What are the rates of major and minor bleeding complications after pharmacologic DVT prophylaxis?

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One discussion this week included the rate of bleeding complications after pharmacologic DVT prophylaxis.

Reference: Leonardi MJ, McGory ML, Ko CY. The rate of bleeding complications after pharmacologic deep venous thrombosis prophylaxis: a systematic review of 33 randomized controlled trials. Archives of Surgery. 2006 Aug;141(8):790-797.

Summary: In a systematic review of 33 RCTs with 33,813 patients, Leonardi et al (2006) concluded that there is a small, but measurable, rate of minor bleeding complications associated with pharmacologic DVT prophylaxis: injection site bruising (6.9%), wound hematoma (5.7%), drain site bleeding (2.0%), and hematuria (1.6%).

The rate of major complications, such as GI tract (0.2%) or RP (<0.1%) bleeding, was extremely low in this review. Complications requiring a change in care, such as subsequent operation (0.7%) or discontinuation of prophylaxis (2.0%), were also infrequent. The subsequent operation rate for bleeding problems for pharmacologic prophylaxis vs placebo was identical, at 0.7%.

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Additional Reading: Leonardi MJ, McGory ML, Ko CY. A systematic review of deep venous thrombosis prophylaxis in cancer patients: implications for improving quality. Annals of Surgical Oncology. 2007 Feb;14(2):929-936.

Restrictive vs liberal red-cell transfusion strategy: the Transfusions Requirements in Critical Care (TRICC) trial

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One discussion this week included the TRICC trial.

Reference: Herbert PC, et al…the Transfusion Requirements in Critical Care Investigators for the Canadian Critical Care Trials Group. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. NEJM. 1999 Feb 11;340(6):409-417.

Summary:  The aim of the study was to determine whether a restrictive strategy of red-cell transfusion and a liberal strategy produced equivalent results in critically ill patients, we compared the rates of death from all causes at 30 days and the severity of organ dysfunction.

Methods: Between 1994 and 1997, the trial enrolled 838 critically ill patients with euvolemia after initial treatment who had hemoglobin concentrations of less than 9.0 g per deciliter within 72 hours after admission to the intensive care unit and randomly assigned 418 patients to a restrictive strategy of transfusion, in which red cells were transfused if the hemoglobin concentration dropped below 7.0 g per deciliter and hemoglobin concentrations were maintained at 7.0 to 9.0 g per deciliter, and 420 patients to a liberal strategy, in which transfusions were given when the hemoglobin concentration fell below 10.0 g per deciliter and hemoglobin concentrations were maintained at 10.0 to 12.0 g per deciliter.

Results: The use of a threshold for red-cell transfusion as low as 7.0 g of hemoglobin per deciliter, combined with maintenance of hemoglobin concentrations in the range of 7.0 to 9.0 g per deciliter, was at least as effective as and possibly superior to a liberal transfusion strategy (threshold, 10.0 g per deciliter; maintenance range, 10.0 to 12.0) in critically ill patients with normovolemia. There was a trend toward decreased 30-day mortality among patients who were treated according to the restrictive transfusion strategy. The significant differences in mortality rates during hospitalization, rates of cardiac complications, and rates of organ dysfunction all favored the restrictive strategy.

TRICC trial

Overall, 30-day mortality was similar in the two groups (18.7 percent vs. 23.3 percent, P= 0.11). However, the rates were significantly lower with the restrictive transfusion strategy among patients who were less acutely ill — those with an Acute Physiology and Chronic Health Evaluation II score of < or =20 (8.7 percent in the restrictive-strategy group and 16.1 percent in the liberal-strategy group; P=0.03) — and among patients who were less than 55 years of age (5.7 percent and 13.0 percent, respectively; P=0.02), but not among patients with clinically significant cardiac disease (20.5 percent and 22.9 percent, respectively; P=0.69). The mortality rate during hospitalization was significantly lower in the restrictive-strategy group (22.3 percent vs. 28.1 percent, P=0.05).

Conclusion:  On the basis of the trial’s results, the authors recommend that critically ill patients receive red-cell transfusions when their hemoglobin concentrations fall below 7.0 g per deciliter and that hemoglobin concentrations should be maintained between 7.0 and 9.0 g per deciliter. The diversity of the patients enrolled in this trial and the consistency of the results suggest that these conclusions may be generalized to most critically ill patients, with the possible exception of patients with active coronary ischemic syndromes.

 

Enterocutaneous fistulas: causes, management, and Emory authors

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One discussion this week involved enterocutaneous fistulas.

Reference: Haak CI, Galloway JR, Srinivasan J. Enterocutaneous fistulas: a look at causes and management. Current Surgery Reports. 2014 Oct;2:71.

Summary: Despite advances in medical technology and surgical care, the management of enterocutaneous fistulas (ECF) remains one of the most challenging problems faced by physicians. Success depends on an expert multidisciplinary team, access to long-term enteral and parenteral nutrition support, advanced wound care, optimal medical management and meticulous, methodical, surgical decision-making and technique.

