[HSF] DVT in cardiac sugery

Sun Apr 20 19:12:17 EDT 2008

I have read similar data - although the references escape me right now.  I
do know that the incidence is much higher than the "vascular and cardiac
patients dont get DVT/PE cuz they get heparinized in the OR" mentality.  I
am actually amazed how many DVTs and PEs that we find (particularly in off
pump patients).  Anyone who complains of any type of leg swelling or SOB
that is out of proportion to their vein harvesting, lung function, volume
status gets worked up - and typically we find something.  Even more
interesting, is that of these patients with DVTs/PEs a reasonable % of them
have positive work-ups for hypercoag states (HITS, anti-lupus, anti-phos,
etc)

What I do not know how to handle the residual stump of GSV that will
obviously have clot in it as it joins into the common femoral.....

We prophyax everyone......and now that heparin SQ is in short supply we are
using LMWH (provided they have normal renal function).... but that is
another issue - all I know I that I keep teasing our local Plavix/Lovenox
rep (same person) about the new boat she just got with he performance bonus.

-michael

On 4/20/08, Edward Bender <ebender001 at charter.net> wrote:
>
> Tea:
> Here is an interesting article from UK:
> Interactive CardioVascular and Thoracic Surgery 2006;5:624.
> Abstract:
> A best evidence topic in cardiac surgery was written according to a
> structured protocol. The question addressed was whether the use of
> prophylactic postoperative low molecular weight heparin (LMWH) or
> unfractionated heparin after cardiac surgery would significantly reduce
> morbidity by reducing the incidence of deep vein thromboses (DVTs) and
> pulmonary emboli (PEs). Altogether 390 papers were identified on Medline.
> Relevant major guidelines were also search together with their reference
> lists. 16 papers represented the best evidence on the topic. The author,
> journal, date and country of publication, patient group studied, study
> type,
> relevant outcomes, results and study weaknesses were tabulated. We
> conclude
> that the benefit of heparin prophylaxis for the prevention of DVTs and PEs
> is well established in non-cardiac surgery with reductions in the
> incidence
> of DVTs reported to be of the order of 50-70% in orthopaedic, general and
> obstetric surgery and in general medicine. No studies have yet been
> performed in cardiac surgery, but contrary to the view that DVTs are rare,
> in fact the incidence of DVT post-cardiac surgery is up to 15-20% and the
> incidence of PE is around 0.5 to 4% although many of these occur after
> discharge and many may be difficult to detect clinically. This is similar
> to
> the incidence of patients undergoing high risk general surgery. There is
> no
> evidence that heparin prophylaxis started the day after surgery increases
> the risk of pericardial effusions and the risk of bleeding complications
> is
> estimated to be 4%. Thus we recommend that all patients post-cardiac
> surgery
> be commenced on heparin prophylaxis the day after their surgery and
> continue
> this up to discharge even if mobile. The particular regime should be
> guided
> by the ACCP recommendations for prophylaxis in high risk general surgical
> patients. Keywords: Low molecular weight heparin; Venous thrombosis;
> Pulmonary embolism
>
>
> On 4/20/08 2:57 PM, "Tea Acuff" <tacuff at swbell.net> wrote:
>
> > One of the peculiarities of our new heart hospital is that we are
> partnered
> > which a local hospital system (Baylor). One of the "benefits" of such
> > arrangement is that for reasons that are somewhat mysterious we get some
> > (all?) of the best practice formulations developed by the flagship
> hospital
> > (medical) staff. At least that is my take on what suddenly appears on my
> > patients chart.
> >
> > One of these efforts is a 3 page DVT work sheet which we check the boxes
> and
> > sign an assessment page, a throw away page that explains the graded
> risks, and
> > a third full page for selection of various prophylaxis options.
> Interestingly,
> > despite many categories for risk and contra indications no where on this
> > document is there mention of other procedure but no specific mention of
> > cardiac surgery, which is obviously the bulk of what we do at the heart
> > hospital.
> >
> > As a bias my present practice is not to rountinely prophylax except for
> the
> > dubious TED hose. Before I start (rather before it becomes noticable)
> that i
> > am markedly out of step, does anyone have information or comments on
> these
> > following points?
> >
> > 1) Is there specific data on the risk and benefits of DVT prophylaxis
> for
> > cardiac patients or any particular subset of rountine CV patients?
> >
> > 2) If there is data, does it break out effects for on and off pump, ASA,
> > plavix, aprotonin, fast track (aggressive mobilization and discharge)
> and
> > other relevant variables?
> >
> > 3) If there are studies of mechanical compression devices for these
> patients,
> > are there comparisons of fast track verses immobility (the default
> nursing
> > solution for all the insulin drips, bladder and invasive lines, etc)? IE
> does
> > a device that has to be hooked up and taken off repeatedly help or hurt
> with
> > DVT compared to mobilization?
> >
> > 4) If there is no data how do others stratify their patients at risk? Is
> just
> > being in the hospital ipso facto a risk, one that favors treatment? Does
> LOS
> > not really matter?
> >
> > tea
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