The prevention of pulmonary embolism in total hip arthroplasty

Balderston, Richard A.; Graham, Timothy S.; Booth, Robert E.; Rothman, Richard H.

doi:10.1016/s0883-5403(89)80017-8

Cited by 24 publications

(8 citation statements)

References 26 publications

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“…Anticoagulant medications are effective prophylactic agents, but are associated with hemorrhagic and other complications [30,[68][69][70][71][72][73][74][75][76]. Patients with tumors often have abnormalities of coagulation that promote bleeding and consumption of clotting factors [77,78].…”

Section: Discussionmentioning

confidence: 99%

Deep venous thrombosis after orthopedic surgery in adult cancer patients

et al. 1998

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Background and Objectives: Patients with cancer and patients undergoing major orthopedic procedures are two groups at risk of deep venous thrombosis (DVT). The objective was to determine the rate of venous thromboembolic disease in patients with a malignant neoplasm and major orthopaedic surgery of the lower limb. Methods The study included 169 patients. All patients were given knee‐high intermittent pneumatic compression devices for prophylaxis. Postoperative surveillance for thrombosis was performed on all patients with venous duplex doppler ultrasonography. Results Proximal DVT occurred in 24 of 169 patients (14.2%). One patient (0.6%) developed a symptomatic, nonfatal pulmonary embolus (PE). The development of DVT was not associated with age, sex, type of surgery, type of neoplasm, location, or pathologic fracture. The addition of anticoagulant medication such as warfarin did not significantly reduce the rate of DVT in a subset of 54 patients. In three patients, the DVT occurred only in the contralateral limb, and in four patients, there were bilateral DVTs. Conclusions When intermittent compression boots were used for prophylaxis in conjunction with ultrasound screening, the risk of proximal DVT was substantial (14.2%), but the rate of symptomatic PE was low (0.6%). J. Surg. Oncol. 1998;68:41–47. © 1998 Wiley‐Liss, Inc.

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Section: Discussionmentioning

confidence: 99%

Deep venous thrombosis after orthopedic surgery in adult cancer patients

et al. 1998

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“…Studies regarding postoperative PE have mainly focussed on orthopaedic and oncological populations, in which the incidence of symptomatic and fatal PE is approximately 1 % and 0.1 %, respectively [17, 18, 37]. Asymptomatic PE is observed in 2–4 %, and is therefore at least twice as common as its symptomatic counterpart [38, 39]. Of note, these numbers are based on studies using a ventilation/perfusion (V/Q) scan.…”

Section: Literaturementioning

confidence: 99%

The aetiology of myocardial injury after non-cardiac surgery

et al. 2013

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Recognition of myocardial injury after non-cardiac surgery is difficult, since strong analgesics (e.g. opioids) can mask anginal symptoms, and ECG abnormalities are subtle or transient. Thorough knowledge of the pathophysiological mechanisms is therefore essential. These mechanisms can be subdivided into four groups: type I myocardial infraction (MI), type II MI, non-ischaemic cardiac pathology, and non-cardiac pathology. The incidence of type I MI in patients with a clinical suspicion of perioperative acute coronary syndrome (ACS) is 45–57 %. This percentage is higher in patients with a high likelihood of MI such as patients with ST-elevation ACS. Of note, the generalisability of this statement is limited due to significant study limitations. Non-ischaemic cardiac pathology and non-cardiac pathology should not be overlooked as a cause of perioperative myocardial injury (PMI). Especially pulmonary embolism and dysrhythmias are a common phenomenon, and may convey important prognostic value. Implementation of routine postoperative troponin assessment and accessible use of minimally invasive imaging should be considered to provide adequate individualised therapy. Also, addition of preoperative imaging may improve the stratification of high-risk patients who may benefit from preoperative or perioperative interventions.

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“…Even more, the ACCP guidelines do not consider the risk of severe bleeding associated with anticoagulation, which ranges from 5.0% to 5.6% after TKA and 0.6% to 1.6% after THA [8,9,17], as well as the risk for minor bleeding complications after TKA and THA (21%-28% and 4.6%-13.5%, respectively). Safety and low risk of complications with the use of lowdose warfarin (ie, aiming for an INR\2) for preventing PE has been demonstrated [1]. We therefore asked whether an INR level of greater than 2, as dictated by the ACCP guidelines, after TJA is protective against PE.…”

Section: Discussionmentioning

confidence: 99%

“…It is from this point of view that the AAOS created the guidelines stating patients at a standard risk of both PE and bleeding can be given aspirin, LMWH, synthetic pentasaccharides, or warfarin to reach an INR goal of 2 or lower [11]. A previous prospective study from this institution that involved performing preoperative and postoperative VQ scans in a consecutive series of patients undergoing TJA found low-dose warfarin (with an INR goal\2) is effective at minimizing development of PE, with a low (2.4%) bleeding complication [1]. Based on these findings, we have used low-dose warfarin as a prophylaxis for prevention of PE in our patients over the last two decades.…”

Section: Discussionmentioning

confidence: 99%

“…With the increased risk of bleeding complications, it is important to understand the effectiveness of therapeutic anticoagulation in minimizing PE. We previously demonstrated the low risk of complications with the use of low-dose warfarin (ie, aiming for an INR \ 2) for preventing PE [1]. That study was the basis for implementing the use of low-dose warfarin (aiming for an INR \ 2) in patients undergoing TJA in 1990.…”

Section: Introductionmentioning

confidence: 89%

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Does International Normalized Ratio Level Predict Pulmonary Embolism?

Hansen

Zmistowski

Restrepo

et al. 2012

Clinical Orthopaedics &Amp; Related Research

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Background Preventing pulmonary embolism is a priority after major musculoskeletal surgery. The literature contains discrepant data regarding the influence of anticoagulation on the incidence of pulmonary embolism after joint arthroplasty. The American College of Chest Physicians guidelines recommend administration of oral anticoagulants (warfarin), aiming for an international normalized ratio (INR) level between 2 and 3. However, recent studies show aggressive anticoagulation (INR [ 2) can lead to hematoma formation and increased risk of subsequent infection. Questions/purposes We asked whether an INR greater than 2 protects against pulmonary embolism. Patients and Methods We identified 9112 patients with 10,122 admissions for joint arthroplasty between 2004 and 2008. All patients received warfarin for prophylaxis, aiming for an INR level of 2 or lower. We assessed 609 of 10,122 admissions (6%) for pulmonary embolism using CT, ventilation/perfusion scan, or pulmonary angiography, and 163 of 10,122 admissions (1.6%) had a proven pulmonary embolism. Results Fifteen of 163 admissions (9%) had an INR greater than 2 before or on the day of workup compared to 35 of 446 admissions (8%) who were negative. We observed no difference between the INR values in patients with or without pulmonary embolism. Conclusions We found no clinically relevant difference in the INR values of patients who did or did not develop pulmonary embolism. The risk of bleeding should be weighed against the risk of pulmonary embolism when determining an appropriate target INR for each patient, as an INR less than 2 may reduce the risk of bleeding while still protecting against pulmonary embolism. Level of Evidence Level III, therapeutic study. See Instructions to Authors for a complete description of levels of evidence.

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The prevention of pulmonary embolism in total hip arthroplasty

Cited by 24 publications

References 26 publications

Deep venous thrombosis after orthopedic surgery in adult cancer patients

Deep venous thrombosis after orthopedic surgery in adult cancer patients

The aetiology of myocardial injury after non-cardiac surgery

Does International Normalized Ratio Level Predict Pulmonary Embolism?

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