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2008 Annual Meeting Abstracts

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Efficacy and Safety of Venous Thromboembolism Prophylaxis in Highest Risk Plastic Surgery Patients

Mitchel Seruya, MD, Steven P. Davison, DDS, MD.
Georgetown University Hospital, Washington, DC, USA.

PURPOSE: With patient safety of paramount concern in current plastic surgery practice, it is surprising that a recent survey of current members of the American Society of Plastic Surgeons found that only 40%-60% of surgeons utilize thromboprophylaxis all the time. The hesitancy in instituting thromboprophylaxis may be due to the belief that there is a low incidence of venous thromboembolism (VTE) or the concern over bleeding complications secondary to chemoprophylaxis. The purpose of this study was to stratify plastic surgery patients into different VTE risk categories, identify plastic surgery patients at highest risk for VTE, and quantify the rates of VTE and post-operative hematoma/bleeding in highest risk patients on different forms of thromboprophylaxis.
METHODS: A retrospective cohort study was carried out on a single plastic surgeon’s experience between July 2005 and September 2007. VTE risk stratification was performed and patients at highest risk were identified. Hospital charts of highest risk patients were reviewed for regimen of thromboprophylaxis and for occurrences of pulmonary embolism (PE), deep venous thrombosis (DVT), and hematoma/bleeding. Rates of PE, DVT, and hematoma/bleeding were calculated for all prophylaxis groups. Fisher’s exact 2-tailed t test was used to determine statistical significance for all comparison groups.
RESULTS: Of 1156 operations performed during the study time period, 173 (15.0%) operations involved 120 patients at highest risk for VTE. Highest risk operations were managed with different forms of thromboprophylaxis (Table I), depending on the primary surgeon’s preference, patients’ comorbidities, or presence of contraindications to chemoprophylaxis. Among highest risk patients, 1 (0.8%) suffered a PE, 8 (6.7%) experienced a DVT, and 15 (12.5%) endured a hematoma/bleed. Complication rates of highest risk patients on different regimens of thromboprophylaxis are listed in Table II.
CONCLUSIONS: In this retrospective cohort study of plastic surgery patients, 15% of operations involved patients at highest risk for VTE. Within highest risk patients, 7.5% experienced a venous thromboembolic event, despite at least one modality of thromboprophylaxis. Mechanical prophylaxis plus subcutaneous heparin conferred a statistically significant reduction in the rate of DVT without a significant increase in the rate of bleeding versus mechanical prophylaxis alone. Therefore, the use of mechanical prophylaxis supplemented with subcutaneous heparin is strongly recommended as the first-line regimen for thromboprophylaxis in plastic surgery patients at highest risk for VTE.

Table I
Patients at Highest Risk for VTE and Thromboprophylaxis Regimen
Total operations173
IPC/ES + single chemoprophylaxis8448.6
IPC/ES + combination chemoprophylaxis 2615.0
LMWH and ASA126.9
UFH and ASA148.1
Therapeutic anticoagulation158.7
IPC/ES = intermittent pneumatic compression/elastic stockings, LMWH = low molecular weight heparin, UFH = unfractionated heparin, ASA = acetylsalicylic acid

Table II
Complication Rates of Patients at Highest Risk for VTE
With Different Regimens of Thromboprophylaxis
The p values reflect comparison between the variable listed for the respective subgroup and the variable for the IPC/ES group.

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