Perioperative Medicine

BALTIMORE — Methods for determining how and when to use pharmacologic and mechanical interventions to prevent venous thromboembolism in surgical patients may remain open to debate, but the need for prophylaxis should not, Dr. Morey A. Blinder said at the annual meeting of the American Society of Plastic Surgeons.

Prophylaxis is underused because many physicians believe that the incidence of deep venous thrombosis (DVT) in hospitalized patients is "too low" to warrant its consideration, said Dr. Blinder of the division of hematology and the department of pathology and immunology at Washington University, St. Louis.

Other physicians voice concerns about bleeding complications—particularly in surgical patients—and about heparin-induced thrombocytopenia, which occurs in 1%–2% of patients on heparin.

"Many clinicians have the sense that venous thrombosis is not a particular problem in their practice," because they have not seen a DVT in one of their patients for several years or may have not known that a patient had a DVT diagnosed a week after surgery by an internist or at the emergency department, Dr. Blinder said.

In the absence of prophylaxis, studies have found a DVT prevalence of 10%–20% in medical patients, 15%–40% in general surgery patients, and about 20%–50% of stroke and orthopedic surgery patients. Even though most patients did not have symptomatic thrombosis in those studies, each patient underwent venography or a fibrinogen uptake procedure. Most series of major procedures in plastic surgery have found a risk of 1%–2% for DVT and/or pulmonary embolism, generally without prophylaxis, he said.

Deficiencies in any of the body's natural anticoagulants, such as antithrombin, protein C, and protein S, lead to a substantial risk of thrombosis. About 5% of people with European heritage carry a mutation in the blood-clotting factor V Leiden, which increases the risk of thrombosis. In fact, 20%–30% of people who have DVT without an identified cause turn out to be positive for the factor V Leiden mutation.

"We've seen many, many patients who have [a factor V Leiden mutation] as an inherited risk factor, and then you add on a second risk factor like surgery or like an estrogen-containing hormone, and that is enough to trigger a blood clot," Dr. Blinder said.

The American College of Chest Physicians' evidence-based guidelines for preventing venous thromboembolism stratify patients undergoing general surgery as low, moderate, high, or highest risk, according to their age, the type of operation, and underlying risk factors (Chest 2004;126:338S-400S).

The guidelines advise early and frequent mobilization for low-risk patients and low-dose unfractionated heparin (LDUH) or low-molecular weight heparin (LMWH) for moderate-risk patients. High-risk patients generally should receive LDUH every 8 hours, or a LMWH such as enoxaparin (Lovenox).

Patients at highest risk for DVT need a full dose of a LMWH such as enoxaparin or the factor Xa inhibitor fondaparinux (Arixtra) in combination with intermittent pneumatic compression (IPC) or graduated compression stockings, said Dr. Blinder, who is on the speakers bureau for GlaxoSmithKline Inc., which manufactures fondaparinux.

Other guidelines that have been issued by the American Society of Plastic Surgeons largely follow these recommendations but instead divide surgical patients into low-, moderate-, and high-risk groups (Plast. Reconstr. Surg. 2002;110:1337–42).

Dr. Blinder suggested that IPC devices may see rising use because newer, fanny pack-size devices are much smaller than previous ones that had to sit at the side of a bed. Graduated compression stockings are thought to increase blood circulation by restricting the venous diameter. IPC devices also restrict venous diameter and are known to more than double the velocity of blood and increase fibrinolytic activity.

A meta-analysis of 15 randomized, controlled trials using IPC to prevent DVT in surgical patients found that the devices could drop the risk of DVT by 60%, compared with no prophylaxis (Thromb. Haemost. 2005;94:1181–5).

Investigators have not resolved the appropriate time to start or stop prophylaxis, but some type of pharmacologic prophylaxis should be included along with mechanical methods, he advised.

BALTIMORE — Methods for determining how and when to use pharmacologic and mechanical interventions to prevent venous thromboembolism in surgical patients may remain open to debate, but the need for prophylaxis should not, Dr. Morey A. Blinder said at the annual meeting of the American Society of Plastic Surgeons.

Prophylaxis is underused because many physicians believe that the incidence of deep venous thrombosis (DVT) in hospitalized patients is "too low" to warrant its consideration, said Dr. Blinder of the division of hematology and the department of pathology and immunology at Washington University, St. Louis.

Other physicians voice concerns about bleeding complications—particularly in surgical patients—and about heparin-induced thrombocytopenia, which occurs in 1%–2% of patients on heparin.

"Many clinicians have the sense that venous thrombosis is not a particular problem in their practice," because they have not seen a DVT in one of their patients for several years or may have not known that a patient had a DVT diagnosed a week after surgery by an internist or at the emergency department, Dr. Blinder said.

In the absence of prophylaxis, studies have found a DVT prevalence of 10%–20% in medical patients, 15%–40% in general surgery patients, and about 20%–50% of stroke and orthopedic surgery patients. Even though most patients did not have symptomatic thrombosis in those studies, each patient underwent venography or a fibrinogen uptake procedure. Most series of major procedures in plastic surgery have found a risk of 1%–2% for DVT and/or pulmonary embolism, generally without prophylaxis, he said.

Deficiencies in any of the body's natural anticoagulants, such as antithrombin, protein C, and protein S, lead to a substantial risk of thrombosis. About 5% of people with European heritage carry a mutation in the blood-clotting factor V Leiden, which increases the risk of thrombosis. In fact, 20%–30% of people who have DVT without an identified cause turn out to be positive for the factor V Leiden mutation.

"We've seen many, many patients who have [a factor V Leiden mutation] as an inherited risk factor, and then you add on a second risk factor like surgery or like an estrogen-containing hormone, and that is enough to trigger a blood clot," Dr. Blinder said.

The American College of Chest Physicians' evidence-based guidelines for preventing venous thromboembolism stratify patients undergoing general surgery as low, moderate, high, or highest risk, according to their age, the type of operation, and underlying risk factors (Chest 2004;126:338S-400S).

The guidelines advise early and frequent mobilization for low-risk patients and low-dose unfractionated heparin (LDUH) or low-molecular weight heparin (LMWH) for moderate-risk patients. High-risk patients generally should receive LDUH every 8 hours, or a LMWH such as enoxaparin (Lovenox).

Patients at highest risk for DVT need a full dose of a LMWH such as enoxaparin or the factor Xa inhibitor fondaparinux (Arixtra) in combination with intermittent pneumatic compression (IPC) or graduated compression stockings, said Dr. Blinder, who is on the speakers bureau for GlaxoSmithKline Inc., which manufactures fondaparinux.

Other guidelines that have been issued by the American Society of Plastic Surgeons largely follow these recommendations but instead divide surgical patients into low-, moderate-, and high-risk groups (Plast. Reconstr. Surg. 2002;110:1337–42).

Dr. Blinder suggested that IPC devices may see rising use because newer, fanny pack-size devices are much smaller than previous ones that had to sit at the side of a bed. Graduated compression stockings are thought to increase blood circulation by restricting the venous diameter. IPC devices also restrict venous diameter and are known to more than double the velocity of blood and increase fibrinolytic activity.

A meta-analysis of 15 randomized, controlled trials using IPC to prevent DVT in surgical patients found that the devices could drop the risk of DVT by 60%, compared with no prophylaxis (Thromb. Haemost. 2005;94:1181–5).

Investigators have not resolved the appropriate time to start or stop prophylaxis, but some type of pharmacologic prophylaxis should be included along with mechanical methods, he advised.

BALTIMORE — Methods for determining how and when to use pharmacologic and mechanical interventions to prevent venous thromboembolism in surgical patients may remain open to debate, but the need for prophylaxis should not, Dr. Morey A. Blinder said at the annual meeting of the American Society of Plastic Surgeons.

Prophylaxis is underused because many physicians believe that the incidence of deep venous thrombosis (DVT) in hospitalized patients is "too low" to warrant its consideration, said Dr. Blinder of the division of hematology and the department of pathology and immunology at Washington University, St. Louis.

Other physicians voice concerns about bleeding complications—particularly in surgical patients—and about heparin-induced thrombocytopenia, which occurs in 1%–2% of patients on heparin.

"Many clinicians have the sense that venous thrombosis is not a particular problem in their practice," because they have not seen a DVT in one of their patients for several years or may have not known that a patient had a DVT diagnosed a week after surgery by an internist or at the emergency department, Dr. Blinder said.

In the absence of prophylaxis, studies have found a DVT prevalence of 10%–20% in medical patients, 15%–40% in general surgery patients, and about 20%–50% of stroke and orthopedic surgery patients. Even though most patients did not have symptomatic thrombosis in those studies, each patient underwent venography or a fibrinogen uptake procedure. Most series of major procedures in plastic surgery have found a risk of 1%–2% for DVT and/or pulmonary embolism, generally without prophylaxis, he said.

