Electronic health record risk-stratification tool reduces venous thromboembolism events in surgical patients.

Background: Venous thromboembolism is a preventable cause of morbidity and mortality after surgery. To ensure that patients receive appropriate venous thromboembolism chemoprophylaxis, a nonmandatory risk-stratification tool based on patient clinical condition was implemented through the electronic health record to stratify patient risk and recommend chemoprophylaxis. We hypothesized that implementing this tool would reduce postoperative venous thromboembolism events in general surgery as well as across all surgical services. Methods: All adult patients undergoing inpatient surgical operations (January 2012-December 2019) at a single quaternary care center and Level 1 trauma center were abstracted from institutional electronic health record database and stratified into patients admitted before and after venous thromboembolism risk-stratification tool implementation. Bivariable analyses compared venous thromboembolism chemoprophylaxis prescription and venous thromboembolism events with implementation and screening among all surgical patients as well as in general surgery patient subset. Results: A total of 64,377 adults underwent operations: 27,819 preimplementation and 36,558 postimplementation. A significant reduction in venous thromboembolism events occurred from pre- to post-tool implementation for all cases (0.77% vs 0.47%, P < .001). General surgery patients (n = 15,723) had a significant increase in chemoprophylaxis prescription (81.9% vs 86.0%, P < .001) and a significant reduction in venous thromboembolism events (1.41% vs 0.59%, P < .001). After tool implementation, use of extended postdischarge chemoprophylaxis was greater among general surgery patient subset than the entire patient cohort (46.7% vs 29.6%, P < .001). Conclusion: The integration of a nonmandatory electronic health record risk-stratification tool was associated with a significant reduction in venous thromboembolism events. Extended chemoprophylaxis was prescribed in nearly half of general surgery patients at very high risk for postdischarge events.

Avatrombopag Effectively Maintained Platelet Counts in a Patient with Immune Thrombocytopenia Who Was Intolerant to Tyrosine Kinase Inhibitor Therapy.

BACKGROUND First-line treatments for patients with immune thrombocytopenia include corticosteroids, intravenous immunoglobulin, and anti-D. These may be followed by second- and third-line options, including thrombopoietin receptor agonists and the tyrosine kinase inhibitor fostamatinib. These treatments have different mechanisms and divergent adverse event profiles. We show that fostamatinib-associated adverse events can be mitigated with fostamatinib dose reduction and the introduction of avatrombopag, and that response can be maintained with avatrombopag monotherapy. CASE REPORT A 61-year-old woman with a history of chronic refractory immune thrombocytopenia since 2006 had previously received steroids, rituximab, splenectomy, and eltrombopag without achieving platelet count stability. The patient reported flu-like symptoms in February 2020, with platelet counts ranging from 25×109/L to 50×109/L and isolated occurrences <10×109/L. Platelet counts did not respond to eltrombopag 75 mg/day, 2 courses of rituximab, or multiple courses of prednisone. Within 2 weeks of starting fostamatinib 150 mg twice daily, she reached a platelet count of 523×109/L. She experienced new-onset diarrhea associated with fostamatinib, so the dose was reduced to 75 mg twice daily, and avatrombopag 20 mg/day was added to augment platelet recovery. Platelet levels remained in the supratherapeutic range. She was transitioned to avatrombopag 40 mg/day monotherapy and then 20 mg/day owing to continued supratherapeutic platelet counts. CONCLUSIONS Avatrombopag can be used in combination with fostamatinib to augment platelet response and reduce the severity of adverse events associated with fostamatinib, while maintaining adequate therapeutic response in chronic immune thrombocytopenia. Avatrombopag 40 mg/day monotherapy was quite effective in achieving and maintaining high platelet counts.

Thrombosis and Thromboprophylaxis in Gynecology Surgery.

Gynecologic surgery offers unique challenges, as pelvic surgery places patients at an increased risk of venous thromboembolism (VTE). Prevention of VTE is a goal of patients, policy makers, and surgeons. In this review, we address the current research and recommendations for VTE prophylaxis.

Bleeding Risk and Management in Interventional Procedures in Chronic Liver Disease.

The coagulopathy of liver disease is distinctly different from therapeutic anticoagulation in a patient. Despite stable elevated standard clot-based coagulation assays, nearly all patients with stable chronic liver disease (CLD) have normal or increased clotting. Common unfamiliarity with the limitations of these assays in CLD may lead to inappropriate and sometimes harmful interventions, including blood product transfusions before a procedure. Knowledge of the distinct hemostatic alterations in CLD can allow identification of the small subset of patients with clinically significant coagulopathy who can benefit from hematologic optimization before invasive procedures.