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PubMed1994

Secondary prevention of venous thromboembolism in joint replacement using duplex ultrasonography.

Prophylaxis of venous thromboembolism can be categorized as primary prevention and secondary prevention. Primary prevention is the deterrence of a disease process before it begins. Secondary prevention is the detection and treatment of an asymptomatic disease process before it becomes symptomatic. This discussion deals with duplex ultrasonography as a method of secondary prevention of venous thromboembolism after total joint replacement. Routine screening by venography and by duplex ultrasonography has been advocated by several authors in cases of total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, compared with venography, duplex ultrasonography has the advantages of being portable, painless, noninvasive, without side effects, less expensive and, depending on the institution, reliable as a screening and surveillance tool for managing deep vein thrombosis (DVT). Part one of a three-part study was designed to substantiate reliability of duplex ultrasonography in detecting DVT after total joint replacement in the lower extremity at our institution (Scripps Clinic and Research Foundation in La Jolla, Calif). Parts two and three were designed to evaluate the utility of duplex ultrasonography for routine screening and surveillance of DVT after THA and TKA.

Hip Prosthesis↗
PubMed2003

Managing thromboembolic risk in hip and knee arthroplasty: state of the art.

Deep vein thrombosis and pulmonary embolism are major causes of morbidity and mortality after knee and hip arthroplasty in the United States. Although patients frequently receive prophylaxis for thromboembolism postarthroplasty, surgeons vary in their choice of modality and often use suboptimal strategies due to the possibility of provoking postoperative bleeding. This article discusses the rationale for the prevention of venous thromboembolism and offers an overview of clinical recommendations for prophylaxis in knee and hip replacement surgery. Supporting medical evidence for these recommendations is described. A summary of current prophylactic regimens and discussion of duration of therapy are also presented.

Arthroplasty, Replacement, Hip↗
PubMed2003

The risk of venous thromboembolism in non-large-joint surgeries.

The risk of venous thromboembolism, particularly deep venous thrombosis, after knee arthroscopy, surgically assisted arthroscopy, or treatment of lower extremity fracture may be substantial in patients with factors known to increase the risk of postoperative thromboembolism. Few prospective studies have examined the effect of prophylaxis in these patient populations. However, results suggest that routine administration of a low-molecular-weight heparin reduces the rate of deep venous thrombosis in such patients. Additional clinical studies are necessary to determine whether the benefits of prophylaxis outweigh its risks and whether it is cost-effective. Until such data are available, risk for deep venous thrombosis must be assessed in all patients undergoing an orthopedic procedure. Thromboprophylaxis with pharmacologic agents may be considered in those at high risk.

Arthroplasty, Replacement, Knee↗
PubMed1996

Management of atrial fibrillation in adults: prevention of thromboembolism and symptomatic treatment.

Because of its prevalence in the population and its associated underlying diseases and morbidity, atrial fibrillation (AF) is an important and costly health problem. Advancing age, diabetes, heart failure, valvular disease, hypertension, and myocardial infarction predict the occurrence of AF within a population. The management of AF is complex and involves prevention of thromboembolic complications and treatment of arrhythmia-related symptoms. Stroke occurs in 4.5% of untreated patients with AF per year. Independent risk factors for stroke in nonrheumatic patients with AF are advanced age; a history of prior embolism, hypertension, or diabetes; and echocardiographic findings of left atrial enlargement and left ventricular dysfunction. Warfarin decreases stroke by two-thirds and death by one-third; aspirin is only about half as effective overall and is insufficient therapy for those with risk factors for stroke. Options for thromboembolic prophylaxis are use of warfarin for all in whom it is safe or, alternatively, warfarin for those with risk factors and aspirin for those without risk factors. One-half of the patients with AF are 75 years of age or older. The uniform applicability and relative safety of warfarin therapy in this age-group are controversial. Specific therapy for the arrhythmia should be dictated by the need to control symptoms. Symptomatic treatments include rate-control medications and strategies designed to terminate and prevent arrhythmia recurrence. Digoxin, beta-adrenergic blockers, verapamil, and diltiazem slow excessive ventricular rates in patients with AF and may favorably manage comorbid conditions. The efficacy of anti-arrhythmic medications is only 40 to 70% per year in preventing recurrences of AF, and these agents, except amiodarone, may increase the risk of sudden death in patients with certain types of organic heart disease and AF. The use of nonpharmacologic symptomatic therapies such as atrioventricular node modification or ablation with a rate-response pacemaker or surgical intervention is increasing.

