Aim: To scrutinize sawboness ‘ pattern of supplying prophylaxis for venous thromboembolism ( VTE ) in patients admitted in surgical section for exigency and elected operations, and to find the effects of deficiency of prophylaxis.
Design: Case-control comparative survey.
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Topographic point and Duration of Study:
All patients admitted in surgical section at Ghulam Muhammad Mehar Medical College Hospital Sukkur who stayed longer than 6 yearss were studied between Jan 2008 to Dec 2009.
Patients and Methods:
Demographic information every bit good as hazard factors for VTE were identified for all patients who were divided in two groups. Patients who received prophylaxis ( Group I ) and those who did non ( Group II ) were both followed up. Type of prophylaxis and any complications were documented. Duplex ultrasound of the lower limbs was done on all patients in both groups and the result for all patients were documented.
Two hundred and 50 patients were studied. Ninety seven ( 38.8 % ) patients ( group I ) received prophylaxis for VTE, while 153 ( 61.2 % ) patients ( group II ) did non have prophylaxis. Duplex echography did non uncover deep venous thrombosis ( DVT ) in any patient of the two groups in infirmary and up to one month after discharge. The mortality was 1.03 % in group I and 5.23 % in group II.
The low decease rate due to DVT and P.E in surgical patients after thromboprophylaxis suggests a inclination towards improved perioperative thromboembolic hazard direction. So there should be a definite protocol of thromboprophylaxis for high hazard surgical patients operated electively or in exigency.
Venous thromboembolism, Thromboprophylaxis, Surgical patients.
Venous thromboembolic ( VTE ) disease is a important cause of morbidity & A ; mortality in hospitalized patients. Postmortem data suggest that about 10 % of deceases that occur in infirmaries are due to pneumonic intercalation ( P.E ) .1 The overall incidence of pneumonic intercalation following general surgery ranges from 0.1 to 9 % , or even higher in patients at greater risk.2-4 The thromboembolism hazard associated with surgery varies harmonizing to the process being performed, with some surgical processs transporting no or small hazard and others transporting a really high hazard. Thrombo-prophylaxis is effectual but is associated with disbursal, incommodiousness and inauspicious effects. So it is necessary to do a balanced judgement for each patient. Three cardinal facets must be considered: ( 1 ) Patient hazard, ( 2 ) Procedure hazard, and ( 3 ) Contraceptive method-efficacy, safety, cost and convenience. When sing prophylaxis for surgical patients, the first measure is to total the hazard to the patient and the hazard of surgical procedures.5 The following measure is to equilibrate the efficaciousness of a contraceptive method against safety, cost and convenience. Contraceptive methods can be loosely divided into mechanical and pharmacological methods ; each has comparative advantages and disadvantages. The establishment of everyday DVT prophylaxis including early ambulation, the usage of mechanical compaction devices, and disposal of anticoagulation therapy has resulted in a pronounced lessening in the incidence of pneumonic intercalation, late documented by a prospective experimental survey of patients undergoing a assortment of different oncologic surgeries.6 Mortality from pneumonic intercalation at 3-month followup has been observed to be 15 % , a surprisingly high rate sing current aggressive intervention protocols.7 In add-on to the acute morbidity and mortality of PE, chronic pneumonic high blood pressure originating in the old ages following PE has been noted.8
VTE is mostly preventable and prophylaxis with low-molecular weight Lipo-Hepin ( LMWH ) has been proven well-tolerated and cost-efficient in legion surveies affecting surgical patients. Datas from tests affecting surgical patients suggest that the hazard of thrombosis persists for several hebdomads and should be treated consequently.
The purpose of this survey was to specify sawboness ‘ pattern with respect to thromboprophylaxis in post-operative surgical patients. It was further tested to place effects of deficiency of thromboprophylaxis in high hazard patients.
