ABSTRACT
Pregnancy-associated pulmonary embolism (PE) is a type of venous thromboembolism (VTE) that seriously threatens the lives of pregnant women and has gained more attention in clinical practice. Due to physiological and anatomical characteristics, the incidence of VTE during pregnancy and postpartum is significantly higher than that during non-pregnancy periods. Currently, guidelines widely acknowledge the exploration of appropriate risk assessment models to evaluate the risk of pregnancy-associated VTE and to take corresponding preventive measures from mechanical to medication methods according to different risk levels. For patients suspected of PE, initial assessments can be made based on whether they exhibit clinical manifestations of deep vein thrombosis, with options including vascular compression ultrasonography or chest X-ray examination. Confirmation relies on CT pulmonary angiography or V/Q imaging. For patients with shock, echocardiography can be quickly used for the diagnosis and differential diagnosis of PE. The management of pregnancy-associated pulmonary embolism PE depends on the patient's hemodynamic status, with options including reperfusion therapy or anticoagulation therapy. Extracorporeal membrane oxygenation may also be beneficial in high risk patients. The overall evidence level for the prevention and management of pregnancy-associated PE is low, and further exploration in clinical practice is still needed to promote the safety of pregnant women.
Subject(s)
Pulmonary Embolism , Humans , Pulmonary Embolism/diagnosis , Pulmonary Embolism/prevention & control , Pulmonary Embolism/therapy , Pregnancy , Female , Pregnancy Complications, Cardiovascular/diagnosis , Pregnancy Complications, Cardiovascular/therapy , Pregnancy Complications, Cardiovascular/prevention & control , Anticoagulants/therapeutic use , Venous Thromboembolism/prevention & control , Venous Thromboembolism/diagnosis , Venous Thromboembolism/therapy , Venous Thromboembolism/etiology , Risk Factors , Venous Thrombosis/diagnosis , Venous Thrombosis/prevention & control , Venous Thrombosis/therapy , Echocardiography , Extracorporeal Membrane OxygenationABSTRACT
Although the incidence of pediatric venous thromboembolism is increasing, it is often overlooked in children due to the overall low incidence. This issue reviews the epidemiology of pediatric venous thromboembolism, including the factors that have led to its increasing prevalence, and discusses the physiology of hemostasis and coagulation. Key features of the history and physical examination, as well as identification of risk factors, are reviewed, as these have the most diagnostic value for venous thromboembolism in pediatric patients. Recommendations are also provided for diagnostic testing and management in the emergency department.
Subject(s)
Venous Thromboembolism , Child , Humans , Emergency Service, Hospital , Physical Examination , Risk Factors , Venous Thromboembolism/diagnosis , Venous Thromboembolism/therapy , Venous Thromboembolism/epidemiologyABSTRACT
It is an honor and a great pleasure for us to be guest editors for this special issue of Hämostaseologie - Progress in Haemostasis, which addresses important issues surrounding the complex of venous thromboembolism (VTE). In February 2023, the revised guideline on "Diagnostics and Therapy of Venous Thrombosis and Pulmonary Embolism" has been published on the website of the Association of the Scientific Medical Societies in Germany (AWMF)1. This guideline was drawn up under the leadership of the German Society of Angiology (DGA), and representatives of 17 scientific societies contributed to its content. As an S2k guideline, its recommendations are consensus based and are the result of a systematic review and evaluation of current evidence and consideration of the benefits and harms of diagnostic and therapeutic options. In this special issue, guideline authors provide a comprehensive overview of selected guideline topics which might be of clinical relevance to our readers and our community of haemostaseologists.
Subject(s)
Practice Guidelines as Topic , Venous Thromboembolism , Humans , Germany , Venous Thromboembolism/diagnosis , Venous Thromboembolism/therapy , Anticoagulants/therapeutic use , Pulmonary Embolism/diagnosis , Pulmonary Embolism/therapyABSTRACT
Venous Thromboembolism (VTE) carries significant clinical implications, and with the rise in cannabis consumption, its potential influence on VTE outcomes warrants investigation. Using the National Inpatient Sample (NIS) database (2016-2019), we analyzed 2,217,184 hospitalized VTE patients. Among these, 1.8 % (38,810) reported cannabis use. We compared demographics, comorbidities, in-hospital outcomes, and quality metrics between cannabis users and non-users with VTE. Cannabis users were chiefly younger males (average age 45 in cannabis users vs. 62 in non-cannabis users) from lower-income brackets. Notably, 5.4 % discharged against medical advice. Although in-hospital mortality was initially lower for cannabis users (2.8 % vs. 5.1 %, OR 0.6, 95 % CI 0.69-0.94, p = 0.008), this difference became non-significant post-propensity-score matching (aOR 0.9, 95% CI 0.72-1.10, p = 0.3). Non-users faced higher in-hospital complications, a trend that persisted post-PSM. Among cannabis users, key mortality predictors were peripheral vascular disease, acute kidney injury, vasopressor use, cardiogenic shock, myocardial infarction, invasive ventilation, and surgical embolectomy. Cannabis users also had a shorter hospital stay (4.2 vs. 5.4 days) and slightly reduced costs ($27,472.95 vs. $31,660.75). The significantly younger age of VTE patients who use cannabis, coupled with the considerable proportion discharging against medical advice, underscores the urgency for tailored care interventions. Additional research is vital to comprehensively understand the interplay between cannabis consumption and VTE outcomes.