Adrenergic beta-Antagonists↗
PubMedDate not supplied

Effect of a single plasma transfusion on thromboembolism in 13 dogs with primary immune-mediated hemolytic anemia.

Thirteen dogs with primary immune-mediated hemolytic anemia received fresh-frozen plasma within 12 hours of admission, in addition to unfractionated heparin and other therapies, such as prednisone, azathioprine, and packed red blood cell transfusion. Antithrombin activity was quantified prior to transfusion and at 30 minutes and 48 hours after transfusion. Plasma antithrombin activity did not change significantly after a single plasma transfusion. There were no deaths in the first 48 hours of treatment. Thromboembolism was identified at necropsy in six of 10 dogs that died within 12 months of admission. There was no significant difference in the incidence of thromboembolism between the current treatment group and a historical control group.

Anemia, Hemolytic, Autoimmune↗
PubMedDate not supplied

A retrospective study of 100 cases of feline distal aortic thromboembolism: 1977-1993.

The medical records of 100 cats with distal aortic thromboembolism were reviewed. The average age was 7.7 years, with the neutered male being the most common signalment (63%). Evidence of preexisting cardiac disease was noted in 11% of the cases. A murmur or arrhythmia was noted in 57% of the cases on presentation. Frequent laboratory abnormalities included elevations in blood glucose, alanine aminotransferase, aspartate aminotransferase, blood urea nitrogen, and creatinine. Radiographic and electrocardiographic abnormalities were common (89% and 85%, respectively). The most frequent, underlying disease was hypertrophic feline cardiomyopathy (58%), with the left atrial size (as measured by M-mode) significantly increased in the majority of cases (mean left atrial-to-aortic ratio, 2.08). The average, long-term survival in the 37% of cases which survived the initial thromboembolic episode was 11.5 months. The remaining cases either died (28%) or were euthanized (35%).

Age Factors↗
PubMed2005

Critical renal artery stenoses may cause a spectrum of cardiorenal failure and associated thromboembolic events.

A wide spectrum of acute or chronic heart failure and thromboembolic events may be causally related to high-grade uni- or bilateral renovascular hypertensive disease, and the variety of these potential interactions may be unrecognized in clinical practice. We present three cases that illustrate the clinical variability of cardiorenal failure and thromboembolic events seen in patients with significant renal artery stenoses. These are high-risk patients where severe morbidity and mortality are threatening. Our patients also demonstrate that the diagnosis often is delayed, and that recanalizing of occluded renal arteries may be highly cost-effective and life-saving in such patients.

Aged↗
PubMed1991

Thromboembolism and its management in pregnancy.

OBJECTIVES: To formulate recommendations for the management of thromboembolism during pregnancy. DATA SOURCES: The English language published literature derived from Medline and covering the following aspects of thromboembolism in pregnancy was reviewed: epidemiology; pathogenesis; clinical features; investigations; the pharmacology of various anticoagulants; management and prophylaxis of deep vein thrombosis and pulmonary embolism; medicolegal aspects. STUDY SELECTION: Publications published between 1960 and 1990 were cited. These studies were selected because data appeared reliable and with appropriate conclusions. DATA SYNTHESIS AND CONCLUSIONS: Many questions are still not completely resolved, but the information gathered should provide firm guidelines to practitioners in the areas of diagnosis, the choice of anticoagulant drugs, methods of administration of the drugs, and measurement of therapeutic endpoints.

Female↗
PubMed1990

Prevention of thromboembolism after spinal cord injury using low-molecular-weight heparin.

OBJECTIVE: To examine the safety and effectiveness of a low-molecular-weight heparin in the prevention of thromboembolism in patients with recent spinal cord injury and complete motor paralysis. DESIGN: Randomized evaluation of two heparin regimens in 41 consecutive patients meeting eligibility requirements for anticoagulant prophylaxis. Daily bedside examinations were supplemented by serial venous flow studies; suspicious or positive tests were confirmed by venography. INTERVENTION: Standard heparin, 5000 units subcutaneously three times a day; low-molecular-weight heparin 3500 anti-Xa units subcutaneously once daily. MEASUREMENTS AND MAIN RESULTS: Five patients in the standard heparin group had thrombotic events, including two patients with fatal pulmonary embolism; two other patients had bleeding severe enough to necessitate withdrawing the heparin. The cumulative event rate was 34.7% (95% CI, 13.7% to 55.2%). None of the patients treated with low-molecular-weight heparin had thrombosis or bleeding (CI, 0% to 14%). The difference between the two groups was significant (P = 0.006, log-rank test). CONCLUSIONS: Low-molecular-weight heparin is safe and effective in the prevention of thromboembolism in selected patients with spinal cord injury and complete motor paralysis, and is superior to standard heparin in fixed doses of 5000 units three times a day.