Patients & A ; Methods:
Patients admitted in surgical unit I, Ghulam Muhammad Mahar Medical College Hospital Sukkur for exigency or elected surgical operations, were indiscriminately selected and included in the survey. The survey was carried out during a period of last two old ages, from Jan 2008 to Dec 2009. This survey included 250 patients, divided into two groups: Group I included those patients who received prophylaxis, and Group II included those who did non. Prophylaxis against deep vena thrombosis ( DVT ) was standard. A weight-adapted regimen of low molecular weight Lipo-Hepin ( clexane ) was administered before surgery and during the infirmary stay in Group I patients. For exigency processs, the prophylaxis was given at least 2 hours before surgery. Demographic information, diagnosing and risk-factors for VTE were documented. The undermentioned possible prognostic factors were tested for their significance: patient features ( sex, age, and organic structure weight ) , indicant for surgery, continuance of operation, type of operation ( exigency versus elected ) . Hazard factors considered for the intent of this survey were defined by the Second Thromboembolic Risk Factors ( THRIFT II ) Consensus Group ( 1998 ) . The organic structure mask index was calculated and a figure transcending 30kg/m2 was considered as corpulent and recorded as a hazard factor. The method of prophylaxis, dosage and type of Lipo-Hepin used and complications were besides recorded. All patients from each of the two groups underwent duplex echography of the lower limbs on the 10th twenty-four hours of admittance or before, if they were for discharge. Patients were followed up at two hebdomads and four hebdomads after discharge. Follow-up consisted of physical scrutiny and duplex echography with peculiar accent on the presence of deep vena thrombosis and its complications.
250 patients were enrolled in the survey. The average age of the patients was 48 old ages. Out of 250 patients, 148 ( 59.2 % ) are males and 102 ( 40.8 % ) are females. The patients included in this survey were operated for exigency and elected abdominal surgery, major gynecological surgery, malignant neoplastic disease surgery, thorax and abdominal injury, hip break, and polytrauma. The patients were divided into two groups: Group I included those patients who received prophylaxis, and Group II included those who did non. Ninety seven ( 38.8 % ) patients received DVT prophylaxis with low molecular weight Lipo-Hepin ( Clexane 40mg daily ) , while 153 ( 61.2 % ) did non. Table I shows the figure of hazard factors, identified in each of the patients, and table II gives the inside informations of both the groups.
Table I: Number of hazard factors in the survey
Number of hazard factors
Number of patients
Table II: Features of patients in Group I and Group II
Group I n=97
Group II n=153
Age ( old ages )
58 ( A± 18.8 )
44.2 ( A± 18.5 )
& lt ; 0.001
57 ( 58.76 % )
91 ( 59.47 % )
Average continuance of stay ( yearss )
& lt ; 0.03
Number of hazard factors
2 ( 2.06 % )
39 ( 25.49 % )
9 ( 9.2 % )
52 ( 33.98 % )
27 ( 27.8 % )
37 ( 24.18 % )
44 ( 45.36 % )
16 ( 10.45 % )
12 ( 12.37 % )
6 ( 3.92 % )
2 ( 2.06 % )
2 ( 1.3 % )
1 ( 1.03 % )
1 ( 0.65 % )
1 ( 1.03 % )
8 ( 5.23 % )
In group I, merely one patient ( 1.03 % ) developed pneumonic intercalation and expired on 3rd postoperative twenty-four hours, and her laparoscopic cholecystectomy was done. She was an old lady of 60 old ages age with corpulent built, and a known diabetic and ischaemic bosom disease. In group II, eight patients ( 5.23 % ) developed pneumonic intercalation and expired. Detailss of these patients are mentioned in table III.
Table Three: Detailss of Group II patients who developed pneumonic intercalation ( P.E )
Nature of operation
Duration of operation
Pyelolithotomy for large staghorn rock
50 years male
Developed P.E on 2nd postoperative twenty-four hours and expired. D-dimer found unnatural
Appendicectomy for perforated and mortified appendix
20 years male
Developed DVT after 2 hebdomads of surgery and expired
Right hemicolectomy for gun-shot venters with caecum perforation
48 years male
Developed pneumonic intercalation on 3rd postoperative twenty-four hours. D-dimer found unnatural
Colonic fix for pang lesion venters
40 years male
Developed P.E on 2nd postoperative twenty-four hours and expired on 3rd twenty-four hours.
