[HSF] DVT in cardiac sugery

Tue Apr 22 13:14:44 EDT 2008

No more than warfarin does.

>o 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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-- 
Ben Bidstrup FRACS FRCSEd FEBCTS
Consultant Cardiothoracic Surgeon