Administration, Cutaneous↗
PubMedDate not supplied

The assessment and management of venous thromboembolism.

This article examines venous thromboembolism (VTE) and offers guidance on its prevention. VTE is a potentially fatal condition, which can be prevented using both pharmacological and mechanical methods. Nursing staff should be aware of the risk factors that predispose patients to venous thromboembolism and ensure that high-risk patients receive the prophylaxis they require.

Anticoagulants↗
PubMed1998

Thromboembolic phenomena in patients with hereditary factor XI deficiency.

Factor XI deficiency is an hereditary coagulopathy that is usually associated with milder tendency to bleeding with comparison to hemophilia A. While the failure of stable fibrin clot formation may lead to bleeding, it is speculated that the same process may provide a protection against thrombosis of injured arteries due to atherosclerotic plaque rupture. Whereas 2 studies indicate that hemophiliacs have decreased mortality rate from cardiovascular diseases, there is no similar data regarding factor XI deficiency patients. In here we report about 3 patients with severe factor XI deficiency who have a long-standing history of thromboembolic phenomena: 2 patients with myocardial infarctions, and one patient with transient ischemic attacks. We discuss the possible role of factor XI in thrombosis, and whether its deficiency may protect patients from thromboembolic phenomena.

Adult↗
PubMed1999

[Frontiers in prevention of thromboembolism in nonvalvular atrial fibrillation].

Atrial fibrillation, which has age-dependent exponentially rising high prevalence, is now well known to frequently predispose to systemic thromboembolism. In the past decade, several large-scale clinical randomized trials for prevention of thromboembolism in nonrheumatic atrial fibrillation have been performed for its primary and secondary preventions. The first five major trials (AFASAK, BAATAF, SPAF-I, CAFA, SPINAF) for primary prevention of stroke have demonstrated a significant risk reduction (68%) for stroke on oral anticoagulation without any significant increase in major hemorrhage. On the other hand, although AFASAK and SPAF I showed controversial results for comparison of aspirin and control, the collaborative analysis revealed a significant risk reduction (36%). In their analysis of risk factors for stroke, prior stroke, diabetes mellitus, and hypertension have been stressed as high risk factors. Recently, some additional trials have been done concerning secondary prophylaxis, primary prevention in high risk patients, the optimal dose of warfarin, the role of aspirin and so on. In EAFT, a secondary prevention trial, warfarin has reduced (66%) stroke from 12%/yr to 4%/yr, while aspirin alone to 10%/yr. In SPAF III, it has been reported that adjusted-dose warfarin with target INR2.0 to 3.0 is effective and safe in high risk patients. However, SPAF II showed that warfarin was not useful in elder patients (75yr <) because of an increase in hemorrhage. That may be why warfarin was still underused (40% >). Anyway, it is of importance to think about the strategy for prevention on the individual level of patients with atrial fibrillation, taking into consideration echocardiographical and hematological data besides clinical risk factors.

Aged↗
PubMedDate not supplied

[Results of a survey on knowledge and habits among hospital doctors concerning primary prevention of venous thromboembolism].

BACKGROUND: The purpose of this study was to analyse the attitudes towards and knowledge of primary prevention of venous thromboembolism (VTE) among hospital doctors in Calabria. METHODS: The survey was based on theoretical knowledge and practical management of hortopedics, surgeons, gynecologists and internists working in 14 hospitals. RESULTS: Out of a total of 340 physicians contacted, 154 (45%) agreed to take part in the survey. 82% of those who responded used VTE prophylaxis on a routine basis. Unfractioned heparin (71%) was the most frequently used methods; early deambulation (55%), low molecular weight heparin (49%) and elastic stocking (49%) were less frequently employed. Surprisingly, one third used aspirin. 75% of those contacted had modified their approach to prevention during the last few years, in particular owing to improvements in pharmacological therapy and increased awareness of the problem. In the survey of clinical practice, 80% of those who took part correctly identified the VTE risk, 86% suggested the best treatment, but only 27% assessed the exact frequency rate of deep venous thrombosis (DVT) and pulmonary embolism (PE) in the absence of prophylaxis. CONCLUSIONS: Most of the doctors contacted showed scant interest in the primary prevention of VTE. The 45% who agreed to be interviewed revealed a good practical approach but were not sufficiently aware of the real incidence of DVT and PE in a clinical risk context without prophylaxis. Although they must be interpreted with caution, these findings allow the real behaviour of hospital physicians in this region to be assessed with regard to the primary prevention of VTE and suggest the need for more correct information about this aspect of venous thromboembolic disease which is not yet sufficiently well known.