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Graft reconstruction in pancreaticoduodenectomy: outcomes and survival

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One discussion this week included use of prosthetic graft reconstruction …

Reference: Chu CK, et al. Prosthetic graft reconstruction after portal vein resection in pancreaticoduodenectomy: a multicenter analysis. Journal of the American College of Surgeons. 2010 Sep;211(3):316-324. doi: 10.1016/j.jamcollsurg.2010.04.005

Summary: Use of prosthetic grafts for reconstruction after portal vein (PV) resection during pancreaticoduodenectomy is controversial. This paper (by Emory authors) review 33 patients who underwent pancreaticoduodenectomy (PD) with vein resection and reconstruction using PTFE grafts between 1994 and 2009. Patient, operative, and outcomes variables were studied. Graft patency and survival were assessed using the Kaplan-Meier technique.

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Air cholangiogram as effective measure for postoperative biliary complications

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One discussion this week involved air cholangiograms.

Reference: Zimmitti G, et al. Systematic use of an intraoperative air leak test at the time of major liver resection reduces the rate of postoperative biliary complications. Journal of the American College of Surgeons. 2013 Dec;217(6):1028-1037. doi: 10.1016/j.jamcollsurg.2013.07.392.

Summary: Advances in surgical technique and better understanding of liver anatomy and physiology have facilitated a decrease in postoperative hepatic insufficiency rates and in perioperative blood transfusion needs. However, these improvements have not been paralleled by a decrease in the rate of postoperative bile leak, which remains the Achilles’ heel of liver resection. While in many cases a postoperative bile leak can be managed successfully with drainage and antibiotics, it almost always entails longer length of stay and increased hospital costs.

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Meta-analysis, systematic review of carbonic anhydrase inhibitors in respiratory failure and metabolic alkalosis

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One discussion this week involved carbonic anhydrase inhibitors (CAIs) in the setting of respiratory failure and metabolic alkalosisa.

Reference: Tanios BY, et al. Carbonic anhydrase inhibitors in patients with respiratory failure and metabolic alkalosis: a systematic review and meta-analysis of randomized controlled trials. Critical Care. 2018 Oct 29;22(1):275.  doi: 10.1186/s13054-018-2207-6

Summary: Metabolic alkalosis is common in patients with respiratory failure and may delay weaning in mechanically ventilated patients. Carbonic anhydrase inhibitors (such as acetazolamide, methazolamide, and dichlorphenamide) block renal bicarbonate reabsorption, and thus reverse metabolic alkalosis. However, uncertainty remains about
their effects in the setting of respiratory failure with concurrent metabolic alkalosis on duration of hospitalization, mechanical ventilation (MV), or noninvasive positive pressure ventilation (NIPPV), and mortality.

The objective of this systematic review is to assess the benefits and harms of carbonic anhydrase inhibitor therapy in patients with respiratory failure and metabolic alkalosis.

Randomized clinical trials were included if they assessed at least one of the following outcomes: mortality, duration of hospital stay, duration of mechanical ventilation, adverse events, and blood gas parameters. Six eligible studies were identified with a total of 564 patients.

There were no definitive results for the effects of CAI therapy on clinically important outcomes such as mortality and duration of hospital stay in patients with respiratory failure and metabolic alkalosis. The results suggest that CAI therapy may decrease the duration of mechanical ventilation. There was a trend towards increased incidence of adverse events in the CAI group; however, most of these adverse events were mild.

On the other hand, the results suggest that CAI therapy has favorable effects on arterial blood gas parameters (PaCO2, PaO2, bicarbonate and pH), with decreased PaCO2, increased PaO2, and, as expected, decreased bicarbonate and pH levels.

Conclusion

In patients with respiratory failure and metabolic alkalosis, carbonic anhydrase inhibitor therapy may have favorable effects on blood gas parameters. The authors note that this analysis did not provide conclusive results for clinically important outcomes.

In mechanically ventilated patients, carbonic anhydrase inhibitor therapy may decrease the duration of mechanical ventilation. A major limitation was that only two trials assessed this clinically important outcome.

Ureteral catheters and injury during colectomy: A NSQIP study

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One discussion this week included ureteral injuries during colectomy.

Reference: Coakley KM, et al. Prophylactic ureteral catheters for colectomy: A National Surgical Quality Improvement Program-based analysis. Diseases of the Colon and Rectum. 2018 Jan;61(1):84-88. doi:10.1097/DCR.0000000000000976.

Summary: Despite improvement in technique and technology, using prophylactic ureteral catheters to avoid iatrogenic ureteral injury during colectomy remains controversial. The aim of this retrospective study was to evaluate outcomes and costs attributable to prophylactic ureteral catheters with colectomy. Conducted at a signle tertiary care center, the authors pulled clinical data, 2012-2014, from ACS NSQIP database.

A total of 51,125 patients were identified with a mean age of 60.9 ± 14.9 years and a BMI of 28.4 ± 6.7 k/m; 4.90% (n = 2486) of colectomies were performed with prophylactic catheters, and 333 ureteral injuries (0.65%) were identified.

  • Prophylactic ureteral catheters were most commonly used for diverticular disease (42.2%; n = 1048), with injury occurring most often during colectomy for diverticular disease (36.0%; n = 120).
  • Univariate analysis of outcomes demonstrated higher rates of ileus, wound infection, urinary tract infection, urinary tract infection as reason for readmission, superficial site infection, and 30-day readmission in patients with prophylactic ureteral catheter placement.
  • On multivariate analysis, prophylactic ureteral catheter placement was associated with a lower rate of ureteral injury (OR = 0.45 (95% CI, 0.25-0.81)).
  • Additional research is needed to delineate patient populations most likely to benefit from prophylactic ureteral stent placement.