PULMONARY EMBOLISM

1. Author Turpie-A-G.
   Institution McMaster University, Hamilton, Ontario, Canada.
   Title Deep vein thrombosis prophylaxis in the outpatient setting: preventing complications following hospital discharge.
   Source Orthopedics 1995 Jul, VOL: 18 Suppl, P: 15-7,
   ISSN: 0147-7447.
   Abstract
   Venous thromboembolism is an important complication in patients undergoing major orthopedic surgery. Without prophylaxis, there is a 50% to 60% incidence of deep vein thrombosis (DVT), a 10% to 30% incidence of proximal vein thrombosis, and a 1% to 2% rate of fatal pulmonary embolism after total hip replacement. The incidence of DVT after knee arthroplasty is even higher, ranging from 55% to 70% and, although there are no accurate figures on the incidence of fatal pulmonary embolism, it is likely to be similar to that following hip arthroplasty. Low molecular weight heparins (LMWHs) have been shown to be effective and safe in the prevention of venous thromboembolism in patients undergoing major orthopedic procedures. In comparative studies, LMWHs are more effective than adjusted dose heparin or warfarin without increased risk of bleeding. Author.

2. Author Sculco-T-P.
   Title Establishing a universal protocol for deep vein thrombosis following orthopedic surgery: total knee arthroplasty.
   SourceOrthopedics 1996 Aug, VOL: 19 Suppl, P: 6-8,
   ISSN: 0147-7447 22 Refs.
   Abstract
   The incidence of deep vein thrombosis (DVT) after total knee replacement surgery is reported to occur in 84% of all unprotected patients and may be as high as 68% in patients who receive DVT prophylaxis. Moreover, controversy exists as to which pharmacologic or mechanical agent is most effective. Although the scientific literature provides some answers, many issues of DVT prophylaxis are not completely addressed, especially with regard to the duration of prophylaxis. The most recent report from the American College of Chest Physicians Consensus Conference on Antithrombotic Therapy reconfirms the recommendations offered from previous consensus groups on the importance of establishing and applying a universal protocol for the prevention of DVT in orthopedic surgery. Author.

3. Author Turner-R-S, Griffiths-H, Heatley-F-W.
   Institution Orthopaedic Academic Unit, Rayne Institute, St Thomas' Hospital, London, UK.
   Title The incidence of deep-vein thrombosis after upper tibial osteotomy. A venographic study.
   Source J-Bone-Joint-Surg-Br 1993 Nov, VOL: 75 (6), P: 942-4,
   ISSN: 0301-620X.
   Abscract We performed postoperative venography on 84 consecutive patients who had undergone upper tibial osteotomy for medial compartment osteoarthritis of the knee. Deep-vein thrombosis was demonstrated in 41%. Only 15% of the cases were diagnosed clinically, all in the calf veins. Cases of proximal thromboses (3) and mixed-vein thromboses (12) were only revealed by venography. Author.
4. Title 4th American College of Chest Physicians Consensus Conference on Antithrombotic Therapy. Tucson, Arizona, April 1995. Proceedings (see comments).
   Source Chest 1995 Oct, VOL: 108 (4 Suppl), P: 225S-522S,
   ISSN: 0012-3692 0 Refs. CM Comment in: Chest 1998 Mar; 113(3):844.

Author Wilson JT; Rogers FB; Wald SL; Shackford SR; Ricci MA
Institution Division of Neurological Surgery, University of Vermont College of Medicine, Medical Center Hospital of Vermont, Burlington.
Title Prophylactic vena cava filter insertion in patients with traumatic spinal cord injury: preliminary results.
Source Neurosurgery 1994 Aug; 35 (2): p234-9; discussion 239
ISSN 0148-396X
Abstract
Pulmonary embolism (PE) is a devastating complication in patients with traumatic spinal cord injury (SCI). Prophylactic measures such as venous compression hose or low-dose heparin are only partially protective in reducing the risk of venous thromboembolism and are contraindicated in some patients. Because of extended perturbations in fibrinolytic activity, catecholamine effects on platelet aggregation, increased activity of complement and acute phase reactants, abnormally high factor VIII concentrations, and persistent venous stasis with ongoing endothelial damage, the patient with an SCI remains at prolonged risk for venous thromboembolism. A retrospective 5-year review at the Medical Center Hospital of Vermont revealed seven patients with eight documented PEs (three fatal; 2.7%) in 111 SCI patients (6.3%). Six PEs (75%) occurred after discharge from the acute care facility. Median time to PE after injury was 78 days (range, 9-5993). Although comprising only 4% of all trauma admissions, SCI accounted for 31% of all PEs in the total trauma population (2525 patients). Beginning in July 1991, a new prophylaxis protocol was instituted, which included the percutaneous insertion of vena cava filters under local anesthesia in all SCI patients with paraplegia or quadriplegia. Fifteen patients have undergone the insertion of titanium filters. Impedance plethysmography was performed weekly to detect deep venous thrombosis. No complications were associated with vena cava filter insertion. No patients developed deep venous thrombosis during their acute hospitalization (median, 22 d), and no patients have developed PE after filter insertion.(Abscract TRUNCATED AT 250 WORDS).