Data Collection↗
PubMed1979

[Iron substitution in postoperative anemia during thromboembolic prophylaxis (author's transl)].

After major operations in 246 patients it was shown that there was no greater blood loss with thromboembolic prophylaxis with heparin and acetylsalicylic acid and healing proceeded undisturbed in view of the demonstrated reductions of hemoglobin and hematocrit which correspond to those of the gynecological operations without thromboembolic prophylaxis, these patients also must be given longterm iron substitution.

Anemia, Hypochromic↗
PubMed1999

Long term outpatient prophylaxis for venous thromboembolism.

Recent reductions in the incidence of postoperative venous thromboembolism are related to the widespread use of prophylactic anticoagulants, but many uncertainties about the most effective ways to use thromboprophylaxis remain. Orthopedic patients are at high risk of thromboembolism, and the trend towards shorter hospital stays means that they may receive less than the recommended 7 to 10 days of prophylaxis. Longer periods of thromboprophylaxis may be beneficial for high risk patients. The relative rarity of symptomatic deep-vein thrombosis and pulmonary embolism means that very large patient populations are required for studies that rely on clinical endpoints, but studies using venographic endpoints have shown 30 days of prophylaxis with low molecular weight heparin (LMWH) to be more effective than 7 days. Other factors that may influence the efficacy of thromboprophylaxis include the timing of the first injection and the choice of agent.

Ambulatory Care↗
PubMedDate not supplied

Management of thromboembolism in patients with cancer.

PURPOSE/OBJECTIVES: To review the phenomenon of thromboembolism in patients with cancer, discuss treatment options for deep vein thrombosis (DVT), and describe oncology nurses' role. DATA SOURCES: Published articles, abstracts, professional communications, drug manufacturer information, and personal clinical experience. DATA SYNTHESIS: The incidence of DVT in patients with cancer can be as high as 15%. The cause of thromboembolism is multifactorial and includes tumor type, alterations in coagulation, specific chemotherapy agents, and clinical considerations. Although these patients traditionally have been treated with standard unfractionated heparin (UFH) therapy, low molecular weight heparin (LMWH) has been studied extensively and is an acceptable alternative treatment. LMWH should be followed by a period of oral anticoagulants, although some patients may benefit from long-term heparin therapy. Oncology nurses are qualified to identify patients who are at risk for DVT and, in expanded roles, may manage patients on anticoagulant therapy successfully. CONCLUSIONS: LMWH followed by a course of oral anticoagulant therapy is an alternative way to treat DVT. Treatment with LMWH is less expensive than traditional UFH and has a preferred side effect profile. IMPLICATIONS FOR NURSING PRACTICE: All oncology nurses should be aware of the different risk factors for DVT in patients with cancer and current clinical management should DVT occur. Oncology nurses in expanded roles or advanced practice nurses may choose to manage DVT with LMWH followed by oral anticoagulant therapy. Some patients may require long-term treatment with heparin therapy rather than oral anticoagulants.

Anticoagulants↗
PubMed2000

[Prevention of venous thromboembolism in polytraumatized patients. Epidemiology and importance].