Subject(s)
Cannabis , Venous Thromboembolism , Male , Humans , United States/epidemiology , Middle Aged , Venous Thromboembolism/epidemiology , Venous Thromboembolism/etiology , Venous Thromboembolism/therapy , Hospitalization , Length of Stay , InpatientsABSTRACT
Venous thromboembolism (VTE) in pediatric patients is an uncommon but serious diagnosis that has an array of therapeutic options and challenges. An assessment of the existing literature on management of pediatric patients with VTE was conducted. The interventions reviewed include anticoagulation, thrombolysis, thrombectomy, inferior vena cava (IVC) filters, and venous stenting. For each intervention, a discussion of mechanism of action, indications, contraindications, and potential complications was performed. While anticoagulants are considered the first-line pediatric VTE treatment, many drugs remain investigational in this patient population and treatment recommendations are extrapolated from adult practice. Thrombolysis may be indicated in cases of acute thrombosis requiring more rapid clot resolution but presents a greater bleeding risk than anticoagulation. Similarly, thrombectomy also provides rapid clot resolution and offers a larger therapeutic window and usage in more mature thrombi than thrombolysis. In select patient groups, IVC filters may be indicated in the prevention of PE but present with inherent thrombogenicity and risk of migration. The data regarding pediatric VTE treatment options, monitoring, and long term outcomes is limited compared to the adult population. The relatively few clinical trials including pediatric patients have a relatively small sample size and are heterogenous with regards to predisposing factors that further exacerbate generalizability. Additional research is needed to help construct and evaluate a robust treatment algorithm for pediatric patients with VTE.
Subject(s)
Anticoagulants , Endovascular Procedures , Venous Thromboembolism , Humans , Venous Thromboembolism/drug therapy , Venous Thromboembolism/therapy , Anticoagulants/therapeutic use , Child , Endovascular Procedures/methods , Thrombolytic Therapy/methods , Thrombectomy/methods , Vena Cava FiltersABSTRACT
Patients hospitalised with acute venous thromboembolism (VTE), and notably patients with pulmonary embolism, often remain in hospital for extended periods due to the perceived risk of complications. However, several studies have shown that home treatment of selected patients is feasible and safe, with a low incidence of adverse events. This may offer clear benefits for patients' quality of life, hospital planning and cost to the health service. Nonetheless, there is a need for a VTE risk-stratification tool specifically addressing prognosis in patients with cancer. This may aid in the selection of low-risk patients with cancer and VTE who are suitable for outpatient treatment. Although several prognostic scores have been proposed, we suggest using a pragmatic clinical decision-making tool such as the Hestia criteria for selecting patients for home care in everyday clinical practice. Once patients have been discharged, it is mandatory to monitor patients regularly (we suggest after 3 days, 10 days, 1 month and 3 months, or more frequently if needed) with the involvement of a multidisciplinary team, so that appropriate and timely remedial action can be taken in case of warning signs of complications. If patients are selected carefully and monitored effectively, many patients who experience acute VTE can be cared for safely at home.
Subject(s)
Home Care Services , Neoplasms , Venous Thromboembolism , Humans , Venous Thromboembolism/epidemiology , Venous Thromboembolism/etiology , Venous Thromboembolism/therapy , Venous Thromboembolism/diagnosis , Neoplasms/complications , Neoplasms/therapy , Neoplasms/epidemiology , Home Care Services/standards , Home Care Services/organization & administration , France/epidemiology , Quality of Life , PrognosisSubject(s)
Critical Pathways , Neoplasms , Patient Care Team , Venous Thromboembolism , Humans , Neoplasms/complications , Neoplasms/epidemiology , Neoplasms/therapy , Venous Thromboembolism/diagnosis , Venous Thromboembolism/epidemiology , Venous Thromboembolism/etiology , Venous Thromboembolism/therapy , Critical Pathways/organization & administration , Critical Pathways/standards , Patient Care Team/organization & administration , Thrombosis/diagnosis , Thrombosis/etiology , Thrombosis/epidemiology , Interdisciplinary CommunicationABSTRACT
ABSTRACT Objective To develop an informative manual on venous thromboembolism prevention for the lay population and to estimate evidences of content and face validity. Methods A methodological study conducted in three stages. The first stage was the preparation of the manual, followed by content validation with cardiovascular specialists who judged clarity, theoretical relevance and practical pertinence on a 4-point Likert scale. Items with a content validity index ≤0.75 were revised and re-evaluated. The last stage was the face validation by lay people, who were interviewed regarding item understanding and visual appearance. Items with more than 80.0% positive opinions were considered adequate. Results The manual was developed containing nine illustrations, definition of the disease, risk factors, signs and symptoms, and preventive measures. In the first assessment round, the validity index was 1.0 for the text of all sections, with suggestions for language adjustments. As to the illustrations, the validity indexes ranged from 0.67 to 1.0. In the second round, the validity index reached 1.0 for all items. A total of 40 lay people participated in the face validation, and all considered the paper type and font size appropriate, as well as the font used as readable; 97.5% were able to understand the information contained in the manual; 98.0% considered it esthetically beautiful; and 90.0% considered the reading not tiresome. Conclusion The informative manual on venous thromboembolism prevention was prepared, its content validated by experts, and considered appropriate by the lay population. These results suggest that the manual may be used as a preventive educational strategy for venous thromboembolism.
