Prevention and management of venous thromboembolism in the surgical patient: options by surgery type and individual patient risk factors.

BACKGROUND: Current evidence-based guidelines provide recommendations for prophylaxis and treatment of venous thromboembolism (VTE) in a variety of surgical patients. DATA SOURCES: A systematic Ovid Medline search (from 1950 to the present) was conducted for relevant articles using the following search terms: "venous thromboembolism," "thrombophlebitis," "thromboembolism," "pulmonary embolism," "heparin," "low-molecular-weight heparin," "postoperative complications," and "anticoagulants." CONCLUSIONS: Pharmacologic and mechanical approaches are available for VTE prophylaxis, including low-dose unfractionated heparin, low-molecular-weight heparin, vitamin K antagonists, fondaparinux, intermittent pneumatic compression devices, and graduated compression stockings. Permanent inferior vena cava filters are not recommended for primary VTE prophylaxis, although they do have a role in the prevention of pulmonary embolism in patients with recent VTE who cannot have surgery delayed. Retrievable inferior vena cava filters are under investigation for primary VTE prophylaxis in trauma patients. New anticoagulants that inhibit factor Xa and thrombin will soon be available for the prevention and treatment of VTE in surgical patients.

Prevention of venous thromboembolism after surgery.

Most surgical patients who require hospitalization are at high risk for venous thromboembolism (VTE) and should receive VTE prophylaxis, usually including pharmacologic prophylaxis. Nevertheless, rates of appropriate perioperative thromboprophylaxis remain stubbornly low, though an expansion in quality-improvement efforts has led to widespread hospital implementation of prophylaxis strategies in recent years. This article reviews important principles and recent developments in perioperative VTE prophylaxis, with a focus on key recommendations and changes in the 2008 update of the American College Chest Physicians' (ACCP) evidence-based guidelines on antithrombotic therapy.

Medicolegal issues in perioperative medicine: Lessons from real cases.

Medical malpractice lawsuits are commonly brought against surgeons, anesthesiologists, and internists involved in perioperative care. They can be enormously expensive as well as damaging to a doctor's career. While physicians cannot eliminate the risk of lawsuits, they can help protect themselves by providing competent and compassionate care, practicing good communication with patients (and their families when possible), and documenting patient communications and justifications for any medical decisions that could be challenged.

Bridging the gap between evidence and practice in acute decompensated heart failure management.

Registry data indicate a gap between evidence-based guidelines and current management of patients with acute decompensated heart failure (ADHF). Bridging this gap is crucial given the frequency and cost of hospitalization for this disorder. Patients with ADHF require rapid assessment to determine appropriate treatment location and initial therapy. Patients with impending respiratory failure or cardiogenic shock should be managed in an intensive care setting, patients with congestion that is expected to require prolonged intravenous therapy should be admitted to the hospital, and patients with congestion that is likely to respond within 12-24 hours can be managed in an observation unit. Clinical status should guide selection of initial therapy. Initially, therapeutic response should be assessed every couple of hours. Once effective acute therapy has been established, it is important to implement strategies to improve long-term outcomes. These strategies include ensuring that care complies with established core performance measures, providing patient education in a manner suited to ensure comprehension and retention, and arranging for appropriate outpatient follow-up, ideally in a comprehensive heart failure disease management program. The purpose of this review is (1) to examine evidence-based guidelines for the treatment of ADHF, (2) to present a practical algorithm for patient assessment and treatment derived from these guidelines and personal experience, and (3) to discuss systems to enhance the ultimate transition of patient care from the inpatient to outpatient setting.

Outcomes of patients with stable heart failure undergoing elective noncardiac surgery.