Deficiencies in any of the body's natural anticoagulants, such as antithrombin, protein C, and protein S, lead to a substantial risk of thrombosis. About 5% of people with European heritage carry a mutation in the blood-clotting factor V Leiden, which increases the risk of thrombosis. In fact, 20%–30% of people who have DVT without an identified cause turn out to be positive for the factor V Leiden mutation.

"We've seen many, many patients who have [a factor V Leiden mutation] as an inherited risk factor, and then you add on a second risk factor like surgery or like an estrogen-containing hormone, and that is enough to trigger a blood clot," Dr. Blinder said.

The American College of Chest Physicians' evidence-based guidelines for preventing venous thromboembolism stratify patients undergoing general surgery as low, moderate, high, or highest risk, according to their age, the type of operation, and underlying risk factors (Chest 2004;126:338S-400S).

The guidelines advise early and frequent mobilization for low-risk patients and low-dose unfractionated heparin (LDUH) or low-molecular weight heparin (LMWH) for moderate-risk patients. High-risk patients generally should receive LDUH every 8 hours, or a LMWH such as enoxaparin (Lovenox).

Patients at highest risk for DVT need a full dose of a LMWH such as enoxaparin or the factor Xa inhibitor fondaparinux (Arixtra) in combination with intermittent pneumatic compression (IPC) or graduated compression stockings, said Dr. Blinder, who is on the speakers bureau for GlaxoSmithKline Inc., which manufactures fondaparinux.

Other guidelines that have been issued by the American Society of Plastic Surgeons largely follow these recommendations but instead divide surgical patients into low-, moderate-, and high-risk groups (Plast. Reconstr. Surg. 2002;110:1337–42).

Dr. Blinder suggested that IPC devices may see rising use because newer, fanny pack-size devices are much smaller than previous ones that had to sit at the side of a bed. Graduated compression stockings are thought to increase blood circulation by restricting the venous diameter. IPC devices also restrict venous diameter and are known to more than double the velocity of blood and increase fibrinolytic activity.

A meta-analysis of 15 randomized, controlled trials using IPC to prevent DVT in surgical patients found that the devices could drop the risk of DVT by 60%, compared with no prophylaxis (Thromb. Haemost. 2005;94:1181–5).

Investigators have not resolved the appropriate time to start or stop prophylaxis, but some type of pharmacologic prophylaxis should be included along with mechanical methods, he advised.

SAN FRANCISCO — Placing a nicotine patch behind a patient's ear before radical retropubic prostatectomy or placing lidocaine patches on each side of the surgical wound could reduce postoperative pain or narcotic use, results of two studies suggest.

The lidocaine patch significantly reduced pain after surgery, and the nicotine patch significantly reduced cumulative morphine consumption 24 hours after surgery, Dr. Ashraf S. Habib and associates reported in two separate poster presentations at the annual meeting of the American Society of Anesthesiologists (ASA).

Both prospective, randomized, double-blind, placebo-controlled studies of patients undergoing radical retropubic prostatectomy used standardized postoperative analgesia via patient-controlled morphine administration and six hourly 15-mg IV doses of ketorolac.

In what may be the first reported study of the treatment of acute postoperative pain with 5% lidocaine patches, surgeons placed a patch on either side of the wound at the end of surgery on 36 patients and a placebo patch on 34 patients. The two groups were similar in age, height, weight, ASA class, length of surgery, and amount of intraoperative opiates received.

Postoperative pain scores on coughing were significantly lower in the lidocaine group than in the placebo group in the postanesthesia care unit (PACU) and at 6, 12, and 24 hours post surgery, after investigators accounted for a significant effect of morphine. Pain scores at rest were significantly lower in the lidocaine group than in the placebo group up to 6 hours after surgery, and were not significantly different at 12 and 24 hours, said Dr. Habib, director of quality improvement at Duke University Medical Center, Durham, N.C.

There were no significant differences between groups in cumulative morphine consumption or in duration of stay in the PACU or in the hospital.

In the other study, a 7-mg nicotine patch was applied behind the ear of 44 patients 30–60 minutes before anesthesia induction, and a placebo patch behind the ear of 46 patients. By 24 hours after surgery, patients in the nicotine group had used a mean of 33 mg of morphine, significantly less than the mean 45 mg used by the placebo group, Dr. Habib said.

There were no significant differences between groups at any time points in pain scores on coughing or at rest, or in incidence of nausea and vomiting.

There were significant negative correlations between serum nicotine levels at 4 hours and cumulative morphine consumption at 24 hours, and between serum nicotine levels at 24 hours and morphine consumption at all time points (in the PACU and at 6, 12, and 24 hours after surgery).

Dr. Habib has no association with the companies that make the lidocaine or nicotine patches.

The nicotine group used 33 mg of morphine, significantly less than the 45 mg used by the placebo group. DR. HABIB

SAN FRANCISCO — Placing a nicotine patch behind a patient's ear before radical retropubic prostatectomy or placing lidocaine patches on each side of the surgical wound could reduce postoperative pain or narcotic use, results of two studies suggest.

The lidocaine patch significantly reduced pain after surgery, and the nicotine patch significantly reduced cumulative morphine consumption 24 hours after surgery, Dr. Ashraf S. Habib and associates reported in two separate poster presentations at the annual meeting of the American Society of Anesthesiologists (ASA).

Both prospective, randomized, double-blind, placebo-controlled studies of patients undergoing radical retropubic prostatectomy used standardized postoperative analgesia via patient-controlled morphine administration and six hourly 15-mg IV doses of ketorolac.

In what may be the first reported study of the treatment of acute postoperative pain with 5% lidocaine patches, surgeons placed a patch on either side of the wound at the end of surgery on 36 patients and a placebo patch on 34 patients. The two groups were similar in age, height, weight, ASA class, length of surgery, and amount of intraoperative opiates received.

Postoperative pain scores on coughing were significantly lower in the lidocaine group than in the placebo group in the postanesthesia care unit (PACU) and at 6, 12, and 24 hours post surgery, after investigators accounted for a significant effect of morphine. Pain scores at rest were significantly lower in the lidocaine group than in the placebo group up to 6 hours after surgery, and were not significantly different at 12 and 24 hours, said Dr. Habib, director of quality improvement at Duke University Medical Center, Durham, N.C.

There were no significant differences between groups in cumulative morphine consumption or in duration of stay in the PACU or in the hospital.

In the other study, a 7-mg nicotine patch was applied behind the ear of 44 patients 30–60 minutes before anesthesia induction, and a placebo patch behind the ear of 46 patients. By 24 hours after surgery, patients in the nicotine group had used a mean of 33 mg of morphine, significantly less than the mean 45 mg used by the placebo group, Dr. Habib said.

There were no significant differences between groups at any time points in pain scores on coughing or at rest, or in incidence of nausea and vomiting.

There were significant negative correlations between serum nicotine levels at 4 hours and cumulative morphine consumption at 24 hours, and between serum nicotine levels at 24 hours and morphine consumption at all time points (in the PACU and at 6, 12, and 24 hours after surgery).

Dr. Habib has no association with the companies that make the lidocaine or nicotine patches.

The nicotine group used 33 mg of morphine, significantly less than the 45 mg used by the placebo group. DR. HABIB

SAN FRANCISCO — Placing a nicotine patch behind a patient's ear before radical retropubic prostatectomy or placing lidocaine patches on each side of the surgical wound could reduce postoperative pain or narcotic use, results of two studies suggest.

The lidocaine patch significantly reduced pain after surgery, and the nicotine patch significantly reduced cumulative morphine consumption 24 hours after surgery, Dr. Ashraf S. Habib and associates reported in two separate poster presentations at the annual meeting of the American Society of Anesthesiologists (ASA).

Both prospective, randomized, double-blind, placebo-controlled studies of patients undergoing radical retropubic prostatectomy used standardized postoperative analgesia via patient-controlled morphine administration and six hourly 15-mg IV doses of ketorolac.

In what may be the first reported study of the treatment of acute postoperative pain with 5% lidocaine patches, surgeons placed a patch on either side of the wound at the end of surgery on 36 patients and a placebo patch on 34 patients. The two groups were similar in age, height, weight, ASA class, length of surgery, and amount of intraoperative opiates received.

Postoperative pain scores on coughing were significantly lower in the lidocaine group than in the placebo group in the postanesthesia care unit (PACU) and at 6, 12, and 24 hours post surgery, after investigators accounted for a significant effect of morphine. Pain scores at rest were significantly lower in the lidocaine group than in the placebo group up to 6 hours after surgery, and were not significantly different at 12 and 24 hours, said Dr. Habib, director of quality improvement at Duke University Medical Center, Durham, N.C.

There were no significant differences between groups in cumulative morphine consumption or in duration of stay in the PACU or in the hospital.