RESUMO Objetivo Elaborar um manual informativo sobre prevenção de tromboembolismo venoso para população leiga e estimar evidências de validade de conteúdo e de face. Métodos Estudo metodológico realizado em três etapas. A primeira etapa foi a construção do manual; a segunda foi a validação de conteúdo com especialistas na área cardiovascular, que julgaram clareza, relevância teórica e pertinência prática, em uma escala tipo Likert de 4 pontos. Itens com índice de validade de conteúdo ≤0,75 foram revisados e reavaliados. A última etapa foi a validação de face por pessoas leigas, entrevistadas quanto à compreensão dos itens e à aparência visual. Itens com opiniões positivas por mais de 80,0% foram considerados adequados. Resultados O manual foi elaborado contendo nove imagens, com definição da doença, fatores de risco, sinais e sintomas e medidas preventivas. Na primeira rodada de avaliação, os índices de validade foram de 1,0 para o texto de todas as seções, com sugestões de ajustes de linguagem. Em relação às imagens, os índices de validade variaram de 0,67 a 1,0. Na segunda rodada, o índice de validade atingiu 1,0 para todos os itens. Na validação de face, 40 pessoas leigas participaram, e todas consideraram o tipo de papel e o tamanho da letra adequados, além da letra legível; 97,5% conseguiram entender as informações contidas no manual; 98,0% o consideraram esteticamente bonito; e 90,0% consideraram a leitura não cansativa. Conclusão O manual sobre prevenção de tromboembolismo venoso foi elaborado, com conteúdo validado por especialistas e considerado adequado pela população leiga. Esses resultados sugerem que o manual pode ser empregado como estratégia educacional preventiva do tromboembolismo venoso.
Subject(s)
Humans , Patient Education as Topic , Venous Thromboembolism/therapy , Manuals as Topic , Reproducibility of Results , LanguageABSTRACT
ABSTRACT Hemostatic abnormalities and thrombotic risk associated with coronavirus disease 2019 (COVID-19) are among the most discussed topics in the management of this disease. The aim of this position paper is to provide the opinion of Brazilian experts on the thromboprophylaxis and management of thrombotic events in patients with suspected COVID-19, in the sphere of healthcare in Brazil. To do so, the Brazilian Society of Thrombosis and Hemostasis (BSTH) and the Thrombosis and Hemostasis Committee of the Brazilian Association of Hematology, Hemotherapy and Cellular Therapy (ABHH) have constituted a panel of experts to carefully review and discuss the available evidence about this topic. The data discussed in this document was reviewed by May 9, 2020. Recommendations and suggestions reflect the opinion of the panel and should be reviewed periodically as new evidence emerges.
Subject(s)
Blood Coagulation Disorders , Venous Thromboembolism/diagnosis , Venous Thromboembolism/prevention & control , Venous Thromboembolism/therapy , COVID-19 , Disseminated Intravascular CoagulationABSTRACT
Resumo Objetivo Comparar o conhecimento autopercebido e objetivo de enfermeiros sobre tromboembolismo venoso e identificar suas práticas e barreiras percebidas para a avaliação de risco e autoeficácia em realizar cuidados preventivos para a doença. Métodos Estudo descritivo transversal realizado com enfermeiros assistenciais lotados nas unidades nos setores de cuidados a pacientes adultos de um hospital-escola da cidade de São Paulo. Os enfermeiros responderam a um instrumento sobre conhecimento percebido e objetivo, avaliação de risco, autoeficácia e barreiras para avaliação de risco de tromboembolismo venoso, o qual foi elaborado e refinado por enfermeiros e médicos com expertise acadêmica e clínica. Os dados foram analisados por estatística descritiva (frequências absolutas e relativas). Resultados Dos 81 enfermeiros, 53,3% percebiam seu conhecimento sobre avaliação de risco de tromboembolismo venoso como "bom", porém 33,1% em média responderam corretamente a questões objetivas sobre a doença; 44,4% realizavam avaliação de risco em apenas alguns pacientes. A barreira mais comum para avaliação do risco foi falta de protocolo (65,4%), seguida de falta de tempo (29,6%). Em relação à autoeficácia, somente 13% a 24,3% se sentem seguros a maior parte do tempo em prevenir e orientar pacientes quanto à prevenção de tromboembolismo venoso. Conclusão Há discrepância entre o conhecimento percebido e objetivo sobre tromboembolismo venoso e a avaliação de risco é insuficiente. Os enfermeiros têm baixa autoeficácia quanto à avaliação de risco. A falta de protocolo é percebida como barreira importante para essa avaliação. Esses resultados podem subsidiar o planejamento individual de educação permanente focada na prevenção da doença.
