Timing of Perioperative Pharmacologic Thromboprophylaxis Initiation and its Effect on Venous Thromboembolism and Bleeding Outcomes: A Systematic Review and Meta-Analysis

McAlpine, Kristen; Breau, Rodney H.; Werlang, Paulo; Carrier, Marc; Gal, Grégoire Le; Fergusson, Dean; Shorr, Risa; Cagiannos, Ilias; Morash, Christopher; Lavallée, Luke T.

doi:10.1016/j.jamcollsurg.2021.07.687

Cited by 11 publications

(15 citation statements)

References 39 publications

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“…Whilst VTE risk necessitates chemoprophylaxis in the perioperative setting, strong evidence now exists demonstrating that chemoprophylaxis confers a clinically significant risk of bleeding [4]. Multiple studies now show that postoperative commencement of chemoprophylaxis is favored over pre‐ and intra‐operative administration because of reduced bleeding risk while preserving VTE protection [24, 26, 36–39]. In this study, our findings indicate that there is no optimal time window for initiating chemoprophylaxis in the early postoperative period.…”

Section: Discussionmentioning

confidence: 80%

Postoperative Timing of Chemoprophylaxis and Its Impact on Thromboembolism and Bleeding Following Major Abdominal Surgery: A Multicenter Cohort Study

2023

World j. surg.

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Background Major abdominal surgery is associated with bleeding and venous thromboembolism (VTE) risks. Chemoprophylaxis prevents VTE but increases bleeding risk. When compared with pre- and intra-operative chemoprophylaxis, recent evidence suggests that starting chemoprophylaxis postoperatively lowers the risk of bleeding without compromising VTE protection. This study investigates whether an optimal window exists in the postoperative period for initiating chemoprophylaxis in patients undergoing major abdominal surgery. Methods Analysis of pooled data from four multicenter PROTECTinG studies, which investigated the timing of perioperative chemoprophylaxis on bleeding and VTE outcomes following major abdominal surgery. Patients that commenced chemoprophylaxis postoperatively were separated into quartiles based on timing of administration within the first 24 h post-surgery. Results Overall, 4729 (Abdominal visceral resection N = 668, cholecystectomies N = 573, major ventral hernia repair N = 1701, antireflux surgery N = 1787) consecutive patients had chemoprophylaxis commenced within 24 h following elective surgery. Baseline characteristics were comparable between quartiles. Across quartiles and within each procedural type, the timing of starting chemoprophylaxis was not associated with bleeding (2.6, 1.7, 2.7 and 3.2%, p = 0.130) or clinical VTE (0.8, 0.2, 0.8 and 0.5%, p = 0.131), and did not predict their occurrences on multivariate analysis. Conclusion Chemoprophylaxis can be safely started at any time within 24 h post-skin closure in major abdominal surgery, without affecting bleeding or VTE risks. This finding encourages the standardization of chemoprophylaxis timing in the postoperative period to pre-defined times during the day to improve workflow efficiency and chemoprophylaxis compliance.

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Section: Discussionmentioning

confidence: 80%

Postoperative Timing of Chemoprophylaxis and Its Impact on Thromboembolism and Bleeding Following Major Abdominal Surgery: A Multicenter Cohort Study

2023

World j. surg.

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“…Additionally, within major abdominal surgery, subgroup analysis of patients with an inherently high thromboembolic risk also favours postoperative chemical thromboprophylaxis over early usage 21 . These reports, along with findings from two recent meta-analyses, one of randomized trials involving different surgical disciplines 22 , and the other of randomized trials and cohort studies involving major abdominal surgery 23 , demonstrated that postoperative chemical thromboprophylaxis did not diminish protection against VTE. Therefore, in the context of significant global variations in practice 4 , 24 , this study contributes to a growing body of evidence, spanning multiple specialties and procedural types, that postoperative chemical thromboprophylaxis is a safer approach for patients, resulting in a similar risk of VTE, but lower rates of bleeding.…”

Section: Discussionmentioning

confidence: 94%

Effect of timing of perioperative chemical thromboprophylaxis on thromboembolic, bleeding, and other complications during and after antireflux surgery: multicentre cohort study