In the other study, a 7-mg nicotine patch was applied behind the ear of 44 patients 30–60 minutes before anesthesia induction, and a placebo patch behind the ear of 46 patients. By 24 hours after surgery, patients in the nicotine group had used a mean of 33 mg of morphine, significantly less than the mean 45 mg used by the placebo group, Dr. Habib said.

There were no significant differences between groups at any time points in pain scores on coughing or at rest, or in incidence of nausea and vomiting.

There were significant negative correlations between serum nicotine levels at 4 hours and cumulative morphine consumption at 24 hours, and between serum nicotine levels at 24 hours and morphine consumption at all time points (in the PACU and at 6, 12, and 24 hours after surgery).

Dr. Habib has no association with the companies that make the lidocaine or nicotine patches.

The nicotine group used 33 mg of morphine, significantly less than the 45 mg used by the placebo group. DR. HABIB

More than half of hospitalized patients worldwide are at risk for venous thromboembolism, and despite the availability of evidence-based guidelines, the rate of appropriate prophylaxis remains low, a new study has found.

With pulmonary embolism accounting for 5%-10% of deaths among hospitalized patients, venous thromboembolism (VTE) remains the most common preventable cause of in-hospital death, investigators reported.

Dr. Alexander T. Cohen of King's College Hospital, London, and his colleagues enrolled 68,183 patients from 358 hospitals in 32 countries into the cross-sectional Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting (ENDORSE) study.

Patients 40 years and older being treated in medical wards and those 18 years and older being treated on general surgical wards were assessed by chart review for risk for VTE according to the 2004 American College of Chest Physicians (ACCP) guidelines.

Among the 37,356 medical patients, 49% were women; the median age was 67 years. Among the 30,827 surgical patients, 48% were women; the median age was 59 years.

The researchers found that 15,487 medical patients (42%) were at risk for VTE, with the most common risk factors present before hospitalization being chronic pulmonary disease and heart failure. They identified 19,842 surgical patients (64%) who were at risk, with obesity being the most common prehospitalization risk factor.

The most common postadmission risk factors among both medical and surgical patients were complete immobilization, immobilization with bathroom privileges, and admission to intensive or critical care units. Overall, 35,329 (52%) were at risk.

Further analysis determined that only half of these at-risk patients (17,732) received ACCP-recommended types of prophylaxis, which include low-dose unfractionated heparin, low-molecular-weight heparin, graduated compression stockings, and/or intermittent pneumatic compression devices. When prophylaxis was given, low-molecular-weight heparin was the agent most often used.

Not only was prophylaxis underused in at-risk patients, but the investigators also found that 34% of surgical patients and 29% of medical patients considered at low risk for VTE were given prophylaxis (Lancet 2008;371:387–94).

Overall, the proportion of hospital patients at risk for VTE ranged from 36% to 73% and the proportion of patients receiving ACCP-recommended prophylaxis ranged from 2% to 84%, the investigators reported.

These differences could reflect factors such as physician awareness, availability of guidelines, and local resources. In the United States, 48% of at-risk medical patients and 71% of at-risk surgical patients received recommended prophylaxis, while in Thailand the corresponding figures were 4% and 0.2%.

They also noted that the use of prophylaxis was particularly low among medical patients, with only 37% of those hospitalized with active malignancy or ischemic stroke—among the highest-risk groups—receiving recommended prophylaxis.

In an editorial, Dr. Walter Ageno and Dr. Francesco Dentali of the University of Insubria, Varese, Italy, noted that local programs such as electronic alerts for clinicians are effective and should be promoted. But before such tools can be effectively implemented, the prevalence of the problem must be more broadly appreciated and disagreements about benefits and risks resolved.

“Different perceptions of the benefit-to-risk ratio of pharmacological prophylaxis exist between ischaemic stroke specialists, and some stroke guidelines do not recommend routine use of pharmacologic prevention strategies.” Guidelines should be more comprehensively endorsed among medical and surgical societies, they wrote (Lancet 2008;371:361–2).

More than half of hospitalized patients worldwide are at risk for venous thromboembolism, and despite the availability of evidence-based guidelines, the rate of appropriate prophylaxis remains low, a new study has found.

With pulmonary embolism accounting for 5%-10% of deaths among hospitalized patients, venous thromboembolism (VTE) remains the most common preventable cause of in-hospital death, investigators reported.

Dr. Alexander T. Cohen of King's College Hospital, London, and his colleagues enrolled 68,183 patients from 358 hospitals in 32 countries into the cross-sectional Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting (ENDORSE) study.

Patients 40 years and older being treated in medical wards and those 18 years and older being treated on general surgical wards were assessed by chart review for risk for VTE according to the 2004 American College of Chest Physicians (ACCP) guidelines.

Among the 37,356 medical patients, 49% were women; the median age was 67 years. Among the 30,827 surgical patients, 48% were women; the median age was 59 years.

The researchers found that 15,487 medical patients (42%) were at risk for VTE, with the most common risk factors present before hospitalization being chronic pulmonary disease and heart failure. They identified 19,842 surgical patients (64%) who were at risk, with obesity being the most common prehospitalization risk factor.

The most common postadmission risk factors among both medical and surgical patients were complete immobilization, immobilization with bathroom privileges, and admission to intensive or critical care units. Overall, 35,329 (52%) were at risk.

Further analysis determined that only half of these at-risk patients (17,732) received ACCP-recommended types of prophylaxis, which include low-dose unfractionated heparin, low-molecular-weight heparin, graduated compression stockings, and/or intermittent pneumatic compression devices. When prophylaxis was given, low-molecular-weight heparin was the agent most often used.

Not only was prophylaxis underused in at-risk patients, but the investigators also found that 34% of surgical patients and 29% of medical patients considered at low risk for VTE were given prophylaxis (Lancet 2008;371:387–94).

Overall, the proportion of hospital patients at risk for VTE ranged from 36% to 73% and the proportion of patients receiving ACCP-recommended prophylaxis ranged from 2% to 84%, the investigators reported.

These differences could reflect factors such as physician awareness, availability of guidelines, and local resources. In the United States, 48% of at-risk medical patients and 71% of at-risk surgical patients received recommended prophylaxis, while in Thailand the corresponding figures were 4% and 0.2%.

They also noted that the use of prophylaxis was particularly low among medical patients, with only 37% of those hospitalized with active malignancy or ischemic stroke—among the highest-risk groups—receiving recommended prophylaxis.

In an editorial, Dr. Walter Ageno and Dr. Francesco Dentali of the University of Insubria, Varese, Italy, noted that local programs such as electronic alerts for clinicians are effective and should be promoted. But before such tools can be effectively implemented, the prevalence of the problem must be more broadly appreciated and disagreements about benefits and risks resolved.

“Different perceptions of the benefit-to-risk ratio of pharmacological prophylaxis exist between ischaemic stroke specialists, and some stroke guidelines do not recommend routine use of pharmacologic prevention strategies.” Guidelines should be more comprehensively endorsed among medical and surgical societies, they wrote (Lancet 2008;371:361–2).

More than half of hospitalized patients worldwide are at risk for venous thromboembolism, and despite the availability of evidence-based guidelines, the rate of appropriate prophylaxis remains low, a new study has found.

With pulmonary embolism accounting for 5%-10% of deaths among hospitalized patients, venous thromboembolism (VTE) remains the most common preventable cause of in-hospital death, investigators reported.

Dr. Alexander T. Cohen of King's College Hospital, London, and his colleagues enrolled 68,183 patients from 358 hospitals in 32 countries into the cross-sectional Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting (ENDORSE) study.

Patients 40 years and older being treated in medical wards and those 18 years and older being treated on general surgical wards were assessed by chart review for risk for VTE according to the 2004 American College of Chest Physicians (ACCP) guidelines.

Among the 37,356 medical patients, 49% were women; the median age was 67 years. Among the 30,827 surgical patients, 48% were women; the median age was 59 years.

The researchers found that 15,487 medical patients (42%) were at risk for VTE, with the most common risk factors present before hospitalization being chronic pulmonary disease and heart failure. They identified 19,842 surgical patients (64%) who were at risk, with obesity being the most common prehospitalization risk factor.

The most common postadmission risk factors among both medical and surgical patients were complete immobilization, immobilization with bathroom privileges, and admission to intensive or critical care units. Overall, 35,329 (52%) were at risk.

Further analysis determined that only half of these at-risk patients (17,732) received ACCP-recommended types of prophylaxis, which include low-dose unfractionated heparin, low-molecular-weight heparin, graduated compression stockings, and/or intermittent pneumatic compression devices. When prophylaxis was given, low-molecular-weight heparin was the agent most often used.

Not only was prophylaxis underused in at-risk patients, but the investigators also found that 34% of surgical patients and 29% of medical patients considered at low risk for VTE were given prophylaxis (Lancet 2008;371:387–94).

Overall, the proportion of hospital patients at risk for VTE ranged from 36% to 73% and the proportion of patients receiving ACCP-recommended prophylaxis ranged from 2% to 84%, the investigators reported.

