Recommendations from the ICM-VTE: Hand & Wrist

Abstract

The ICM-VTE Hand & Wrist Delegates* Question: 1 -Concerning VTE risk, which surgeries can be considered major, and which surgeries can be considered non-major in hand surgery?Response/Recommendation: Surgeries involving general anesthesia for >90 minutes, surgeries requiring bedrest or limited ambulation postoperatively, and surgeries involving replantation or free vascularized tissue transfer should be considered major in Hand Surgery.Strength of Recommendation: Consensus.Delegates vote: Agree 90.48% Disagree 4.76% Abstain 4.76% (Strong Consensus)Rationale: Risk factors for venous thromboembolism (VTE) following hand surgery are poorly studied. This is partly due to the very low incidence of these adverse events, which was determined to be 0.0018% by Hastie et al., in a sample of 3,357 consecutive upper extremity surgeries 1 . As a result, it is extremely challenging to stratify procedures into high-or low-risk categories for VTE.Some studies of VTE risk following surgical procedures have included hand and wrist surgery in their samples. A study by Keller et al., of VTE following endoprosthesis surgeries included 183,420 upper extremity surgeries and reported a 0.4% incidence of VTE (2.69 times lower than that of lower extremity endoprosthesis surgery), but this study did not differentiate between hand, wrist, elbow, and shoulder procedures 2 . Similarly, studies investigating VTE prophylaxis following free tissue transfer have included upper extremity tissue transfers. Ricci et al., recommended subcutaneous heparin VTE prophylaxis following upper extremity free flaps, but based this recommendation on expert opinion given the lack of available evidence 3 . A National Surgical Quality Improvement Program (NSQIP) database study of VTE following plastic surgery analyzed 19,276 plastic surgery cases performed under general anesthesia and found a VTE incidence of 1.3% in cases lasting over 5 hours. In cases lasting less than 5 hours, VTE incidence was less than 0.36%. There were no hand surgical procedures that resulted in >2 VTE within this sample, although the total number of hand surgical cases that were complicated by VTE was not reported 4 . Consensus guidelines from the British Society for Surgery of the Hand (BSSH) cur-rently recommend mechanical VTE prophylaxis for cases under general anesthesia lasting >90 minutes and/or in patients with at least one VTE risk factor, and recommend the consideration of pharmacological prophylaxis in patients undergoing >90 minutes of general anesthesia with more than one risk factor, or prolonged immobility 5 .Given the lack of evidence differentiating high-and lowrisk hand surgeries, further study in this topic is needed, and current recommendations are based on a consensus of opinion among experts.

International consensus on prevention of venous thromboembolism in patients after orthopedic interventions

“…У березні 2022 року опубліковано нові міжнародні рекомендації щодо профілактики венозної тромбоемболії в пацієнтів після великих ортопедичних утручань (Recommendations from the International Consensus Meeting on Venous Thromboembolism) [1][2][3][4][5][6][7][8][9][10]. Передумовою для створення цього консенсусу послужила недосконалість наявних даних і рекомендацій щодо профілактики тромбоемболії в періопераційному періоді.…”

“…Рекомендації містять розділ зі загальними підходами тромбопрофілактики після ортопедичних утручань [1] та спеціалізованими, зокрема: у разі хірургії верхньої кінцівки та зап'ястка [2], плеча або ліктя [3], стопи або гомілки [4], стегна або коліна [5], хребта [6], за умов онкології [7], у випадку операцій у дітей [8], після ушкоджень [9] і спортивних травм [10].…”