Filtro de vena cava inferior ante diagnóstico de trombosis venosa profunda en gestante en trabajo de parto. A propósito de un caso clínico / Inferior vena cava filter before diagnosis of deep venous thrombosis in a pregnant woman in labor: A case report

Introducción: El embarazo representa un estado procoagulante que aumenta el riesgo de fenómenos trombóticos en la mujer. Al igual que en la población no gestante, deberemos diagnosticar y tratar lo más precozmente posible dichos eventos para evitar la migración del trombo a otras localizaciones. La anticoagulación constituye la medida terapéutica de primera línea. Sin embargo, ciertas situaciones de aumento de sangrado como el trabajo de parto pueden suponer una contraindicación para iniciar dicha anticoagulación. En el siguiente artículo se desarrolla un caso clínico en el que el diagnóstico de trombosis venosa profunda tuvo lugar al inicio del trabajo de parto. Principales síntomas y/o hallazgos clínicos: Aumento de diámetro de miembro inferior izquierdo, con enrojecimiento del mismo y aumento de temperatura local. La paciente describía dolor a nivel de dicha extremidad desde hacía 15 días. No presentaba disnea y la saturación de oxígeno era del 100%. Diagnósticos principales: Trombosis venosa profunda, trabajo de parto. Intervenciones terapéuticas: La contraindicación de anticoagulación y la necesidad de un tratamiento inmediato plantearon el filtro de vena cava inferior como la opción más razonable. Resultados: Tras la colocación del filtro, el parto cursó sin incidencias; no migró el émbolo y el filtro se retiró a los 29 días del parto sin complicaciones. Conclusión: Pese a nuestra escasa experiencia clínica en el manejo de estos casos, podemos afirmar que el filtro de vena cava inferior representa una opción razonable y segura en los casos de trombosis de miembros inferiores en mujeres en trabajo de parto.(AU)

Introduction: Pregnancy represents a procoagulant state that increases women's risk of thrombotic phenomena. As in the non-pregnant population, we must diagnose and treat these events as early as possible to avoid the migration of the thrombus to other locations. Anticoagulation is the first-line therapeutic measure. However, certain situations of increased bleeding such as labor may be a contraindication to initiate such anticoagulation. The following article develops a clinical case in which the deep vein thrombosis diagnosis occurred at the onset of labor. Main symptoms and/or clinical findings: Increase in diameter of the left lower limb, with redness of the same and increase in local temperature. The patient described pain at the level of this limb for 15 days. He had no dyspnea and oxygen saturation was 100%. Main diagnoses: Deep vein thrombosis, labor. Therapeutic interventions: The contraindication of anticoagulation and the need for immediate treatment raised the inferior vena cava filter as the most reasonable option. Results: After the placement of the filter, the delivery proceeded without incident. The plunger did not migrate and the filter was removed 29 days after delivery without complications. Conclusion: Despite our limited clinical experience in the management of these cases, we can affirm that the inferior vena cava filter represents a reasonable and safe option in cases of thrombosis of the lower limbs in women in labor.(AU)

A mudança de paradigma no tratamento do tromboembolismo venoso grave / The paradigm shift in treatment of severe venous thromboembolism

Resumo A embolia pulmonar (EP) é a terceira maior causa de morte cardiovascular e a principal de morte evitável intra-hospitalar no mundo. O conceito PERT® (do inglês, pulmonary embolism response team) envolve seu diagnóstico e tratamento precoce e multidisciplinar. A trombose venosa profunda (TVP) é a sua causa inicial na maioria dos casos e é responsável por complicações como a recidiva tromboembólica, a síndrome pós-trombótica e a hipertensão pulmonar tromboembólica crônica. Uma abordagem inicial semelhante ao PERT nos casos de TVP ilíaco-femoral grave pode reduzir não apenas o risco imediato de EP e morte, mas também suas sequelas tardias. Novas técnicas percutâneas e aparatos de trombectomia mecânica para o tromboembolismo venoso (TEV) vêm demonstrando resultados clínicos encorajadores. Propomos o desenvolvimento de um conceito ampliado de resposta rápida ao TEV, que envolve não apenas a EP (PERT®) mas também os casos graves de TVP: o time de resposta rápida para o TEV (TRETEV®), ou do inglês Venous Thromboembolism Response Team (VTERT®).

Abstract Pulmonary embolism (PE) is the third leading cause of cardiovascular death and the main cause of preventable in-hospital death in the world. The PERT® (Pulmonary Embolism Response Team) concept involves multidisciplinary diagnosis and immediate treatment. Deep venous thrombosis (DVT) is the initial cause of most cases of PE and is responsible for complications such as chronic thromboembolic recurrence, postthrombotic syndrome, and chronic thromboembolic pulmonary hypertension. An aggressive approach to severe cases of iliofemoral DVT similar to the PERT® system can not only reduce the immediate risk of PE and death but can also reduce later sequelae. New percutaneous techniques and mechanical thrombectomy devices for venous thromboembolism (VTE) have shown encouraging clinical results. We propose the development of an expanded concept of rapid response to VTE, which involves not only PE (PERT®) but also severe cases of DVT: the Venous Thromboembolism Response Team (VTERT®).

Rivaroxaban versus enoxaparin for thromboprophylaxis in orthopedic surgery: A meta-analysis. / Rivaroxaban frente a enoxaparina como tromboprofilaxis en cirugía ortopédica y traumatología: un metaanálisis.

INTRODUCTION: Venous thromboembolism is highly associated with orthopedic surgery, so thromboprophylaxis is an important consideration for orthopedic surgeons. The new oral anticoagulants have clear advantages for clinical practice. OBJECTIVES: To analyze the efficacy and safety of rivaroxaban versus enoxaparin for thromboprophylaxis in different orthopedic surgeries. MATERIAL AND METHODS: Systematic electronic search of clinical trials was carried out. Data extraction of efficacy outcomes (deep venous thrombosis, pulmonary embolism and death) and safety outcomes (major bleeding and clinical relevant bleeding) was realized. RESULTS: Six randomized and controlled clinical trials were included in this meta-analysis. Compared with enoxaparin the risk of venous thromboembolism was lower with rivaroxaban both in different orthopedic surgeries (RR: 0.51; 95% CI: 0.36-0.73; P=.0002). This result was even better and more homogeneous in the analysis of symptomatic deep venous thrombosis outcome (RR: 0.43; 95% CI: 0.28-0.65; P<.0001; I2=0%; P=.49). The risk of bleeding was not significantly higher with rivaroxaban (RR: 1.20; 95% CI: 0.97-1.49; P=.09). CONCLUSIONS: Rivaroxaban should be considerate such as a more effective alternative for thromboprophylaxis in orthopedic surgery.

Risk of thrombosis recurrence among patients with COVID-19 and surgery-associated venous thromboembolism.

