In-hospital thromboprophylaxis alone seen as safe with fast-track TJA

http://www.healio.com/orthopedics/total-joint-reconstruction/news/print/orthopedics-today/%7B4f5322b4-c588-4053-9085-67def5446d5e%7D/in-hospital-thromboprophylaxis-alone-seen-as-safe-with-fast-track-tja

In-hospital thromboprophylaxis alone seen as safe with fast-track TJA

La tasa de eventos tromboembólicos fue de 0,84% entre los cerca de 4.500 por la vía rápida unilateral artroplastia total de cadera o artroplastia total de rodilla pacientes que tuvieron una estancia hospitalaria media de 2 días y sólo recibieron tromboprofilaxis durante ese tiempo, según un estudio de investigadores de Dinamarca.

Christoffer Jørgensen C., MD, y sus colegas encontraron una tasa de 0,41% de los eventos tromboembólicos venosos (TEV) en el mismo seguimiento en su estudio prospectivo de cohortes multicéntrico. Los resultados les llevan a la conclusión de que es seguro para limitar la administración de la tromboprofilaxis en la estancia en el hospital solo en pacientes que se someten a la vía rápida la artroplastia total de cadera (ATC) o la artroplastia total de rodilla (PTR).

Jørgensentold Ortopedia hoy que lo más innovador de estos hallazgos es que “alrededor del 95% de los casi 5.000 pacientes con trombosis de una mediana de 2 días tenía TEV comparables o inferiores a los de estudios previos con la profilaxis de 30 días a 35 días.

The rate of thromboembolic events was 0.84% among about 4,500 fast-track unilateral total hip arthroplasty or total knee arthroplasty patients who had a median hospital stay of 2 days and only received thromboprophylaxis during that time, according to research by investigators from Denmark.
Christoffer C. Jørgensen, MD, and colleagues found a 0.41% rate of venous thromboembolic events (VTEs) at the same follow-up in their prospective multicenter cohort study. The findings lead them to conclude that it is safe to limit administration of thromboprophylaxis to the hospital stay alone in patients who undergo fast-track total hip arthroplasty (THA) or total knee arthroplasty (TKA).
Jørgensentold Orthopedics Today that what is most groundbreaking about these findings is that “about 95% of almost 5,000 patients with thromboprophylaxis for a median of 2 days had VTEs comparable to or lower than in previous studies with prophylaxis of 30 days to 35 days.”

LMWH or factor Xa-inhibitors

The study included 4,924 consecutive unselected unilateral THAs and TKAs performed in 4,718 patients at six Danish clinics. None of the patients were given continuous “potent” anticoagulative therapy preoperatively, and during their hospital stays of 5 days or less, the VTE prophylaxis they were administered consisted of either low-molecular weight heparin or factor Xa-inhibitors.
Jørgensen told Orthopedics Today that the investigators all used a similar fast-track protocol for the study. “There were minor differences with regard to the protocols used at the participating departments, mainly considering the use of NSAIDs/COX-2 inhibitors and also regarding the use of postoperative restrictions in THA. However, none of this should influence incidence of venous thromboembolic events,” he said.
“Early mobilization seems to be the most critical factor for fewer thromboembolic events after total joint arthroplasty. This also makes sense from a pathophysiological point of view, as mobilization in itself may prevent the occurrence of thromboembolic events. However, it is important to remember that patients are difficult to mobilize if they have insufficient analgesia, are dizzy from opioids or hindered by drains and catheters etc. Consequently, all the elements of the fast-track methodology need to be included in order to facilitate early mobilization,” Jørgensen said.
Of the documented VTEs, five were pulmonary embolisms (0.11%), one of which was fatal, and 14 were deep venous thrombosis (0.30%).

Reconsideration of guidelines

Given these findings, which support discontinuing thromboprophylaxis after discharge from hospital in this patient population, Jørgensen and colleagues wrote in their study that “guidelines on postoperative thromboprophylaxis need reconsideration in modern elective surgical procedures.”
Jørgensen noted the possibility that some thromboembolic events may have went undetected as a potential limitation of the study. “In addition, our study cannot be used to analyze differences between the specific antithrombotic drugs used or to identify the ideal duration of thromboprophylaxis. However, this was not the aim of the study; rather, we wanted to investigate whether thromboprophylaxis only during hospitalization was safe in patients admitted for 5 days or less,” he told Orthopedics Today. – by Christian Ingram
Reference:

Jørgensen CC. BMJ Open. 2013;doi: 10.1136/bmjopen-2013-003965.

For more information:

Christoffer C. Jørgensen, MD, can be reached at the Section for Surgical Pathophysiology 7621, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark; email: christoffer.calov.joergensen@regionh.dk.
Disclosure: Two of the study’s co-authors are board members of the Health Care initiatives, Biomet Rapid Recovery.

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