Resumen Objetivo Comparar el conocimiento autopercibido y objetivo de enfermeros sobre tromboembolismo venoso e identificar las prácticas y barreras percibidas para evaluar el riesgo y la autoeficacia de cuidados preventivos para la enfermedad. Métodos Estudio descriptivo transversal realizado con enfermeros asistenciales destinados a unidades en sectores de cuidados a pacientes adultos en un hospital universitario de la ciudad de São Paulo. Los enfermeros respondieron un instrumento sobre conocimientos percibidos y objetivos, evaluación de riesgos, autoeficacia y barreras para evaluar el riesgo de tromboembolismo venoso, que fue elaborado y refinado por enfermeros y médicos con expertise académica y clínica. Los datos fueron analizados por estadística descriptiva (frecuencias absolutas y relativas). Resultados De los 81 enfermeros, el 53,3% percibió que sus conocimientos sobre evaluación de riesgos de tromboembolismo venoso eran "buenos", pero un promedio de 33,1% respondió correctamente las preguntas objetivas sobre la enfermedad y el 44,4% realizaba evaluación de riesgos solo en algunos pacientes. La barrera más común para evaluar los riesgos fue la falta de protocolo (65,4%), seguida de la falta de tiempo (29,6%). Respecto a la autoeficacia, solamente entre el 13% y el 24,3% se siente seguro la mayor parte del tiempo para prevenir y orientar pacientes sobre la prevención de tromboembolismo venoso. Conclusión Hay discrepancias entre el conocimiento percibido y objetivo sobre tromboembolismo venoso y la evaluación de riesgos es insuficiente. Los enfermeros tienen una autoeficacia baja respecto a la evaluación de riesgos. La falta de un protocolo se percibe como barrera importante para esta evaluación. Estos resultados pueden contribuir a la planificación individual de educación permanente centrada en la prevención de la enfermedad.
Abstract Objectives To compare nurses' self-perceived and objective knowledge of venous thromboembolism, and to identify their risk assessment practices and perceived barriers, and self-efficacy in delivering care to prevent venous thromboembolism. Methods A cross-sectional, descriptive study including bedside nurses working in adult units at a teaching hospital in the city of São Paulo. Nurses answered a questionnaire on self-perceived and objective knowledge, risk assessment, self-efficacy, and barriers to venous thromboembolism risk assessment, which was developed and refined by nurses and physicians with academic and clinical expertise. Data were analyzed using descriptive statistics (absolute and relative frequencies). Results Out of 81 nurses, 53.3% perceived their own knowledge of venous thromboembolism risk assessment as good, however, only an average of 33.1% of nurses answered objective questions about the disease correctly; and 44.4% performed risk assessment for only a few patients. The most common barrier for risk assessment was the lack of protocol (65.4%), followed by the lack of time (29.6%). Regarding self-efficacy, only 13% to 24.3% were sure most of the time that they could prevent venous thromboembolism and educate patients for prevention. Conclusion A gap between self-perceived and objective knowledge of venous thromboembolism was identified, and risk assessment was considered insufficient. Nurses had low risk assessment self-efficacy. The lack of a protocol is perceived as a significant barrier for assessment. These results may support individual planning of permanent education focusing on disease prevention.
Subject(s)
Humans , Risk Assessment , Knowledge , Self Efficacy , Venous Thromboembolism/prevention & control , Venous Thromboembolism/therapy , Nurses , Epidemiology, Descriptive , Cross-Sectional Studies , Surveys and QuestionnairesABSTRACT
A number of limitations of standard therapy with warfarin for deep vein thrombosis (DVT) have been established. This overview of systematic reviews presents the baseline results for efficacy and safety of the new direct oral anticoagulants (DOACs) thrombin inhibitors, and activated factor X (Xa) inhibitors in patients with DVT. Searches were run on PubMed and the Cochrane Database of Systematic Reviews. Twenty-three studies were retrieved, and one systematic review was judged eligible. This review scored maximum according to AMSTAR criteria and included 7,596 patients for analysis of thrombin inhibitors and 16,356 patients for analysis of factor Xa inhibitors. The results of the meta-analysis indicate that DOACs are similar for DVT treatment when compared to standard treatment with warfarin. The incidence of major bleeding is somewhat lower in patients treated with factor Xa inhibitors and similar to standard therapy when treated with direct thrombin inhibitors
A terapia padrão com varfarina para a trombose venosa profunda (TVP) tem uma série de limitações já estabelecidas. Essa revisão de revisões sistemáticas elenca os principais resultados de eficácia e segurança dos anticoagulantes orais diretos (DOACs), inibidores da trombina e do fator X ativado (Xa), em pacientes com TVP. A pesquisa foi realizada nas bases PubMed e Cochrane Database of Systematic Reviews. Foram recuperados 23 estudos, e uma revisão sistemática foi considerada elegível. Essa revisão atingiu escore máximo no AMSTAR e incluiu 7.596 pacientes para análise dos inibidores da trombina e 16.356 pacientes para a análise dos inibidores do fator Xa. Os resultados da metanálise indicam que os DOACs apresentam eficácia similar à terapia padrão no tratamento da TVP. A incidência de sangramento maior é um pouco menor nos pacientes tratados com os inibidores do fator Xa e similar à terapia padrão no tratamento com inibidores diretos da trombina