INTRODUCTION: Recent surgery is a well-known major transient risk factor for venous thromboembolism (VTE) due to the low risk of VTE recurrence after anticoagulation is discontinued. On the other hand, the risk of VTE recurrence among patients with COVID-19-associated VTE is unknown. This study aimed to compare the risk of VTE recurrence between patients with COVID-19- and surgery-associated VTE. METHODS: A prospective observational single-center study was performed including consecutive patients diagnosed with VTE in a tertiary hospital from January 2020 to May 2022 and followed up for at least 90 days. Baseline characteristics, clinical presentation, and outcomes were assessed. The incidence of VTE recurrence, bleeding, and death was compared between both groups. RESULTS: A total of 344 patients were included in the study: 111 patients with surgery-associated VTE and 233 patients with COVID-19-associated VTE. Patients with COVID-19-associated VTE were more frequently men (65.7% vs 48.6%, p =  0.003). VTE recurrence was 3% among COVID-19 patients and 5.4% among surgical patients, with no significant differences (p =  0.364). The incidence rate of recurrent VTE was 1.25 per 1000 person-months in COVID-19 patients and 2.29 person-months in surgical patients, without significant differences (p =  0.29). In the multivariate analysis, COVID-19 was associated with higher mortality (HR 2.34; 95% CI 1.19-4.58), but not with a higher risk of recurrence (HR 0.52; 95% CI 0.17-1.61). No differences were found in recurrence in the multivariate competing risk analysis (SHR 0.82; 95% CI 0.40-2.05). CONCLUSIONS: In patients with COVID-19 and surgery-associated VTE, the risk of recurrence was low, with no differences between both groups.

Efficacy and safety of direct oral anticoagulants for the treatment of cancer-associated venous thromboembolism: A systematic review and Bayesian network meta-analysis / Eficacia y seguridad de los anticoagulantes orales directos para el tratamiento de la tromboembolia venosa asociada al cáncer: una revisión sistemática y un metaanálisis en red bayesiana

Introduction: Direct oral anticoagulants (DOACs) could effectively prevent the occurrence of cancer-associated venous thromboembolism (CAVTE), which incidence rate was estimated to be 4–20%. But the efficacy and safety remain controversial between DOACs and low molecular weight heparin (LMWH).Materials and methodsPubMed, Cochrane Library, Embase, ClinicalTrials.gov databases for randomized controlled trials (RCTs) were systematically searched from inception to March 15, 2022. A random-effects model was used to report the odds ratio (OR) and 95% confidence interval (CI) for both direct and network meta-analyses.ResultsSeven studies were included totaling 3242 patients. A lower rate of recurrence VTE was noted in the DOACs compared with LMWH (OR 0.62, 95% CI 0.47–0.82, I2=0.0%). The aspect of major bleeding (MB) was similar (OR 1.30, 95% CI 0.77–2.18, I2=34.9%). When assessing clinically relevant nonmajor bleeding (CRNMB) (OR 1.61, 95% CI 1.17–2.22, I2=20.7%) and clinically relevant bleeding (CRB) (OR 1.39, 95% CI 1.11–1.74, I2=0.0%), a higher risk of events was observed in DOACs. In subgroup analyses, the MB of gastrointestinal and genitourinary malignancies had a higher rate in the DOACs. For ranking, apixaban ranked the first in prevention of VTE and reducing MB events. Edoxaban had the highest risk drug in MB. In terms of CRNMB and CRB, LMWH showed the lowest risk.ConclusionsCompared with LMWH, DOACs seemed to have a decreased risk of recurrence VTE while increasing CRNMB and CRB. DOACs and LMWH were equivalent to the aspect of MB, but DOACs had a higher MB risk in patients with gastrointestinal and genitourinary malignancies. Apixaban may be the lowest risk compared to the other DOACs in precaution of VTE and reducing bleeding events. (AU)

Introducción: Los anticoagulantes orales directos (ACOD) son eficaces en la prevención de la tromboembolia venosa (TEV) relacionada con el cáncer, cuya tasa de incidencia se estima en 4-20%. Sin embargo, la eficacia y seguridad de ACOD y heparina de bajo peso molecular (HBPM) siguen siendo controvertidas.Materiales y métodosDesde el inicio hasta el 15 de marzo de 2022 se realizaron búsquedas sistemáticas en las bases de datos de ensayos controlados aleatorios (ECA) en PubMed, The Cochrane Library, Embase, ClinicalTrials.gov. Se utilizó el modelo de efectos aleatorios para informar la razón de probabilidades (RP) y los intervalos de confianza (IC) de 95% para los metaanálisis directos y de red.ResultadosSe incluyeron siete estudios con un total de 3.242 pacientes. En comparación con HBPM, los ACOD tienen una tasa más baja de recurrencia de TEV (OR 0,62, IC 95%: 0,47 a 0,82, I2 = 0,0%). La frecuencia de hemorragias mayores fue similar (OR 1,30, IC 95% 0,77 a 2,18, I2 = 34,9%). Se observó un mayor riesgo de eventos en los ACOD. Cuando se evaluaron las hemorragias no mayores clínicamente relevantes (CRNMB) (OR 1,61, IC 95%: 1,17 a 2,22, I2 = 20,7%) y las hemorragias clínicamente relevantes (OR 1,39, IC 95%: 1,11 a 1,74, I2 = 0,0%), En los análisis de subgrupos, las hemorragias mayores en las neoplasias malignas gastrointestinales y genitourinarias fueron más frecuentes con los ACOD. Apixabán ocupó el primer lugar en la prevención de TEV y la reducción de eventos hemorrágicos mayores. Edoxabán tuvo el mayor riesgo de hemorragias mayores. Las HBPM demostraron tener menor riesgo de hemorragias mayores clínicamente relevantes y hemorragias clínicamente relevantes. (AU)

Efficacy and safety of direct oral anticoagulants for the treatment of cancer-associated venous thromboembolism: A systematic review and Bayesian network meta-analysis.

INTRODUCTION: Direct oral anticoagulants (DOACs) could effectively prevent the occurrence of cancer-associated venous thromboembolism (CAVTE), which incidence rate was estimated to be 4-20%. But the efficacy and safety remain controversial between DOACs and low molecular weight heparin (LMWH). MATERIALS AND METHODS: PubMed, Cochrane Library, Embase, ClinicalTrials.gov databases for randomized controlled trials (RCTs) were systematically searched from inception to March 15, 2022. A random-effects model was used to report the odds ratio (OR) and 95% confidence interval (CI) for both direct and network meta-analyses. RESULTS: Seven studies were included totaling 3242 patients. A lower rate of recurrence VTE was noted in the DOACs compared with LMWH (OR 0.62, 95% CI 0.47-0.82, I2=0.0%). The aspect of major bleeding (MB) was similar (OR 1.30, 95% CI 0.77-2.18, I2=34.9%). When assessing clinically relevant nonmajor bleeding (CRNMB) (OR 1.61, 95% CI 1.17-2.22, I2=20.7%) and clinically relevant bleeding (CRB) (OR 1.39, 95% CI 1.11-1.74, I2=0.0%), a higher risk of events was observed in DOACs. In subgroup analyses, the MB of gastrointestinal and genitourinary malignancies had a higher rate in the DOACs. For ranking, apixaban ranked the first in prevention of VTE and reducing MB events. Edoxaban had the highest risk drug in MB. In terms of CRNMB and CRB, LMWH showed the lowest risk. CONCLUSIONS: Compared with LMWH, DOACs seemed to have a decreased risk of recurrence VTE while increasing CRNMB and CRB. DOACs and LMWH were equivalent to the aspect of MB, but DOACs had a higher MB risk in patients with gastrointestinal and genitourinary malignancies. Apixaban may be the lowest risk compared to the other DOACs in precaution of VTE and reducing bleeding events.

