Venous Thromboembolism Prevention in Emergency General Surgery

BackgroundPatients with liver cirrhosis have altered hepatic synthetic functions which theoretically result in reduced levels of pro-and anti-coagulant factors as well as thrombocytopenia. Initially, cirrhotic patients were thought to be at an increased risk of bleeding and a reduced risk of thrombosis. Several studies have recently reported an increased occurrence of venous thromboembolism (VTE) in cirrhotic patients. In this study, we aimed to assess the current practice of deep venous thrombosis (DVT) prophylaxis, the incidence and predictors of VTE, and the associated bleeding sequelae in patients with liver cirrhosis.MethodsA retrospective cohort study was performed. We included all adult patients with a diagnosis of liver cirrhosis from January 2010 to June 2019 admitted to the hospital. Our cohort patients were divided into two groups, cirrhotic patients with pharmacological VTE prophylaxis and those with mechanical or no VTE prophylaxis.ResultsWe included 601 cirrhotic patients in our study. The incidence of VTE occurring within the first 6 months of their admission was 1.5%. Seven patients (1.49%) developed VTE with the majority being DVTs while not on pharmacologic prophylaxis, and two patients developed VTE despite being on pharmacologic prophylaxis; however, there was no statistical difference. Alcohol use was the most common underlying cause of liver cirrhosis (40.4%), followed by chronic hepatitis C (21.1%), and nonalcoholic steatohepatitis (11.3%). Out of the 601 patients included, 69 patients received neither pharmacologic nor mechanical VTE prophylactic agent (11.48%), while the remaining majority received either pharmacological or mechanical prophylaxis (88.52%).ConclusionsOur study did not show a statistically significant association between the use of pharmacological VTE prophylactic agents and a reduction in the risk of VTE in cirrhotic patients. The rates of usage of DVT prophylactic agents among our Northwell hospitals during the study period appeared to be no longer suboptimal when compared to prior studies. Low albumin appears to be a predictor factor to develop VTE. There was a statistically significant increase in bleeding risk and transfusion requirement in cirrhotic patients receiving no pharmacological VTE prophylactic agents. Further prospective trials are needed to shed more light on this subject and identify the group of cirrhotic patients who could safely benefit from pharmacologic VTE prophylaxis.

Introduction Hospital acquired venous thromboembolism (VTE) is potentially preventable yet still accounts for 60% of all VTE seen. This study aimed to establish adherence to guidelines on VTE prevention including completion of VTE risk assessment within 24 hours of admission and appropriate prescription of mechanical and pharmacological VTE prophylaxis. Methods A database of all general surgical inpatients in our hospital at any point during the 48-hour period from 21/12/2021 to 22/12/2021 was obtained. Electronic records were examined to check for the presence of 11 established risk factors for VTE and to check for adherence to VTE guidelines. Every surgical patient was reviewed to check whether they were wearing anti-embolic stockings. Standard statistical analyses were undertaken. Results There were 107 general surgical patients in hospital during the study period. Of these, 33 (31%) had 3 or more risk factors on admission for VTE. 106 (99%) patients had VTE assessments completed within 24 hours of admission. Of these 107 patients, 93 (87%) had appropriate pharmacological VTE prophylaxis or had a documented reason why this was not prescribed. 14 (13%) patients had no pharmacological VTE prophylaxis prescribed. 84 patients were assessed as requiring anti-embolic stockings. Of these, 57 (68%) of patients were prescribed stockings, and 30 (36%) were physically wearing stockings. Conclusions This study has shown that adherence to VTE guidelines among surgical patients in our hospital is substandard. We suggest having a VTE safeguard during the ward round responsible for identifying any deficits in VTE prophylaxis and ensuring recommendations are acted upon.