60 years female
P.E on 3rd postop: twenty-four hours
Mastectomy for gynaecomastia
22 years male
P.E on 2nd postop: twenty-four hours
50 years male
P.E on 2nd postop: twenty-four hours
Internal arrested development of thighbone & A ; Tibia fract:
35 years male
P.E on 2nd postop: twenty-four hours and expired on 3rd.
The patients, suspected to develop pneumonic intercalation postoperatively in the survey, were investigated by X-ray thorax, ECG, and D-dimer.
Out of 97 patients on prophylaxis, the patients with low hazard received low molecular weight Lipo-Hepin ( clexane ) 20mg subcutaneously day-to-day with moderate hazard 40mg day-to-day and with high hazard 60mg daily. Seven patients had extra compaction stockings. None of the patients who received prophylaxis with low molecular weight Lipo-Hepin developed shed blooding or Lipo-Hepin induced thrombocytopenia asking backdown of therapy.
Age was besides a hazard factor for P.E after surgery. The addition in hazard started at 40 old ages of age. Other important hazard factors included organic structure weight, the type of surgical process, and continuance of operation. Emergency processs showed a about fourfold increased hazard of P.E. The continuance of operation was besides prognostic operation, with higher hazard of P.E in longer operations.
Venous thromboembolism ( VTE ) remains an of import cause of morbidity and mortality, particularly among hospitalized surgical patients. While the hazard for the development of VTE to surgical patients, particularly those undergoing pelvic and abdominal surgery is good recognized. The hazard factors for surgical patients are old or personal history of VTE, increasing age ( & gt ; 60 old ages ) , drawn-out stationariness ( & gt ; 4 hebdomads before or after surgery ) , recent myocardial infarction or shot, cardinal venous catheter in situ, malignant neoplastic disease ( including intervention ) , fleshiness ( BMI a‰? 30 kg/m2, varicose venas with associated phlebitis, terrible infection, and inflammatory intestine diseases.
This survey showed that one tierce ( 83 out 250 ) of the hospitalized surgical patients had 3 or more hazard factors for VTE. They were, hence, considered to be at high hazard. Patients who received thromboprophylaxis were significantly older than those who did non ( p & lt ; 0.001 ) and there were more males, although this difference did non make statistical significance ( p = 0.74 ) . This reflected the expected hazard factors, which included ischaemic shot and myocardial infarction, both of which are more common in older males. An norm of 28.91 % of patients with 3 or more hazard factors did non received thromboprophylaxis while 71.09 % did. There was important under usage of physical methods of prophylaxis in this survey. This is partially explained by the choice standards since all the patients selected for the survey had no contraindication to decoagulants. Second, we were non worried about the hemorrhage in most of the postoperative surgical instances. Low molecular weight Lipo-Hepin ( LMWH ) , nevertheless, was associated with 52 % lower rate of bleeding.9 All the 97 patients in this survey received LMWH. LMWH has shown to cut down the incidence of thromboembolic events in surgical patients when compared to placebo to a comparable extent.9 In add-on, it has better bioavailability, longer half life, leting for one time day-to-day dosing, and predictable pharmacokinetics. These advantages make it a better option peculiarly for surgical patients who may necessitate to go on thromboprophylaxis at place. Cost remains the lone disadvantage. National Institute of Health and Clinical Excellence ( NICE ) recommends mechanical prophylaxis for all surgical patients, irrespective of the type of operation being performed.10 For high hazard patients or those with extra hazard factors, extra anticoagulation with LMWH or fondaparinux is advised.10 Department of Health ( DoH ) working group on Venous Thromboembolism reported that low-risk surgical patients need early mobilisation and that thromboprophylaxis is needed merely if patients develop a hazard factor that places them at intermediate or higher risk.11 However, the Royal College of Obstetricians and gynecologists ( RCOG ) has raised concern over the NICE recommendations, saying that hazard classs need to be re-evaluated and that there is limited grounds for the usage of mechanical prophylaxis or fondaparinux over LMWH.12 However, if the drug is given excessively long earlier surgery, plasma degrees will be excessively low for contraceptive consequence ; if given excessively close to surgery so surgical hemorrhage can be expected.13 In North America, LMWH are given after surgery at higher dosage and more often ( eg, enoxaparin 30mg twice daily ) . This may cut down the hazard of surgical hemorrhage, but the intraoperative hazard factors are non covered and thrombi may hold already begun to organize. The drug is now expected to be curative instead than contraceptive. So the prophylaxis with LMWH demands to be given near but non excessively close to surgery. In our survey, we used to administrate LMWH about 2 to 4 hours prior to surgery and found good consequences of thromboprophylaxis.