Subject(s)
Humans , Male , Female , Review , Venous Thrombosis/therapy , Anticoagulants/therapeutic use , Warfarin/therapeutic use , Heparin/therapeutic use , Thrombin , Risk Factors , Drug Interactions , Venous Thromboembolism/therapy , Factor Xa Inhibitors/therapeutic use , Rivaroxaban/therapeutic use , Dabigatran/therapeutic use , HemorrhageABSTRACT
Contexto: O tromboembolismo venoso (TEV) representa uma preocupação crescente nas instituições hospitalares, tem grande impacto sobre a morbimortalidade em pacientes clínicos e cirúrgicos, e é a principal causa de morte evitável hospitalar. Embora existam modelos de avaliação de risco para pacientes hospitalizados, a profilaxia ainda é subutilizada ou é feita de forma incorreta. Objetivos: Avaliar o perfil de risco para TEV de pacientes clínicos e cirúrgicos recém-internados, bem como as medidas tromboprofiláticas aplicadas nas primeiras 24 horas de internação. Métodos: Este estudo transversal foi realizado em um hospital geral de grande porte do interior do estado de São Paulo entre março e julho de 2015. Os escores de Pádua e Caprini foram utilizados para estratificação de risco dos pacientes clínicos e cirúrgicos, respectivamente, enquanto a análise das medidas tromboprofiláticas baseou-se nas recomendações do 8º e 9º Consenso do American College of Chest Physicians. Resultados: Foram analisados 592 pacientes (62% clínicos e 38% cirúrgicos). A estratificação de risco revelou necessidade de quimioprofilaxia em 42% dos pacientes clínicos e 81% dos cirúrgicos (51% de alto risco e 30% de moderado risco). Por outro lado, receberam profilaxia adequada nas primeiras 24 horas de internação 54% dos pacientes clínicos de alto risco, 85% dos cirúrgicos de alto risco e 4% dos cirúrgicos de moderado risco, todos sem contraindicação. Conclusões: Há necessidade de aprimoramento da segurança do paciente em relação ao TEV já nas primeiras horas de internação. Existe uma subutilização da quimioprofilaxia especialmente nos pacientes clínicos de alto risco e cirúrgicos de moderado risco
Background: Venous thromboembolism (VTE) is a cause for growing concern in hospitals, has great impact on morbidity and mortality in clinical and surgical patients, and is the leading cause of preventable hospital deaths. Although there are risk assessment models for hospital inpatients, prophylaxis is still underused or is administered incorrectly. Objectives: To assess the risk profile for VTE in recently hospitalized clinical and surgical patients and evaluate the thromboprophylactic measures implemented in the first 24 hours of hospitalization. Methods: Cross-sectional study conducted in a large general hospital in the state of São Paulo, Brazil, between March and July 2015. Padua and Caprini scores were used for risk stratification of clinical and surgical patients, respectively, while thromboprophylactic measures were analyzed for compliance with the recommendations contained in the 8th and 9th Consensus of the American College of Chest Physicians. Results: A total of 592 patients (62% clinical and 38% surgical) were assessed. Risk stratification revealed a need for chemoprophylaxis in 42% of clinical patients and 81% of surgical patients (51% high risk and 30% moderate risk). However, 54% of high-risk clinical patients, 85% of high-risk surgical patients, and 4% of moderate-risk surgical patients, who were free from contraindications, were actually given the correct prophylaxis in the first 24 hours of hospitalization. Conclusions: There is a need to improve patient safety in relation to VTE in the first hours of hospitalization, since there is underutilization of chemoprophylaxis, especially in high-risk clinical patients and moderate-risk surgical patients
Subject(s)
Humans , Male , Female , Disease Prevention , Hospitals , Venous Thrombosis/therapy , Chemoprevention/methods , Cross-Sectional Studies , Heparin/therapeutic use , Hospitalization , Indicators of Morbidity and Mortality , Mobility Limitation , Obesity , Risk Factors , Therapeutics , Venous Thromboembolism/complications , Venous Thromboembolism/therapyABSTRACT
A aviação civil vem apresentando aumento progressivo do número de voos regulares nos últimos 10 anos e, em função disso, mais passageiros estão sendo transportados em viagens aéreas (VAs). Associado a isso, há um aumento das doenças relacionadas às VAs, especialmente naquelas de longa duração. Uma das complicações mais temidas dos voos é o tromboembolismo venoso (TEV), mas a sua real incidência é de difícil mensuração devido à falta de consenso sobre, por exemplo, quanto tempo após o pouso podemos considerar que o TEV possa estar relacionado à VA realizada ou mesmo quanto tempo de voo pode ser considerado como de longa duração. Muito tem se discutido sobre os mecanismos fisiopatológicos do TEV relacionado às VAs, quais passageiros são os de maior risco e quais medidas profiláticas podemos adotar com segurança e eficácia. O objetivo desta revisão é esclarecer esses pontos e as condutas consensuais atuais
Civil aviation has seen a steady increase in the number of scheduled flights over the last ten years and, as a result, more passengers are traveling by air. This has been associated with an increase in flight-related diseases, especially on long-haul flights. One of the most feared complications during flights is venous thromboembolism (VTE), but its true incidence is difficult to measure because of a lack of consensus on elements such as the definition of how long after landing a VTE can be considered to be related to a flight and even how long a flight must last to be considered of long duration. There has been much discussion of the pathophysiological mechanisms of flight-related VTE, of which passengers are at greatest risk, and of what prophylactic measures can be adopted safely and effectively. The purpose of this review is to clarify these points and describe current consensual conduct
