembolism in 190 hip arthroplasties. Comparison of LMW heparin and placebo.

Prophylactic efficacy and safety of a low molecular weight (LMW) heparin against postoperative thromboembolic complications were investigated in a double-blind, randomized study. Totally, 210 consecutive patients undergoing total hip replacement were allocated to two groups. Patients in the heparin group received 50 IU anti-Xa per kilo body weight of Logiparin once daily, and patients in the placebo group received one daily injection of saline. Additional prophylaxis in all the patients was thigh-length compression stockings beginning on the day of the operation. Deep vein thrombosis was diagnosed by bilateral ascending phlebography between Days 8 and 10 after the operation. Twenty patients were excluded from the evaluation. Thirty of 93 patients in the heparin group compared with 45 of 97 patients in the placebo group suffered a thromboembolic complication during the study (P = 0.02). The postoperative blood loss and total number of blood transfusions in the heparin group were higher than in the placebo group. However, the observed differences were of no clinical importance. Adverse effects, including bleeding complications and wound hematomas, were observed in 13 heparin patients and 7 placebo patients (NS). One patient in each group died. Thrombo-prophylaxis with LMW heparin once daily was safe and more effective than the placebo in patients undergoing total hip replacement.

Adult↗
PubMed1998

Thromboembolic complications after arthroscopic knee surgery. Incidence and risk factors in 101 patients.

Deep venous thrombosis (DVT) and pulmonary embolism (PE) are less common after knee arthroscopy than after elective hip and knee arthroplasties. There is no consensus on the optimal prophylaxis. In this prospective cohort study, we used ultrasound, phlebography and lung scan pre- and postoperatively to assess the incidence of thromboembolic complications in 101 consecutive patients who underwent knee arthroscopy. Preoperatively, patients were screened for typical risk factors for DVT such as age, obesity, varicose veins, contraceptive pills and nicotine abuse. All patients received a once-daily injection of 5000 IU of low molecular weight heparin, at least 12 hours prior to surgery. 5 weeks after surgery, the same screening tests were repeated. In 12 of the 101 patients either DVT or PE was diagnosed. DVT occurred in 8 cases, 4 of which were silent and 4 symptomatic. The number of PEs was 9, 8 silent and 1 symptomatic. We found no correlation between DVT or PE and individual clinical risk factors, but there was a tendency towards the development of DVT and PE, with a higher number of risk factors. We found no correlation between DVT and intraoperative risk factors such as use of a tourniquet, type of anesthesia or duration of surgery. The relatively high rate of thromboembolic events after knee arthroscopy in our study suggests the need of all patients for routine use of thromboprophylaxis, probably in a higher dose than given.

Adolescent↗
PubMed1987

Risk of intracranial hemorrhage in glioma patients receiving anticoagulant therapy for venous thromboembolism.

To determine the risk of intracranial hemorrhage in patients with malignant gliomas who are treated with anticoagulant drugs for late postoperative venous thromboembolism, the authors retrospectively reviewed the computerized data base of all patients with primary brain tumors seen at the University of California, San Francisco, over a 9-year period. Of 915 patients 18 years of age or older who had a pathological diagnosis of malignant glioma and an initial Karnofsky performance scale score of 60% or higher, 36 (4%) developed venous thromboembolism 6 to 246 weeks postoperatively and 22 were treated with anticoagulant drugs. Anticoagulant therapy usually consisted of intravenous heparin for 7 to 10 days, followed for at least 3 to 6 months by either subcutaneous heparin (5000 to 8000 U twice daily) or oral warfarin. All patients were closely monitored to ensure control of hypertension, compliance with therapy, maintenance of prothrombin time within the therapeutic range, and early recognition of adverse side effects. No patient had an intracranial hemorrhage. Thus, anticoagulant agents can be safely administered after intracranial operations for malignant gliomas without increased risk of morbidity or mortality if the patients are carefully monitored according to established guidelines.

Adolescent↗