Majör ortopedik cerrahilerde venöz tromboemboli profilaksisi: Çokmerkezli, prospektif, gözlem çalışması

Amaç: Ülkemizde majör ortopedik cerrahi (MOC) için farmakolojik profilaksi uygulanan hastalarda venöz tromboembolizm (VTE) risk faktörleri, kullanılan profilaksi yöntemleri ve klinik bulgu veren derin ven trombozu (DVT) ve pulmoner emboli (PE) sıklığı araştırıldı. Çalışma planı: Prospektif, çokmerkezli, açık, müdahalesiz bir gözlem çalışması planlanarak, 21 merkezden 899 hasta çalışmaya alındı. Olguların 316’sında (%35.2) total kalça protezi (TKP), 328’inde (%36.5) total diz protezi (TDP), 255’inde (%28.4) kalça kırığı (KK) cerrahisi uygulandı. Tüm hastalarda farmakolojik DVT profilaksisine başvuruldu. Sonuçlar: Olguların %73.2’sinde VTE risk faktörleri vardı. En sık görülen risk faktörleri obezite (%72) ve uzamış immobilizasyon (%36.3) idi. Profilaksi için olguların %91.1’inde düşük molekül ağırlıklı heparin, %8.9’unda fondaparinuks kullanıldı. Olguların 273’üne (%30.4) kısa dönem, 626’sına (%69.6) uzun dönem profilaksi uygulandı. Mekanik profilaksi 610 olguda (%67.9) elastik çorap ile, 67 olguda (%7.5) aralıklı hava basınç cihazı ile uygulandı. Üç aylık takip sonucunda sekiz olguda (%0.9) klinik bulgu veren DVT, dört olguda (%0.4) PE gelişti. Mortalite 10 olguda (%1.1) görüldü. Kanama komplikasyonu sekiz olguda (%0.9) majör, 40 olguda (%4.5) minör idi. Çıkarımlar: Etkin VTE profilaksi yapıldığında MOC’de klinik bulgu veren DVT ve PE oranları düşük olmaktadır.

Anahtar Kelimeler:

Artroplasti, replasman, kalça, Kalça kırıkları, Ortopedik işlemler, Venöz tromboembolizm, Artroplasti, replasman, diz, Antikoagülanlar, Heparin, düşük molekül ağırlıklı, Hareketsizleştirme, Obezite, Polisakkaritler, İleriye dönük çalışma, Pulmoner emboli, Risk faktörleri

Venous thromboembolism prophylaxis in major orthopaedic surgery: A multicenter, prospective, observational study

Objectives: We investigated risk factors for venous thromboembolism (VTE), prophylaxis measures employed, and incidence of symptomatic deep venous thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing major orthopaedic surgery (MOS). Methods: An open, multicenter, prospective, observational study was conducted in 21 medical centers, comprising 899 patients. Of these, 316 patients (35.2%) underwent total hip arthroplasty (THA), 328 patients (36.5%) underwent total knee arthroplasty (TKA), and 255 patients (28.4%) underwent surgery for hip fractures (HF). Pharmacologic prophylaxis was employed in all the patients. Results: Risk factors for VTE were seen in 73.2% of the patents, the most common being obesity (72%) and prolonged immobilization (36.3%). Low-molecular-weight heparin (91.1%) and fondaparinux (8.9%) were used for prophylaxis, which was short-term in 273 patients (30.4%) and long-term in 626 patients (69.6%). Mechanical prophylaxis was performed with compression stockings in 610 patients (67.9%) and by intermittent pneumatic compression in 67 patients (7.5%). During three-months of follow-up, symptomatic DVT and PE were seen in eight (0.9%) and four patients (0.4%), respectively. Mortality occurred in 10 patients (1.1%). Complications of major and minor bleeding were seen in eight (0.9%) and 40 (4.5%) patients, respectively. Conclusion: Effective VTE prophylaxis is associated with low risk of clinically apparent DVT and PE in MOS.

Keywords:

Arthroplasty, Replacement, Hip, Hip Fractures, Orthopedic Procedures, Venous Thromboembolism, Arthroplasty, Replacement, Knee, Anticoagulants, Heparin, Low-Molecular-Weight, Immobilization, Obesity, Polysaccharides, Prospective Studies, Pulmonary Embolism, Risk Factors,