Subject(s)
Humans , Male , Female , Air Travel/trends , Disease Prevention , Venous Thromboembolism/therapy , Venous Thrombosis/therapy , Aerospace Medicine/methods , Anticoagulants , Heparin , Hypoxia/complications , Incidence , Platelet Aggregation Inhibitors , Prevalence , Pulmonary Embolism/complications , Review , Risk FactorsABSTRACT
Introdução: A abdominoplastia é uma cirurgia estética muito realizada, na qual o risco de tromboembolismo (TEV) deve ser considerado pelos fatores predisponentes envolvidos e por sua gravidade. Não há, até o momento, protocolos bem definidos para profilaxia de TEV em Cirurgia Plástica. O objetivo é apresentar um protocolo de profilaxia de TEV utilizado no serviço de Cirurgia Plástica do HMCP - PUC Campinas, mostrando a incidência de TEV nas abdominoplastias antes e após o início do protocolo, bem como a incidência de hematomas após, no período total de 6 anos. Métodos: Revisão de prontuários de pacientes submetidos à abdominoplastia no período de janeiro de 2010 a dezembro de 2015, identificando os casos de TEV nesse período, associados ou não ao emprego de profilaxia farmacológica, e os de hematoma após início do protocolo. Resultados: O protocolo de profilaxia de TEV que é utilizado no serviço desde 2014 tem como base o protocolo de Anger e inclui medidas não farmacológicas e farmacológicas. Foram analisados 243 prontuários nesse estudo. Após início do protocolo, não foi evidenciado nenhum caso de TEV nos 74 pacientes submetidos à abdominoplastia e foi observado apenas um caso de hematoma. Já antes do mesmo, 2 casos de TEV ocorreram entre 169 pacientes operados. Conclusão: Após a adoção do protocolo de profilaxia de TEV, alcançamos uma incidência de TEV de 0% nas abdominoplastias nesse período, enquanto a mesma foi de 1,18% antes do protocolo. Já a incidência de hematomas após foi de 1,35%, comparável a taxas da literatura para a cirurgia sem a utilização de profilaxia farmacológica.
Introduction: Abdominoplasty is an accomplished cosmetic surgery, in which the risk of venous thromboembolism (VTE) must be considered, based on the predisposing factors involved and their severity. There are, to date, no well-defined protocols for VTE prophylaxis in plastic surgery. The objective of this paper is to present a protocol for the prophylaxis of VTE used in the Plastic Surgery Service of the Hospital e Maternidade Celso Pierro (HMCP) - Pontifícia Universidade Católica (PUC) de Campinas in São Paulo (SP), while also showing the incidence of VTE in patients undergoing abdominoplasties before and after initiation of the protocol, as well as the incidence of hematomas after the total period of 6 years. Methods: For the creation of this protocol, medical records of patients who underwent abdominoplasty from January 2010 to December 2015 were revised, identifying cases of VTE in this period, associated or not with the use of pharmacological prophylaxis, and those of hematoma after initiation of the protocol. Results: The protocol for prophylaxis of VTE that has been used in the service since 2014 is based on the Anger Protocol and includes non-pharmacological measures and pharmacological measures. Two hundred and forty-three medical records were analyzed in this study. After initiation of the protocol, no cases of VTE were observed in the 74 patients who underwent abdominoplasty, and only one case of hematoma was observed. Before the protocol was initiated, VTE developed in 2 cases among 169 operated patients. Conclusion: After adopting the VTE prophylaxis protocol, we achieved an incidence of 0% VTE in the abdominoplasties in this period, compared to an incidence of 1.18% before the protocol. The incidence of bruising after surgery was 1.35%, which is comparable to rates in the literature for surgery without the use of pharmacological prophylaxis.
Subject(s)
Humans , History, 21st Century , Surgery, Plastic , Retrospective Studies , Chemoprevention , Plastic Surgery Procedures , Guidelines as Topic , Abdomen , Venous Thromboembolism , Abdominoplasty , Surgery, Plastic/methods , Surgery, Plastic/rehabilitation , Chemoprevention/adverse effects , Chemoprevention/methods , Plastic Surgery Procedures/adverse effects , Plastic Surgery Procedures/methods , Guidelines as Topic/analysis , Guidelines as Topic/methods , Venous Thromboembolism/surgery , Venous Thromboembolism/complications , Venous Thromboembolism/therapy , Abdominoplasty/adverse effects , Abdominoplasty/methods , Abdomen/surgeryABSTRACT
Abstract Venous thromboembolism events are important causes of maternal death during pregnancyandthepostpartumperiodworldwide.Are view of the literature with the objective of evaluating venous thromboembolism events in the puerperium according to the route of delivery was performed through a bibliographic survey in the Medline, LILACS and Scielo databases. We observed that patients submitted to cesarean sections present a significantlyhigher riskofdeveloping venousthromboembolismwhencomparedwiththose who undergo spontaneous vaginal delivery. The pathophysiological bases for this difference were explored and described in this review, as well as the indications of prophylaxis and treatment. Doctors and health professionals must be continuously vigilant regarding this condition, since it is associated with high morbidity and mortality.