Successful use of rivaroxaban achieving therapeutic anti-factor xa levels in a morbidly obese patient with acute intermediate-high risk pulmonary embolism / Uso bem-sucedido de rivaroxabana com níveis terapêuticos de antifator xa em paciente com obesidade mórbida e embolia pulmonar aguda de risco intermediário-alto

Abstract Direct oral anticoagulants (DOACs) have become the standard of care for acute and long-term therapy for venous thromboembolism (VTE) due to their efficacy and safety profiles. The 2021 International Society on Thrombosis and Haemostasis guidelines recommend using standard DOAC dosages in patients with BMI >40 kg/m2 or weight >120 kg. Use of DOACs remains uncertain in morbidly obese patients with VTE, including acute PE. A morbidly obese woman in her 30s who presented with acute worsening of dyspnea was diagnosed with acute intermediate-high risk acute pulmonary embolism and concomitant proximal deep vein thrombosis, constituting a clinically challenging scenario for treating her with rivaroxaban. Standard doses of rivaroxaban for acute and extended phase treatment of venous thromboembolism in individuals with morbid obesity at BMI>70 kg/m2 may be effective, and safe.

Resumo Devido à sua eficácia e aos seus perfis de segurança, os anticoagulantes orais diretos (DOACs) tornaram-se o padrão de cuidado para a terapia aguda e de longo prazo de tromboembolismo venoso (TEV). As diretrizes da Sociedade Internacional de Trombose e Hemostasia de 2021 recomendam o uso de dosagens padrão de DOACs em pacientes com índice de massa corporal (IMC) > 40 kg/m2 ou peso > 120 kg. O uso de DOACs em pacientes com obesidade mórbida e TEV, incluindo embolia pulmonar aguda, ainda não foi esclarecido. Uma mulher com obesidade mórbida na faixa dos 30 anos que apresentou piora aguda da dispneia foi diagnosticada com embolia pulmonar aguda de risco intermediário-alto e trombose venosa profunda proximal concomitante, com o cenário clínico desafiador de tratá-la com rivaroxabana. Doses padrão de rivaroxabana para tratamento e recorrência de tromboembolismo venoso em indivíduos com obesidade mórbida e IMC > 70 kg/m2 podem ser eficazes e seguras.

Adequação da estratificação de risco e da profilaxia do tromboembolismo venoso em hospital universitário terciário / Adequacy of venous thromboembolism risk stratification and prophylaxis in a tertiary university hospital

Resumo Contexto O tromboembolismo venoso (TEV) é a terceira doença cardiovascular mais comum e a principal causa de óbito evitável em pacientes internados. Apesar de diretrizes bem estabelecidos na literatura, a profilaxia dessa afecção ainda é subutilizada. Estudos apontam taxa de adequação da profilaxia próxima de 50% mundialmente. Objetivos Avaliar a adequação da estratificação de risco e da prescrição de medidas de profilaxia do TEV em um hospital universitário terciário. Métodos Estudo transversal observacional realizado através da coleta de dados de prontuário. Foram incluídos pacientes adultos internados em diferentes especialidades e divididos em grupos cirúrgico e clínico. A estratificação de risco de TEV realizada pelos médicos assistentes foi comparada com a realizada pelos médicos pesquisadores, com base nas diretrizes recentes. A prescrição de medidas de profilaxia realizadas pelos médicos assistentes foi comparada com as recomendações das diretrizes, obtendo assim a taxa de adequação da profilaxia. Resultados Foram avaliados 400 pacientes, sendo 169 (42,3%) cirúrgicos e 231 (57,7%) clínicos. A taxa geral de adequação da estratificação foi de 50,8%. Nos grupos cirúrgico e clínico, as taxas de adequação foram respectivamente 39,1% e 59,3% (p < 0,0001). A taxa geral de adequação da profilaxia foi de 71,5%, enquanto no grupo cirúrgico foi de 78,1% e no grupo clínico de 66,7% (p = 0,0137). Conclusões A adequação da estratificação de risco para TEV foi baixa, demonstrando a pouca conscientização dos médicos assistentes sobre esse problema. No entanto, as taxas de adequação da prescrição de medidas de profilaxia estão superiores às de dados globais.

Abstract Background Venous thromboembolism is the third most common cardiovascular disease and the main cause of preventable death in hospitalized patients. Prophylaxis is still underused, despite well-established guidelines in the literature. Studies show a worldwide prophylaxis adequacy rate close to 50%. Objectives To assess the adequacy of risk stratification and prophylactic measures for venous thromboembolism in a tertiary university hospital. Methods A cross-sectional observational study was carried out, collecting data from medical records. Adult patients hospitalized by different specialties were enrolled and divided into surgical and clinical groups. The risk stratification of venous thromboembolism performed by the attending physicians was compared with stratification based on recent guidelines performed by the research physicians. Prophylaxis measures prescribed by the attending physicians were compared with guideline recommendations, thus obtaining the prophylaxis adequacy rate. Results 400 patients were analyzed, 169 (42.3%) surgical and 231 (57.7%) clinical. The overall stratification adequacy rate was 50.8%. Adequacy rates were 39.1% and 59.3% in the surgical and clinical groups respectively (P < 0.0001). The overall prophylaxis adequacy rate was 71.5%, with 78.1% in the surgical group and 66.7% in the clinical group (P=0.0137). Conclusions Risk stratification adequacy is low, demonstrating a low awareness among prescribing physicians of the need for adequate stratification for prescription of prophylaxis. However, the prophylaxis prescription adequacy rates are higher than those in global data.

Estratificação do risco de tromboembolismo venoso em pacientes vítimas de traumas ortopédicos / Risk stratification of venous thromboembolism in orthopedic traumas patients / Estratificación del riesgo de tromboembolismo venoso en pacientes con traumas ortopédicos

Objetivo: identificar a estratificação de risco para tromboembolismo venoso em pacientes de traumas ortopédicos. Método: estudo de abordagem quantitativa, descritivo, do tipo transversal, com dados coletados de março a agosto de 2021 e risco de tromboembolismo venoso baseado na escala de Pádua e na escala de Caprini. Resultados: a amostra do estudo foi de 216 pacientes, composta pela maioria do sexo masculino, com a mediana de idade de 37 anos. Em relação a gravidade do paciente, 60,19% foram classificados como atendimento de urgência e o tipo de acidente mais frequente foi o motociclístico. A região mais acometida em decorrência do trauma foi a perna e a coxa, sendo descritos os principais determinantes para a elevação da escala. Conclusão: o tromboembolismo venoso é um evento passível de atenção e cuidados para a prevenção. Por isso, a avaliação para estratificação de risco deve ser realizada para todos os pacientes vítimas de traumas ortopédicos.

Objective: to identify stratification of venous thromboembolism risk in orthopedic trauma patients. Method: in this quantitative, descriptive, cross-sectional study, data were collected from March to August 2021 and risk of venous thromboembolism based on the Padua and Caprini scales. Results: the study sample of 216, mostly male, patients were of median age 37 years. The patients were classified, by severity, as 60.19% emergency care and motorcycle accidents were the most frequent type. Leg and thigh were the region most affected by trauma and the main determinants for raising the scale were described. Conclusion: venous thromboembolism is an event amenable to preventive attention and care. Risk stratification assessment should thus be performed for all orthopedic trauma patients.