Background:A large number of patients live with undiagnosed HIV and/or hepatitis C despite broadened national screening guidelines. European studies, however, suggest many patients falsely believe they have been screened during a prior hospitalization. This study aims to define current perceptions among trauma and emergency general surgery (EGS) patients regarding HIV and hepatitis C screening practices.Methods:Prospective survey administered to adult (>18 years old) acute care surgery service (trauma and EGS) patients at a Level 1 academic trauma center. The survey consisted of 13 multiple choice questions: demographics, whether admission tests included HIV and hepatitis C at index and prior hospital visits and whether receiving no result indicated a negative result, prior primary care screening. Response percentages calculated in standard fashion.Results:One hundred and twenty-five patients were surveyed: 80 trauma and 45 EGS patients. Overall, 32% and 29.6% of patients believed they were screened for HIV and hepatitis C at admission. There was no significant difference in beliefs between trauma and EGS. Sixty-eight percent of patients had a hospital visit within 10 years of these, 49.3% and 44.1% believe they had been screened for HIV and hepatitis C. More EGS patients believed they had a prior screen for both conditions. Among patients who believed they had a prior screen and did not receive any results, 75.9% (HIV) and 80.8% (hepatitis C) believed a lack of results meant they were negative. Only 28.9% and 23.6% of patients had ever been offered outpatient HIV and hepatitis C screening.Conclusions:A large portion of patients believe they received admission or prior hospitalization HIV and/or hepatitis C screening and the majority interpreted a lack of results as a negative diagnosis. Due to these factors, routine screening of trauma/EGS patients should be considered to conform to patient expectations and national guidelines, increase diagnosis and referral for medical management, and decrease disease transmission.

Fragmentation of care (FOC) is defined as readmission to a nonindex hospital and can be associated with worse outcomes among emergency general surgery (EGS) patients. This study assessed hospital characteristics associated with patterns of FOC in EGS patients and the effect of interfacility transfer after FOC on mortality. Using the Nationwide Readmissions Database 2019, we included patients 18 years or older who were admitted to an index hospital with an EGS diagnosis managed operatively and had an emergency readmission within 90 days. Patients were classified into 4 patterns of fragmentation: no FOC, FOC, defragmented care (readmitted to a nonindex hospital, then transferred back), and hyperfragmented care (readmitted to a nonindex hospital, then transferred to another nonindex hospital). Patient severity of illness was defined using severity of illness categories of All Patient-Refined Diagnosis Related Groups (APR-DRG). Multivariable logistic regression analyses were used to identify hospital characteristics associated with FOC and the effect of FOC on 90-day mortality. Of 26,100 patients included, 82.5% had no FOC, 16.4% had FOC, 0.3% had defragmented care, and 0.9% had hyperfragmented care. Index hospital characteristics associated with FOC were small size (by number of beds), private investor or government owned, and low EGS volumes. Controlling for hospital and patient characteristics, FOC (odds ratio 1.22; 95% CI 1.01 to 1.47; p = 0.045) was significantly associated with increased 90-day mortality, driven by those with major or extreme severity of illness of APR-DRGs (odds ratio 1.36; 95% CI 1.13 to 1.64; p = 0.001). FOC is associated with worse outcomes in EGS patients. This study highlights the impact of FOC and the hospital characteristics associated with FOC, highlighting the need for further investigation into EGS systems of care.

Retrospective cohort study. To examine the impact of early (<48 hr) versus late (≥48 hr) initiation of pharmacological venous thromboembolism (VTE) prophylaxis on outcomes and complications among trauma patients undergoing operative fixation of spine fractures. VTE complications are associated with poor outcomes after trauma. Although pharmacological prophylaxis decreases the risk of VTE after trauma, concerns regarding bleeding-related complications among certain patient subgroups persist. At present, there are limited data regarding the safety of early VTE prophylaxis in trauma patients undergoing operative fixation of spine fractures. We performed a 5-year retrospective analysis of our level 1 trauma center registry to identify consecutive patients undergoing operative fixation of spine fractures. Demographics, injury patterns and severity, details of operative procedures, timing of administration of VTE prophylaxis, and outcomes were analyzed. Patients receiving early VTE prophylaxis were compared with patients receiving late VTE prophylaxis. Multivariate analysis was performed to identify independent predictors of VTE. Of 1432 patients with spine fractures, 206 patients (14.4%) underwent operative fixation. Forty-eight (23.3%) received early VTE prophylaxis and 158 (76.7%) received late VTE prophylaxis. No patient developed an epidural hematoma or postoperative bleeding necessitating intervention in either group. Thirteen patients (6.2%) developed VTE, of which 12 occurred in the late VTE prophylaxis group. Age 45 years or more (odds ratio = 5.12, 95% confidence interval = 1.01-25.94, P = 0.048) and traumatic brain injury (odds ratio = 6.94, 95% confidence interval = 1.19-40.35, P = 0.031) were independently associated with an increased risk for VTE. Pharmacological VTE prophylaxis initiated within 48 hours of operative fixation of traumatic spine fractures seems to be safe and is not associated with an increased risk of bleeding or neurological complications. Large, multicenter prospective studies are required to further define the efficacy and safety of an early pharmacological VTE prophylaxis strategy in this at-risk patient population. 3.

