After studying this article and viewing the videos, the participant should be able to: 1. Demonstrate an understanding of risk stratification for venous thromboembolism in surgical patients. 2. ...Calculate and interpret a 2005 Caprini score. 3. Give examples of modifiable risk factors for perioperative venous thromboembolism. 4. Propose a venous thromboembolism risk reduction strategy using mechanical and/or chemoprophylaxis and justify the risks and benefits of the proposed strategy.
This CME article provides an evidence-based summary of venous thromboembolism in plastic and reconstructive surgery patients, with a focus on current knowledge surrounding risk stratification, risk modification, and risk reduction.
Identifying and Avoiding Bias in Research PANNUCCI, Christopher J; WILKINS, Edwin G
Plastic and reconstructive surgery (1963),
08/2010, Volume:
126, Issue:
2
Journal Article
Peer reviewed
Open access
This narrative review provides an overview on the topic of bias as part of a series of articles in Plastic and Reconstructive Surgery on evidence-based medicine. Bias can occur in the planning, data ...collection, analysis, and publication phases of research. Understanding research bias allows readers to critically and independently review the scientific literature and avoid treatments that are suboptimal or potentially harmful. A thorough understanding of bias and how it affects study results is essential for the practice of evidence-based medicine.
OBJECTIVE:We performed a meta-analysis to investigate benefits and harms of chemoprophylaxis among surgical patients individually risk stratified for venous thromboembolism (VTE) using Caprini ...scores.
SUMMARY OF BACKGROUND DATA:Individualized VTE risk stratification may identify high risk surgical patients who benefit from peri-operative chemoprophylaxis.
METHODS:MEDLINE, EMBASE, and the Cochrane Library (CENTRAL) databases were queried. Eligible studies contained data on postoperative VTE and/or bleeding events with and without chemoprophylaxis. Primary outcomes included rates of VTE and clinically relevant bleeding after surgical procedures, stratified by Caprini score. A meta-analysis was conducted using a random-effects model.
RESULTS:Among 13 included studies, 11 (n = 14,776) contained data for VTE events and 8 (n = 7590) contained data for clinically relevant bleeding with and without chemoprophylaxis. The majority of patients received mechanical prophylaxis. A 14-fold variation in VTE risk (from 0.7% to 10.7%) was identified among surgical patients who did not receive chemoprophylaxis, and patients at increased levels of Caprini risk were significantly more likely to have VTE. Patients with Caprini scores of 7 to 8 odds ratio (OR) 0.60, 95% confidence interval (95% CI) 0.37–0.97 and >8 (OR 0.41, 95% CI 0.26–0.65) had significant VTE risk reduction after surgery with chemoprophylaxis. Patients with Caprini scores ≤6 comprised 75% of the overall population, and these patients did not have a significant VTE risk reduction with chemoprophylaxis. No association between postoperative bleeding risk and Caprini score was identified.
CONCLUSIONS:The benefit of peri-operative VTE chemoprophylaxis was only found among surgical patients with Caprini scores ≥7. Precision medicine using individualized VTE risk stratification helps ensure that chemoprophylaxis is used only in appropriate surgical patients and may minimize bleeding complications.
Abstract
The purpose of this Continuing Medical Education (CME) article is to provide a framework for practicing surgeons to conceptualize and quantify venous thromboembolism risk among the aesthetic ...and ambulatory surgery population. The article provides a practical approach to identify and minimize venous thromboembolism risk in the preoperative, intraoperative, and postoperative settings.
Background The Venous Thromboembolism Prevention Study (VTEPS) Network is a consortium of 5 tertiary referral centers established to examine venous thromboembolism (VTE) in plastic surgery patients. ...We report our midterm analyses of the study's control group to evaluate the incidence of VTE in patients who receive no chemoprophylaxis, and validate the Caprini Risk Assessment Model (RAM) in plastic surgery patients. Study Design Medical record review was performed at VTEPS centers for all eligible plastic surgery patients between March 2006 and June 2009. Inclusion criteria were Caprini score ≥3, surgery under general anesthesia, and postoperative hospital admission. Patients who received chemoprophylaxis were excluded. Dependent variables included symptomatic deep vein thrombosis (DVT) or pulmonary embolism (PE) within the first 60 postoperative days and time to DVT or PE. Results We identified 1,126 historic control patients. The overall VTE incidence was 1.69%. Approximately 1 in 9 (11.3%) patients with Caprini score >8 had a VTE event. Patients with Caprini score >8 were significantly more likely to develop VTE when compared with patients with Caprini score of 3 to 4 (odds ratio OR 20.9, p < 0.001), 5 to 6 (OR 9.9, p < 0.001), or 7 to 8 (OR 4.6, p = 0.015). Among patients with Caprini score 7 to 8 or Caprini score >8, VTE risk was not limited to the immediate postoperative period (postoperative days 1-14). In these high-risk patients, more than 50% of VTE events were diagnosed in the late (days 15-60) postoperative period. Conclusions The Caprini RAM effectively risk-stratifies plastic and reconstructive surgery patients for VTE risk. Among patients with Caprini score >8, 11.3% have a postoperative VTE when chemoprophylaxis is not provided. In higher risk patients, there was no evidence that VTE risk is limited to the immediate postoperative period.