Objetivo: identificar la estratificación del riesgo de tromboembolismo venoso en pacientes de traumas ortopédicos. Método: estudio de enfoque cuantitativo, descriptivo, transversal, con datos recolectados de marzo a agosto de 2021 y riesgo de tromboembolismo venoso con base en la escala de Padua y la escala de Caprini. Resultados: la muestra del estudio estuvo constituida por 216 pacientes, en su mayoría del sexo masculino, con un promedio de edad de 37 años. En cuanto a la gravedad del paciente, el 60,19% se clasificó como atención de urgencia y el tipo de accidente más frecuente fue el de motocicleta. La región más afectada a consecuencia del traumatismo fue la pierna y el muslo, y se describieron los principales determinantes para la elevación de la escala. Conclusión: el tromboembolismo venoso es un evento que requiere atención y cuidados para su prevención. Por lo tanto, se debe realizar una evaluación de la estratificación del riesgo para todos los pacientes víctimas de traumas ortopédicos.

Tromboprofilaxis entrauma / Thromboprophylaxis in Trauma Santiago Castañeda Palacio1

Introducción: Las lesiones traumáticas son una de las principales causas de morbilidad y mortalidad en todo el mundo. Los pacientes que sufren traumatismos tienen riesgo de estados de hipercoagulación y aumentan el riesgo de sufrir enfermedad tromboembólica venosa. La tromboprofilaxis hace referencia a cualquier intervención usada para prevenir el desarrollo del tromboembolismo venoso como son la trombosis venosa profunda y el tromboembolismo pulmonar. Objetivo: Realizar una revisión sobre los principales mecanismos de tromboprofilaxis y sus principales esquemas en relación con el trauma ortopédico. Métodos: Se realizó una búsqueda de artículos de investigaciones originales en las bases de datos MEDLINE, EMBASE, Lilacs y Science Direct. Se seleccionaron palabras claves y términos del MeSH relacionados con anticoagulantes, tromboembolismo venoso, y embolismo pulmonar entre otros. La mayoría de bibliografía utilizada tuvo un rango de publicación no mayor a 5 años. Conclusiones: Los pacientes que sufren traumas tienen riesgo de sufrir estados de hipercoagulación y aumentan el riesgo de una enfermedad tromboembólica venosa. Con el fin de prevenirla se utilizan en la tromboprofilaxis distintos medicamentos, como heparinas de bajo peso molecular, y dispositivos de compresión(AU)

Introduction: Traumatic injuries are one of the leading causes of morbidity and mortality worldwide. Up to six million people die due to this cause. Trauma patients are at risk for hypercoagulable states and are at increased risk for venous thromboembolic disease. Thromboprophylaxis refers to any intervention used to prevent the development of venous thromboembolism such as deep vein thrombosis and pulmonary thromboembolism. Objective: To carry out a practical review of the main mechanisms of thromboprophylaxis and its main schemes in relation to orthopedic trauma. Methods: A search for original research articles was conducted in MEDLINE, EMBASE, Lilacs, and Science Direct databases. The keywords and MeSH terms related to anticoagulants, venous thromboembolism, and pulmonary embolism were selected among others. Most of the bibliography used had a publication range of no more than 5 years. Conclusions: Patients who suffer trauma are at risk of hypercoagulable states and these increase the risk of venous thromboembolic disease. In order to prevent it, different drugs are used in thromboprophylaxis, such as low molecular weight heparins, among others, as well as other compression devices(AU)

Tromboembolismo pulmonar masivo en covid-19: reporte de caso clínico / Massive pulmonary thromboembolism in covid-19: Clinical case report

La pandemia de COVID-19 actualmente ha demostrado la importancia de una evaluación y un manejo agresivos, al considerar su exposición como una enfermedad viral muy trasmisible que tiene efectos multisistémicos y una alta tasa de mortalidad. Es así que el diagnóstico y el tratamiento de la embolia pulmonar, son desafiantes en circunstancias habituales. Objetivo: Describir un caso clínico de tromboembolismo pulmonar masivo en covid-19. Reporte de Caso: Paciente de sexo masculino 42 años con antecedentes patológico personales de hipertensión arterial con prueba rápida para SARS COV-2 IGG e IGM positivo. Resultados: Se estima que cada año hay 900.000 casos de tromboembolismo venoso (TEV) en los Estados Unidos, 150.000 a 250.000 hospitalizaciones relacionadas con la embolia pulmonar (EP) y 60.000 a 100.000 muertes, lo que la convierte en la tercera causa más común de enfermedades cardiovasculares. Conclusión: Una vez que se diagnostica una embolia pulmonar, es necesaria la estratificación del riesgo para definir el manejo adecuado. Los tratamientos disponibles al momento pueden variar desde anticoagulación sola, trombólisis dirigida por catéter, trombólisis sistémica de dosis completa, embolectomía con catéter, embolectomía quirúrgica y soporte circulatorio mecánico como oxigenación por membrana extracorpórea (ECMO)(AU)

The COVID-19 pandemic has currently demonstrated the importance of aggressive evaluation and management, considering its exposure as a highly transmissible viral disease that has multisystem effects and a high mortality rate. Thus, the diagnosis and treatment of pulmonary embolism are challenging under usual circumstances. Objective: To describe a clinical case of massive pulmonary thromboembolism in covid-19. Case Report: A 42-year-old male patient with a personal pathological history of arterial hypertension with a positive rapid test for SARS COV-2 IGG and IGM. Results: There are an estimated 900,000 cases of venous thromboembolism (VTE) in the United States each year, 150,000 to 250,000 pulmonary embolism (PE)-related hospitalizations, and 60,000 to 100,000 deaths, making it the third most common cause of pulmonary embolism. cardiovascular diseases. Conclusion: Once a pulmonary embolism is diagnosed, risk stratification is necessary to define the appropriate management. Currently available treatments may range from anticoagulation alone, catheter-directed thrombolysis, full-dose systemic thrombolysis, catheter embolectomy, surgical embolectomy, and mechanical circulatory support such as extracorporeal membrane oxygenation (ECMO)(AU)

Profilaxia pré-exposição de tromboembolia venosa e enfermagem: A realidade de um hospital público universitário / Profilaxis preexposición de la tromboembolia venosa y enfermería: La realidad de un hospital público universitario / Pre-exposure prophylaxis of venous thromboembolism and nursing: The reality of a university public hospital

Objetivo: caracterizar o risco de tromboembolismo venoso e uso de profilaxia em pacientes clínicos e cirúrgicos, avaliando a conformidade ou não-conformidade da prescrição de profilaxia medicamentosa. Método: estudo transversal, com 3341 pacientes clínicos e cirúrgicos com protocolo de profilaxia de tromboembolismo venoso preenchido aprovado pelo Comitê de Ética em Pesquisa CAAE 62055616.7.00005411, com dados extraídos de relatório personalizado gerado automaticamente do prontuário eletrônico do paciente em planilha Excel®, do período de março/2017 a dezembro 2017. As análises iniciais foram obtidas a partir de medidas descritivas para as variáveis quantitativas e frequências e percentuais para variáveis categorizadas. Resultados: A taxa global de conformidade foi de 70% e os pacientes clínicos apresentaram maior conformidade de prescrição de profilaxia em relação aos pacientes cirúrgicos. Conclusão: A profilaxia medicamentosa para tromboembolismo venoso é subutilizada, principalmente em pacientes cirúrgicos. Os pacientes clínicos receberam mais profilaxia que os cirúrgicos, predominando a indicação da enoxaparina sódica.(AU)