6. Author Janku-G-V, Paiement-G-D, Green-H-D.
   Institution University of California at San Francisco, CA, USA.
   Title Prevention of venous thromboembolism in orthopaedics in the United States.
   Source Clin-Orthop 1996 Apr (325), P: 313-21,
   ISSN: 0009-921X.
   Abscract
   The use of different types of antithrombotic prophylactics in various clinical settings was examined. A standardized questionnaire was mailed to 5000 randomly selected practicing orthopaedic surgeons that detailed practice profile, surgical case type and frequency, method of thromboembolism prophylaxis used, incidence of morbidity, and type of screening used. Twenty-one percent (n = 1046) of surgeons surveyed returned the questionnaire. Four of 5 surgeons performing elective hip arthroplasty used some form of thromboembolic prophylaxis for all of their patients, 13% used prophylaxis only for patients considered to be at high risk, and 3% of respondents never used prophylaxis. The rates of prophylactic use for patients undergoing elective knee arthroplasty were similar. A considerably lower rate of routine prophylactic use was seen among surgeons performing surgery for pelvic and lower extremity trauma. Except for cases involving neurologic compromise, most patients undergoing either elective or traumatic spinal surgery were not given prophylaxis. Low dose warfarin alone was the most commonly used prophylaxis modality. A comparison of the results of the current survey with those of past surveys showed that the use of aspirin has fallen. The use of routine pharmacologic prophylaxis against thromboembolism in hip and knee arthroplasty has become the standard of care in the United States. Among patients undergoing surgery for hip fracture and other lower extremity trauma, however, prophylaxis remains underused. Author.
7. Author Francis-R-M, Brenkel-I-J.
   Institution Queen Margaret Hospital, Dunfermline, Fife.
   Title Survey of use of thromboprophylaxis for routine total hip replacement by British orthopaedic surgeons.
   Source Br-J-Hosp-Med 1997 May 7-20, VOL: 57 (9), P: 427-31,
   ISSN: 0007-1064 36 Refs.
   Abstract
   This study looked at current use of thromboprophylaxis for routine total hip replacement surgery among British orthopaedic surgeons. Of those who replied to a postal survey, 85% use chemical prophylaxis, 15% used mechanical prophylaxis and only 1% use no prophylaxis. This showed a significant increase in the number of surgeons using chemical prophylaxis, particularly low molecular weight heparin, compared to a similar survey in 1989. Author.

8. Author Leyvraz-P-F, Richard-J, Bachmann-F, Van-Melle-G, Treyvaud-J-M, Livio- J-J, Candardjis-G.
   Institution Department of Orthopedics, Vaudois University Hospital Centre, CHUV, Lausanne, Switzerland.
   Title Adjusted versus fixed-dose subcutaneous heparin in the prevention of deep-vein thrombosis after total hip replacement.
   Source N-Engl-J-Med 1983 Oct 20, VOL: 309 (16), P: 954-8,
   ISSN: 0028-4793.
   Abstract Venous thromboembolism after total hip replacement continues to be a serious problem. We conducted a study to determine whether adjustment of the dose of subcutaneous heparin to yield partial thromboplastin times in the high-normal range results in a greater reduction of postoperative deep-vein thrombosis than fixed doses of heparin. Seventy-nine patients undergoing elective hip arthroplasty were randomly divided into two groups two days before surgery. Group 1 (41 patients) received a fixed dose of 3500 IU of heparin subcutaneously ever eight hours; 16 of the 41 (39 per cent) had deep-vein thrombosis diagnosed by venography. Group 2 (38 patients) was started on the same dose, which was then adjusted to keep the activated partial thromboplastin time between 31.5 and 36 seconds. From the day of operation to the eighth postoperative day these patients needed progressively more heparin to maintain the activated partial thromboplastin time in the prescribed range. Only 5 of the 38 (13 per cent) had deep-vein thrombosis (P less than 0.01), and the number of thrombi in proximal veins was also lower in this group (P = 0.003). The number of units of blood transfused, the frequency of postoperative wound hematomas, and the drop in hemoglobin levels were identical in the two groups. Adjusted low-dose heparin prophylaxis appears to be a safe and efficacious method to reduce the frequency of deep-vein thrombosis in patients undergoing total hip replacement. Author.

9. Author Collins-R, Scrimgeour-A, Yusuf-S, Peto-R.
   Institution Clinical Trial Service Unit, Radcliffe Infirmary, Oxford, United Kingdom.
   Title Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of subcutaneous heparin. Overview of results of randomized trials in general, orthopedic, and urologic surgery.
   Source N-Engl-J-Med 1988 May 5, VOL: 318 (18), P: 1162-73,
   ISSN: 0028-4793 153 Refs.

10. Author Schmidt-J, Hackenbroch-M-H.
    Institution Klinik und Poliklinik fur Orthopadie der Universitat zu Koln, Germany.
    Title Prevention of deep venous thrombosis in ambulatory or discharged orthopaedic patients. Actual management.
    Source Arch-Orthop-Trauma-Surg 1995, VOL: 114 (4), P: 226-8,
    ISSN: 0936-8051.
    Abstract
    In recent years the problem of deep venous thrombosis (DVT) in outpatients and discharged patients has grown into a medical and juridical problem. In traumatology certain recommendations and statistical material exist: similar recommendations were made by the Berufsverband der Arzte fur Orthopadie, Germany, pointing out the lack of sufficient statistical material. With the present study we tried to evaluate the actual management of DVT in discharged patients or outpatients in leading orthopaedic hospitals. The results from December 1993 reveal an inhomogeneous procedure which does not precisely follow the above recommendations. However, most orthopaedic surgeons agree that either general or individual means to prevent DVT should be available for ambulatory and discharged patients with plaster immobilisation of the leg according to presently accepted standards, i.e. low-dose heparin or low-molecular-weight heparins. Reduced weight-bearing, in contrast, is considered not to require preventive heparinisation to any great extent. Author.

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