Development of consensus guidelines for venous thromboembolism prophylaxis in patients undergoing microvascular reconstruction of the mandible

Head & Neck (Impact Factor: 2.64). 07/2011; 33(7):1034 - 1040. DOI: 10.1002/hed.21571


The purpose of this study was to determine how guidelines for venous thromboembolism prophylaxis can be applied to patients undergoing microsurgical reconstruction of the mandible.Methods
Retrospective review of our institutional use of thromboprophylaxis and the associated outcomes in 114 patients (58 free fibular flaps and 56 osteocutaneous radial forearm flaps).ResultsTwenty-two patients (19.3%) received only intermittent pneumatic compression. Overall, 80.7% received postoperative chemoprophylaxis. Sixty-four percent initiated chemoprophylaxis within 24 hours after surgery. Only 13.2% received the recommended frequency of chemoprophylaxis. One patient had development of a pulmonary embolism. Four patients undergoing chemoprophylaxis had development of neck hematomas; in each case the cause of bleeding could be attributed to a cause distinct from chemoprophylaxis.Conclusions
No consistent chemoprophylaxis protocol was followed. Chemoprophylaxis was not associated with an increased risk of bleeding. Physician education is the next step in decreasing variations in chemoprophylaxis and adopting guidelines similar to The American College of Chest Physicians. © 2010 Wiley Periodicals, Inc. Head Neck, 2011

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    ABSTRACT: The Institute of Medicine has identified a "quality chasm" between existing evidence and actual clinical practice. The Venous Thromboembolism Prevention Study has shown that enoxaparin prophylaxis is a safe and effective way of preventing postoperative venous thromboembolism. This article presents a "how-to" guide for implementation of a venous thromboembolism prophylaxis protocol. The Venous Thromboembolism Prevention Study prophylaxis protocol included provision of postoperative, prophylactic dose enoxaparin for the duration of inpatient stay. Compliance was considered at the individual patient level and defined as appropriate provision of protocol-appropriate enoxaparin prophylaxis. Multiple simultaneous interventions to improve protocol compliance were undertaken. Both physician and physician assistant "champions" were identified. Interventions included staff and surgeon educational sessions, discussion of venous thromboembolism-themed articles at journal club, and monthly e-mail reminders specific to the protocol, among others. Compliance rates over time were compared using the chi-square test. The authors reviewed medical records from 945 consecutive admissions to the plastic surgery service who met Venous Thromboembolism Prevention Study eligibility criteria over a 30-month period. Initial education sessions significantly increased compliance over baseline (55 percent versus 10 percent; p<0.001). After formal protocol adoption, compliance increased steadily over the first 9 months and peaked by 1 year. In the absence of any direct intervention, compliance remained stable at 90 percent for the final 12 months of the study. This was significantly increased when compared with the period of time immediately following protocol adoption (90 percent versus 77 percent; p<0.001). This article provides readers with a practical approach for implementation of a venous thromboembolism prophylaxis protocol at their hospital.
    Plastic and Reconstructive Surgery 07/2011; 128(5):1085-92. DOI:10.1097/PRS.0b013e31822b67ff · 2.99 Impact Factor
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    ABSTRACT: The risk of postoperative bleeding is the chief concern expressed by plastic surgeons who do not use pharmacologic prophylaxis against venous thromboembolism. The Plastic Surgery Foundation-funded Venous Thromboembolism Prevention Study examined whether receipt of postoperative enoxaparin prophylaxis changed 60-day reoperative hematoma rates. In 2009, the study's network sites uniformly adopted a "best practice" clinical protocol to provide postoperative enoxaparin to adult plastic surgery patients at risk for perioperative venous thromboembolism. Historical control patients (2006 to 2008) received no chemoprophylaxis for 60 days after surgery. Retrospective chart review identified demographic and surgery-specific risk factors that potentially contributed to bleeding risk. The primary study outcome was 60-day reoperative hematoma. Stratified analyses examined reoperative hematoma in the overall population and among high-risk patients. Multivariable logistic regression controlled for identified confounders. Complete data were available for 3681 patients (2114 controls and 1567 enoxaparin patients). Overall, postoperative enoxaparin did not change the reoperative hematoma rate when compared with controls (3.38 percent versus 2.65 percent, p = 0.169). Similar results were seen in subgroup analyses for breast reconstruction (5.25 percent versus 4.21 percent, p = 0.737), breast reduction (7.04 percent versus 8.29 percent, p = 0.194), and nonbreast plastic surgery (2.20 percent versus 1.46 percent, p = 0.465). In the regression model, independent predictors of reoperative hematoma included breast surgery, microsurgical procedure, and post-bariatric surgery body contouring. Receipt of postoperative enoxaparin was not an independent predictor (odds ratio, 1.16; 95 percent CI, 0.77 to 1.76). Postoperative enoxaparin does not produce a clinically relevant or statistically significant increase in observed rates of reoperative hematoma. Risk: II.
    Plastic and Reconstructive Surgery 09/2011; 129(1):160-8. DOI:10.1097/PRS.0b013e318236215c · 2.99 Impact Factor
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