What is your DVT prophylaxis method of choice?
I practiced in centers in which “mini-heparin” was considered as the gold standard for DVT prophylaxis. Peri-operative heparin prophylaxis was used by us selectively according to well known protocols. My personal experience is not recorded- but for many years -working in large University hospitals ,I do not recall encountering any case of clinically significant postoperative pulmonary embolism.
DVT prophylaxis in USA
In this country, however, everybody around me uses Venodyne-pneumatic compression device for DVT prophylaxis. Over a period of 2 years we presented, however, in our M & M at least 4 patients with clinically significant PE in patients in whom this devise was used.
To my comments that mini-heparin is a more effective prophylactic method I am told that the pneumatic devise is as good. I am also told that the pneumatic devise is as effective when applied to the arm-generating systemic anti-thrombotic effects.
Now, I have seen studies which compare pneumatic devise to NO prophylaxis; but I am not aware about any study prospectively comparing heparin prophylaxis to the pneumatic compression devise in high risk patients.
What is your DVT prophylaxis method of choice? Why?
Mini-heparin.
Why? Like you I have many years experience with no PE’s on low dose heparin. I occasionaly use the boots, but find they are abandoned after about 48 hours by both the nurses and the patients.
Myself and the other surgeon that I work with and most all of the Intensivists that follow the major surgical cases use both Heparin SC (5,000 u q 8 or q 12h) and sequential compression devices along with early ambulation. I know of no study comparing the two separately or together. We still have a very occasional PE and just two weeks ago had a death from PE three weeks post op following gastric surgery in patient whose weight was 486 lbs. He was in the hospital 5 days post op and went home and two weeks later was SOB for 3 days before coming to the ER and died there one hour later.
The flaw in your argument is so obviously one you routinely point out to us! You know–anecdotal observation not being valid, etc–need I really go on? Do we really need to answer your questions? I routinely use subcu mini-dose heparin in elective or emergent general surgery cases with the classic risk for DVT–in trauma we do as well, though here we are more apt to use SCD;s on uninjured extremities when there is some contraindication to heparin–both are clearly shown to be equal in their DVT prophylactic efficacy in trauma, though both together add nothing over either alone–I am not aware off-hand of studies of SCD’s in non-trauma surgical patients. Obviously PE’s are rare–you may go another year or two and see none….but of course you know THAT part of the argument!
In my message I did not claim to bring science, only my biased level 6 observations. Being somewhat ignorant on this important topic my aim was to hear what others have to say. I think that before adopting and trusting SCD on our high risk-for-DVT -general surgical patients, we need to see level 5 data. Meanwhile, heparin should remain the gold standard.
What I actually do (encumbered by some data and strongly influenced by my last year’s lawsuit which I won but which consumed far too much of my time):
1. Low dose subcu heparin q8 hours plus SCD’s in anyone with risk factors (obesity, general anesthesia for abdominal or pelvic surgery over 30 minutes, laparoscopic surgery (not just quick diagnostic laparoscopy), over 40 plus any combination of above).
2. SCD’s alone for mastectomies and other over 30 minute general anesthetics not involving the pelvis or abdomen (note, I don’t do thoracic surgery).
3. Low molecular weight heparin plus SCD’s for pelvic malignancies, especially gynecologic oncology which is considered especially high risk.
I tell them they can take off the SCD (sequential compression device) stockings when they walk 8x in 24 hours around our entire surgical floor (remember I work at a relatively small hospital, so this is not onerous, although a usual post-op patient would be walking 4x in 24 hours around the circle so they do have to be committed to ambulation to do this). This seems to work for both the patients and nurses–they know there is a way to get out of them, so if they really dislike them, they ambulate more and this seems to fulfill the guidelines: SCD’s until ambulating well. Otherwise, as you say, the nurses and the patients both stop using them.
We use heparin for most af cases and we use it for any surgery lasting more than 30 minutes, women over 40, etc… (even lap choles). For liver resection and any surgery performed on a cirrhotic patient (higher risk of bleeding), we use pneumatic compression device. Post-op, for those patients we follow the INR and keep the pneumatic compression device if above 1.4, switch to low-molecular weight heparin (very expensive) between 1.1 and 1.4 and when INR is normal (1.1 or less), we give heparin. I can’t recall a PE on a surgical patient during my training, neither significant bleeding in high risk patients with heparin and LMWH. Though I am not aware of any study supporting this practice.
It’s hard for me to imagine using compression device on every patient receiving heparinoprophylaxis (we only have a limited number of them in the hospital). What are your indications of DVT prophylaxis? How long do you you keep the pneumatic compression device postoperatively?
For standard abdominal surgery ( appendect, gallblader, hernia, colon and gastric surg) ,most of surgeons use NOTHING for profilaxis of DVT. But,if the postop indications are given by “studious doctors,” as anesthesiologist or intensivist,the new heparin is the rule.
We give LMWH (low molecular weight heparin) 2500 IU for all major abdominal and thoracic surgery, patients over 90kg receive 5000 IU. In pelvic surgery (mainly rectal neoplasms) we give 5000 IU to all patients.
For some reason pneumatic compression devices have not found their way to most hospitals in Switzerland (I have had good personal experience with them during my time in England).
There was a recent article that stated that DVT/PE risk remains high for about one month after total joint replacement, so the article recommended DVT/PE prophylaxis for about one month in these patients (which would include post-hospitalization prophylaxis). It makes me wonder whether this is also true of general surgical patients, especially abdominal and pelvic surgery patients.
