15 Th Oct Course

7/30/2019 15 Th Oct Course

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Two third of deaths from pulmonaryembolism occur within 30 minutes

of the first symptoms


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Explain the importance of venousthromboembolism in gynaecologicalsurgeryIdentify the level of risk in preoperative

patientsExplain the pros and cons of various

prophylactic methodsBased on best evidence, use theappropriate method/s of VTE prophylaxis inclinical practice


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Most common cause of preventable deathin hospitalized patientsRisk of fatal perioperative PE ~0.8%International Multicentre Trial. Lancet . 1975

150,000 to 200,000 deaths per year; ~1/3 inperioperative patients

Horlander et al. Arch Intern Med . 2003;163:1711-1717.AHRQ: VTE prevention is number one priorityto improve safety in hospitals


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2003 Nationwide Inpatient SampleAdult surgical patients, LOS 2 days

7.8 million surgical discharges44% low risk 15% moderate risk 24% high risk 17% very high risk

4.4 million at risk for VTE

Anderson et al. Am J Hematol . 2007;82:777-782.


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Population-based, prospective cohort study947,454 middle-aged women in U.K.

enrolled between 1996-2001Mean follow-up 6.2 years239,614 underwent surgery

5,419 readmitted for VTE within 12 weeks ofinpatient surgery

270 deaths from fatal PE

Sweetland et al. BMJ. 2009;339:b4583.


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Degree of risk for individual patientOutcomes Research: What are our bestoptions?Intensity of prophylaxisManagementRecommendations/ConsensusStatementsFuture directions


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Venous stasisHypercoagulability

Endothelial damage


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Past history of DVTCancer Age>40 >60Prior radiation therapyAnkle edema

Varicose veinsRadical vulvectomy or exenterationProlonged OT time (> 4 hrs)

Clarke-Pearson, Obstet Gynecol, 69:146, 1987


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Low-dose heparinLow molecular weight heparin

Anti -embolism stockings Pneumatic leg compression

WarfarinIVC interruption


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Controls (2076)

Fatal PE 16

Death assoc with PE 6

Heparin (2045)

2 p


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Outcome LDUHN=2045

No ProphylaxisN=2076

RR

Death any cause 80 100 0.81 (0.61 to 1.1)

Fatal PE 2 16 0.13 (0.02 to 0.55)

Death with PE 3 6 0.51 (0.13 to 2.0)

Suspected DVT 39 81 0.49 (0.33 to 0.71)Confirmed DVT 11 32 0.35 (0.18 to 0.69)

DVT by FUT 48/625 164/667 0.31 (0.23 to 0.42)

Proximal DVT 5/625 49/667 0.11 (0.04 to 0.27)


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In benign gynaecologic surgeryLDUH 5000 u every 12H

Control heparin

Ballard 1973 29% 3.6%

Adolf 1978 29% 7%

Taberner 1978 23% 6%


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Does Low Dose Heparin Work for Every Patient?

How about gynecologic cancer

patients?


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LOW-DOSE HEPARIN In GynecologicOncology Surgery5000 U every 12 hours for 7 day

Clarke-Pearson. Am J Obstet Gynecol 145:606, 1983

DVT(FUT) (%)

Contros n=97 12 (12.4)

LDUH n=88 13 (14.8)


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What about a more intense

Low Dose Heparin Regimen for Cancer Patients?