Resumo Os eventos de tromboembolismo venoso são causas importantes de morte materna durante a gravidez e o período do pós-parto em todo o mundo. Foi realizada uma revisão da literatura com o objetivo de avaliar os eventos de tromboembolismo venoso no puerpério de acordo com a via de parto utilizada, por meio de uma pesquisa bibliográfica nas bases de dados Medline, LILACS e Scielo. Observou-se que as pacientes submetidas a cesariana apresentam um risco significativamente maior de desenvolver tromboembolismo venoso do que aquelas que se submetem a parto vaginal espontâneo. As bases fisiopatológicas desta diferença foram exploradas e descritas nesta revisão, bem como as indicações de profilaxia e tratamento. O alerta contínuo dos médicos e profissionais de saúde é necessário, uma vez que se trata de uma condição comum associada a alta morbidade e mortalidade.
Subject(s)
Humans , Female , Pregnancy , Puerperal Disorders/etiology , Puerperal Disorders/physiopathology , Puerperal Disorders/therapy , Puerperal Disorders/epidemiology , Delivery, Obstetric , Venous Thromboembolism/etiology , Venous Thromboembolism/physiopathology , Venous Thromboembolism/therapy , Venous Thromboembolism/epidemiologyABSTRACT
Introdução: O tromboembolismo venoso (TEV), incluindo a embolia pulmonar (EP) e a trombose venosa profunda (TVP), é a terceira causa de mortalidade em todo o mundo. O diagnóstico ainda é subestimado nas emergências. Os fatores desencadeantes são bem definidos, o que auxilia a estratificação de risco e o diagnóstico de TEV provocada ou não e influenciará muito o tempo de tratamento. O aumento do ventrículo direito e de marcadores biológicos tem desempenhado grande papel no prognóstico. O quadro clínico é bem definido e tem várias ferramentas, tanto para o diagnóstico como para a estratificação de risco, tais como os critérios de Wells e de Genebra, além de outros. Os exames complementares atualmente estão bem definidos, com a angiografia pulmonar sendo o padrão de referência; porém, com a melhora da tecnologia e a alta sensibilidade e especificidade, a angiotomografia computadorizada ocupou um lugar de destaque. Outros exames ainda são importantes em várias situações, como o D-dímero e outros biomarcadores, a radiografia de tórax, a cintilografia de perfusão/ventilação, eletrocardiograma, ecocardiografia e doppler venoso de membros inferiores. Método: Neste artigo, revisamos aspectos básicos de epidemiologia, diagnóstico e estratificação de risco. O foco principal foi o tratamento com a terapia anticoagulante, sobre a qual revisamos os seis estudos clínicos descritos entre 2009 e 2013, que abordam os novos anticoagulantes orais, hoje denominados anticoagulantes orais diretos. Esses estudos têm desenhos diferentes, com três deles começando com anticoagulantes orais desde o início do quadro agudo de TVP e EP (rivaroxabana e edoxabana). Os outros três iniciaram com enoxaparina e varfarina durante os primeiros dias e depois seguiram com a medicação do grupo em avaliação (dabigatrana e apixabana). Resultados: Nos estudos analisados, todos obtiveram uma redução (valor de p de não inferioridade) dos eventos de recorrência de TEV com relação à varfarina. Nos desfechos de segurança, definidos como sangramento fatal, clinicamente relevante e outros, os novos anticoagulantes orais obtiveram uma diminuição significativa. Conclusões: Os anticoagulantes orais diretos tiveram redução da recorrência de eventos tromboembólicos (periférico e pulmonar), com redução significativa dos índices de sangramentos fatais ou não. A segurança coloca-os como opção segura e eficaz para o tratamento desses pacientes com risco baixo e intermediário de TEV
Introduction: Venous thromboembolism (VTE), including pulmonary embolism (PE) and deep vein thrombosis (DVT), is the third leading cause of death worldwide. The diagnosis is still underestimated in emergencies. The triggering factors are well defined, which assists in the stratification of risk and in the diagnosis of VTE, whether provoked or not, and will greatly influence the treatment time. Increased right ventricle and biological markers have played a large role in the prognosis. The clinical features are well defined, and there are various tools for diagnosis and for risk stratification, such as the Wells and Geneva criteria, among others. Complementary exams are now well defined, with pulmonary angiography being the gold standard, but with improved technology and high sensitivity and specificity, computerized angiotomography has played a prominent role. Other exams are still important in certain situations, such as D-dimer and other biomarkers, chest radiography, perfusion/ventilation scintigraphy, electrocardiogram, echocardiography, and lower limb venous Doppler. Method: In this article we review basic aspects of epidemiology, diagnosis, and risk stratification. The main focus was treatment with anticoagulant therapy, under which we reviewed the six clinical studies described between 2009 and 2013 that address the new oral anticoagulants, now called direct oral anticoagulants. These studies have different designs; three of them start with oral anticoagulants from the onset of acute DVT and