Screening duplex ultrasonography in neurosurgery patients does not correlate with a reduction in pulmonary embolism rate or decreased mortality

Abstract

OBJECTIVEDeep vein thrombosis (DVT) is a major focus of patient safety indicators and a common cause of morbidity and mortality. Many practices have employed lower-extremity screening ultrasonography in addition to chemoprophylaxis and the use of sequential compression devices in an effort to reduce poor outcomes. However, the role of screening in directly decreasing pulmonary emboli (PEs) and mortality is unclear. At the University of Mississippi Medical Center, a policy change provided the opportunity to compare independent groups: patients treated under a prior paradigm of weekly screening ultrasonography versus a post–policy change group in which weekly surveillance was no longer performed.METHODSA total of 2532 consecutive cases were reviewed, with a 4-month washout period around the time of the policy change. Criteria for inclusion were admission to the neurosurgical service or consultation for ≥ 72 hours and hospitalization for ≥ 72 hours. Patients with a known diagnosis of DVT on admission or previous inferior vena cava (IVC) filter placement were excluded. The primary outcome examined was the rate of PE diagnosis, with secondary outcomes of all-cause mortality at discharge, DVT diagnosis rate, and IVC filter placement rate. A p value < 0.05 was considered significant.RESULTSA total of 485 patients met the criteria for the pre–policy change group and 504 for the post–policy change group. Data are presented as screening (pre–policy change) versus no screening (post–policy change). There was no difference in the PE rate (2% in both groups, p = 0.72) or all-cause mortality at discharge (7% vs 6%, p = 0.49). There were significant differences in the lower-extremity DVT rate (10% vs 3%, p < 0.01) or IVC filter rate (6% vs 2%, p < 0.01).CONCLUSIONSBased on these data, screening Doppler ultrasound examinations, in conjunction with standard-of-practice techniques to prevent thromboembolism, do not appear to confer a benefit to patients. While the screening group had significantly higher rates of DVT diagnosis and IVC filter placement, the screening, additional diagnoses, and subsequent interventions did not appear to improve patient outcomes. Ultimately, this makes DVT screening difficult to justify.

European guidelines on peri-operative venous thromboembolism prophylaxis: first update.

“…Unfortunately, validated risk stratification scales are lacking, and it is not possible to provide general recommendations for this peri-operative risk specifically 3 . Moreover, attempts to demonstrate the effectiveness of peri-operative VTE screening strategies in improving outcomes have mainly proved inconclusive 4 . The risk of permanent neurological sequelae and the need for urgent decompression of a postoperative haematoma generally discourages chemoprophylaxis in the absence of major thromboembolic risk factors.…”

Effect Analysis of Nursing Intervention on Lower Extremity Deep Venous Thrombosis in Patients

“…In the study, the author discussed the Theory of Deep Venous Thrombosis (T-DVT) is the risk after Achilles tendon breakup treatment is decreased when the leg is immobilized (Dickerson et al, 2019). A second objective has been to assess whether there was an impact on the risk of DVT on weight-bearing and daily measures (Zhang et al, 2019).…”

Point‐of‐care ultrasound for deep venous thrombosis of the lower limb

“…In several centres, pre‐operative therapeutic anticoagulation was stopped prior to neurosurgery and an inferior vena cava filter inserted to prevent proximal migration of the DVT during the perioperative period when anticoagulation was ceased . Although it is logical that earlier detection and treatment of DVT may result in less morbidity and mortality from PE, there is some doubt, but due to the lack of adequately powered randomised trials, this research question is yet to be proven either way. The guidelines from the American College of Chest Physicians recommend against routine use of ultrasound to screen for DVT's, but they do recommend treatment with either anticoagulant medication or inferior vena cava filter placement in patients diagnosed with an asymptomatic proximal DVT…”