Liu,

Wong,

Goh

et al. 2023

BJS Open

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Background Although guidelines recommend the use of perioperative chemical thromboprophylaxis for antireflux surgery, the optimal timing for its initiation is unknown. The aim of this study was to investigate whether perioperative timing of chemical thromboprophylaxis affects bleeding, symptomatic venous thromboembolism, and complication rates in patients undergoing antireflux surgery. Methods This study involved analysis of prospectively maintained databases and medical records of all elective antireflux surgeries in 36 hospitals across Australia over 10 years. Results Overall, chemical thromboprophylaxis was given early (before surgery or intraoperatively) in 1099 (25.6 per cent) patients, and after surgery in 3202 (74.4 per cent) patients, with comparable exposure doses between the two groups. Symptomatic venous thromboembolism risk was unrelated to chemical thromboprophylaxis timing (0.5 versus 0.6 per cent for early and postoperative chemical thromboprophylaxis respectively (odds ratio (OR) 0.97, 95 per cent c.i. 0.41 to 2.47, P = 1.000). Postoperative bleeding developed in 34 (0.8 per cent) patients, and 781 intraoperative adverse events were identified in 544 (12.6 per cent) patients. Both intraoperative bleeding and complications were associated with significantly higher postoperative morbidity affecting multiple organ systems. Importantly, compared with postoperative chemical thromboprophylaxis, early administration increased the risk of postoperative bleeding ((1.5 versus 0.5 per cent for early and postoperative chemical thromboprophylaxis respectively (OR 2.94, 95 per cent c.i. 1.48 to 5.84, P = 0.002)) and intraoperative adverse events ((16.1 versus 11.5 per cent for early and postoperative chemical thromboprophylaxis respectively (OR 1.48, 95 per cent c.i. 1.22 to 1.80, P < 0.001)), as well as independently predicted their occurrences. Conclusion Intraoperative adverse events and bleeding that occur during and after antireflux surgery are associated with significant morbidity. Compared with postoperative chemical thromboprophylaxis, early initiation of chemical thromboprophylaxis confers a significantly higher risk of intraoperative bleeding complications, without appreciable additional protection from symptomatic venous thromboembolism. Therefore, postoperative chemical thromboprophylaxis should be recommended for patients undergoing antireflux surgery.

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“…In a recent meta-analysis, McAlpine et al8 investigated 17,124 patients from 22 studies exploring the impact of chemoprophylaxis timing on postoperative VTE and bleeding rates. They demonstrated no difference in VTE and bleeding rates between early and postoperative cohorts.…”

Section: Discussionmentioning

confidence: 99%

“…McAlpine et al 8 recently conducted a meta-analysis on the timing of perioperative thromboprophylaxis across multiple surgical specialties. Notably, these authors combined data from orthopedic, thoracic, cardiac, breast, obstetric, and abdominal surgeries.…”

mentioning

confidence: 99%

Optimal Timing of Perioperative Chemical Thromboprophylaxis in Elective Major Abdominal Surgery

et al. 2022

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To investigate the effect of the timing of chemoprophylaxis on venous thromboembolisms (VTEs) and bleeding rates in patients undergoing major abdominal surgery. Background: Postoperative bleeding and VTE incur significant morbidity, mortality, and health care costs. Chemoprophylaxis is used routinely to prevent VTEs but increases bleeding risk. The perioperative timing of chemoprophylaxis initiation may influence both VTE and bleeding risks. The optimal window for commencing chemoprophylaxis in the perioperative period is unclear. Methods: MEDLINE, EMBASE, Cochrane Library, and Web of Science databases were searched using PRISMA guidelines. Randomized trials and cohort studies published between January 1, 2000 to May 10, 2022, which reported on chemoprophylaxis timing as well as the incidence of VTE and bleeding after elective abdominal surgery were meta-analyzed. Results: From 6175 studies, 14 (24,922 patients) were meta-analyzed. Bariatric (4 studies), antireflux (1 study), hepato-pancreatic-biliary (5 studies), colorectal (1 study), ventral hernia (1 study), and major intraabdominal surgeries (2 studies) were included. Chemoprophylaxis was initiated before skin closure in 10,403 patients, and postoperatively in 14,519 patients. Both symptomatic [risk ratios (RR), 0.81; 95% CI, 0.45-1.43; P = 0.460] and overall (RR, 0.74; 95% CI, 0.45-1.24; P = 0.250) VTE rates were comparable between study groups. Compared with postoperative chemoprophylaxis, early usage increased the risk of all bleeding (

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Timing of Perioperative Pharmacologic Thromboprophylaxis Initiation and its Effect on Venous Thromboembolism and Bleeding Outcomes: A Systematic Review and Meta-Analysis

Cited by 11 publications

References 39 publications

Postoperative Timing of Chemoprophylaxis and Its Impact on Thromboembolism and Bleeding Following Major Abdominal Surgery: A Multicenter Cohort Study

Postoperative Timing of Chemoprophylaxis and Its Impact on Thromboembolism and Bleeding Following Major Abdominal Surgery: A Multicenter Cohort Study

Effect of timing of perioperative chemical thromboprophylaxis on thromboembolic, bleeding, and other complications during and after antireflux surgery: multicentre cohort study

Optimal Timing of Perioperative Chemical Thromboprophylaxis in Elective Major Abdominal Surgery

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