Venous Thromboembolism Prevention in Emergency General Surgery

“Venous thromboembolism (VTE) represents the most preventable cause of morbidity and mortality in hospitalized patients, and the Agency for Healthcare Research and Quality (AHRQ) suggests appropriate VTE prophylaxis as a top patient safety practice. The burden of operative and nonoperative emergency general surgery (EGS) is increasing and represents 7% of all hospital admissions in the United States. The reported rate of VTE among patients undergoing EGS is approximately 2.5%. Numerous observational studies, quality improvement studies, randomized clinical trials, reviews, and practice management guidelines are available to guide acute care surgeons in VTE prevention for patients with trauma. However, little guidance is available for the emergency general surgeon. Patients undergoing EGS represent a challenge regarding VTE prevention. Despite the substantial number of annual EGS admissions, little is known about the risk of VTE or the use of mechanical and/or pharmacologic prophylaxis in EGS patients. Furthermore, although guidelines for VTE prophylaxis are available, they are difficult to interpret in the context of admission to an EGS service for an acute condition, particularly when admissions to such services include as many as 70% of patients who do not require operative intervention.”

Continue reading

Anticoagulant bridging in left-sided mechanical heart valve patients

“There are two strategies for heparin bridging; administration of intravenous unfractionated heparin (UFH), and subcutaneous low-molecular-weight heparin (LMWH). While both strategies reduce the risk of valve thrombus formation, they have distinct biomedical, financial, and logistical profiles. UFH is administered intravenously according to a nomogram and hence requires peri-procedural hospital admission and continuous monitoring of
activated partial thromboplastin time (aPTT). In contrast, LMWH is administered subcutaneously once or twice daily in an outpatient setting and usually does not require continuous blood monitoring of anti-Xa levels.”

Continue reading

Management of anticoagulation in patients with human immunodeficiency virus/acquired immunodeficiency virus

“There is evidence of endothelial dysfunction and a dysregulation of coagulation and fibrinolysis in individuals with HIV. In a study of 109 HIV-infected patients with advanced disease, 10% developed venous thrombosis and 6% developed arterial thrombosis. A variety of laboratory abnormalities were reported, including protein C deficiency, increased factor VIII concentrations, high fibrinogen concentrations, and free protein S deficiency. HIV infection is also associated with an increased D-dimer level, which suggests that HIV infection might be associated with a pro-thrombotic state. HIV disease is theorized to produce a pro-thrombotic state through mechanisms related to activation of the innate and adaptive immune system by low level HIV replication, co-pathogens, and microbial products trans-located from the gastrointestinal tract,”

“The impact of HAART on coagulation is unclear. Protease inhibitors (PI) have been associated with higher fibrinogen levels and lipodystrophy. PIs are also thought to interfere with cytochrome P (CYP) 450 metabolism and regulation of thrombotic proteins. This may
cause a pro-thrombotic state in HIV-infected individuals”

Continue reading

Trends and Risk Factors for Venous Thromboembolism Among Hospitalized Medical Patients

“Hospital-associated venous thromboembolism (HA-VTE), commonly defined as deep vein thrombosis (DVT), pulmonary embolism (PE), or both occurring during or within 90 days of hospital admission, is a frequent complication of hospitalization, accounting for approximately one-half to two-thirds of VTE incidence worldwide. HA-VTE events are associated with substantial burdens. They are a leading factor associated with hospital mortality and lost disability-adjusted life-years.”

Continue reading

Analysis of hematoma after mastectomy with immediate reconstruction

“Although the risk of postoperative bleeding is inherent to all surgical subspecialties, the development of a hematoma after mastectomy with implant reconstruction involves unique risk factors, including the routine involvement of 2 distinct surgical teams. However, despite numerous studies reporting their outcomes following these operations, a rigorous analysis of individual andcoperative factors that contribute to postoperative hematoma formation
has never been documented.”

Continue reading

Risk of breast hematoma after mastectomy with reconstruction.

“Among patients undergoing lumpectomy and Sentinel Lymph Node Biopsy with multimodal analgesia, the risk of hematoma in the 30-day postoperative period, including hematoma requiring reoperation and in-office aspiration or drainage, was low overall and not statistically significantly higher despite increased use of intraoperative ketorolac and implementtion of a standard discharge regimen of NSAIDs in lieu of opioids.”

Continue reading