OBJECTIVE: To evaluate modern surgical outcomes in patients with stable heart failure undergoing elective major noncardiac surgery and to compare the experience of patients with heart failure who have reduced vs preserved left ventricular ejection fraction (EF). PATIENTS AND METHODS: We retrospectively studied 557 consecutive patients with heart failure (192 EF less than or equal to 40% and 365 EF greater than 40%) and 10,583 controls who underwent systematic evaluation by hospitalists in a preoperative clinic before having major elective noncardiac surgery between January 1, 2003, and March 31, 2006. We examined outcomes in the entire cohort and in propensity-matched case-control groups. RESULTS: Unadjusted 1-month postoperative mortality in patients with both types of heart failure vs controls was 1.3% vs 0.4% (P equals .009), but this difference was not significant in propensity-matched groups (P equals .09). Unadjusted differences in mean hospital length of stay among heart failure patients vs controls (5.7 vs 4.3 days; P less than .001) and 1-month readmission (17.8% vs 8.5%; P less than .001) were also markedly attenuated in propensity-matched groups. Crude 1-year hazard ratios for mortality were 1.71 (95% confidence interval [CI], 1.5-2.0) for both types of heart failure, 2.1 (95% CI, 1.7-2.6) in patients with heart failure who had EF less than or equal to 40%, and 1.4 (95% CI, 1.2-1.8) in those who had EF greater than 40% (P less than .01 for all 3 comparisons); however, the differences were not significant in propensity-matched groups (P equals .43). CONCLUSION: Patients with clinically stable heart failure did not have high perioperative mortality rates in association with elective major noncardiac surgery, but they were more likely than patients without heart failure to have longer hospital stays, were more likely to require hospital readmission, and had a substantial long-term mortality rate.

Bridging the gap between evidence and practice in venous thromboembolism prophylaxis: the quality improvement process.

Venous thromboembolism (VTE) is considered to be the most common preventable cause of hospital-related death. Hospitalized patients undergoing major Surgery and hospitalized patients with acute medical illness have an increased risk of VTE. Although there is overwhelming evidence for the need and efficacy of VTE prophylaxis in patients at risk, only about a third of those who are at risk of VTE receive appropriate prophylaxis. To address the shortfall in VTE prophylaxis, the US Joint Commission and the National Quality Forum (NQF) endorse standardized VTE prophylaxis practices, and are identifying and testing measures to monitor these standards. Hospitals in the USA accredited by Centers for Medicare and Medicaid Services to receive medicare patients will need VTE prophylaxis programs in place to conform to these national consensus standards. This review aims to give background information on initiatives to improve the prevention of VTE and to identify key features of a successful quality improvement strategy for prevention of VTE in the hospital. A literature review shows that the key features of effective quality improvement strategies includes an active strategy, a multifaceted approach, and a continuous iterative process of audit and feedback. Risk assessment models may be helpful for deciding which patients should receive prophylaxis and for matching VTE risk with the appropriate intensity of prophylaxis. This approach should assist in implementing the NQF/Joint Commission-endorsed standards, as well as increase the use of appropriate VTE prophylaxis.

Preventing venous thromboembolism in surgical patients.

Hospital strategies to prevent VTE are important to reduce acute morbidity and mortality as well as the long-term consequences caused by venous stasis syndrome. Patients at low risk (eg, those who are ambulatory or undergoing a same-day procedure) or who are at high risk for bleeding (including those with severe renal impairment) are candidates for nonpharmacologic strategies for thromboembolic prophylaxis. Mechanical devices are effective if used appropriately, but compliance is a challenge. Patients who require a hospital stay of more than a day or two should receive a medication-based strategy, preferably using LMWH or fondaparinux. Patients undergoing hip replacement should receive extended prophylaxis with LMWH.

Venous thromboembolism prophylaxis in medical patients.

