Incidence of venous thromboembolism and hemorrhage related safety studies of preoperative anticoagulation therapy in hip fracture patients undergoing surgical treatment: a case–control study

Abstract

BackgroundVenous thromboembolism is a common postoperative complication following orthopedic surgeries, with morbid and potentially fatal consequences. Perioperative low-molecular-weight heparin (LMWH) therapy can reduce the incidence of venous thromboembolism, but may also increase the risk of bleeding complications. Current literature reflects the need to balance the improved efficacy of early initiating prophylaxis with increased risk of perioperative bleeding. The purpose of this study was to compare the effectiveness and hemorrhage related safety of preoperative versus postoperative LMWH therapy for prevention of deep venous thrombosis (DVT) and pulmonary embolism (PE) in hip fracture patients.MethodsWe retrospectively evaluated 222 patients who underwent surgical treatment at Peking University People's Hospital between January 2009 and December 2010. Patients were allocated to two groups, receiving either preoperative or postoperative initiation of LMWH therapy for venous thromboembolism prophylaxis. Preoperative anticoagulation therapy was initiated 1–12 days prior to surgery (133 patients), and postoperative anticoagulation therapy was initiated 12 h after completion of surgery (89 patients). The preoperative group was further subdivided into four subgroups according to the time of initiation of therapy: 1–3 days before surgery (group A, 54 patients), 4–6 days before surgery (group B, 57 patients), 7–9 days before surgery (group C, 15 patients), and 10–12 days before surgery (group D, 7 patients). Occurrences of DVT, PE, adverse drug effects, intraoperative and postoperative bleeding were recorded, along with concentrations of preoperative and postoperative hemoglobin and length of hospital stay. The above parameters were compared between groups.ResultsAmong recipients of preoperative anticoagulation therapy, two patients developed postoperative PE (1.5 %), one patient developed DVT (0.75 %). In the group receiving postoperative initiation of anticoagulation therapy, one patient each developed PE and DVT (1.1 %, 1.1 %). There was no difference in the occurrence of PE and DVT between the two groups (P>0.05, Chi-square tests). We identified the incidences of major bleeding, minor bleeding, and intraspinal hematoma after spinal anesthesia, which were 0 %/0 %, 3.76 %/3.37 %, and 0 %/0 %, respectively in preoperative and postoperative anticoagulation groups. There was no significant difference in the incidence of bleeding complications between patients receiving preoperatively initiated LMWH with patients receiving postoperatively initiated LMWH. Spinal anesthesia was administered to 168 patients, with no cases of postoperative intraspinal hematoma.ConclusionsPreoperative anticoagulation therapy with LMWH may not increase intraoperative or postoperative blood loss, or the rate of intraspinal hematoma after spinal anesthesia, but also does not significantly reduce the risk of postoperative DVT or PE, compared to postoperative initiation.

Blood Orders and Predictors for Hemotransfusion in Elective Femur Fracture Repair Surgery

“…This reinforces the aggravating characteristics of patients submitted to this type of surgery. [26][27] Low preoperative hemoglobin levels was another aggravating factor for individuals with femur fractures. A retrospective study with 7,420 patients showed an increase in 30-day mortality in patients with low hemoglobin levels on admission, even after correcting for comorbidities.…”

“…31 Although the study showed significant risk of interoperative hypotension, similar to the results of the present study, in which hypotension was the most frequent complication, and that epidural anesthesia is still the main choice of and moat recommended type of anesthesia for this type of surgery. [25][26]32 Regarding time in days between date of admission and date of surgery, differences were found between Brazilian and international studies, with means between 1.44 and 19 days. It is worth emphasizing that delays in femur fracture repair surgery greater than 48 hours increase the risk of complications and can result in greater one-year mortality rates.…”

“…[33][34] Regarding the duration of the surgical procedure, the present study showed a mean duration of 166.77 (±59.534) minutes, similar to that found in recent studies, whose duration times varied between 71.8 and 176 minutes. 26,35 A documentary study carried out in the South of Brazil analyzed the completion and content of a surgical safety checklist in 257 orthopedic surgeries. The results showed a 51.8% incidence of blood orders, lower than that found in the present study.…”

“…ASA scores, age and preoperative use of anticoagulants and/or antiplatelets did not show statistically significant results as predictors for blood transfusion, corroborating a study that showed that the use of heparin in the preoperative period did not increase risk of bleeding, and another study which showed that it was safe to conduct surgery 24 hours after the last dose of clopidogrel. 26,45 On the other hand, a retrospective study associated ASA classification with the need for intraoperative blood transfusion; however, it also observed that the literature presents conflicting results when using the ASA classification as an algorithm for blood orders, because the risk of hemorrhage is determined by the procedure. 31 Other similar research associated the female gender with blood transfusion, among them, a retrospective study with 1,484 participants carried out in Tel Aviv, Israel.…”

Introductory Chapter: Anticoagulant Therapy in Clinical Practice - Challenges and Wishes

“…The clinical practice involving the use of anticoagulants, e.g., dosing, timing, and managing complications, has been a real challenge even to some of the best experts in the field mainly due to their potential to cause serious adverse effects, both hemorrhagic and nonhemorrhagic which may occur with all the currently used anticoagulants regardless of their year of discovery [2,[5][6][7][8].…”