These differences could reflect factors such as physician awareness, availability of guidelines, and local resources. In the United States, 48% of at-risk medical patients and 71% of at-risk surgical patients received recommended prophylaxis, while in Thailand the corresponding figures were 4% and 0.2%.

They also noted that the use of prophylaxis was particularly low among medical patients, with only 37% of those hospitalized with active malignancy or ischemic stroke—among the highest-risk groups—receiving recommended prophylaxis.

In an editorial, Dr. Walter Ageno and Dr. Francesco Dentali of the University of Insubria, Varese, Italy, noted that local programs such as electronic alerts for clinicians are effective and should be promoted. But before such tools can be effectively implemented, the prevalence of the problem must be more broadly appreciated and disagreements about benefits and risks resolved.

“Different perceptions of the benefit-to-risk ratio of pharmacological prophylaxis exist between ischaemic stroke specialists, and some stroke guidelines do not recommend routine use of pharmacologic prevention strategies.” Guidelines should be more comprehensively endorsed among medical and surgical societies, they wrote (Lancet 2008;371:361–2).

SAN FRANCISCO — A longer preoperative period without fluids led to a higher incidence of postoperative delirium in the recovery room, Dr. Finn M. Radtke reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

In his study of 516 patients, 45 (9%) who later developed delirium went without fluids for a median of 12 hours before surgery, compared with 10 hours for the 471 patients without delirium, a statistically significant difference. Delirium after surgical procedures is associated with increased morbidity and mortality, said Dr. Radtke of Charité School of Medicine-Berlin and his associates.

“There's no reason that a patient shouldn't get clear fluids until 2 hours before an operation,” Dr. Radtke said.

The study included adult patients who were moved to a recovery room after general anesthesia and surgery. It excluded patients who were undergoing neurosurgery or who had a history of psychiatric or immunologic illness. Nurses assessed patients in the recovery room using the Nursing Delirium Screening Scale, an observational five-item scale that can be completed within about a minute.

In addition to preoperative fluid fasting, the duration of anesthesia was associated with delirium in the recovery room. Patients with delirium had a significantly longer duration of anesthesia (a median of 150 minutes), compared with nondelirious patients (120 minutes), he reported. Similarly, patients with delirium stayed a median of 5 minutes longer in the recovery room than did their counterparts, a statistically significant difference.

A physician in the audience at the poster presentation commented, “I expected to see an older population in the delirium group, but there wasn't [a significant age difference].” The median age in the delirium group was 58 years, compared with 53 years in those without delirium.

The study did not assess the depth of anesthesia experienced by patients, which could have played some role in the risk for postoperative delirium, Dr. Radtke said. He said his hospital performs approximately 90,000 operations each year.

'There's no reason that a patient shouldn't get clear fluids until 2 hours before an operation.' DR. RADTKE

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — A longer preoperative period without fluids led to a higher incidence of postoperative delirium in the recovery room, Dr. Finn M. Radtke reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

In his study of 516 patients, 45 (9%) who later developed delirium went without fluids for a median of 12 hours before surgery, compared with 10 hours for the 471 patients without delirium, a statistically significant difference. Delirium after surgical procedures is associated with increased morbidity and mortality, said Dr. Radtke of Charité School of Medicine-Berlin and his associates.

“There's no reason that a patient shouldn't get clear fluids until 2 hours before an operation,” Dr. Radtke said.

The study included adult patients who were moved to a recovery room after general anesthesia and surgery. It excluded patients who were undergoing neurosurgery or who had a history of psychiatric or immunologic illness. Nurses assessed patients in the recovery room using the Nursing Delirium Screening Scale, an observational five-item scale that can be completed within about a minute.

In addition to preoperative fluid fasting, the duration of anesthesia was associated with delirium in the recovery room. Patients with delirium had a significantly longer duration of anesthesia (a median of 150 minutes), compared with nondelirious patients (120 minutes), he reported. Similarly, patients with delirium stayed a median of 5 minutes longer in the recovery room than did their counterparts, a statistically significant difference.

A physician in the audience at the poster presentation commented, “I expected to see an older population in the delirium group, but there wasn't [a significant age difference].” The median age in the delirium group was 58 years, compared with 53 years in those without delirium.

The study did not assess the depth of anesthesia experienced by patients, which could have played some role in the risk for postoperative delirium, Dr. Radtke said. He said his hospital performs approximately 90,000 operations each year.

'There's no reason that a patient shouldn't get clear fluids until 2 hours before an operation.' DR. RADTKE

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — A longer preoperative period without fluids led to a higher incidence of postoperative delirium in the recovery room, Dr. Finn M. Radtke reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

In his study of 516 patients, 45 (9%) who later developed delirium went without fluids for a median of 12 hours before surgery, compared with 10 hours for the 471 patients without delirium, a statistically significant difference. Delirium after surgical procedures is associated with increased morbidity and mortality, said Dr. Radtke of Charité School of Medicine-Berlin and his associates.

“There's no reason that a patient shouldn't get clear fluids until 2 hours before an operation,” Dr. Radtke said.

The study included adult patients who were moved to a recovery room after general anesthesia and surgery. It excluded patients who were undergoing neurosurgery or who had a history of psychiatric or immunologic illness. Nurses assessed patients in the recovery room using the Nursing Delirium Screening Scale, an observational five-item scale that can be completed within about a minute.

In addition to preoperative fluid fasting, the duration of anesthesia was associated with delirium in the recovery room. Patients with delirium had a significantly longer duration of anesthesia (a median of 150 minutes), compared with nondelirious patients (120 minutes), he reported. Similarly, patients with delirium stayed a median of 5 minutes longer in the recovery room than did their counterparts, a statistically significant difference.

A physician in the audience at the poster presentation commented, “I expected to see an older population in the delirium group, but there wasn't [a significant age difference].” The median age in the delirium group was 58 years, compared with 53 years in those without delirium.

The study did not assess the depth of anesthesia experienced by patients, which could have played some role in the risk for postoperative delirium, Dr. Radtke said. He said his hospital performs approximately 90,000 operations each year.

'There's no reason that a patient shouldn't get clear fluids until 2 hours before an operation.' DR. RADTKE

ELSEVIER GLOBAL MEDICAL NEWS

LAS VEGAS — Being male and having a higher than normal preoperative hemoglobin A_1c level were significantly associated with having a major complication following Roux-en-Y gastric bypass surgery, results from an ongoing single-center study showed.

However, the rate of overall complications at 1 year was 15%, which is lower than the 20%–25% that has been reported in the medical literature, Dr. D. Brandon Williams said during a poster session at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

“In centers where we have a high volume—we do over 400 of these operations a year—the complication rate is very low, especially the rate of major complications,” said Dr. Williams, of the department of surgery at Stanford (Calif.) University.

Between June 5, 2000, and December 5, 2006, 613 patients with a mean age of 43 years and a mean body mass index of 47 kg/m

Major complications were defined as anastomotic leak, bleeding, deep vein thrombosis (DVT)/pulmonary embolism (PE), bowel obstruction, myocardial infarction (MI), cerebrovascular accident (CVA), intra-abdominal abscess, and pneumonia. Minor complications were defined as micronutrient deficiency, arrhythmia, wound infection/dehiscence/hernia, and ulcers/strictures.

Dr. Williams reported that 92 patients (15%) experienced 133 complications. Of those, 60 patients had minor complications, and 32 had major complications.

The most common complications included bleeding (28), ulcers/strictures (23), vitamin/nutrient deficiency (15), anastomotic leak (12), bowel obstruction (12), wound infection (11), pneumonia (10), DVT/PE (9), abscess (5), MI (3), arrhythmia (3), and CVA (2). None of the patients died.

Univariate analysis revealed that patients with minor complications were generally older than those with major complications (a mean of 47 vs. 41 years, respectively).

Multivariate analysis revealed that significant predictors of having a major versus a minor complication were being male (odds ratio [OR] 2.1) and having a preoperative hemoglobin A_1c level that was higher than the normal HbA_1c level (OR 0.8).

“We actually expected more [factors] would be predictors of complications,” Dr. Williams said. “But there are a couple of things that you can use to counsel your patients preoperatively: They might be more likely to have problems if they have uncontrolled diabetes and if they're male.”

The researchers also observed a strong association between the rate of major complications and surgeon experience. For example, 16 major complications were attributed to surgeons who had performed up to 200 gastric bypass operations. That rate dropped to 6 for those who had performed more than 401 procedures.

However, the rate of minor complications remained about the same, regardless of surgeon experience. “This would suggest that there are patient-dependent [risk factors for complications] that you're not going to be able to predict no matter how good [a surgeon] you are,” he said.

