[HSF] DVT in cardiac sugery

Mon Apr 21 18:38:44 EDT 2008

I concur with nothing.  Anything that can happen will happen at some point
to some patient(s).  My practice has been to give sq heparin beginning on
the evening of surgery to my morbidly obese patients (about 15% of my
population using the twice normal body weight or > 100 lbs overweight
criteria).  I also use TED hose, but I don't know why.

Ed Bender, MD

On 4/21/08 5:30 PM, "Tea Acuff" <tacuff at swbell.net> wrote:

> So the article as I read it suggests that we trade a 15-20% risk of DVT and
> .5-4% risk of PE for a 4% risk of bleeding. This is of coursed based on
> analogous indirect evidence, not direct data. Do we all concur that rountine
> post op heparinization will not increase the risk of pericardial "effusions"
> (sic) ?
> 
> tea
> 
> 
> 
> ----- Original Message ----
> From: Edward Bender <ebender001 at charter.net>
> To: OpenHeart-L at lists.hsforum.com
> Sent: Sunday, April 20, 2008 4:41:39 PM
> Subject: Re: [HSF] DVT in cardiac sugery
> 
> 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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