Risk-to-Benefit Ratio of Venous Thromboembolism Prophylaxis for Neurosurgical Procedures at a Quaternary Referral Center

BACKGROUND Pharmacological prophylaxis for venous thromboembolism (VTE) in the neurosurgical population is still a matter of debate, as the risk-to-benefit ratio is not well defined. OBJECTIVE To further evaluate the risk-to-benefit ratio of VTE prophylaxis (VTEP) for all neurosurgical procedures. METHODS A prospective evaluation was performed after the initiation of a VTEP protocol for 11 436 patients undergoing neurosurgical procedures over 24 mo. Unless a bleeding complication was present, 5000 international units of subcutaneous heparin every 8 h was ordered on postoperative day (POD) 1 for spine, POD2 for cranial, and by POD4 for subdural, intracerebral, and epidural hematoma cases. Incidence of VTE and any subsequent bleeding complications were noted. RESULTS A total of 70 VTEs (0.6% overall) were documented (28 deep vein thrombosis, 42 pulmonary embnolism). The highest rates of VTE were associated with deformity (6.7%); open cerebrovascular (6.5%); subdural, intracerebral, and epidural hematoma (3.2%); spinal trauma (2.4%); and craniotomy for tumor (1.6%) cases. Seven cases of deep vein thrombosis progressed to pulmonary embolisms, and 66 of 70 VTEs occurred while on pharmacological VTEP. Fifty-four bleeding complications occurred on or after POD2 following initiation of VTEP. These bleeding complications consisted of any new clinically or radiographically observed hemorrhages. Twenty-eight of the 54 delayed bleeding complications required operative intervention with 1 mortality. Forty-five patients were on anticoagulation when the initial bleeding event occurred. Overall, an estimated 0.5% incidence of delayed bleeding complications was noted with 99.4% of patients within the study cohort remaining VTE free. CONCLUSION This VTEP protocol was determined to afford a good risk-to-benefit ratio for a wide variety of neurosurgical procedures.

[1]  D. Damania,et al.  Systematic Review of Safety and Cost‐Effectiveness of Venous Thromboembolism Prophylaxis Strategies in Patients Undergoing Craniotomy for Brain Tumor , 2018, Neurosurgery.

[2]  Jodi L. Smith,et al.  Risk of deep venous thrombosis in elective neurosurgical procedures: a prospective, Doppler ultrasound-based study in children 12 years of age or younger. , 2017, Journal of neurosurgery. Pediatrics.

[3]  K. Bekelis,et al.  Risk of Venous Thromboembolism and Operative Duration in Patients Undergoing Neurosurgical Procedures , 2017, Neurosurgery.

[4]  E. Aytaç,et al.  The Use of Surgical Care Improvement Projects in Prevention of Venous Thromboembolism. , 2016, Advances in experimental medicine and biology.

[5]  K. Bilimoria,et al.  Evaluation of an institutional project to improve venous thromboembolism prevention. , 2016, Journal of hospital medicine.

[6]  K. Bailey,et al.  Corrigendum to ‘Direct medical costs attributable to venous thromboembolism among persons hospitalized for major operation: A population-based longitudinal study’: [Surgery 2015;157:423-31] , 2015 .

[7]  B. Jahromi,et al.  Analysis of Venous Thromboembolism Risk in Patients Undergoing Craniotomy. , 2015, World neurosurgery.

[8]  B. Jahromi,et al.  Clinical factors associated with venous thromboembolism risk in patients undergoing craniotomy. , 2015, Journal of neurosurgery.

[9]  K. Bailey,et al.  Direct medical costs attributable to venous thromboembolism among persons hospitalized for major operation: a population-based longitudinal study. , 2015, Surgery.

[10]  K. Bailey,et al.  Direct Medical Costs Attributable to Venous Thromboembolism among Persons Hospitalized for Major Surgery: A Population-based Longitudinal Study , 2015 .

[11]  A. Neugut,et al.  Incidence, cost, and mortality associated with hospital-acquired conditions after resection of cranial neoplasms. , 2014, Neurosurgery.

[12]  R. Strom,et al.  Low-Molecular-Weight Heparin Prophylaxis 24 to 36 Hours After Degenerative Spine Surgery: Risk of Hemorrhage and Venous Thromboembolism , 2013, Spine.

[13]  Michael K Gould,et al.  Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. , 2012, Chest.

[14]  W. Ghali,et al.  Venous Thromboembolism Prophylaxis in Patients Undergoing Cranial Neurosurgery: A Systematic Review and Meta-analysis , 2011, Neurosurgery.

[15]  M. Marden,et al.  Prevalence of clinical venous thromboembolism in the USA: Current trends and future projections , 2011, American journal of hematology.

[16]  S. Rathbun Cardiology patient pages. The Surgeon General's call to action to prevent deep vein thrombosis and pulmonary embolism. , 2009, Circulation.

[17]  K. Wood,et al.  Thromboembolic Disease in Spinal Surgery: A Systematic Review , 2009, Spine.

[18]  Moira C McKinnon,et al.  Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination) , 2007 .

[19]  Jonathan Dreyer,et al.  Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. , 2003, The New England journal of medicine.