Patients 'might be more likely to have problems if they have uncontrolled diabetes and if they're male.' DR. WILLIAMS

LAS VEGAS — Being male and having a higher than normal preoperative hemoglobin A_1c level were significantly associated with having a major complication following Roux-en-Y gastric bypass surgery, results from an ongoing single-center study showed.

However, the rate of overall complications at 1 year was 15%, which is lower than the 20%–25% that has been reported in the medical literature, Dr. D. Brandon Williams said during a poster session at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

“In centers where we have a high volume—we do over 400 of these operations a year—the complication rate is very low, especially the rate of major complications,” said Dr. Williams, of the department of surgery at Stanford (Calif.) University.

Between June 5, 2000, and December 5, 2006, 613 patients with a mean age of 43 years and a mean body mass index of 47 kg/m

Major complications were defined as anastomotic leak, bleeding, deep vein thrombosis (DVT)/pulmonary embolism (PE), bowel obstruction, myocardial infarction (MI), cerebrovascular accident (CVA), intra-abdominal abscess, and pneumonia. Minor complications were defined as micronutrient deficiency, arrhythmia, wound infection/dehiscence/hernia, and ulcers/strictures.

Dr. Williams reported that 92 patients (15%) experienced 133 complications. Of those, 60 patients had minor complications, and 32 had major complications.

The most common complications included bleeding (28), ulcers/strictures (23), vitamin/nutrient deficiency (15), anastomotic leak (12), bowel obstruction (12), wound infection (11), pneumonia (10), DVT/PE (9), abscess (5), MI (3), arrhythmia (3), and CVA (2). None of the patients died.

Univariate analysis revealed that patients with minor complications were generally older than those with major complications (a mean of 47 vs. 41 years, respectively).

Multivariate analysis revealed that significant predictors of having a major versus a minor complication were being male (odds ratio [OR] 2.1) and having a preoperative hemoglobin A_1c level that was higher than the normal HbA_1c level (OR 0.8).

“We actually expected more [factors] would be predictors of complications,” Dr. Williams said. “But there are a couple of things that you can use to counsel your patients preoperatively: They might be more likely to have problems if they have uncontrolled diabetes and if they're male.”

The researchers also observed a strong association between the rate of major complications and surgeon experience. For example, 16 major complications were attributed to surgeons who had performed up to 200 gastric bypass operations. That rate dropped to 6 for those who had performed more than 401 procedures.

However, the rate of minor complications remained about the same, regardless of surgeon experience. “This would suggest that there are patient-dependent [risk factors for complications] that you're not going to be able to predict no matter how good [a surgeon] you are,” he said.

Patients 'might be more likely to have problems if they have uncontrolled diabetes and if they're male.' DR. WILLIAMS

LAS VEGAS — Being male and having a higher than normal preoperative hemoglobin A_1c level were significantly associated with having a major complication following Roux-en-Y gastric bypass surgery, results from an ongoing single-center study showed.

However, the rate of overall complications at 1 year was 15%, which is lower than the 20%–25% that has been reported in the medical literature, Dr. D. Brandon Williams said during a poster session at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

“In centers where we have a high volume—we do over 400 of these operations a year—the complication rate is very low, especially the rate of major complications,” said Dr. Williams, of the department of surgery at Stanford (Calif.) University.

Between June 5, 2000, and December 5, 2006, 613 patients with a mean age of 43 years and a mean body mass index of 47 kg/m

Major complications were defined as anastomotic leak, bleeding, deep vein thrombosis (DVT)/pulmonary embolism (PE), bowel obstruction, myocardial infarction (MI), cerebrovascular accident (CVA), intra-abdominal abscess, and pneumonia. Minor complications were defined as micronutrient deficiency, arrhythmia, wound infection/dehiscence/hernia, and ulcers/strictures.

Dr. Williams reported that 92 patients (15%) experienced 133 complications. Of those, 60 patients had minor complications, and 32 had major complications.

The most common complications included bleeding (28), ulcers/strictures (23), vitamin/nutrient deficiency (15), anastomotic leak (12), bowel obstruction (12), wound infection (11), pneumonia (10), DVT/PE (9), abscess (5), MI (3), arrhythmia (3), and CVA (2). None of the patients died.

Univariate analysis revealed that patients with minor complications were generally older than those with major complications (a mean of 47 vs. 41 years, respectively).

Multivariate analysis revealed that significant predictors of having a major versus a minor complication were being male (odds ratio [OR] 2.1) and having a preoperative hemoglobin A_1c level that was higher than the normal HbA_1c level (OR 0.8).

“We actually expected more [factors] would be predictors of complications,” Dr. Williams said. “But there are a couple of things that you can use to counsel your patients preoperatively: They might be more likely to have problems if they have uncontrolled diabetes and if they're male.”

The researchers also observed a strong association between the rate of major complications and surgeon experience. For example, 16 major complications were attributed to surgeons who had performed up to 200 gastric bypass operations. That rate dropped to 6 for those who had performed more than 401 procedures.

However, the rate of minor complications remained about the same, regardless of surgeon experience. “This would suggest that there are patient-dependent [risk factors for complications] that you're not going to be able to predict no matter how good [a surgeon] you are,” he said.

Patients 'might be more likely to have problems if they have uncontrolled diabetes and if they're male.' DR. WILLIAMS

SAN DIEGO — Pharmacologic prophylaxis can sharply reduce the risk of deep venous thrombosis when cancer patients undergo surgery, Dr. Michael J. Leonardi reported at a symposium sponsored by the Society of Surgical Oncology.

The deep venous thrombosis (DVT) rate falls from 35% without prophylaxis to 12% when surgical oncology patients are given heparin, according to Dr. Leonardi of the University of California, Los Angeles. A combination of mechanical prophylaxis with heparin further reduces the DVT rate to just 5%.

“Cancer patients need some form of prophylaxis,” Dr. Leonardi said in an interview after his review of data from dozens of randomized, controlled trials. “If bleeding risk is not a concern,” he added, “pharmacological prophylaxis is better than mechanical prophylaxis, and combination therapy has been shown to be even more effective.”

Dr. Leonardi and his colleagues in the UCLA surgery department undertook their study to help institutions develop guidelines for DVT. They searched the Medline database for English-language trials and found 55 randomized, controlled trials published from 1966 to 2005 on DVT prophylaxis in general surgery. Among these, 26 trials reported outcomes for 7,639 cancer patients, Dr. Leonardi said.

Colorectal and major abdominal surgical procedures accounted for 39% and 38% of cases, respectively. Upper gastrointestinal and small bowel operations were the next most common at 11%, followed by gynecologic surgery at 3%.

After a review of the wide variety of patients and surgeons in these trials, he said the best prophylaxis for individual cancers is still not known. For example, not even one randomized controlled trial was found that evaluated DVT prophylaxis in breast cancer patients. The incidence of DVT in breast cancer “is probably not as high as in some other cancers, but because breast cancer is so common, a lot of DVTs are associated with it,” he said.

Among the findings from the analysis, Dr. Leonardi reported that:

▸ DVT rates vary with the detection method used. Venography was the most sensitive method, and ultrasound the least.

▸ Higher heparin doses are more effective than lower doses. DVT rates were 8% for higher doses and 14% for lower doses of the forms of heparin in 17 trials with a total of 4,005 patients.

▸ Low-molecular-weight heparin and low-weight unfractionated heparin are equally effective. Both cut DVT rates to 8% at high doses in the 17 trials just cited. At low doses, the rate was 14% for LMW heparin and 13% for unfractionated heparin.

▸ Heparin reduces the rate of proximal DVTs. The rate went from 41% to 13% in nine trials reporting on 284 patients with DVTs. Location was unaffected by the use of LMW vs. unfractionated heparin.

▸ Major complications occur in only 1% of cases with pharmacologic prophylaxis. Based on seven trials, minor complications occurred in 10% of patients and major complications in 1%, he reported. There was no difference between LMW and unfractionated heparin. In four trials, 3% of patients discontinued prophylaxis.

'If bleeding risk is not a concern, pharmacological prophylaxis is better than mechanical prophylaxis.' DR. LEONARDI

SAN DIEGO — Pharmacologic prophylaxis can sharply reduce the risk of deep venous thrombosis when cancer patients undergo surgery, Dr. Michael J. Leonardi reported at a symposium sponsored by the Society of Surgical Oncology.

The deep venous thrombosis (DVT) rate falls from 35% without prophylaxis to 12% when surgical oncology patients are given heparin, according to Dr. Leonardi of the University of California, Los Angeles. A combination of mechanical prophylaxis with heparin further reduces the DVT rate to just 5%.

“Cancer patients need some form of prophylaxis,” Dr. Leonardi said in an interview after his review of data from dozens of randomized, controlled trials. “If bleeding risk is not a concern,” he added, “pharmacological prophylaxis is better than mechanical prophylaxis, and combination therapy has been shown to be even more effective.”

