Prevention of Fatal Postoperative Pulmonary Embolism by Low-Dose Heparin

Gruber, U F; Duckert, F; Fridrich, R; Rem, J. A.; Torhorst, J.; Vv, Kakkar; Corrigan, T.; Fossard, D. P.; Sutherland, Ian; Thirlwell, J.

doi:10.1016/s0140-6736(77)91213-2

Cited by 51 publications

(3 citation statements)

References 2 publications

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“…Clouded in controversy, the authors first reported in 1975 34 that patients receiving heparin had a 3-fold reduction in DVT and 8-fold decrease in fatal PE events. The results of the study were re-issued in 1977 35 because one of the sites 36 withdrew its data suggesting that they observed the opposite effect. Almost all subsequent studies have been either underpowered or used radiographic endpoints.…”

Section: Discussionmentioning

confidence: 99%

Perioperative Pharmacologic Prophylaxis for Venous Thromboembolism in Colorectal Surgery

Kwon

Meissner

Symons

et al. 2011

Journal of the American College of Surgeons

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Background To determine the effectiveness of pharmacologic prophylaxis on preventing clinically relevant venothromboembolic (VTE) events and deaths after surgery. Surgical Care Improvement Project recommends that VTE pharmacologic prophylaxis be given within 24 hours of the operation. The bulk of evidence supporting this recommendation uses radiographic endpoints. Study Design The Surgical Care and Outcomes Assessment Program (SCOAP) is a Washington State quality improvement initiative with data linked to hospital admission/discharge and vital status records. We compared the rates of death, clinically relevant VTE and a composite adverse event (CAE) in the 90-days after elective, colon/rectal resections, based on the receipt of pharmacologic prophylaxis (within 24 hours of surgery) at 36 SCOAP hospitals (2005-2009). Results Of 4,195 (61.1±15.6 yrs; 54.1% women) patients, 56.5% received pharmacologic prophylaxis. 90-day death (2.5% vs. 1.6%, p-value=0.03), VTE (1.8% vs. 1.1%, p-value=0.04), and CAE (4.2% vs. 2.5%, p-value=0.002) were lower in those who received pharmacologic prophylaxis. After adjustment for patient and procedure characteristics, the odds were 36% lower for CAE (OR 0.64, 95% CI 0.44-0.93) with pharmacologic prophylaxis. In any given quarter, hospitals where patients more often received pharmacologic prophylaxis (highest tertile of use) had the lowest rates of CAE (2.3% vs. 3.6%, p=0.05) compared to hospitals in the lowest tertile. Conclusions Using clinical endpoints this study demonstrates the effectiveness of VTE pharmacologic prophylaxis in patients having elective colorectal surgery. Hospitals that used pharmacologic prophylaxis more often had the lowest rates of adverse events.

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Section: Discussionmentioning

confidence: 99%

Perioperative Pharmacologic Prophylaxis for Venous Thromboembolism in Colorectal Surgery

Kwon

Meissner

Symons

et al. 2011

Journal of the American College of Surgeons

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“…McDowall [7] reported only 2 patients with clinically evident deep venous thrombosis in a series of 1,000 consecutive admissions. The use of low-dose heparin as prophylaxis for thromboembolic events is based upon the multicenter study of Kakkar and coworkers [9] which reviewed the safety and efficacy of such prophylaxis in postoperative surgical patients. A 1.2% incidence of clinically significant pulmonary emboli was reduced to 0.4% with low-dose heparin therapy.…”