Objective: to characterize the risk of venous thromboembolism and the use of prophylaxis in clinical and surgical patients, evaluating the compliance or non-compliance with the prescription of drug prophylaxis. Method: a cross-sectional study with 3341 clinical and surgical patients with a completed venous thromboembolism prophylaxis protocol approved by the Research Ethics Committee CAAE 62055616.7.00005411, with data extracted from a personalized report automatically generated from the patient's electronic medical record in an Excel® spreadsheet, from the period from March/2017 to December 2017. The initial analyzes were obtained from descriptive measures for quantitative variables and frequencies and percentages for categorized variables. Results: The overall compliance rate was 70% and clinical patients showed greater compliance with prophylaxis prescriptions compared to surgical patients. Conclusion: Drug prophylaxis for venous thromboembolism is underused, especially in surgical patients. Clinical patients received more prophylaxis than surgical patients, with the indication of enoxaparin sodium predominating.(AU)

Objetivo: caracterizar el riesgo de tromboembolismo venoso y el uso de profilaxis en pacientes clínicos y quirúrgicos, evaluando el cumplimiento o incumplimiento de la prescripción de profilaxis farmacológica. Método: estudio transversal con 3341 pacientes clínicos y quirúrgicos con protocolo completo de profilaxis de tromboembolismo venoso aprobado por el Comité de Ética en Investigación CAAE 62055616.7.00005411, con datos extraídos de un informe personalizado generado automáticamente a partir de la historia clínica electrónica del paciente en un Excel® hoja de cálculo, del período de marzo/2017 a diciembre de 2017. Los análisis iniciales se obtuvieron a partir de medidas descriptivas para variables cuantitativas y frecuencias y porcentajes para variables categorizadas. Resultados: La tasa de cumplimiento global fue del 70% y los pacientes clínicos mostraron un mayor cumplimiento de las prescripciones de profilaxis en comparación con los pacientes quirúrgicos. Conclusión: La profilaxis farmacológica del tromboembolismo venoso está infrautilizada, especialmente en pacientes quirúrgicos. Los pacientes clínicos recibieron más profilaxis que los pacientes quirúrgicos, predominando la indicación de enoxaparina sódica.(AU)

Plasma D-dimer value corrected by inflammatory markers in patients with SARS-CoV-2 infection: Its prognostic value in the diagnosis of venous thromboembolism / Valor del dímero-D corregido por marcadores inflamatorios en pacientes con infección por SARS-CoV-2 en el diagnóstico de enfermedad tromboembólica venosa

Introduction:D-dimer levels are elevated in COVID 19 and they correlate to the levels of other inflammatory markers such us ferritin, fibrinogen and C-reactive protein. It may be possible to correct D-dimer value in function of inflammatory markers, thus identifying patients at higher risk of venous thromboembolism (VTE). Our objectives are estimating a corrected value of plasma D-dimer as a linear function of ferritin, C-reactive protein and fibrinogen and stablishing a cut-off point of high probability of VTE.Patients and methods:Age and sex matched case-control study of all patients diagnosed with COVID 19 and VTE between March and May 2020 in a tertiary hospital in Madrid (Spain). Using linear regression, the best predictive model will be estimated and residual D-dimer values will be obtained and analyzed using ROC curves to determine its discriminative performance.Results:Thirty-eight cases and seventy-six controls were included. There was 63.2% of men and mean age was 68.2. D-dimer was best predicted by a linear model including fibrinogen, ferritin and C-reactive protein. Using residual values, the optimal cutoff point was 2165ng/mL, with a sensitivity of 57.9% and specificity of 98.7%.Conclusion:It is possible to estimate a D-dimer corrected value in function of ferritin, C-reactive protein and fibrinogen. Using the observed and estimated value we can obtain a residual value that performs well as a screening method to detect patients who would benefit for further VTE diagnostic testing.(AU)

Introducción:El dímero-D está elevado en la COVID-19 y se correlacionan con los niveles de otros marcadores inflamatorios como ferritina, fibrinógeno y proteína C reactiva. Cabe la posibilidad de corregir el dímero-D en función de dichos marcadores inflamatorios, identificando así los pacientes con mayor riesgo de enfermedad tromboembólica venosa (ETV). Nuestros objetivos son estimar un valor corregido de dímero-D como función lineal de ferritina, proteína C reactiva y fibrinógeno, y establecer un punto de corte de alta probabilidad de ETV.Pacientes y métodos:Estudio de casos y controles emparejados por sexo y edad de todos los pacientes diagnosticados con COVID-19 y ETV entre marzo y mayo de 2020 en un hospital terciario de Madrid, España. Mediante regresión lineal, se estima el mejor modelo predictivo y se obtiene el valor residual de dímero-D. Este se analizará con curvas ROC para determinar su capacidad discriminativa.Resultados:Se incluyeron 38 casos y 76 controles. Había un 63,2% de varones y la edad media fue de 68,2 años. El valor de dímero-D fue predicho por un modelo que incluyó fibrinógeno, ferritina y proteína C reactiva. Usando los valores residuales, el punto de corte óptimo estimado de 2.165ng/ml, con una sensibilidad del 57,9% y una especificidad del 98,7%.Conclusiones:Es posible estimar un valor corregido de dímero-D en función de ferritina, fibrinógeno y proteína C reactiva. Usando el valor observado y estimado podemos obtener un valor residual que funciona bien como método de cribado para detectar pacientes que podrían beneficiarse de más estudios diagnósticos de la ETV. (AU)

Plasma D-dimer value corrected by inflammatory markers in patients with SARS-CoV-2 infection: Its prognostic value in the diagnosis of venous thromboembolism.

INTRODUCTION: D-dimer levels are elevated in COVID 19 and they correlate to the levels of other inflammatory markers such us ferritin, fibrinogen and C-reactive protein. It may be possible to correct D-dimer value in function of inflammatory markers, thus identifying patients at higher risk of venous thromboembolism (VTE). Our objectives are estimating a corrected value of plasma D-dimer as a linear function of ferritin, C-reactive protein and fibrinogen and stablishing a cut-off point of high probability of VTE. PATIENTS AND METHODS: Age and sex matched case-control study of all patients diagnosed with COVID 19 and VTE between March and May 2020 in a tertiary hospital in Madrid (Spain). Using linear regression, the best predictive model will be estimated and residual D-dimer values will be obtained and analyzed using ROC curves to determine its discriminative performance. RESULTS: Thirty-eight cases and seventy-six controls were included. There was 63.2% of men and mean age was 68.2. D-dimer was best predicted by a linear model including fibrinogen, ferritin and C-reactive protein. Using residual values, the optimal cutoff point was 2165ng/mL, with a sensitivity of 57.9% and specificity of 98.7%. CONCLUSION: It is possible to estimate a D-dimer corrected value in function of ferritin, C-reactive protein and fibrinogen. Using the observed and estimated value we can obtain a residual value that performs well as a screening method to detect patients who would benefit for further VTE diagnostic testing.