PURPOSE OF REVIEW: Venous thromboembolism, including deep vein thrombosis and pulmonary embolism, represents a significant source of morbidity and mortality in the United States and worldwide. Most acutely ill medical patients are at risk for venous thromboembolism, and prophylaxis is recommended. However, acutely ill medical patients are heterogeneous, and the degrees of risk, the length of prophylaxis, as well as the most safe and efficacious strategies to prevent venous thromboembolism in specific medical patients continue to evolve. RECENT FINDINGS: Most medically ill patients in the hospital do not receive any form of venous thromboembolism prophylaxis despite evidence that their venous thromboembolism risk is similar to surgical patients. Low-molecular weight heparins demonstrate at least equal efficacy and improved safety over standard unfractionated heparin for the prevention of venous thromboembolism in medical patients. Patients with renal impairment, obesity, or those who are critically ill are special populations for prophylaxis that require individual approaches. Many patients recently discharged from the hospital remain at high risk for thrombosis. SUMMARY: All hospitalized patients should be assessed for venous thromboembolism risk. Most acutely ill medical patients will be in the high- to very high-risk category for thrombosis. Patients who have an estimated thrombosis risk greater than bleeding risk should receive pharmacologic prophylaxis. Low-molecular weight heparin is the preferred drug-based approach over standard unfractionated heparin for the prevention of venous thromboembolism in the acutely ill medical patient. Patients with higher risks for bleeding than thrombosis should receive mechanical methods of prophylaxis. Patients who have not returned to baseline health should be considered for extended venous thromboembolism prophylaxis out of the hospital.

The preoperative evaluation: use the history and physical rather than routine testing.

The history and physical examination, rather than routine laboratory, cardiovascular, and pulmonary testing, are the most important components of the preoperative evaluation. The history should include a complete review of systems (especially cardiovascular and pulmonary), medication history, allergies, surgical and anesthetic history, and functional status.

Rational use of D-dimer measurement to exclude acute venous thromboembolic disease.

Clinical diagnosis of venous thromboembolic (VTE) disease is often inaccurate because signs and symptoms are nonspecific. Testing for the absence of D-dimer levels in the blood of patients with suspected deep venous thrombosis and pulmonary embolism can assist in ruling out these illnesses. Some highly sensitive D-dimer assays have sufficient specificity to assist in the exclusion of VTE disease. Numerous clinical management trials using D-dimer measurement in association with additional diagnostic tests have shown that it is safe to withhold anticoagulant therapy in selected patients with suspected VTE disease who have negative D-dimer assay results. Applying these diagnostic strategies can potentially decrease the need for radiological testing. The simplicity of measuring D-dimer levels creates the potential for misuse. For safe patient management, clinicians must understand the indications for and limitations of D-dimer measurement in the diagnosis of VTE disease.

Venous thromboembolism prophylaxis in the medically ill patient.

All general medical patients should be assessed for clinical risk factors for VTE. The ACCP has recommended that general medical patients with clinical risk factors receive either LDUH twice or three times daily or once-daily LMWH. Current evidence suggests that twice-daily LDUH may not be efficacious enough in the acutely ill medical inpatient. LDUH three times daily may be efficacious in most medical patients; however, it is associated with an increased risk for bleeding. The preferred strategy for prevention in the medically ill population at high to very high risk for VTE is LMWH. For patients who have a high to very high risk for bleeding, nonpharmacologic strategies such as ES or IPC devices are recommended.

Perioperative management of the hospitalized patient.

The hospitalized surgical patient requires a team approach. Because of increasing patient age and complexity of conditions, a comprehensive preoperative evaluation and medical optimization is often necessary to allow the anesthesiologist and surgeon to deliver the best surgical outcome. Surgical patients at an increased risk for postoperative complications should be followed carefully by a medical consultant throughout the hospital stay. This continuity of perioperative care improves the likelihood that postoperative problems, such as delirium, early myocardial ischemia, or VTE, are quickly identified, and appropriate therapeutic interventions are initiated before more serious adverse events occur. Special surgical populations, such as those patients who need perioperative anticoagulation, further benefit from a surgical team that includes a medical specialist. Expertise and close supervision throughout the perioperative period will give the hospitalized surgical patient the greatest chance for a quick and successful recovery.