Full text
Available for:
GEOZS, NUK, OILJ, SBJE, UL, UPUK
IMPORTANCE: Appropriate risk stratification for venous thromboembolism (VTE) is essential to providing appropriate thromboprophylaxis and avoiding morbidity and mortality. OBJECTIVE: To validate the ...Caprini VTE risk assessment model in a previously unstudied high-risk cohort: critically ill surgical patients. DESIGN, SETTING, AND PARTICIPANTS: We performed a retrospective cohort study of 4844 adults (≥18 years old) admitted to a 20-bed surgical intensive care unit in a large tertiary care academic hospital during a 5-year period (July 1, 2007, through June 30, 2012). MAIN OUTCOMES AND MEASURES: The main study outcome was VTE (defined as patients with deep vein thrombosis or pulmonary embolism) that occurred during the patient’s initial hospital admission. RESULTS: The study population was distributed among risk levels as follows: low, 5.3%; moderate, 19.9%; high, 31.6%; highest, 25.4%; and superhigh, 14.9%. The overall incidence of inpatient VTE was 7.5% and increased with risk level: 3.5% in low-risk patients, 5.5% in moderate-risk patients, 6.6% in high-risk patients, 8.6% in highest-risk patients, and 11.5% in superhigh-risk patients. Patients with Caprini scores greater than 8 were significantly more likely to develop inpatient VTE events when compared with patients with Caprini scores of 7 to 8 (odds ratio OR, 1.37; 95% CI, 1.02-1.85; P = .04), 5 to 6 (OR, 1.35; 95% CI, 1.16-1.57; P < .001), 3 to 4 (OR, 1.30; 95% CI, 1.16-1.47; P < .001), or 0 to 2 (OR, 1.37; 95% CI, 1.16-1.64; P < .001). Similarly, patients with Caprini scores of 7 to 8 were significantly more likely to develop inpatient VTE when compared with patients with Caprini scores of 5 to 6 (OR, 1.33; 95% CI, 1.01-1.75; P = .04), 3 to 4 (OR, 1.27; 95% CI, 1.08-1.51; P = .005), or 0 to 2 (OR, 1.38; 95% CI, 1.10-1.74; P = .006). CONCLUSIONS AND RELEVANCE: The Caprini VTE risk assessment model is valid. This study supports the use of individual risk assessment in critically ill surgical patients.
Venous thromboembolism can present with devastating complications and sequalae, particularly in the surgical patient. Current data support prophylactic anticoagulant use in high-risk hospitalized ...patients, defined as those with a Caprini Risk Assessment Model score of 7 or greater. The most frequently used chemoprophylaxis agents include unfractionated heparin, low-molecular-weight heparin, and indirect factor Xa inhibitors. The authors review the mechanisms of action, metabolism, reversal agents, indications, contraindications, advantages, and disadvantages of these medications in plastic and reconstructive surgery.
Abstract Background Between 2% and 10% of highest risk surgery patients have a “breakthrough” VTE event despite receipt of chemoprophylaxis. The goals of this review are to summarize how ...patient-level factors may predict enoxaparin metabolism and to summarize how alterations in enoxaparin dose magnitude and frequency affects both anti-Factor Xa (aFXa) levels and downstream VTE events. Data Sources and Findings Relevant articles were identified on PubMed. Fixed dose prophylaxis provides inadequate enoxaparin prophylaxis for the majority of surgical patients based on anti-Factor Xa levels. Inadequate enoxaparin dosing has been correlated with both asymptomatic and symptomatic VTE events. Patient-level factors like gross weight and extent of injury predict enoxaparin metabolism. Weight-based or weight-tiered dosing regimens, as well as real-time dose adjustment based on anti-Factor Xa levels, allows an increased proportion of patients to have in range anti-Factor Xa levels. Conclusions Inadequate enoxaparin dosing may explain why some patients have VTE despite enoxaparin prophylaxis. Ongoing research into the utility of weight-based or anti-Factor Xa level driven enoxaparin dosing and dose adjustment is reasonable.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
PDF