Aspectos clínico-patológicos associados a eventos tromboembólicos venosos em pessoas diagnosticadas com neoplasias malignas não hematológicas: um estudo caso controle / Clinicopathological aspects associated with venous thromboembolic events in people diagnosed with non-hematological malignancies: a case-control study

INTRODUÇÃO: Tromboembolismo venoso (TEV) apresenta incidência elevada em pacientes oncológicos e é importante causa de morbimortalidade nesse grupo. Fatores relacionados ao paciente, ao câncer ou mesmo aos tratamentos empregados podem associar-se com um maior risco de eventos trombóticos venosos. Entretanto, o tema ainda é pouco compreendido e pouco estudado na população brasileira. OBJETIVOS: Avaliar comparativamente aspectos demográficos, histopatológicos e clínicos em pacientes com neoplasias sólidas que apresentaram ou não TEV. Avaliar possíveis fatores associados a eventos tromboembólicos venosos. Analisar as características dos eventos tromboembólicos venosos identificados. MÉTODOS: Trata-se de um estudo observacional, retrospectivo, etiológico, tipo caso controle, não pareado. Foram selecionados pacientes diagnosticados com câncer entre 2014 e 2019, acompanhados no Hospital das Clínicas da Universidade Federal de Minas Gerais, um serviço público de referência em oncologia. Casos foram definidos como pacientes com diagnóstico de TEV (desfecho) e controles aqueles sem eventos trombóticos. A exposição avaliada foi a realização de algum tratamento oncológico específico (quimioterápico, endócrino, radioterápico ou cirúrgico). Variáveis de relevância clínica foram selecionadas para análise univariada (idade, sexo, estadiamento da doença, sítios tumorais conforme escore de Khorana, realização de tratamento oncológico específico, realização de tratamentos conhecidamente trombogênicos) e potenciais fatores de confusão foram adicionados para análise multivariada. Todos os dados foram coletados por meio de revisão de prontuários médicos. RESULTADOS: Foram incluídos 91 pacientes no grupo casos e 182 no grupo controles (1:2). Ambos os grupos foram semelhantes em relação às características demográficas, histopatológicas e clínicas, porém o grupo casos apresentou maior taxa de mortalidade (30,8% versus 15,9%, p=0,04). Em análise univariada, estadiamento avançado foi associado a maior risco de TEV (OR 1,85; IC 95% 1,04-3,30; p=0,036) e tratamento com hormonioterapia foi fator protetor (OR 0,41; IC 95% 0,21-0,82; p=0,010). Após adição de fatores confundidores, análises multivariadaa mantiveram terapia endócrina associada a menor risco de TEV (OR 0,18; IC 95% 0,07-0,47; p=0,000 e OR 0,41; IC 95% 0,20-0,86; p=0,018), sem identificação de fatores de risco. Internação hospitalar (35,2%) e cirurgia (23,1%) foram os principais fatores de risco presentes nos três meses que precederam os eventos. Trombose venosa profunda (TVP) em membros inferiores ocorreu em 54,9% dos casos e tromboembolismo pulmonar (TEP) em 37,4%. Em relação ao tratamento para TEV, 52,7% dos pacientes fizeram uso de varfarina e 40,7% de novos anticoagulantes orais. CONCLUSÃO: TEV é importante causa de mortalidade em pacientes oncológicos, uma população bastante heterogênea, em que fatores associados podem se comportar de formas diferentes. No presente estudo, hormonioterapia foi fator de proteção para TEV, possivelmente porque pacientes com indicação de terapia endócrina apresentam doença inicial ou metastática controlada, com menor risco para eventos tromboembólicos venosos.

INTRODUCTION: Venous thromboembolism (VTE) has a high incidence in cancer patients, being a cause of significant morbidity and mortality in this group. Several factors are associated with a higher risk of thrombotic events, which may be related to the patient, cancer or even the treatments used. However, this topic is still poorly understood and there are few studies in the Brazilian population. OBJECTIVES: To comparatively evaluate demographic, histopathological and clinical aspects in patients with solid tumors who had or did not have VTE. To assess possible factors associated with venous thromboembolic events. To analyze the characteristics of the venous thromboembolic events. METHODS: This is an observational, retrospective, etiological, case-control, unpaired study. Were selected patients diagnosed with cancer between 2014 and 2019 and treated at the Hospital das Clínicas da Universidade Federal de Minas Gerais, a public service of reference in oncology. Cases were defined as patients diagnosed with VTE (outcome) and controls as those without thrombotic events. Exposure was defined as receiving a specific oncological treatment (chemotherapy, endocrine therapy, radiotherapy or surgery). Clinically relevant variables were selected for univariate analysis (age, sex, disease staging, tumor sites according to Khorana score, specific oncological treatment, known thrombogenic treatments) and potential confounders were added for multivariate analysis. All data were collected by reviewing medical records. RESULTS: Ninety-one patients were included in the case group and 182 in the control group (1:2). Both groups were similar in terms of demographic, histopathological and clinical characteristics, but the case group had a higher mortality rate (30.8% versus 15.9%, p=0.04). In univariate analysis, advanced staging was associated with a higher risk of VTE (OR 1,85; CI 95% 1,04-3,30; p=0,036) and treatment with hormone therapy was a protective factor (OR 0,41; CI 95% 0,21-0,82; p=0,010). After adding confounding factors, multivariate analyzes maintained endocrine therapy associated with a lower risk of VTE (OR 0.18; 95% CI 0.07-0.47; p=0.000 and OR 0.41; 95% CI 0.20- 0.86; p=0.018), without identifying risk factors. Hospitalization (35.2%) and surgery (23.1%) were the main risk factors present in the three months preceding the events. Lower extremity deep venous thrombosis (DVT) occurred in 54.9% of cases and pulmonary embolism (PE) in 37.4%. About treatment for VTE, 52.7% of the patients used warfarin and 40.7% used new oral anticoagulants. CONCLUSION: VTE is an important cause of mortality in cancer patients, a very heterogeneous population, in which associated factors can behave in different ways. In the present study, hormone therapy was a protective factor for VTE, possibly because patients with indication for endocrine therapy have initial or controlled metastatic disease, with a lower risk for venous thromboembolic events.

Profilaxia do tromboembolismo venoso nas cirurgias ortopédicas / Venous thromboprophylaxis in orthopedic surgeries