Dr. Leonardi and his colleagues in the UCLA surgery department undertook their study to help institutions develop guidelines for DVT. They searched the Medline database for English-language trials and found 55 randomized, controlled trials published from 1966 to 2005 on DVT prophylaxis in general surgery. Among these, 26 trials reported outcomes for 7,639 cancer patients, Dr. Leonardi said.

Colorectal and major abdominal surgical procedures accounted for 39% and 38% of cases, respectively. Upper gastrointestinal and small bowel operations were the next most common at 11%, followed by gynecologic surgery at 3%.

After a review of the wide variety of patients and surgeons in these trials, he said the best prophylaxis for individual cancers is still not known. For example, not even one randomized controlled trial was found that evaluated DVT prophylaxis in breast cancer patients. The incidence of DVT in breast cancer “is probably not as high as in some other cancers, but because breast cancer is so common, a lot of DVTs are associated with it,” he said.

Among the findings from the analysis, Dr. Leonardi reported that:

▸ DVT rates vary with the detection method used. Venography was the most sensitive method, and ultrasound the least.

▸ Higher heparin doses are more effective than lower doses. DVT rates were 8% for higher doses and 14% for lower doses of the forms of heparin in 17 trials with a total of 4,005 patients.

▸ Low-molecular-weight heparin and low-weight unfractionated heparin are equally effective. Both cut DVT rates to 8% at high doses in the 17 trials just cited. At low doses, the rate was 14% for LMW heparin and 13% for unfractionated heparin.

▸ Heparin reduces the rate of proximal DVTs. The rate went from 41% to 13% in nine trials reporting on 284 patients with DVTs. Location was unaffected by the use of LMW vs. unfractionated heparin.

▸ Major complications occur in only 1% of cases with pharmacologic prophylaxis. Based on seven trials, minor complications occurred in 10% of patients and major complications in 1%, he reported. There was no difference between LMW and unfractionated heparin. In four trials, 3% of patients discontinued prophylaxis.

'If bleeding risk is not a concern, pharmacological prophylaxis is better than mechanical prophylaxis.' DR. LEONARDI

SAN DIEGO — Pharmacologic prophylaxis can sharply reduce the risk of deep venous thrombosis when cancer patients undergo surgery, Dr. Michael J. Leonardi reported at a symposium sponsored by the Society of Surgical Oncology.

The deep venous thrombosis (DVT) rate falls from 35% without prophylaxis to 12% when surgical oncology patients are given heparin, according to Dr. Leonardi of the University of California, Los Angeles. A combination of mechanical prophylaxis with heparin further reduces the DVT rate to just 5%.

“Cancer patients need some form of prophylaxis,” Dr. Leonardi said in an interview after his review of data from dozens of randomized, controlled trials. “If bleeding risk is not a concern,” he added, “pharmacological prophylaxis is better than mechanical prophylaxis, and combination therapy has been shown to be even more effective.”

Dr. Leonardi and his colleagues in the UCLA surgery department undertook their study to help institutions develop guidelines for DVT. They searched the Medline database for English-language trials and found 55 randomized, controlled trials published from 1966 to 2005 on DVT prophylaxis in general surgery. Among these, 26 trials reported outcomes for 7,639 cancer patients, Dr. Leonardi said.

Colorectal and major abdominal surgical procedures accounted for 39% and 38% of cases, respectively. Upper gastrointestinal and small bowel operations were the next most common at 11%, followed by gynecologic surgery at 3%.

After a review of the wide variety of patients and surgeons in these trials, he said the best prophylaxis for individual cancers is still not known. For example, not even one randomized controlled trial was found that evaluated DVT prophylaxis in breast cancer patients. The incidence of DVT in breast cancer “is probably not as high as in some other cancers, but because breast cancer is so common, a lot of DVTs are associated with it,” he said.

Among the findings from the analysis, Dr. Leonardi reported that:

▸ DVT rates vary with the detection method used. Venography was the most sensitive method, and ultrasound the least.

▸ Higher heparin doses are more effective than lower doses. DVT rates were 8% for higher doses and 14% for lower doses of the forms of heparin in 17 trials with a total of 4,005 patients.

▸ Low-molecular-weight heparin and low-weight unfractionated heparin are equally effective. Both cut DVT rates to 8% at high doses in the 17 trials just cited. At low doses, the rate was 14% for LMW heparin and 13% for unfractionated heparin.

▸ Heparin reduces the rate of proximal DVTs. The rate went from 41% to 13% in nine trials reporting on 284 patients with DVTs. Location was unaffected by the use of LMW vs. unfractionated heparin.

▸ Major complications occur in only 1% of cases with pharmacologic prophylaxis. Based on seven trials, minor complications occurred in 10% of patients and major complications in 1%, he reported. There was no difference between LMW and unfractionated heparin. In four trials, 3% of patients discontinued prophylaxis.

'If bleeding risk is not a concern, pharmacological prophylaxis is better than mechanical prophylaxis.' DR. LEONARDI

PHILADELPHIA — Pneumonia was one of five new risk factors for postoperative venous thromboembolism identified in an analysis of more than 75,000 patients.

Other new risk factors for venous thromboembolism (VTE) were the need for a blood transfusion because of bleeding, renal insufficiency, urinary tract infection, and a low level of serum albumin, Dr. Chethan Gangireddy said at the Vascular Annual Meeting.

“These newly described risk factors can aid in further stratifying a patient's risk for postoperative VTE,” said Dr. Gangireddy, a surgeon at the University of Michigan in Ann Arbor.

The analysis included data collected by the National Surgical Quality Improvement Program of the Department of Veterans Affairs system during 1996–2001. The database included all of the more than 118,000 patients who had surgery at 114 hospitals for one of the nine most common operations done at these hospitals; complete data were available for 75,711 patients.

The overall incidence of VTE was 0.7%, but the incidence varied significantly based on the type of surgery. Carotid endarterectomy carried the lowest risk for VTE, with a 0.14% postoperative risk. Total hip arthroplasty posed the biggest risk for VTE, with a 1.3% postoperative rate.

In a multivariate analysis that evaluated the independent risk added by many different clinical and demographic factors, pneumonia was the strongest risk factor, boosting the risk of VTE 2.7-fold. Several other risk factors each boosted the risk for VTE by about twofold (see table), and three factors were found to reduce VTE risk.

In an analysis of the two most common manifestations of VTE, the list of significant risk factors for causing deep vein thrombosis was found to be different from the list linked with pulmonary embolism. The top risks for DVT were need for a transfusion due to bleeding (3.3-fold increased risk), pneumonia (2.5-fold increased risk), and urinary tract infection (1.7-fold increased risk).

For pulmonary embolism, the top risk factor was cardiac arrest (7.6-fold increased risk), followed by pneumonia (3.9-fold increased risk) and need for a transfusion (2.4-fold increased risk).

Another finding was that patients with VTE had a 2.4-fold increased risk of death, compared with all other patients, Dr. Gangireddy said.

ELSEVIER GLOBAL MEDICAL NEWS

PHILADELPHIA — Pneumonia was one of five new risk factors for postoperative venous thromboembolism identified in an analysis of more than 75,000 patients.

Other new risk factors for venous thromboembolism (VTE) were the need for a blood transfusion because of bleeding, renal insufficiency, urinary tract infection, and a low level of serum albumin, Dr. Chethan Gangireddy said at the Vascular Annual Meeting.

“These newly described risk factors can aid in further stratifying a patient's risk for postoperative VTE,” said Dr. Gangireddy, a surgeon at the University of Michigan in Ann Arbor.

The analysis included data collected by the National Surgical Quality Improvement Program of the Department of Veterans Affairs system during 1996–2001. The database included all of the more than 118,000 patients who had surgery at 114 hospitals for one of the nine most common operations done at these hospitals; complete data were available for 75,711 patients.

The overall incidence of VTE was 0.7%, but the incidence varied significantly based on the type of surgery. Carotid endarterectomy carried the lowest risk for VTE, with a 0.14% postoperative risk. Total hip arthroplasty posed the biggest risk for VTE, with a 1.3% postoperative rate.

In a multivariate analysis that evaluated the independent risk added by many different clinical and demographic factors, pneumonia was the strongest risk factor, boosting the risk of VTE 2.7-fold. Several other risk factors each boosted the risk for VTE by about twofold (see table), and three factors were found to reduce VTE risk.

In an analysis of the two most common manifestations of VTE, the list of significant risk factors for causing deep vein thrombosis was found to be different from the list linked with pulmonary embolism. The top risks for DVT were need for a transfusion due to bleeding (3.3-fold increased risk), pneumonia (2.5-fold increased risk), and urinary tract infection (1.7-fold increased risk).

For pulmonary embolism, the top risk factor was cardiac arrest (7.6-fold increased risk), followed by pneumonia (3.9-fold increased risk) and need for a transfusion (2.4-fold increased risk).

