January 22, 2015
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VTE prophylaxis a ‘never event’ without clear superiority of a single regime

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KOLOA, Hawaii — The current state of venous thromboembolism prophylaxis is that it is not a “never event,” particularly among patients with numerous comorbidities, according to a presenter here.

“This ‘never event’ is one we have to battle. We have to keep pounding that it into the people — the insurance companies and government — who tell us what to do because it is not a ‘never event,’” Robert D. D’Ambrosia, MD, said at Orthopedics Today Hawaii 2015.

Venous thromboembolism (VTE) prophylaxis is considered best clinical practice, yet there is no clear superiority of a single regime, he said. Clot formation and VTE cannot be completely prevented after total hip arthroplasty (THA) or total knee arthroplasty (TKA).

“It is a real problem because the government and insurance companies are going to call when you get an infection or get a pulmonary embolism (PE). It is a never event. If it is a never event, we are not going to get paid for it,” he said.

Robert D. D'Ambrosia

He said current guidelines are dominated by those of the American College of Chest Physicians, which emphasize venographically proven deep vein thrombosis and recommend all agents be used for 10 to 14 days. Low-molecular-weight heparin (LMWH) is preferred over all pharmacologic agents, as is 35 days of prophylaxis. During hospital stays, use of dual prophylaxis with pharmacological agents and an intermittent pneumatic compression device (IPCD) are recommended. Additionally, there is no Doppler ultrasound before hospital discharge.

Guidelines from the American Academy of Orthopaedic Surgeons recommend the discontinuation of antiplatelet agents prior to THA and TKA, as well as the use of IPCD and pharmacologic agents and a neuraxial delivery to limit blood loss. Patients with bleeding disorders or liver diseases should use an IPCD. Additionally, there is no recommendation for use of any specific prophylaxis. The guidelines recommend patients and physician discuss the duration of prophylaxis, with patients having early mobilization and no routine postoperative Doppler ultrasound.

“They came out with good guidelines that I think are very practical,” D’Ambrosia said.

Guidelines of the Surgical Care Improvement Project (SCIP) recommend patients receive appropriate VTE prophylaxis within 24 hours prior to surgery to 24 hours after surgery, as well as the use of LMWH factor Xa inhibitors, oral factor Xa inhibitor, vitamin K antagonist, IPCD, venous foot pump, low-dose unfractionated heparin and aspirin.

D’Ambrosia said that during a 10-year period using the SCIP guidelines among more than 28,000 patients, there was an increase in the rate of superficial infection, unchanged deep surgical site infections, increased rates of PE and an unchanged rate of DVT. – by Kristine Houck, MA, ELS

Reference:

D’Ambrosia RD. VTED prophylaxis: what do the guidelines say. Presented at: Orthopedics Today Hawaii 2015. Jan. 18-22, 2015; Koloa, Hawaii.

Disclosure: D’Ambrosia has no relevant financial disclosures.