A trombose venosa profunda (TVP) e o tromboembolismo pulmonar (TEP) são as principais manifestações clínicas do tromboembolismo venoso (TEV). O TEV é uma complicação comum e potencialmente grave das cirurgias ortopédicas, uma vez que pode levar à limitação funcional e morte pós-operatória. O uso da tromboprofilaxia reduz acentuadamente a incidência de TEV relacionado às intervenções ortopédicas, e seu uso é recomendado por diversas diretrizes. Entretanto, a indicação e o tipo de tromboprofilaxia para algumas intervenções ortopédicas, assim como o uso de ferramentas de predição de risco, ainda não estão bem estabelecidos e constituem pontos de debate. Os objetivos deste trabalho foram identificar os fatores de risco para TEV e suas interações nas cirurgias ortopédicas e avaliar a aplicabilidade do escore de risco de Caprini na predição de TEV em pacientes ortopédicos. Além disso, devido à escassez de conhecimento e recomendações sobre tromboprofilaxia nas intervenções ortopédicas de tornozelo e pé, realizaram-se uma revisão narrativa e uma enquete internacional sobre o assunto. Para analisar a interação de fatores de risco de TEV e a aplicabilidade preditiva do escore de Caprini nas cirurgias ortopédicas, foram utilizados os dados do Multiple Environmental and Genetic Assessment of risk factors for venous thrombosis (MEGA), um estudo caso-controle holandês de base populacional cujo desfecho de interesse é o TEV. Neste, 263 indivíduos que tiveram TEV e 94 controles foram submetidos à cirurgia ortopédica. O risco de TEV foi maior nos primeiros 30 dias após a cirurgia [odds ratio ajustada (ORadj) 17,5; intervalo de confiança (IC) 95%, 9,2-33,4] e manteve-se aumentado até 90 dias (ORadj 11,5; IC 95%, 7,3-17,7). Houve interação entre cirurgia ortopédica e mutação fator V Leiden (ORadj 17,5; IC 95%, 4,1-73,6), tipo de sangue não-O (ORadj 11,2; 95% IC, 3,4-34,0) e níveis séricos de fator VIII maiores que 150 mg/dl (ORadj 18,6; IC, 7,4-46,9). Quanto ao escore de Caprini, foram avaliados 357 indivíduos com TEV submetidos à cirurgia ortopédica. Um total de 20,9% dos casos e 41,5% dos controles foram classificados no grupo de menor risco (Caprini < 5 pontos). Pacientes com um escore de Caprini maior que 11 pontos tiveram um risco de TEV seis vezes maior (OR 6,3; IC 95%, 1,7-22,9), e pacientes com um escore de 9 a 10 tiveram um risco três vezes maior (OR 3,5; IC 95% 1,2-10,3). A área sob a curva (AUC) do escore de Caprini foi de 0,64, evidenciando uma discriminação de predição de TEV moderada. Na enquete internacional sobre tromboprofilaxia de pé e tornozelo, 693 cirurgiões ortopédicos de pé e tornozelo de 49 países participaram. Aproximadamente 50% informaram prescrever tromboprofilaxia durante a imobilização do paciente. Quando utilizada, as escolhas preferidas em ordem decrescente foram ácido acetilsalicílico (AAS), heparina de baixo peso molecular (HBPM) e anticoagulantes orais diretos. AAS e HBPM foram predominantemente prescritos na América do Norte e Europa, respectivamente. TVP prévia, imobilidade, obesidade e trombofilia hereditária foram considerados os principais fatores de risco indicativos do uso de tromboprofilaxia. Concluiu-se que: houve risco aumentado de TEV e interação entre os fatores de risco fator V Leiden, níveis elevados de fator VIII e grupo sanguíneo não- O com cirurgia ortopédica; o escore de Caprini é uma ferramenta que pode auxiliar os cirurgiões ortopédicos a classificarem o risco de TEV no pós-operatório, embora seu desempenho preditivo discriminativo tenha sido moderado; apesar de a maioria dos cirurgiões ortopédicos de tornozelo e pé considerarem que a tromboprofilaxia está indicada para cirurgias de tornozelo e pé (principalmente na presença de fatores de risco como TVP prévia, imobilidade, obesidade e trombofilia hereditária), a prescrição, o tipo e a duração apresentam grande discrepância intercontinental. Assim, este trabalho contribui para a identificação de pacientes sob alto risco de TEV, ponto estratégico para o uso individualizado e seguro da tromboprofilaxia como ferramenta para redução do risco de TEV relacionado às cirurgias ortopédicas.

Deep vein thrombosis (DVT) and pulmonary embolism are the main clinical manifestations of venous thromboembolism (VTE). VTE is a common and potentially serious complication of orthopedic surgeries, as it can lead to functional limitation and postoperative death. The use of thromboprophylaxis markedly reduces the incidence of VTE related to orthopedic interventions, and its use is recommended by several guidelines. However, the indication and type of thromboprophylaxis for some orthopedic interventions, as well as the use of risk prediction tools are still not well established and is debatable. The objectives of this study were to identify risk factors for VTE and their interactions in orthopedic surgeries and to evaluate the applicability of the Caprini risk score in predicting VTE in orthopedic patients. In addition, due to the lack of knowledge and recommendations on thromboprophylaxis in foot and ankle surgeries, a narrative review and an international survey on the subject were carried out. Data from the MEGA Study (Multiple Environmental and Genetic Assessment of risk factors for venous thrombosis) which is a Dutch population-based case-control study whose outcome of interest is VTE were used. A total of 263 subjects who had VTE and 94 controls underwent orthopedic surgery. The risk of VTE was the highest in the first 30 days after surgery (adjusted odds ratio [ORadj] 17.5; 95% CI [confidence interval], 9.2-33.4) and remained increased up to 90 days (ORadj, 11.5; 95% CI, 7.3- 17.7). There was interaction between orthopedic surgery and factor V Leiden mutation (ORadj 17.5, 95%CI 4.1-73.6), non-O blood type (ORadj 11.2; 95%CI 3.4-34.0) and factor VIII plasma levels greater than 150 mg/dl (ORadj 18.6; CI 7.4-46.9). To assess the applicability of the Caprini Score, 357 individuals with VTE undergoing orthopedic surgery in the MEGA were evaluated. A total of 20.9% of cases and 41.5% of controls were classified in the lowest risk group (Caprini <5 points). Patients with a Caprini score greater than 11 points had a six-fold increased risk of VTE (OR 6.3, 95% CI 1.7- 22.9) and patients with a score of 9-10 had about three-fold increased risk (OR 3.5, 95% CI 1.2-10.3). The area under curve for the Caprini score was 0.64, evidencing a moderate VTE prediction discrimination. In the international survey on foot and ankle thromboprophylaxis, 693 orthopedic foot and ankle surgeons from 49 countries participated. Approximately 50% reported prescribing thromboprophylaxis during patient immobilization that, when used, the preferred choice, in descending order, was acetylsalicylic acid (ASA), low molecular weight heparin (LMWH) and direct oral anticoagulants. ASA and LMWH were predominantly prescribed in North America and Europe, respectively. Previous DVT, immobility, obesity and hereditary thrombophilia were considered the main risk factors indicative of the use of thromboprophylaxis. It is concluded that there was increased risk of VTE and interaction between factor V Leiden, high plasma levels of factor VIII or non-O blood group and orthopedic surgery; that the Caprini score is a tool that can help orthopedic surgeons to classify the risk of postoperative VTE, although its discriminative predictive performance was moderate and that although most ankle and foot orthopedic surgeons consider that thromboprophylaxis is indicated for ankle and foot surgeries (especially in the presence of risk factors such as previous DVT, immobility, obesity and hereditary thrombophilia), the prescription, type and duration present a large intercontinental discrepancy. Thus, this work contributed to the identification of patients at high risk of VTE, a strategic point for the individualized and safe use of thromboprophylaxis as a tool to reduce the risk of VTE related to orthopedic surgeries.

