Postoperative venous Postoperative venous thromboembolic disease prevention in thromboembolic disease prevention in

the neurosurgery populationthe neurosurgery population

Ahmad Khaldi, M.D. Ahmad Khaldi, M.D. 11

Michael Wall, PharmD Michael Wall, PharmD 22

T.C. Origitano, M.D., Ph.D.T.C. Origitano, M.D., Ph.D. 11

11 Department of NeurosurgeryDepartment of Neurosurgery

2 2 Center for Clinical EffectivenessCenter for Clinical Effectiveness Confidential- For Quality Improvement Purposes Only

VTE in NeurosurgeryVTE in Neurosurgery

Neurosurgical inpatients have increased immobility and are Neurosurgical inpatients have increased immobility and are at an increased risk of VTEat an increased risk of VTE– DVT development can be as high as 29%-43% in following DVT development can be as high as 29%-43% in following

cranial/spinal surgery (no prophylaxis). *cranial/spinal surgery (no prophylaxis). *

– The rate of “clinically evident DVT” in craniotomy patients is around The rate of “clinically evident DVT” in craniotomy patients is around 2-4%.2-4%.

– PE occurs between 0.8%-2% in patients undergoing craniotomy PE occurs between 0.8%-2% in patients undergoing craniotomy with mortality rate between 9-59%. with mortality rate between 9-59%.

* * Farray, D., Carman, T., Fernandez, B. The treatment and prevention of deep vein thrombosis in the preoperative management of Farray, D., Carman, T., Fernandez, B. The treatment and prevention of deep vein thrombosis in the preoperative management of

patients who have neurologic disease. Neurological Clin N Am (2004), 22: 423-439. patients who have neurologic disease. Neurological Clin N Am (2004), 22: 423-439.

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ObjectiveObjective

Reduce the rate of post-operative VTE Reduce the rate of post-operative VTE in neurosurgical patients through in neurosurgical patients through increased use of pharmacologic increased use of pharmacologic

prophylaxisprophylaxis

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Duplex Study Patients (n=555)Duplex Study Patients (n=555)

All patients received mechanical DVT prophylaxis (both All patients received mechanical DVT prophylaxis (both compression stocking and sequential compression device)compression stocking and sequential compression device)

Patients had a surveillance ultra-sound (duplex) of the Patients had a surveillance ultra-sound (duplex) of the lower extremities (twice a week, Monday and Thursday)lower extremities (twice a week, Monday and Thursday)– During their ICU stay or During their ICU stay or – If they are deemed to have a high risk of developing DVT while they If they are deemed to have a high risk of developing DVT while they

were on the floorwere on the floor

Patients who developed clinical sign or symptoms of DVT Patients who developed clinical sign or symptoms of DVT (calf swelling, tenderness along deep venous system, (calf swelling, tenderness along deep venous system, pitting edema) prompted an immediate ultra-soundpitting edema) prompted an immediate ultra-sound

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49%

35%

8%

2% 2%4%

0%0%

10%

20%

30%

40%

50%

60%

First* Second* Third* Fourth Fifth Sixth >7th

Duplex

VTE develop soon after VTE develop soon after neurosurgeryneurosurgery

•* First Duplex (hospital day 1-4)•* Second Duplex (hospital day 2-7)•* Third Duplex (hospital day 7-11) Confidential- For Quality Improvement Purposes Only

R2 = 0.6543

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

0 2 4 6 8 10 12

Surgery Time (hrs)

Pe

rce

nta

ge

of

DV

T

Longer duration of surgery increases chance for DVT

Surgery Length (hr) <1 1 2 3 4 5 6 7 8 9 >10

Cases 38 343 587 449 221 134 92 41 26 15 19

Positive DVT 0 6 15 8 13 5 10 1 4 2 2

Percent 0% 2% 3% 2% 6% 4% 11% 2% 15% 13% 11%

Con

fide

ntia

l- F

or Q

ualit

y Im

pro

vem

ent

Pu

rpo

ses

On

ly

Effect of Pharmacologic Effect of Pharmacologic Prophylaxis of DVTProphylaxis of DVT

The use of pharmacological subcutaneous The use of pharmacological subcutaneous heparin at 5000 units every 12 hours was heparin at 5000 units every 12 hours was inconsistentinconsistent in neurosurgical patients prior to in neurosurgical patients prior to March 2007March 2007

As of March of 2007, the compliance for early As of March of 2007, the compliance for early (POD1) increased to 62% (55 to 85) after the (POD1) increased to 62% (55 to 85) after the implementation of standard pharmacological implementation of standard pharmacological prophylaxis to the order set.prophylaxis to the order set.

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62% Compliance

Compliance with heparin administration Compliance with heparin administration within 24 hours increased significantlywithin 24 hours increased significantly

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Pharmacologic VTE prophylaxis further reduces DVT incidence

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

Po

sit

ive D

up

lex

Heparin within 24 hrs

Heparin between 24 and 48 hrs

Mechanical prophylaxis only

VTE ProphylaxisPositive Duplex

Negative Duplex Total

Percent positive

Heparin within 24 hrs 26 256 282 9%

Heparin between 24 and 48 hrs 7 68 75 9%

Mechanical prophylaxis only 31 167 198 16%

Total 64 410 555 12%

**

*<0.005

Con

fide

ntial- F

or Qua

lity Imp

rovem

ent P

urp

ose

s On

ly

Heparin administration within 24 hours reduces DVT occurence

0%

5%

10%

15%

20%

25%

30%

35%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Heparin administration within 24 hrs

Po

siti

ve D

up

lex

R2= 0.56p= 0.006

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ConclusionsConclusions

Increased compliance of early subcutaneous Increased compliance of early subcutaneous heparin within 24 hours resulted a 43% risk heparin within 24 hours resulted a 43% risk reduction of developing DVT (from 16% to 9%).reduction of developing DVT (from 16% to 9%).

There is a direct relationship between heparin There is a direct relationship between heparin prophylaxis and reduction in DVT in prophylaxis and reduction in DVT in neurosurgical inpatientsneurosurgical inpatients

There was a correlation between the duration of There was a correlation between the duration of surgery and DVT development.surgery and DVT development.

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Future workFuture work

Include analyzing the data for complication (rate of Include analyzing the data for complication (rate of hemorrhage) with and without pharmacological hemorrhage) with and without pharmacological DVT prophylaxis (POD 0, POD1 and POD 2)DVT prophylaxis (POD 0, POD1 and POD 2)

Preoperative surveillance duplex to rule out pre-Preoperative surveillance duplex to rule out pre-existing DVT (high risk patients) existing DVT (high risk patients)

Assessing the usefulness of starting Assessing the usefulness of starting pharmacological DVT prophylaxis intra-operatively pharmacological DVT prophylaxis intra-operatively in reducing the rate of VTEin reducing the rate of VTE

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