[HSF] DVT in cardiac sugery

Wed Apr 23 15:33:49 EDT 2008

Not from where I am standing

>Sounds like a sarcastic understatement to me. Are all statements 
>from down under "under"statements?
>
>tea
>
>
>
>----- Original Message ----
>From: Ben Bidstrup <benjamin.bidstrup at bigpond.com>
>To: OpenHeart-L at lists.hsforum.com
>Sent: Monday, April 21, 2008 9:14:44 PM
>Subject: Re: [HSF] DVT in cardiac sugery
>
>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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>>
>>
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>
>
>--
>Ben Bidstrup FRACS FRCSEd FEBCTS
>Consultant Cardiothoracic Surgeon
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-- 
Ben Bidstrup FRACS FRCSEd FEBCTS
Consultant Cardiothoracic Surgeon