I started using sequential compression 10-12 years ago after attending a conference where Dr. Nicoliades (sp?) presented data which convinced me that pulmonary embolism was a real problem despite each of our personal experiences that it was not. He presented convincing data that SCD’s (sequential compression devices) were as beneficial as mini-heparin. I still use mini-heparin in high risk patients, but use SCD’s in all my major operations, and in all laparoscopic cases. Like everyone else, I can’t recall a case of fatal PE in a patient of mine since I started doing this. I once had a fatal PE in a patient who had an umbilical hernia repair as an out patient. She was on oral contraceptives. I haven’t done an elective operation without 2 weeks off oral contraceptives since!
I guess I’m wasting my breath, but there is absolutely no basis for this and a real inconvenience to your patient to boot. Basing such gyrations on anecdotal experience is a well-established flaw in thinking. By this logic, and without exaggeration, if your next PE occurs in someone with blonde hair, you will require all blondes to become brunettes before doing major surgery, this is not being facetious! This is exactly what yo8u have done to your patients on oral contraceptives–yes, they do have some increased risk of DVT (NOT PE to my knowledge!), but where did you find any evidence that stopping them for 2 weeks at all reduces that risk? Why 2 weeks as opposed to one week, or 10 days, or one month…well, do I make my point? Think about this anytime one of us is tempted to change our practices based on a single case (which can safely be said to always be fallacious), while so many of us on this very net refuse to change practice in the face of mountains of class I data (i.e. only 30% of women in this country who are eligible for breast conservation ever get it, in 90+% of cases solely because the surgeon refuses!) We are a fickle and stubborn lot!
I think I had a fatal PE shortly after I started using SCD’s. We didn’t get a post, but it was a sudden death 5 days after otherwise uneventful colon resection. The patient had been ambulating well in the halls too. There was no EKG or cardiac enzyme evidence of MI and the patient turned blue and was unresuscitatable.
As someone else mentioned also, the nurses and patients like to take them off or shut them off, also, decreasing their effectiveness.
I still use them, but that was a chilling experience. He had a rectal cancer with lymph node mets and had had a lymphoma or some other malignancy previously. Luckily for me, the family was understanding (and of course, they knew that he had the SCD’s to prevent PE so they thought I had done everything I could).
Don’t you think low dose heparin is adequate in the patient on oral contraceptives?
Here’s a case report, and a recommendation regarding BCP’s. Someone is at least thinking about the subject. Another paper identifies BCP’s as the highest risk factor for DVT in young women. It would seem appropriate to discontinue them in young women undergoing elective operations, and I must admit that this has not been my practice. Perhaps it should be. The question at hand is to stop them for how long, not about stopping them at all. The question deserves investigation and an answer. Other questions come to mind: does the use of the other modalities discussed, ie, mini heparin, SCD’s, offset the effect of BCP’s? How many surgeons routinely discontinue oral contraceptives in their female patients undergoing elective operations?
Not me–how many out there post pone all surgery in females within one month of delivery of a child, also a high risk setting for DVT? How many don’t perform major surgery umder general anesthesia that takes more than 30 minutes–also a high risk setting for DVT? How many do not perform surgery in women over 40, also a high risk setting for DVT? See my point? We have already methods of reducing risk in these settings–such as subcu heparin–so no, it doesn’t make any sense to me at all to D/C OCP’s prior to surgery in the absence of any information as to whether there is any benefit at all! This has come purely out of your imagination. Once again that is the wrong question, because the answer means nothing–as we see on these boards, people do all sorts of things out there–if something makes no sense, a thousand people doing it does not make it any more rational/ The better question might be–Who has any information on whether stopping OCP’s prior to surgery has any benefit? What did your medline search show about that?
Another high risk period is pregnancy and the first 6 weeks after delivery–this is also a hypercoagulable state. I use low dose heparin if I operate on women during pregnancy or the 6 weeks after delivery.
In patients who require an emergency cholecystectomy while on full anticoagulation we found subtotal cholecystectomy-leaving the hepatic GB’s wall intact -and closing the cystic duct from within the Hartmann pouch-very useful and virtually bloodless.
There was a recent article that stated that DVT/PE risk remains high for about one month after total joint replacement, so the article recommended DVT/PE prophylaxis for about one month in these patients (which would include post-hospitalization prophylaxis). It makes me wonder whether this is also true of general surgical patients, especially abdominal and pelvic surgery patients.
I certainly didn’t intend to get everyone stirred up over the issue of stopping oral contraceptives prior to elective surgery. I’ll bet we all do things because of our anecdotal experiences–I don’t think it means we’re bad doctors. Even if there is something in the literature supporting stopping OC pre-op, it probably wouldn’t pass muster as a valid study. It just seems like a rather harmless thing to do, if possible. I always discuss the theoretical risk of increased clotting with my patients who are on OC’s and find that they are very willing to be off for a while. I guess the only harm in being off is an unwanted pregnancy. I let them participate in the decision and use the usual precautions–SCD’s and/or mini-heparin. BTW, I just saw a study that concluded the DVT incidence with SCD’s is 7%. If TED stockings used under the SCD’s, only 1%.
Sorry for prolonging this discussion but I can’t let this irrational statemnet above go unchallenged–because it is so much hogwash! Another knee-jerk reflex being embraced regardless of how flawed the data, because we so WANT to believe it! And only one study is all it takes when we want to believe it–how many studies again to get surgeons to practice breast conservation? Now, I admit, I don’t know what study you are talking about, and in reality I may be decrying the landmark study of the decade like a fool–so I’ll stick my neck out and predict that whatever study you mean in fact shows no such thing–knowing in advance how many worthwhile studies have already shown no advantage whatsoever to TED hose, so sheer probability is on my side–so, rub my face in it please–and tell us what randomized prospective trial you are referring to.
My only (so far) case of fatal PE (verified by autopsy) was a 60 year old man following emergent incarcerated inguinal hernia repair under spinal (no SCDs or heparin) walking out to his car the day after surgery. Don’t you hate it when that happens!