Risks for hemorrhagic complications after placement of external ventricular drains with early chemical prophylaxis against venous thromboembolisms

Abstract

Object Patients undergoing placement of an external ventricular drain (EVD) are at increased risk for development of venous thromboembolisms (VTEs). Early chemical prophylaxis has been shown to decrease rates of embolism formation, but the risks for bleeding and the optimal time to initiate prophylaxis have not been clearly defined for this patient population. The authors evaluated the safety and risks for bleeding when chemical prophylaxis for VTEs was started within 24 hours of EVD placement. Methods To compare rates of hemorrhage among patients who received prophylaxis within 24 hours and those who received it later than 24 hours after admission, the authors conducted an institutional review board–approved retrospective review. Patients were those who had had an EVD placed and postprocedural imaging conducted at Bellevue Hospital, New York, from January 2009 through April 2012. Data collected included demographics, diagnosis, coagulation panel results, time to VTE prophylaxis and imaging, and occurrence of VTEs. The EVD-associated hemorrhages were classified as Grade 0, no hemorrhage; Grade 1, petechial hyperdensity near the drain; Grade 2, hematoma of 1–15 ml; Grade 3, epidural or subdural hematoma greater than 15 ml; or Grade 4, intraventricular hemorrhage or hematoma requiring surgical intervention. Results Among 99 patients, 111 EVDs had been placed. Low-dose unfractionated heparin had been given within 24 hours of admission (early prophylaxis) to 56 patients and later than 24 hours after admission (delayed prophylaxis) to 55 patients. There were no statistical differences across all grades (0–4) among those who received early prophylaxis (n = 45, 5, 5, 1, and 0, respectively) and those who received delayed prophylaxis (n = 46, 4, 1, 1, and 3, respectively) (p = 0.731). In the early prophylaxis group, 3 VTEs were discovered among 32 of 56 patients screened for clinically suspected VTEs. In the delayed prophylaxis group, 5 VTEs were discovered among 33 of 55 patients screened for clinically suspected VTEs (p = 0.71). Conclusions Hemorrhagic complications did not increase when chemical prophylaxis was started within 24 hours of admission. Also, the incidence of VTEs did not differ between patients in the early and delayed prophylaxis groups. Larger randomized controlled trials are probably needed to assess decreases in VTEs with earlier prophylaxis.

Venous thromboembolism chemical prophylaxis after endoscopic trans-sphenoidal pituitary surgery

“…As such, decision making surrounding chemoprophylaxis must be made on a case by case basis by balancing the benefits of VTE reduction with potentially increased risk of bleeding events. Meta-analyses and prior institutional series including neurosurgical patients from different subspecialties have demonstrated that pharmacological thromboprophylaxis with heparin agents can be used postoperatively to decrease the rate of VTE with a minimal risk of bleeding [7][8][9][10][11][12]. However, there is a lack of subset outcome data for patients undergoing trans-sphenoidal pituitary surgery.…”

Safety of Early Pharmacological Thromboprophylaxis after Subarachnoid Hemorrhage

“…The presence of an EVD has also been used as a relative contraindication to early PTP initiation. However, Tanweer et al 29 have shown in a recent retrospective study including 34 SAH patients, that the early start of PTP in patients with EVD was not associated with an increased rate of IHC.…”

Perioperative Management of Adult Patients With External Ventricular and Lumbar Drains: Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care

“…Contrary to popular concern, chemical prophylaxis against venous thromboembolism started within 24 hours of admission and therapeutic heparinization initiated within 24 hours of placement of the EVD does not increase bleeding risk. 112,113 The incidence of hemorrhage during removal of EVD can be higher than during placement, 66 and similar indices of coagulopathy must be maintained before removal of EVD.…”