Section: Discussionmentioning

confidence: 99%

Thromboembolic complications in thermally injured patients

et al. 1992

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The frequency of thromboembolic complications in burn patients has been estimated to range from 0.4% to 7%. The clinical significance of these events is often debated and has prompted some centers to adopt the routine prophylactic use of low dose heparin prophylaxis. A 10 year review of 2,103 burn patients treated at this institution was undertaken. Twenty‐five (1.2%) patients, with a mean age of 40.0 years and an average burn size of 49.3% total body surface area (TBSA), were identified as having significant pulmonary thromboembolism (PTE). In only 3 (0.14%) patients was the thromboembolism considered to be a cause of death. Nineteen (0.9%) patients, with an average age of 36.7 years and a mean burn size of 48.3% TBSA, developed clinically evident deep venous thrombosis (DVT); however, in only 1 (0.05%) patient did the disease progress to fatal PTE.A review of the literature reveals a 0.6% to 5% incidence of complications related to low dose heparin therapy which includes bleeding, thrombocytopenia, and arterial thrombosis. We feel that the infrequency of clinically significant PTE and DVT in burn patients and the comparable or greater rate of complications associated with heparin prophylaxis mitigate against the routine use of low dose heparin therapy except in patients at high risk for these events.

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“…43 Other studies similarly reported no effect of heparin on the incidence of any VTE or PE in patients with trauma or those undergoing major surgical operations. 44,45 This effect was hypothesized to be due to a deficiency of antithrombin III (ATIII) in critically ill patients diminishing the anticoagulant activity of heparin, plus the ability of heparin to induce platelet aggregation. 46 Reports of thromboprophylaxis failure with fixed-dose thromboprophylaxis led to interest in the investigation of adjusted-dose heparin prophylaxis based on common coagulation assays.…”

Section: Venous Thromboembolism Prophylaxis Historical Perspectivementioning

confidence: 99%

Venous Thromboembolism Prophylaxis: A Narrative Review With a Focus on the High-Risk Critically Ill Patient

Lewis

Altshuler

Papadopoulos

2018

J Intensive Care Med

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Venous thromboembolism (VTE) is a major health concern associated with significant morbidity and mortality. Critically ill patients are at an increased risk of VTE compared to general medical patients due to unique risk factors: prolonged immobilization, invasive lines and devices, certain medications, and acquired thrombophilia. Furthermore, VTE in the critically ill is associated with increased duration of mechanical ventilation, increased length of intensive care unit and hospital stay, and a trend toward increased mortality. Clinical practice guidelines therefore recommend VTE prophylaxis with either subcutaneous heparin or low-molecular-weight heparin for all critically ill patients without contraindication. Yet, many patients will develop VTE despite appropriate pharmacologic prophylaxis, which has led to interest in risk-stratifying critically ill patients for more aggressive prophylaxis strategies. Recent research identified patients at highest risk of failure of thromboprophylaxis and provided insight into the pathophysiologic mechanisms. Obesity and the receipt of vasopressors are 2 risk factors consistently identified in observational studies; further clinical data support decreased absorption of anticoagulant administered via the subcutaneous route as the likely mechanism behind thromboprophylaxis failure in these patient populations. Several studies have investigated novel thromboprophylaxis strategies to circumvent pharmacokinetic limitations in patients who are obese or on vasopressors: increased fixed-dose, weight-based subcutaneous, or continuous intravenous infusion of a prophylactic dose of anticoagulant has shown promise in limited studies; however, the results have yet to demonstrate superiority compared to current standard-of-care. This review discusses observational studies identifying patients at risk of thromboprophylaxis failure and critiques clinical studies evaluating novel thromboprophylaxis strategies in high-risk, critically ill patients with a focus on their limitations. Future studies are currently being conducted that will provide further guidance into the appropriate use of individualized thromboprophylaxis.

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Prevention of Fatal Postoperative Pulmonary Embolism by Low-Dose Heparin

Cited by 51 publications

References 2 publications

Perioperative Pharmacologic Prophylaxis for Venous Thromboembolism in Colorectal Surgery

Perioperative Pharmacologic Prophylaxis for Venous Thromboembolism in Colorectal Surgery

Thromboembolic complications in thermally injured patients

Venous Thromboembolism Prophylaxis: A Narrative Review With a Focus on the High-Risk Critically Ill Patient

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