Perioperative thromboprophylaxis is highly variable in general surgery: results from a multicentre survey

Liu, David Shi Hao; Wong, Enoch; Fong, Jonathan J.; Stevens, Sean; Mori, Krinal

doi:10.1111/ans.16223

Cited by 9 publications

(22 citation statements)

References 6 publications

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“…This has been shown in multicenter studies by the PROTECTinG (Perioperative Timing of Elective Chemical Thromboprophylaxis in General surgery) investigators within the VERITAS (Victorian-collaborative for Education, Research, Innovation, Training and Audit by Surgical trainees) collaborative. 1 , 4 , 5 Within this general surgical cohort, there is particular heterogeneity amongst patients undergoing major abdominal visceral resections. 1 Timing of chemoprophylaxis has been shown to affect the risk of bleeding in other general surgical procedures such as cholecystectomy and breast surgery.…”

Section: Introductionmentioning

confidence: 99%

Early Versus Postoperative Chemical Thromboprophylaxis Is Associated with Increased Bleeding Risk Following Abdominal Visceral Resections: a Multicenter Cohort Study

Liu

Newbold

Stevens

et al. 2022

Journal of Gastrointestinal Surgery

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Background Abdominal visceral resections incur relatively higher rates of postoperative bleeding and venous thromboembolism (VTE). While guidelines recommend the use of perioperative chemical thromboprophylaxis, the most appropriate time for its initiation is unknown. Here, we investigated whether early (before skin closure) versus postoperative commencement of chemoprophylaxis affected VTE and bleeding rates following abdominal visceral resection. Methods Retrospective review of all elective abdominal visceral resections undertaken between January 1, 2018, and June 30, 2019, across four tertiary-referral hospitals. Major bleeding was defined as the need for blood transfusion, reintervention, or > 20 g/L fall in hemoglobin from baseline. Clinical VTE was defined as imaging-proven symptomatic disease < 30 days post-surgery. Results A total of 945 cases were analyzed. Chemoprophylaxis was given early in 265 (28.0%) patients and postoperatively in 680 (72.0%) patients. Mean chemoprophylaxis exposure doses were similar between the two groups. Clinical VTE developed in 14 (1.5%) patients and was unrelated to chemoprophylaxis timing. Postoperative bleeding occurred in 71 (7.5%) patients, with 57 (80.3%) major bleeds, requiring blood transfusion in 48 (67.6%) cases and reintervention in 31 (43.7%) cases. Bleeding extended length-of-stay (median (IQR), 12 (7–27) versus 7 (5–11) days, p < 0.001). Importantly, compared to postoperative chemoprophylaxis, early administration significantly increased the risk of bleeding (10.6% versus 6.3%, RR 1.45, 95% CI 1.05–1.93, p = 0.038) and independently predicted its occurrence. Conclusions The risk of bleeding following elective abdominal visceral resections is substantial and is higher than the risk of clinical VTE. Compared with early chemoprophylaxis, postoperative initiation reduces bleeding risk without an increased risk of clinical VTE.

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Section: Introductionmentioning

confidence: 99%

Early Versus Postoperative Chemical Thromboprophylaxis Is Associated with Increased Bleeding Risk Following Abdominal Visceral Resections: a Multicenter Cohort Study

Liu

Newbold

Stevens

et al. 2022

Journal of Gastrointestinal Surgery

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“…The dogma that “VTE occurs on-table”8 and therefore all patients should receive chemoprophylaxis before skin closure was not borne out in this study of high-risk patients. Notably, this sentiment stemmed from a period, some 30 to 40 years ago, when mechanical thromboprophylaxis was not routinely used 2,3.…”

Section: Discussionmentioning

confidence: 92%

“…Consequently, this has led to significant variations in practice, 1 with usage commonly based on personal biases, surgical dogma, and incomplete evidence. 8 Such practice variation is suboptimal and can potentially compromise patient outcomes through increased incidence of bleeding and VTE.…”

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confidence: 99%

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Optimal Timing of Perioperative Chemoprophylaxis in Patients With High Thromboembolic Risk Undergoing Major Abdominal Surgery

Liu¹,

Stevens²,

Watson³

et al. 2022

Annals of Surgery

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To determine whether early (before skin closure) versus postoperative chemoprophylaxis affects the incidence of venous thromboembolism (VTE) and bleeding following major abdominal surgery, in a high thromboembolic risk population. Background: Major abdominal surgery incurs both VTE and bleeding risks. Patients with high preoperative VTE risk derive the most benefit from chemoprophylaxis, but carry an increased risk of bleeding. The optimal window for chemoprophylaxis in the perioperative period, whereby both VTE and bleeding risks are minimized, is unknown. Methods: Analysis of pooled data from 5 multicenter studies including only high thromboembolic risk (Caprini score > 4) patients. Clinical VTE was defined as radiographically proven symptomatic disease <30 days postsurgery. Major bleeding was defined as the need for blood transfusion, reintervention, or > 20 g/L fall in hemoglobin. Results: From 5501 cases, chemoprophylaxis was initiated early in 1752 (31.8%) patients and postoperatively in 3749 (68.2%) patients. Baseline characteristics were similar between study groups. The incidence of clinical VTE was not associated with chemoprophylaxis timing [early 0.7% vs. postop 0.7%, odds ratio (OR): 1.11, 95% confidence interval (CI): 0.60-2.15, P = 0.730]. Contrastingly, compared with postoperative chemoprophylaxis, early usage increased the risk of all bleeding (5.1% vs. 2.6%, OR: 2.04, 95% CI: 1.52-2.73, P < 0.001) major bleeding (3.6% vs. 1.8%, OR: 1.99, 95% CI: 1.40-2.81, P < 0.001), and reintervention (2.0% vs. 1.0%, OR: 2.10, 95% CI: 1.32-3.35, P = 0.003). Early chemoprophylaxis independently predicted postoperative bleeding (OR: 1.71, 95% CI: 1.25-2.34, P < 0.001), but not VTE. Conclusions: In high VTE risk patients undergoing major abdominal surgery, chemoprophylaxis commenced postoperatively reduces bleeding risk without affecting clinical VTE risk.

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“…Despite establishment of guidelines and encouragement from numerous surgical societies [ 13 , 14 ], clinicians do not consistently identify at-risk patients and frequently do not select appropriate chemoprophylaxis. Inappropriate chemoprophylaxis including erroneous dose prescription or failure to order any chemoprophylaxis occurs for up to 40%–50% of surgical patients [ 6 , 15 , 16 ]. There has been increasing use of risk assessment models to aid in identification and stratification of at-risk patients [ 17 ].…”

Section: Introductionmentioning

confidence: 99%

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

Rastogi

Lattimore

Mehaffey

et al. 2022

Surgery Open Science

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Perioperative thromboprophylaxis is highly variable in general surgery: results from a multicentre survey

Cited by 9 publications

References 6 publications

Early Versus Postoperative Chemical Thromboprophylaxis Is Associated with Increased Bleeding Risk Following Abdominal Visceral Resections: a Multicenter Cohort Study

Early Versus Postoperative Chemical Thromboprophylaxis Is Associated with Increased Bleeding Risk Following Abdominal Visceral Resections: a Multicenter Cohort Study

Optimal Timing of Perioperative Chemoprophylaxis in Patients With High Thromboembolic Risk Undergoing Major Abdominal Surgery

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

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