Type of anaesthesia and the safety and efficacy of thromboprophylaxis with enoxaparin or dabigatran etexilate in major orthopaedic surgery: pooled analysis of three randomized controlled trials

Rosencher, Nadia; Noack, Herbert; Feuring, Martin; Clemens, Andreas; Friedman, Richard J.; Eriksson, Bengt I.

doi:10.1186/1477-9560-10-9

Cited by 18 publications

(10 citation statements)

References 23 publications

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“…85,88 Interestingly, the type of anaesthesia may also infuence VTE risk: regional anaesthesia has been reported to carry a lower VTE risk than general anaesthesia; consequently it is often recommended in guidelines and commonly used in practice. 17,51,89,90 A recent study reported that East Asian patients experience very little to no symptomatic VTE following hip and knee arthroplasty, suggesting the value of using routine thromboprophylaxis is debatable in East Asia. 81 Notably, studies in South East Asia have actually reported higher symptomatic VTE rates to other studies (5.1%).…”

Section: Other Influencing Factorsmentioning

confidence: 99%

Thromboprophylaxis following hip and knee arthroplasty

Mirkazemi

Bereznicki

Peterson

2013

Internal Medicine Journal

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Aim To determine local thromboprophylaxis prescribing practices following arthroplasty. Methods A retrospective review was performed of 300 consecutive hip and knee arthroplasty patients (150 each) over a 2‐year period at Tasmania's major public hospital. The provision of thromboprophylaxis, the presence of bleeding/thrombotic risk factors and the prevalence of symptomatic venous thromboembolism (VTE) and major bleeding occurring within 90 days postoperatively were documented. Results The mean age of the 300 patients (169 females, 131 males) was 68.7 years (standard deviation 10.4). Only 11.3% of knee arthroplasty and 16.7% of hip arthroplasty inpatients had mechanical thromboprophylaxis documented during their stay. All inpatients received pharmacological thromboprophylaxis, predominantly injectable anticoagulants (98.4%). Only 36.5% continued to receive pharmacological thromboprophylaxis following discharge, predominantly an antiplatelet agent (55.5%). The 90‐day incidence of symptomatic VTE was 2.7% (95% confidence interval: 1.0–5.0%); 4.0% (95% confidence interval: 1.0–8.0%) for knees and 1.3% (95% confidence interval: 0–5.0%) for hips. The in‐hospital and post‐discharge VTE incidence was 0.7% and 2.0% respectively. All readmissions for VTE occurred within 1 month of surgery. Conclusions While inpatient thromboprophylaxis was routine, it generally was not continued on discharge, potentially leaving many patients exposed to a higher risk of VTE. Most cases of symptomatic VTE occurred after discharge, with the majority requiring readmission to hospital under medical units.Within the limitations of a retrospective study, these findings suggest a need for further research and discussion regarding what constitutes appropriate thromboprophylaxis (type, agent and duration) following hip or knee arthroplasty.

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Section: Other Influencing Factorsmentioning

confidence: 99%

Thromboprophylaxis following hip and knee arthroplasty

Mirkazemi

Bereznicki

Peterson

2013

Internal Medicine Journal

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“…A pooled analysis of phase Ⅲ studies of orthopedic thromboprophylaxis (excluding RE-NOVATE Ⅱ) found no differences in surgical site bleeding or wound infection although smaller independent investigations have since suggested a possible increased risk of post-operative wound complications with dabigatran compared to LMWH [55,56] . No incidence of spinal hematoma was ob-served in patients receiving both dabigatran and neuraxial anesthesia during three of four phase Ⅲ studies (excluded RE-NOVATE Ⅱ) [57] . As previously noted, the risk of bleeding in Phase Ⅲ studies of dabigatran in orthopedic surgery patients was not increased by concurrent NSAID or antiplatelet drug use [50] .…”

Section: Results Of Both Re-novate and Re-novatementioning

confidence: 99%

New oral pharmacotherapeutic agents for venous thromboprophylaxis after total hip arthroplasty

Aikens

Osmundson

Rivey

2014

WJO

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Patients undergoing total hip arthroplasty (THA) are at high risk for developing venous thromboembolism and, therefore, require short term prophylaxis with antithrombotic agents. Recently, target specific oral anticoagulants (TSOA) including the direct thrombin inhibitor, dabigatran, and the factor Ⅹa inhibitors rivaroxaban, apixaban, and edoxaban have been approved for THA thrombopropylaxis in various countries. The TSOAs provide a rapid acting, oral alternative to parenteral agents including low-molecular weight heparins (LMWH) and fondaparinux; and compared to warfarin, they do not require routine laboratory monitoring and possess much fewer drug-drug interactions. Based on phase Ⅲ clinical studies, TSOAs have established themselves as an effective and safe option for thromboprophylaxis after THA compared to LMWH, particularly enoxaparin, but require additional evaluation in specific populations such as the renally impaired or elderly. The ability to monitor and reverse these TSOAs in the case of bleeding complications or suspected sub-or supra-therapeutic anticoagulation is of importance, but remains investigational. This review will focus on the drug-specific characteristics, efficacy, safety, and economic impact of the TSOAs for thromboprophylaxis following THA, as well as the aspects of therapeutic monitoring and anticoagulation reversal in the event of bleeding complications or a need for urgent reversal. Key words: Oral; Thromboprophylaxis; Venous thromboembolism; Hip; Arthroplasty Core tip: This review focuses on the drug-specific characteristics, efficacy, safety, and economic impact of the target specific oral anticoagulants including dabigatran, rivaroxaban, apixaban, and edoxaban for thromboprophylaxis following total hip arthroplasty, as well as the aspects of therapeutic monitoring and anticoagulation reversal in the event of bleeding complications or a need for urgent reversal.Aikens GB, Osmundson JR, Rivey MP. New oral pharmacotherapeutic agents for venous thromboprophylaxis after total hip arthroplasty. World J Orthop 2014; 5(3): 188-203 Available from:

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“…Rosencher et al [5] summarized from licensing studies involving 4212 neuraxial blocks that bleeding complications were not different in patients receiving neuraxial anesthesia or general anesthesia. The first dose of dabigatran was given at least 2 h after epidural catheter removal, and patients who had undergone at least three attempts to place spinal or epidural anesthesia or in whom the placement was traumatic were excluded.…”

Section: Dabigatranmentioning

confidence: 99%

“…The first dose of dabigatran was given at least 2 h after epidural catheter removal, and patients who had undergone at least three attempts to place spinal or epidural anesthesia or in whom the placement was traumatic were excluded. Interestingly, a slightly higher rate of major venous thromboembolism (VTE) and VTE-related mortality with general anesthesia alone versus neuraxial anesthesia alone (odds ratio 1.40, 95% confidence interval 1.03-1.90, P ¼ 0.035) was found [5]. Neuraxial single shot blocks apparently seem well tolerated if the block is provided for surgery.…”

Section: Dabigatranmentioning

confidence: 99%