Another finding was that patients with VTE had a 2.4-fold increased risk of death, compared with all other patients, Dr. Gangireddy said.

ELSEVIER GLOBAL MEDICAL NEWS

PHILADELPHIA — Pneumonia was one of five new risk factors for postoperative venous thromboembolism identified in an analysis of more than 75,000 patients.

Other new risk factors for venous thromboembolism (VTE) were the need for a blood transfusion because of bleeding, renal insufficiency, urinary tract infection, and a low level of serum albumin, Dr. Chethan Gangireddy said at the Vascular Annual Meeting.

“These newly described risk factors can aid in further stratifying a patient's risk for postoperative VTE,” said Dr. Gangireddy, a surgeon at the University of Michigan in Ann Arbor.

The analysis included data collected by the National Surgical Quality Improvement Program of the Department of Veterans Affairs system during 1996–2001. The database included all of the more than 118,000 patients who had surgery at 114 hospitals for one of the nine most common operations done at these hospitals; complete data were available for 75,711 patients.

The overall incidence of VTE was 0.7%, but the incidence varied significantly based on the type of surgery. Carotid endarterectomy carried the lowest risk for VTE, with a 0.14% postoperative risk. Total hip arthroplasty posed the biggest risk for VTE, with a 1.3% postoperative rate.

In a multivariate analysis that evaluated the independent risk added by many different clinical and demographic factors, pneumonia was the strongest risk factor, boosting the risk of VTE 2.7-fold. Several other risk factors each boosted the risk for VTE by about twofold (see table), and three factors were found to reduce VTE risk.

In an analysis of the two most common manifestations of VTE, the list of significant risk factors for causing deep vein thrombosis was found to be different from the list linked with pulmonary embolism. The top risks for DVT were need for a transfusion due to bleeding (3.3-fold increased risk), pneumonia (2.5-fold increased risk), and urinary tract infection (1.7-fold increased risk).

For pulmonary embolism, the top risk factor was cardiac arrest (7.6-fold increased risk), followed by pneumonia (3.9-fold increased risk) and need for a transfusion (2.4-fold increased risk).

Another finding was that patients with VTE had a 2.4-fold increased risk of death, compared with all other patients, Dr. Gangireddy said.

ELSEVIER GLOBAL MEDICAL NEWS

PARIS — Prophylactic use of heparin made no difference in the incidence of symptomatic deep vein thrombosis and/or pulmonary embolism after 4,609 laparoscopic radical prostatectomies reviewed by the International Laparoscopy Prostate Cancer Working Group.

Eleven centers in seven countries contributed patients to the ongoing study. Dr. Fernando P. Secin presented an interim analysis of the study data at the annual congress of the European Association of Urology.

The overall rate of deep vein thrombosis and/or pulmonary embolism (DVT/PE) was low: 0.6%, according to Dr. Secin, a urology fellow at Memorial Sloan-Kettering Cancer Center in New York.

Dr. Secin speculated that most patients undergoing laparoscopic radical prostatectomies are probably at low risk for thromboembolic events.

“Most prostate cancers [that] are operated [on] are early prostate cancers, so the impact of the cancer itself on the thrombotic mechanism may not be that serious,” he said in an interview at the meeting.

Although heparin use was not a statistically significant factor in univariate or multivariate analyses, the latter did identify the following risk factors as being significant for DVT/PE in patients undergoing laparoscopic radical prostatectomy:

▸ Patients undergoing a reexploration were 20 times more likely to have a thromboembolic event.

▸ The odds were 13 times greater for those with a prior history of DVT.

▸ Every 10-g increase in prostate size raised the odds ratio by 1.2.

The investigators concluded that the data do not support heparin prophylaxis in patients who do not have these risk factors. Randomized trials are needed to establish its utility, they said.

Centers in France, Belgium, Austria, the United Kingdom, Spain, Sweden, and the United States contributed patients to the analysis. Dr. Secin said he hopes to accumulate another 1,000 patients before completing the study.

Prophylaxis protocols ranged from no heparin use to both preoperative and postoperative use of heparin, with no discernible relationship to the rate of DVT/PE at each hospital. All the institutions used mechanical prophylaxis: either a pneumatic compression device or a gradual compression stocking.

The lowest and highest DVT/PE rates (0% and 1.4%, respectively) were both found at centers that administered heparin before and after surgery. At the Cleveland Clinic, where heparin prophylaxis was not used, the rate was 0.5%.

Patients receiving preoperative heparin had significantly higher intraoperative mean blood loss, compared with those given postoperative heparin or no heparin: 444 mL vs. 332 mL.

This difference in blood loss did not translate into longer hospital stays or higher transfusion or reoperation rates, according to Dr. Secin.

Estimating the cost of heparin at $80 per dose, the investigators calculated the total cost as $2,955,057 for the 11 centers that contributed data.

“You spend so much money and there isn't any use for that,” said Dr. Bertrand D. Guillonneau, the study's senior author and section head of minimally invasive surgery, department of urology, Memorial Sloan-Kettering.

PARIS — Prophylactic use of heparin made no difference in the incidence of symptomatic deep vein thrombosis and/or pulmonary embolism after 4,609 laparoscopic radical prostatectomies reviewed by the International Laparoscopy Prostate Cancer Working Group.

Eleven centers in seven countries contributed patients to the ongoing study. Dr. Fernando P. Secin presented an interim analysis of the study data at the annual congress of the European Association of Urology.

The overall rate of deep vein thrombosis and/or pulmonary embolism (DVT/PE) was low: 0.6%, according to Dr. Secin, a urology fellow at Memorial Sloan-Kettering Cancer Center in New York.

Dr. Secin speculated that most patients undergoing laparoscopic radical prostatectomies are probably at low risk for thromboembolic events.

“Most prostate cancers [that] are operated [on] are early prostate cancers, so the impact of the cancer itself on the thrombotic mechanism may not be that serious,” he said in an interview at the meeting.

Although heparin use was not a statistically significant factor in univariate or multivariate analyses, the latter did identify the following risk factors as being significant for DVT/PE in patients undergoing laparoscopic radical prostatectomy:

▸ Patients undergoing a reexploration were 20 times more likely to have a thromboembolic event.

▸ The odds were 13 times greater for those with a prior history of DVT.

▸ Every 10-g increase in prostate size raised the odds ratio by 1.2.

The investigators concluded that the data do not support heparin prophylaxis in patients who do not have these risk factors. Randomized trials are needed to establish its utility, they said.

Centers in France, Belgium, Austria, the United Kingdom, Spain, Sweden, and the United States contributed patients to the analysis. Dr. Secin said he hopes to accumulate another 1,000 patients before completing the study.

Prophylaxis protocols ranged from no heparin use to both preoperative and postoperative use of heparin, with no discernible relationship to the rate of DVT/PE at each hospital. All the institutions used mechanical prophylaxis: either a pneumatic compression device or a gradual compression stocking.

The lowest and highest DVT/PE rates (0% and 1.4%, respectively) were both found at centers that administered heparin before and after surgery. At the Cleveland Clinic, where heparin prophylaxis was not used, the rate was 0.5%.

Patients receiving preoperative heparin had significantly higher intraoperative mean blood loss, compared with those given postoperative heparin or no heparin: 444 mL vs. 332 mL.

This difference in blood loss did not translate into longer hospital stays or higher transfusion or reoperation rates, according to Dr. Secin.

Estimating the cost of heparin at $80 per dose, the investigators calculated the total cost as $2,955,057 for the 11 centers that contributed data.

“You spend so much money and there isn't any use for that,” said Dr. Bertrand D. Guillonneau, the study's senior author and section head of minimally invasive surgery, department of urology, Memorial Sloan-Kettering.

PARIS — Prophylactic use of heparin made no difference in the incidence of symptomatic deep vein thrombosis and/or pulmonary embolism after 4,609 laparoscopic radical prostatectomies reviewed by the International Laparoscopy Prostate Cancer Working Group.

Eleven centers in seven countries contributed patients to the ongoing study. Dr. Fernando P. Secin presented an interim analysis of the study data at the annual congress of the European Association of Urology.

The overall rate of deep vein thrombosis and/or pulmonary embolism (DVT/PE) was low: 0.6%, according to Dr. Secin, a urology fellow at Memorial Sloan-Kettering Cancer Center in New York.

Dr. Secin speculated that most patients undergoing laparoscopic radical prostatectomies are probably at low risk for thromboembolic events.

“Most prostate cancers [that] are operated [on] are early prostate cancers, so the impact of the cancer itself on the thrombotic mechanism may not be that serious,” he said in an interview at the meeting.

Although heparin use was not a statistically significant factor in univariate or multivariate analyses, the latter did identify the following risk factors as being significant for DVT/PE in patients undergoing laparoscopic radical prostatectomy:

▸ Patients undergoing a reexploration were 20 times more likely to have a thromboembolic event.

▸ The odds were 13 times greater for those with a prior history of DVT.