PE (rivaroxaban and edoxaban), and the other three start with enoxaparin and warfarin during the first days and then with the medication of the study group being evaluated (dabigatran and apixaban). Results: In the analyzed studies, all of them obtained a reduction (non-inferiority p-value) of the events of VTE recurrence in relation to warfarin. In the safety outcomes, defined as clinically relevant fatal bleeding and others, the new oral anticoagulants achieved a significant reduction. Conclusions: Direct oral anticoagulants had a reduction in the recurrence of thromboembolic events (peripheral and pulmonary), with a significant reduction in rates of fatal or non-fatal bleeding. Their safety makes them a reliable and effective option for the treatment of these patients, with low and intermediate risk of VTE
Subject(s)
Humans , Male , Female , Pulmonary Embolism/diagnosis , Pulmonary Embolism/therapy , Venous Thromboembolism/mortality , Venous Thromboembolism/therapy , Anticoagulants/therapeutic use , Prognosis , Warfarin/therapeutic use , Heparin/therapeutic use , Radiography, Thoracic/methods , Risk Factors , Age Factors , Lower Extremity/diagnostic imaging , Electrocardiography/methods , Computed Tomography Angiography/methods , Heart Ventricles/physiopathology , HemorrhageSubject(s)
Humans , Male , Female , Middle Aged , Aged , Aged, 80 and over , Venous Thromboembolism/therapy , Venous Thromboembolism/epidemiology , Argentina/epidemiology , Pulmonary Embolism/therapy , Pulmonary Embolism/epidemiology , Records , Prospective Studies , Risk Factors , Hemorrhage , HospitalizationSubject(s)
Humans , Pneumonia, Viral/complications , Thrombosis/virology , Coronavirus Infections/complications , Venous Thromboembolism/virology , Betacoronavirus , Inflammation/virology , Pneumonia, Viral/therapy , Coronavirus Infections/diagnosis , Clinical Laboratory Techniques , Venous Thromboembolism/therapy , Pandemics , COVID-19 Testing , SARS-CoV-2 , COVID-19 , Inflammation/diagnosisABSTRACT
CONTEXT: The question of what is the best loading dosage of warfarin when starting anticoagulant treatment has been under discussion for ten years. We were unable to find any comparative studies of these characteristics conducted here in Brazil. OBJECTIVE: To compare the safety and efficacy of two initial warfarin dosage regimens for anticoagulant treatment. METHODS: One-hundred and ten consecutive patients of both sexes, with indications for anticoagulation because of venous or arterial thromboembolism, were analyzed prospectively. During the first 3 days of treatment, these patients were given adequate heparin to keep aPTT (activated partial thromboplastin time) between 1.5 and 2.5, plus 5 mg of warfarin. From the fourth day onwards, their warfarin doses were adjusted using International Normalized Ratios (INR; target range: 2 to 3). This prospective cohort was compared with a historical series of 110 patients had been given 10 mg of warfarin on the first 2 days and 5 mg on the third day with adjustments based on INR thereafter. Outcomes analyzed were as follows: recurrence of thromboembolism, bleeding events and time taken to enter the therapeutic range. RESULTS: Efficacy, safety and length of hospital stay were similar in both samples. The sample that were given 10 mg entered the therapeutic range earlier (means: 4.5 days vs. 5.8 days), were on lower doses at discharge and had better therapeutic indicators at the first return appointment. CONCLUSIONS: The 10 mg dosage regimen took less time to attain the therapeutic range and was associated with lower warfarin doses at discharge and better INR at first out-patients follow-up visit. .
CONTEXTO: A melhor dose para o início do tratamento anticoagulante com varfarina vem sendo debatida nos últimos dez anos. Em nosso meio, não observamos nenhum estudo comparativo quanto a estas características. OBJETIVO: Comparar segurança e eficácia de dois esquemas de dosagem inicial de varfarina para tratamento anticoagulante. MÉTODOS: Foram estudados prospectivamente 110 pacientes de ambos os sexos, consecutivos, com indicação de anticoagulação por tromboembolismo venoso ou arterial. Durante os três primeiros dias de tratamento, estes pacientes receberam doses adequadas de heparina (RT - razão dos tempos - alvo entre 1,5 e 2,5) e 5 mg de varfarina, cuja dose foi reajustada a partir do quarto dia pelo Razão Normatizada Internacional - RNI (alvo entre 2 e 3). Esse grupo foi comparado com série histórica de 110 pacientes que receberam 10 mg nos dois primeiros dias, 5 mg a partir do terceiro dia, com ajuste posterior de dose baseado no RNI. Os desfechos foram: recorrência do tromboembolismo, sangramentos e tempo para alcançar níveis terapêuticos. RESULTADOS: A eficácia, a segurança e o tempo de internação foram similares entre os grupos. O grupo que recebeu 10 mg atingiu níveis terapêuticos mais precocemente (média de 4,5 dias × 5,8 dias), sendo as doses na alta menores e os níveis terapêuticos mais adequados na primeira visita de retorno. CONCLUSÃO: O esquema de dosagem de 10 mg proporcionou menor tempo para alcançar nível terapêutico, com menores doses de varfarina na alta e RNI mais adequado no retorno. .