___

1. Anderson FA Jr, Spencer FA. Risk factors for venous thromboembolism. Circulation 2003;107(23 Suppl 1):I9-16.
2. Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126(3 Suppl):338S-400S.
3. Altintas F. Thromboembolism in hip and knee arthroplasties. [Article in Turkish] Acta Orthop Traumatol Turc 2000;34:100-9.
4. Ercan S, Altıntaş F. Tromboembolizmin dekstran 70 ile proflaksisi. Göztepe Tıp Dergisi 1987;2:31-5.
5. Warwick D, Friedman RJ, Agnelli G, Gil-Garay E, Johnson K, FitzGerald G, et al. Insufficient duration of venous thromboembolism prophylaxis after total hip or knee replacement when compared with the time course of thromboembolic events: findings from the Global Orthopaedic Registry. J Bone Joint Surg [Br] 2007;89:799-807.
6. Beksac B, Gonzalez Della Valle A, Salvati EA. Thromboembolic disease after total hip arthroplasty: who is at risk? Clin Orthop Relat Res 2006;(453):211-24.
7. Turpie AG, Levine MN, Hirsh J, Carter CJ, Jay RM, Powers PJ, et al. A randomized controlled trial of a low-molecular- weight heparin (enoxaparin) to prevent deep-vein thrombosis in patients undergoing elective hip surgery. N Engl J Med 1986;315:925-9.
8. Esemenli T. Kalça cerrahisinde derin ven trombozu insidansı. Acta Orthop Traumatol Turc 1991;25:34-8.
9. Tokgözoğlu AM. Ortopedik açıdan tromboembolik hastalıklar ve proflaksisi. Hacettepe Ortopedi Dergisi 1992;2:42-5.
10. Altintas F, Ipekoglu C, Konal A, Kuru LI. Color Doppler ultrasonography and venography for the detection of deep venous thrombosis in patients who had a fracture of the hip. [Article in Turkish] Acta Orthop Traumatol Turc 1995;29:197-201.
11. Leizorovicz A, Turpie AG, Cohen AT, Wong L, Yoo MC, Dans A, et al. Epidemiology of venous thromboembolism in Asian patients undergoing major orthopedic surgery without thromboprophylaxis. The SMART study. J Thromb Haemost 2005;3:28-34.
12. Lowe GD, Haverkate F, Thompson SG, Turner RM, Bertina RM, Turpie AG, et al. Prediction of deep vein thrombosis after elective hip replacement surgery by preoperative clinical and haemostatic variables: the ECAT DVT Study. European Concerted Action on Thrombosis. Thromb Haemost 1999;81:879-86.
13. White RH, Zhou H, Romano PS. Incidence of symptomatic venous thromboembolism after different elective or urgent surgical procedures. Thromb Haemost 2003;90:446-55.
14. Heit JA, Silverstein MD, Mohr DN, Petterson TM, O’Fallon WM, Melton LJ 3rd. Risk factors for deep vein thrombosis and pulmonary embolism: a population-based case-control study. Arch Intern Med 2000;160:809-15.
15. Weill-Engerer S, Meaume S, Lahlou A, Piette F, Saint-Jean O, Sachet A, et al. Risk factors for deep vein thrombosis in inpatients aged 65 and older: a case-control multicenter study. J Am Geriatr Soc 2004;52:1299-304.
16. Planes A, Vochelle N, Darmon JY, Fagola M, Bellaud M, Huet Y. Risk of deep-venous thrombosis after hospital discharge in patients having undergone total hip replacement: double-blind randomised comparison of enoxaparin versus placebo. Lancet 1996;348:224-8.
17. Nicolaides AN, Fareed J, Kakkar AK, Breddin HK, Goldhaber SZ, Hull R, et al. Prevention and treatment of venous thromboembolism. International Consensus Statement (guidelines according to scientific evidence). Int Angiol 2006;25:101-61.
18. Lassen MR, Borris LC, Christiansen HM, Boll KL, Eiskjaer SP, Nielsen BW, et al. Prevention of thromboembolism in 190 hip arthroplasties. Comparison of LMW heparin and placebo. Acta Orthop Scand 1991;62:33-8.
19. Colwell CW Jr, Collis DK, Paulson R, McCutchen JW, Bigler GT, Lutz S, et al. Comparison of enoxaparin and warfarin for the prevention of venous thromboembolic disease after total hip arthroplasty. Evaluation during hospitalization and three months after discharge. J Bone Joint Surg [Am] 1999;81:932-40.
20. Hirsh J. Fondaparinux. Hamilton: B. C. Decker; 2007.
21. Hull RD, Pineo GF, Stein PD, Mah AF, MacIsaac SM, Dahl OE, et al. Extended out-of-hospital low-molecular-weight heparin prophylaxis against deep venous thrombosis in patients after elective hip arthroplasty: a systematic review. Ann Intern Med 2001;135:858-69.
22. Patel VP, Walsh M, Sehgal B, Preston C, DeWal H, Di Cesare PE. Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty. J Bone Joint Surg [Am] 2007;89:33-8.
23. Howie C, Hughes H, Watts AC. Venous thromboembolism associated with hip and knee replacement over a ten-year period: a population-based study. J Bone Joint Surg [Br] 2005;87:1675-80.