▸ Every 10-g increase in prostate size raised the odds ratio by 1.2.

The investigators concluded that the data do not support heparin prophylaxis in patients who do not have these risk factors. Randomized trials are needed to establish its utility, they said.

Centers in France, Belgium, Austria, the United Kingdom, Spain, Sweden, and the United States contributed patients to the analysis. Dr. Secin said he hopes to accumulate another 1,000 patients before completing the study.

Prophylaxis protocols ranged from no heparin use to both preoperative and postoperative use of heparin, with no discernible relationship to the rate of DVT/PE at each hospital. All the institutions used mechanical prophylaxis: either a pneumatic compression device or a gradual compression stocking.

The lowest and highest DVT/PE rates (0% and 1.4%, respectively) were both found at centers that administered heparin before and after surgery. At the Cleveland Clinic, where heparin prophylaxis was not used, the rate was 0.5%.

Patients receiving preoperative heparin had significantly higher intraoperative mean blood loss, compared with those given postoperative heparin or no heparin: 444 mL vs. 332 mL.

This difference in blood loss did not translate into longer hospital stays or higher transfusion or reoperation rates, according to Dr. Secin.

Estimating the cost of heparin at $80 per dose, the investigators calculated the total cost as $2,955,057 for the 11 centers that contributed data.

“You spend so much money and there isn't any use for that,” said Dr. Bertrand D. Guillonneau, the study's senior author and section head of minimally invasive surgery, department of urology, Memorial Sloan-Kettering.

ORLANDO — Several factors predict an increased likelihood of deep vein thrombosis and/or pulmonary embolism for morbidly obese patients undergoing Roux-en-Y gastric bypass surgery, according to the results of a study presented by Rodrigo Gonzalez, M.D., at the annual meeting of the American Society for Bariatric Surgery.

Obesity is a major risk factor for perioperative deep vein thrombosis (DVT) and pulmonary embolism (PE). PE occurs in 2% of patients undergoing any surgical procedure, and it is responsible for 150,000 deaths in the United States each year, Dr. Gonzalez said. In bariatric surgery, the incidence of PE is estimated as 0.8%–4%, and the incidence of DVT as 0.6%–2%.

To identify the risk factors associated with these complications, the study looked at 660 consecutive patients undergoing Roux-en-Y gastric bypass. Prospectively collected data were reviewed by Dr. Gonzalez and his associates in the Interdisciplinary Obesity Treatment Group, department of surgery, University of South Florida, Tampa.

All patients received antithrombotic prophylaxis with heparin and sequential compression devices. Patients with a prior history of DVT, PE, or hypercoagulable diseases received inferior vena cava (IVC) filters; however, this practice was adopted only partway through the study, so some patients treated early did not receive the filters.

Postoperative low-molecular-weight heparin was dosed according to body mass index. Patients with a BMI less than 50 kg/m

The researchers used Doppler ultrasound to diagnose DVT. PE was diagnosed on the basis of clinical, necropsy, and/or radiologic findings. The radiologic techniques included CT angiography and ventilation/perfusion scans. In patients with IVC filters, DVT was diagnosed using duplex ultrasound; these patients had mainly lower-extremity DVTs.

In all, 9 patients developed DVT, 6 developed PE, and 7 developed both DVT and PE, to give a total of 16 patients with DVT (2.5% incidence) and 13 with PE (2% incidence). These figures are consistent with values reported in the literature.

A multivariate analysis, comparing the group that developed DVT, PE, or both complications with patients who did not, showed that a significantly greater number were older than 50 years (50% vs. 29%) or had an anastomotic leak (32% vs. 3%), a history of smoking (23% vs 7%), or a history of DVT and/or PE (23% vs. 7%).

An open surgical technique and revision operations also were more common in the group that developed DVT, PE, or both complications.

Additional screening is warranted in patients with one or more of these risk factors before Roux-en-Y gastric bypass, Dr. Gonzalez said. He added that supplementary postoperative prophylaxis might be warranted.

ORLANDO — Several factors predict an increased likelihood of deep vein thrombosis and/or pulmonary embolism for morbidly obese patients undergoing Roux-en-Y gastric bypass surgery, according to the results of a study presented by Rodrigo Gonzalez, M.D., at the annual meeting of the American Society for Bariatric Surgery.

Obesity is a major risk factor for perioperative deep vein thrombosis (DVT) and pulmonary embolism (PE). PE occurs in 2% of patients undergoing any surgical procedure, and it is responsible for 150,000 deaths in the United States each year, Dr. Gonzalez said. In bariatric surgery, the incidence of PE is estimated as 0.8%–4%, and the incidence of DVT as 0.6%–2%.

To identify the risk factors associated with these complications, the study looked at 660 consecutive patients undergoing Roux-en-Y gastric bypass. Prospectively collected data were reviewed by Dr. Gonzalez and his associates in the Interdisciplinary Obesity Treatment Group, department of surgery, University of South Florida, Tampa.

All patients received antithrombotic prophylaxis with heparin and sequential compression devices. Patients with a prior history of DVT, PE, or hypercoagulable diseases received inferior vena cava (IVC) filters; however, this practice was adopted only partway through the study, so some patients treated early did not receive the filters.

Postoperative low-molecular-weight heparin was dosed according to body mass index. Patients with a BMI less than 50 kg/m

The researchers used Doppler ultrasound to diagnose DVT. PE was diagnosed on the basis of clinical, necropsy, and/or radiologic findings. The radiologic techniques included CT angiography and ventilation/perfusion scans. In patients with IVC filters, DVT was diagnosed using duplex ultrasound; these patients had mainly lower-extremity DVTs.

In all, 9 patients developed DVT, 6 developed PE, and 7 developed both DVT and PE, to give a total of 16 patients with DVT (2.5% incidence) and 13 with PE (2% incidence). These figures are consistent with values reported in the literature.

A multivariate analysis, comparing the group that developed DVT, PE, or both complications with patients who did not, showed that a significantly greater number were older than 50 years (50% vs. 29%) or had an anastomotic leak (32% vs. 3%), a history of smoking (23% vs 7%), or a history of DVT and/or PE (23% vs. 7%).

An open surgical technique and revision operations also were more common in the group that developed DVT, PE, or both complications.

Additional screening is warranted in patients with one or more of these risk factors before Roux-en-Y gastric bypass, Dr. Gonzalez said. He added that supplementary postoperative prophylaxis might be warranted.

ORLANDO — Several factors predict an increased likelihood of deep vein thrombosis and/or pulmonary embolism for morbidly obese patients undergoing Roux-en-Y gastric bypass surgery, according to the results of a study presented by Rodrigo Gonzalez, M.D., at the annual meeting of the American Society for Bariatric Surgery.

Obesity is a major risk factor for perioperative deep vein thrombosis (DVT) and pulmonary embolism (PE). PE occurs in 2% of patients undergoing any surgical procedure, and it is responsible for 150,000 deaths in the United States each year, Dr. Gonzalez said. In bariatric surgery, the incidence of PE is estimated as 0.8%–4%, and the incidence of DVT as 0.6%–2%.

To identify the risk factors associated with these complications, the study looked at 660 consecutive patients undergoing Roux-en-Y gastric bypass. Prospectively collected data were reviewed by Dr. Gonzalez and his associates in the Interdisciplinary Obesity Treatment Group, department of surgery, University of South Florida, Tampa.

All patients received antithrombotic prophylaxis with heparin and sequential compression devices. Patients with a prior history of DVT, PE, or hypercoagulable diseases received inferior vena cava (IVC) filters; however, this practice was adopted only partway through the study, so some patients treated early did not receive the filters.

Postoperative low-molecular-weight heparin was dosed according to body mass index. Patients with a BMI less than 50 kg/m

The researchers used Doppler ultrasound to diagnose DVT. PE was diagnosed on the basis of clinical, necropsy, and/or radiologic findings. The radiologic techniques included CT angiography and ventilation/perfusion scans. In patients with IVC filters, DVT was diagnosed using duplex ultrasound; these patients had mainly lower-extremity DVTs.

In all, 9 patients developed DVT, 6 developed PE, and 7 developed both DVT and PE, to give a total of 16 patients with DVT (2.5% incidence) and 13 with PE (2% incidence). These figures are consistent with values reported in the literature.

A multivariate analysis, comparing the group that developed DVT, PE, or both complications with patients who did not, showed that a significantly greater number were older than 50 years (50% vs. 29%) or had an anastomotic leak (32% vs. 3%), a history of smoking (23% vs 7%), or a history of DVT and/or PE (23% vs. 7%).

An open surgical technique and revision operations also were more common in the group that developed DVT, PE, or both complications.

Additional screening is warranted in patients with one or more of these risk factors before Roux-en-Y gastric bypass, Dr. Gonzalez said. He added that supplementary postoperative prophylaxis might be warranted.