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Enoxaparin, dalteparin, tinzaparin,fondaparinuxEffectiveness in thromboprophylaxis

- equivalent to LDUH- similar frequency of complications

Convenience of once a day dosing with

dose variation between different LMWH(greater bioavailability, rapid onset, predictable dose- response effect and low rate HIT, more anti Xa, lessantithrombin thus less bleeding & haematoma)

Cost vs. Convenience


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16 RCTs11,847 patients with cancers.Efficacy and safetyConclusion: no difference betweenperioperative thromboprophylaxis withLMWH vs. LDUH on mortality and embolicoutcomes


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Graded compression

stockings, anti embolismstockings (TED Hose).Intermittent pneumaticcompression


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Systematic reviews should be integralpart of VTE prophylaxis in both moderateor high risk patients either asmonotherapy or in combination.More efficacious when combined with

pharmacological methods


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Obstet Gynecol. 1984 Jan;63(1):92-8.Prevention of postoperative venous thromboembolism by external pneumatic

calf compression in patients with gynecologic malignancy.Clarke-Pearson DL , Synan IS , Hinshaw WM , Coleman RE , Creasman WT .

Most effective in first 5 daysIncidence mostly among patient high risk group
http://www.ncbi.nlm.nih.gov/pubmed/6691021http://www.ncbi.nlm.nih.gov/pubmed?term=Clarke-Pearson%20DL[Author]&cauthor=true&cauthor_uid=6691021http://www.ncbi.nlm.nih.gov/pubmed?term=Synan%20IS[Author]&cauthor=true&cauthor_uid=6691021http://www.ncbi.nlm.nih.gov/pubmed?term=Hinshaw%20WM[Author]&cauthor=true&cauthor_uid=6691021http://www.ncbi.nlm.nih.gov/pubmed?term=Coleman%20RE[Author]&cauthor=true&cauthor_uid=6691021http://www.ncbi.nlm.nih.gov/pubmed?term=Creasman%20WT[Author]&cauthor=true&cauthor_uid=6691021http://www.ncbi.nlm.nih.gov/pubmed?term=Creasman%20WT[Author]&cauthor=true&cauthor_uid=6691021http://www.ncbi.nlm.nih.gov/pubmed?term=Coleman%20RE[Author]&cauthor=true&cauthor_uid=6691021http://www.ncbi.nlm.nih.gov/pubmed?term=Hinshaw%20WM[Author]&cauthor=true&cauthor_uid=6691021http://www.ncbi.nlm.nih.gov/pubmed?term=Synan%20IS[Author]&cauthor=true&cauthor_uid=6691021http://www.ncbi.nlm.nih.gov/pubmed?term=Clarke-Pearson%20DL[Author]&cauthor=true&cauthor_uid=6691021http://www.ncbi.nlm.nih.gov/pubmed?term=Clarke-Pearson%20DL[Author]&cauthor=true&cauthor_uid=6691021http://www.ncbi.nlm.nih.gov/pubmed?term=Clarke-Pearson%20DL[Author]&cauthor=true&cauthor_uid=6691021http://www.ncbi.nlm.nih.gov/pubmed/6691021http://www.ncbi.nlm.nih.gov/pubmed/6691021


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Low dose heparin Intermittent pneumaticcompression

N= 107 N=101

DVT7 (6.5%) 4 (4%)

Pulmonary emboli0

p=0.54

Increased transfusion Increasedretroperitoneal drainage 23% prolonged PTT

0


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No difference in bloodloss and transfusionpost op

DVT PE

IPC 1/106 0


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Regimens #trials #patients #DVT Incidence(%)

RRR

controls 54 4710 1074 25

LDUH 50 7716 648 8 68

LMWH 13 4320 226 5 80

IPC 14 780 61 8 67

GCS 9 472 51 11 56


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What should we do toprevent VTE following

gynaecological surgery?


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Major gyn surgery with additional risk factors, major surgery for malignancy-LDUH 5000u tds, LMWH high dose, IPC (1A)

Alternatively combination LDUH/LMWH + GCS/IPC,prophylaxis should continue until discharge

Continued prophylaxis up to 4 weeks after discharge for cancer cases & >60 years


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Explain the importance of venousthromboembolism in gynaecologicalsurgery

Identify the level of risk in preoperativepatientsExplain the pros and cons of various

prophylactic methodsBased on best evidence, use theappropriate method/s of VTE prophylaxis inclinical practice

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15 Th Oct Course