Cancer surgery is bad surgery and there are few recognized recommendations for the direction of malignant neoplastic disease patients undergoing such surgery. The
Scots Intercollegiate Guidelines Network ( SIGN ) guidelines14 suggest that both UFH and LMWH are effectual in malignant neoplastic disease surgery thromboprophylaxis and that this is improved farther by the add-on of calibrated elastic compaction stockings. The incidence of DVT in major unfastened urological processs is more as compared to endoscopic processs, runing from 40 % in unfastened prostatectomy to 10 % in transurethral surgery. There is wide understanding that prophylaxis is required for unfastened processs and this comes down, at present, to surgeon-specific protocols15, based upon recognized published guidelines. VTE is besides an of import complication of major gynecological surgery. In pattern, most adult females undergoing gynecological surgery will have once-daily LMWH, compaction stockings, and early mobilisation. NICE recommends mechanical prophylaxis in all adult females undergoing gynecological processs, with added LMWH if they have one or more hazard factors for VTE.10 The most recent counsel issued by the RCOG notes that any adult female suspected of holding VTE should undergo nonsubjective testing and intervention with LMWH, unless this is strongly contraindicated or proven unnecessary12 LMWH are the agents of pick for prenatal thromboprophylaxis. They are effectual and safer than UFH in gestation. In this survey, the infirmary mortality for Group II patients was significantly higher than those in Group I. Merely one patient ( 1.03 % ) expired in Group I and 8 ( 5.23 % ) patients expired in Group II perchance because of suspected pneumonic intercalation. In the absence of station mortem, it will be hard to impute the full difference to deficiency of thromboprophylaxis. Many surveies describe the house association with DVT as a beginning of P.E.16-20 The sensing of DVT itself is besides hard owing to ambivalent clinical marks. The incidence is based on the consequences of echography or venography.21 Sakon et al4 reviewed the incidence of clinical P.E. after general surgery with standard thromboprophylaxis in Japan from 1985 to 2002. The overall incidence was 0.33 % , fatal P.E. occurred in 0.08 % of patients and the mortality rate after P.E was 31 % . Podnos et al3 reviewed 18 series of stomachic beltwaies and noted a P.E rate of 0.41 % after laparoscopic and 0.78 % of unfastened gastic beltway. Few surveies have assessed the hazard profile of patients holding abdominal surgery without separating between unfastened and laparoscopic techniques.22-25 Keenan and White23 found age to be a dependable forecaster of the hazard of P.E, even in the absence of other more specific hazard factors. In this survey, most patients affected are above the age of 40 old ages. Fleshiness as a hazard factor for thromboembolism is good documented.19,21,25 In this survey, the patients operated in exigency developed increased rate of DVT and P.E as compared to elective operations. Emergency operation was the hazard factor with highest odds ratio ( 3.97 ) in one study.26 With respect to exigency processs in abdominal surgery, the increased hazard of thromboembolism may be explained by deficient thromboprophylaxis, as many patients have surgery within a few hours of admittance without get downing or modifying thromboprophylaxis.
The low decease rate due to DVT and P.E in surgical patients after thromboprophylaxis suggests a inclination towards improved perioperative thromboembolic hazard direction. So there should be a definite protocol of thromboprophylaxis for high hazard surgical patients operated electively or in exigency. This should give the patient the benefit of best pattern and give the infirmary protection against hazard.