Protocol for prophylaxis of venous thromboembolism in varicose vein surgery of the lower limbs / Protocolo para a profilaxia do tromboembolismo venoso em cirurgia de varizes dos membros inferiores

ABSTRACT Pulmonary embolism is the most feared complication of venous thromboembolism (VTE) and the third leading cause of cardiovascular mortality in the world, after acute myocardial infarction and stroke. The risk of VTE is virtually universal in hospitalized patients, especially those with reduced mobility. Although variable in incidence between clinical and surgical patients, up to 66.6% of events related to hospitalizations can occur after discharge, with this risk remaining for up to 90 days. Despite all the investment made in VTE prophylaxis in recent decades, there is still no consensus or specific guidelines for its prevention in patients undergoing conventional surgery for varicose veins of lower limbs. The adoption of a validated risk assessment model for VTE prophylaxis, based on the current literature, may help in the implementation and standardization of VTE prophylaxis in conventional lower limb varicose vein surgery, in addition to this benefit, it may lead to a reduction in the length of hospital stay and the number of readmissions.

RESUMO O tromboembolismo pulmonar é a complicação mais temida do tromboembolismo venoso (TEV) e a terceira causa de mortalidade cardiovascular no mundo, atrás apenas do infarto agudo do miocárdio e do acidente vascular cerebral. O risco de TEV é praticamente universal nos pacientes hospitalizados, especialmente naqueles com redução da mobilidade. Embora variável em incidência entre os pacientes clínicos e cirúrgicos, até 66,6% dos eventos relacionados às internações, podem ocorrer após a alta, permanecendo este risco por até 90 dias. Apesar de todo investimento feito na profilaxia do TEV nas últimas décadas, ainda não existem consensos ou diretrizes específicos para a sua prevenção em pacientes submetidos à cirurgia convencional de varizes dos membros inferiores. A adoção de um modelo de avaliação de risco validado para a profilaxia do TEV, embasado na literatura vigente, poderá ajudar na implementação e padronização da profilaxia do TEV na cirurgia convencional de varizes de membros inferiores, além deste benefício, poderá levar a diminuição do tempo de internação hospitalar e do número de reinternações.

Identificación del riesgo de trombosis en pacientes con padecimientos oncológicos ambulatorios en quimioterapia

RESUMEN Fundamento existe una relación establecida entre el cáncer y la aparición y desarrollo de enfermedad tromboembólica. Se hace necesario identificar a los pacientes con un riesgo aumentado de tromboembolismo venoso utilizando escalas predictivas para individualizar el riesgo. Objetivo identificar el riesgo de trombosis en el paciente con padecimientos oncológicos ambulatorios en quimioterapia. Método se realizó un estudio descriptivo de corte transversal, en una serie de casos, atendidos en el Servicio de Oncología Clínica del Hospital General Universitario Dr. Gustavo Aldereguía Lima, de Cienfuegos, en el período comprendido entre el primero de junio de 2020 hasta el treinta de abril de 2021. La información se obtuvo del expediente clínico y un modelo recolector de datos. Las variables analizadas fueron: edad, sexo, sitio del tumor primario, conteo de plaquetas previo a la quimioterapia, niveles de hemoglobina sérica, uso de eritropoyetina, conteo leucocitario previo a la quimioterapia e índice de masa corporal. Los datos obtenidos se procesaron mediante el programa estadístico SPSS versión 21 y los resultados se presentan en tablas mediante números absolutos y porcientos. Resultados el grupo de edad más frecuente fue el de 60 años y más con 77 pacientes (51,3 %), del sexo masculino 45 (30 %). La aplicación del modelo de predicción de Khorana marcó un porcentaje relevante (26 %) de pacientes con riesgo intermedio y alto de trombosis. Conclusiones la investigación muestra una población adulta mayoritariamente envejecida, con factores de riesgo de trombosis relacionados con el paciente, la enfermedad oncológica y los tratamientos sistémicos.

ABSTRACT Background: there is an established relationship between cancer and the appearance and development of thromboembolic disease. It is necessary to identify patients with an increased risk of venous thromboembolism using predictive scales to individualize the risk. Objective: to identify the risk of thrombosis in patients with suffering cancer conditions undergoing chemotherapy. Method: a series of cases descriptive cross-sectional study, treated at the Clinical Oncology Service of the Dr. Gustavo Aldereguía Lima University General Hospital, Cienfuegos, from June the 1st, 2020 to April 30th, 2021. The information was obtained from the clinical record and a data collection model. The variables analyzed were: age, sex, site of the primary tumor, platelet count prior to chemotherapy, serum hemoglobin levels, erythropoietin use, leukocyte count prior to chemotherapy, and body mass index. The data obtained were processed using the SPSS version 21 statistical program and the results are presented in tables using absolute numbers and percentages. Results: the most frequent age group was 60 years old and over with 77 patients (51.3 %), 45 (30 %) male. The application of the Khorana score marked a relevant percentage (26 %) of patients with intermediate and high risk of thrombosis. Conclusions: the research shows a mostly aged adult population, with risk factors for thrombosis related to the patient, oncological disease and systemic treatments.

Enfoque del tromboembolismo pulmonar agudo desde el momento inicial en el servicio de urgencias / Initial Approach to Acute Pulmonary Embolism since the Initial Moment in the Emergency Department / Abordagem para tromboembolismo pulmonar agudo desde o momento inicial no departamento de emergência

El tromboembolismo pulmonar es la manifestación más grave de la enfermedad tromboembólica venosa y la tercera causa de mortalidad cardiovascular. Su sintomatología puede ir desde un cuadro asintomático o con síntomas leves, hasta el paro cardiaco. Dentro del enfoque de esta patología es importante tener en cuenta escalas que permiten estimar la probabilidad de que determinado paciente con ciertos signos, síntomas y factores de riesgo presente un tromboembolismo pulmonar, así como escalas diseñadas para valorar el riesgo de morir, en pacientes en los que ya se estableció este diagnóstico. Los pilares del tratamiento son la anticoagulación y la trombólisis, sin embargo, esta última está indicada únicamente en algunos casos. La presente revisión tiene como objetivo presentar una actualización de la evidencia sobre el enfoque diagnóstico y terapéutico del tromboembolismo pulmonar agudo, desde el ingreso del paciente al servicio de urgencias.

Pulmonary embolism is the most severe manifestation of venous thromboembolic disease and the third cause of cardiovascular mortality. Its symptoms can range from asymp-tomatic or mild symptoms to cardiac arrest. The approach to patients with suspected pulmonary embolism includes scores that allow estimating the clinical probability that a certain patient with certain signs, symptoms and risk factors will present a pulmonary thromboembolism, as well as scores that classify patients by severity and risk of hemody-namic decompensation. Treatment is based on anticoagulation and thrombolysis, which is used only in certain patients. The goal of this review is to present updated evidence regarding diagnosis and treatment of acute pulmonary embolism from the moment the patient arrives at the emergency room.

A embolia pulmonar é a manifestação mais grave da doença tromboembólica venosa e a terceira principal causa de mortalidade cardiovascular. Seus sintomas podem variar de sintomas assintomáticos ou leves a parada cardíaca. No enfoque desta patologia, é importante levar em consideração escalas que permitem estimar a probabilidade de um determinado paciente com determinados sinais, sintomas e fatores de risco apresentar tromboembolismo pulmonar, bem como escalas destinadas a avaliar o risco de morrer, em pacientes nos quais esse diagnóstico já foi estabelecido. Os pilares do tratamento são a anticoagulação e a trombólise, porém, esta última está indicada apenas em alguns casos. A presente revisão tem como objetivo apresentar uma atualização das evidências sobre a abordagem diagnóstica e terapêutica do tromboembolismo pulmonar agudo, desde a admissão do paciente no pronto-socorro.