OBJECTIVE: Unfractionated heparin, low-molecular-weight heparin (LMWH), mechanical compression, and vena cava filters are part of a large panel of chemical or physical methods proposed to trauma patients as prophylaxis against venous thromboembolism. This prophylactic strategy is based on a 1961 autopsy survey showing a 16.6% rate of pulmonary embolism in this population. The objective of this study was to assess the incidence of deep venous thrombosis (DVT) and pulmonary embolism (PE) in multiple trauma patients. METHODS: A Medline and Current Contents search was conducted for prospective studies including trauma patients with ISS > 9 whose incidence of DVT and PE was evaluated by contrast venography and/or duplex scan and by ventilation/perfusion lung scan and/or pulmonary angiography and/or autopsy, respectively. RESULTS: Twelve studies met the selection criteria for DVT. Among the global population of 2,374 trauma patients (14% of all admissions) 47% suffered lower limb injury and 17% had severe head injury. Overall incidence of DVT was about 20%. It was about 38% in patients without prophylaxis (range 2 to 61.5%) and about 13% in patients with prophylaxis (range 0.8 to 37%). Similar variations were observed for proximal DVT. In comparative studies (unfractionated heparin versus LMWH or versus mechanical compression devices), the incidence of thromboembolic events varied from 3.2 to 44% in patients given unfractionated heparin, 0.8 to 31% in those given LMWH, and 3.1% to 12% with mechanical compression. Thirteen studies met the selection criteria for PE and included an overall population of 4,245 trauma patients where the diagnosis of PE was suspected only if the patient had clinical signs. The incidence of PE and fatal PE was about 1.4% and 0.3% respectively. Only one study systematically studied the presence of PE and showed an incidence of 18.7% for PE in a population of 32 patients. DISCUSSION: The current literature reports wide variability in methodology, characteristics of the study population and prophylaxis. These differences explain the wide variability from one study to another in the risk factors for venous thrombosis identified by univariate and multivariate analysis. CONCLUSION: Current methodological imperfections make it impossible to correctly assess the incidence of DVT and PE in the multiple trauma population. Studies with a rigorous methodology using a precise stratification of the trauma injuries are required to determine the real risk for DVT/PE in trauma patients and to assess the impact of early systematic prophylaxis.

Adolescent↗
PubMed1999

Duplex screening as a method of quality assurance of perioperative thromboembolism prophylaxis.

BACKGROUND: Improvements in thrombosis prophylaxis in both the operative and non-operative fields aim to reduce further the not inconsiderable residual risk of suffering a deep vein thrombosis or embolism. The goal of the study was to establish the part played in a quality assurance strategy by early diagnosis of a thrombosis and by knowledge of the hospital's internal patient-risk profile in order to counter the unpredictability of thromboembolic complications and make rational decisions about thromboembolism prophylaxis. METHODS: Duplex ultrasonography has been used routinely in trauma surgical patients in Krefeld Hospital since September 1991 as a screening method for diagnosing deep leg and pelvic vein thrombosis prior to mobilisation of the patients. 778 patients were investigated up to March 1997. In the period from September 1991 to September 1994, patients received standardised low-dose prophylaxis with unfractionated heparin (UFH). In October 1994, the prophylaxis regimen was modified by changing the anti-embolism stockings from bidirectional elastic stockings to transverse elastic graduated compression stockings (TED) and by adapting the dosage of the heparin prophylaxis to patient risk, with the use of low molecular weight heparin (LMWH) Certoparin (Mono-Embolex NM) since April 1995. All patients with a deep vein thrombosis were treated immediately with APTT-monitored full heparinisation and immobilisation. RESULTS: In the period from September 1991 to March 1997, an asymptomatic deep vein thrombosis of the lower limbs was diagnosed in 68 cases (8.7%) out of 778 trauma surgical patients by means of routine duplex ultrasound. Using a strategy of duplex screening and immediate anticoagulation/immobilisation, no clinically significant pulmonary emboli occurred in this period. At the same time, the antithrombotic efficacy of the prophylaxis could be improved and assessed objectively by means of duplex screening: with optimal compression stockings and consistent use of risk-adapted UFH prophylaxis, it was possible to reduce the residual thrombosis rate, which was 11.5% (95% CI 7.7-15.2%) with standard UFH prophylaxis, to 8.7 % (95% CI 4.5-12.9%) and ultimately, using the combination of optimal anti-embolism stockings and LMWH prophylaxis, to 6.0% (95% CI 3.0-8.9%) which was significant (p<0.05). The cost-effectiveness analysis resulted in a cost-relation per successfully treated patient of about 1:100 for the diagnosis of a deep vein thrombosis using duplex ultrasound and subsequent heparin treatment compared to the diagnosis and intensive care treatment of a massive pulmonary embolism. CONCLUSIONS: Duplex ultrasound screening for asymptomatic deep vein thrombosis thus proves to be a suitable instrument for internal hospital quality control in thrombosis prophylaxis. Its routine use can be recommended at least in high-risk patients, not only from the medicolegal aspect but also from the purely economic aspect.

Adolescent↗