Variations in practice of thromboprophylaxis across general surgical subspecialties: a multicentre (<scp>PROTECTinG</scp>) study of elective major surgeries

Liu, David S.; Stevens, Sean; Wong, Enoch; Fong, Jonathan J.; Mori, Krinal; Fleming, Nicola; Beh, Pith Soh; Crowe, Amy; Howard, T. Leon; Slevin, Maeve; Jain, Anshini; Gill, Anna Sonia; Lee, Sharon; Jamel, Wael; Bennet, Simon; Chung, C. C.; Ward, Salena; Muralidharan, Vijayaragavan; collaborative, Veritas

doi:10.1111/ans.16374

Cited by 13 publications

(37 citation statements)

References 17 publications

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“…Patients were identified from each hospital’s administrative database using the Australian Classification of Health Interventions procedural code for esophagectomy, gastrectomy, splenectomy, hepatectomy, pancreatectomy, duodenectomy, small bowel resection, colectomy, and proctectomy. 1 These procedures were chosen as they shared a similar bleeding and VTE risk profile, 1 and patients were expected to stay in hospital for greater than two postoperative days. We excluded patients under 18 years of age, stand-alone cholecystectomy, and bariatric and emergency procedures.…”

Section: Methodsmentioning

confidence: 99%

“…Patients undergoing major abdominal visceral resection are at risk of both venous thromboembolism (VTE) and postoperative bleeding. 1 Both perioperative complications cause significant morbidity and mortality and contribute to the burden of healthcare costs. International guidelines recommend the use of both pharmacological and mechanical strategies to prevent perioperative VTE.…”

Section: Introductionmentioning

confidence: 99%

“…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%

“… 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. 5 , 6 We believe that poorly timed chemoprophylaxis may result in increased patient morbidity, due to either postoperative bleeding or VTE.…”

Section: Introductionmentioning

confidence: 99%

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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: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

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 first paper 1 reports on a survey of surgeons' stated practice. The second 2 is a large retrospective study of around 6000 general surgical procedures performed within the same hospitals which documented not only their actual practice, but also the rates of post‐operative thromboembolic (0.4%) and bleeding (3.5%) complications. The most striking feature of both papers is the great heterogeneity in thromboprophylaxis (both between and within the subspecialities).…”

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confidence: 99%

Perioperative thromboprophylaxis: inconsistent guidelines and evidence gaps lead to variable practice

Stupart

Watters

2020

ANZ Journal of Surgery

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Timing of Major Postoperative Bleeding Among Patients Undergoing Surgery

Halme,

Roshanov,

Tornberg

et al. 2024

JAMA Netw Open

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ImportanceAlthough major bleeding is among the most common and prognostically important perioperative complications, the relative timing of bleeding events is not well established. This information is critical for preventing bleeding complications and for informing the timing of pharmacologic thromboprophylaxis.ObjectiveTo determine the timing of postoperative bleeding among patients undergoing surgery for up to 30 days after surgery.Design, Setting, and ParticipantsThis is a secondary analysis of a prospective cohort study. Patients aged 45 years or older who underwent inpatient noncardiac surgery were recruited in 14 countries between 2007 and 2013, with follow-up until December 2014. Data analysis was performed from June to July 2023.ExposureNoncardiac surgery requiring overnight hospital admission.Main Outcomes and MeasuresThe primary outcome (postoperative major bleeding) was a composite of the timing of the following bleeding outcomes: (1) bleeding leading to transfusion, (2) bleeding leading to a postoperative hemoglobin level less than 7 g/dL, (3) bleeding leading to death, and (4) bleeding associated with reintervention. Each of the components of the composite primary outcome (1-4) and bleeding independently associated with mortality after noncardiac surgery, which was defined as a composite of outcomes 1 to 3, were secondary outcomes.ResultsAmong 39 813 patients (median [IQR] age, 63.0 [54.8-72.5] years; 19 793 women [49.7%]), there were 5340 major bleeding events (primary outcome) in 4638 patients (11.6%) within the first 30 days after surgery. Of these events, 42.7% (95% CI, 40.9%-44.6%) occurred within 24 hours after surgery, 77.7% (95% CI, 75.8%-79.5%) by postoperative day 7, 88.3% (95% CI, 86.5%-90.2%) by postoperative day 14, and 94.6% (95% CI, 92.7%-96.5%) by postoperative day 21. Within 48 hours of surgery, 56.2% of major bleeding events, 56.2% of bleeding leading to transfusion, 56.1% of bleeding independently associated with mortality after noncardiac surgery, 51.8% of bleeding associated with hemoglobin less than 7 g/dL, and 51.8% of bleeding associated with reintervention had occurred.Conclusions and RelevanceIn this cohort study, of the major postoperative bleeding events in the first 30 days, more than three-quarters occurred during the first postoperative week. These findings are useful for researchers for the planning future clinical research and for clinicians in prevention of bleeding-related surgical complications and in decision-making regarding starting of pharmacologic thromboprophylaxis after surgery.

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Variations in practice of thromboprophylaxis across general surgical subspecialties: a multicentre (PROTECTinG) study of elective major surgeries

Cited by 13 publications

References 17 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

Perioperative thromboprophylaxis: inconsistent guidelines and evidence gaps lead to variable practice

Timing of Major Postoperative Bleeding Among Patients Undergoing Surgery

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