To evaluate the prevalence of risk for venous thromboembolism (VTE) and the proportion of at-risk patients who receive appropriate thromboprophylaxis among inpatients in acute hospital care settings in Oman. A related objective was to evaluate the type and time of initiation of VTE prophylaxis. This multicenter, cross-sectional study was conducted in three tertiary hospitals in Oman. The study included acutely ill medical and surgical inpatients admitted from August to September 2022. VTE risk assessment and prophylaxis were assessed based on the 2012 recommendations of the American College of Chest Physicians (ACCP). A total of 384 patients were enrolled, 240 were medical patients and 144 were surgical patients. As per the ACCP criteria, 179 (74.6%) of medical and 92 (63.9%) of surgical patients were at risk for VTE and required prophylaxis. Appropriate prophylaxis was received by 142 (79.3%) at-risk medical and 70 (76.1%) at-risk surgical patients. In cases where pharmacological prophylaxis was contraindicated, mechanical prophylaxis was markedly underused. For medical patients, the median day of initiating VTE prophylaxis was day one of admission. For surgical patients, the median day of initiating VTE prophylaxis was postoperative day one. The majority of hospitalized patients in Oman are at risk of VTE. However, a significant minority of patients do not receive the required pharmacological or mechanical prophylaxis. We recommend the development of a national VTE risk assessment and guiding tool with a facility for monitoring compliance.

Creation and Implementation of an Emergency General Surgery Registry Modeled after the National Trauma Data Bank

A Reassessment of Needs and Practice Patterns in Pharmacologic Prophylaxis of Venous Thromboembolism Following Elective Major Surgery

Data from the trauma patient population suggests handsewn (HS) anastomoses are superior to stapled (ST). A recent retrospective study in emergency general surgery (EGS) patients had similar findings. The aim of the current study was to evaluate HS and ST anastomoses in EGS patients undergoing urgent/emergent operations. The study was sponsored by the American Association for the Surgery of Trauma Multi-Institutional Studies Committee. Patients undergoing urgent/emergent bowel resection for EGS pathology were prospectively enrolled from July 22, 2013 to December 31, 2015. Patients were grouped by HS/ST anastomoses, and variables were collected. The primary outcome was anastomotic failure. Similar to other studies, anastomotic failure was evaluated at the anastomosis level. Multivariable logistic regression was performed controlling for age and risk factors for anastomotic failure. Fifteen institutions enrolled a total of 595 patients with 649 anastomoses (253 HS and 396 ST). Mean age was 61 years, 51% were men, 7% overall mortality. Age and sex were the same between groups. The overall anastomotic failure rate was 12.5%. The HS group had higher lactate, lower albumin, and were more likely to be on vasopressors. Hospital and intensive care unit days, as well as mortality, were greater in the HS group. Anastomotic failure rates and operative time were equivalent for HS and ST. On multivariate regression, the presence of contamination at initial resection (odds ratio, 1.965; 95% confidence interval, 1.183-3.264) and the patient being managed with open abdomen (odds ratio, 2.529; 95% confidence interval, 1.492-4.286) were independently associated with anastomotic failure, while the type of anastomosis was not. EGS patients requiring bowel resection and anastomosis are at high risk for anastomotic failure. The current study illustrates an apparent bias among acute care surgeons to perform HS techniques in higher-risk patients. Despite the individualized application of technique for differing patient populations, the risk of anastomotic failure was equivalent when comparing HS and ST anastomoses. Therapeutic study, level II.

Efficacité et sécurité des anticoagulants oraux directs (DOA) versus la thromboprophylaxie conventionnelle dans les fractures de l’extrémité supérieure du fémur: revue systématique et méta-analyse des essais randomisés

Aim Venous thromboembolism (VTE) is a serious global health care safety concern for both patients and staff. Although it has been amply demonstrated that pharmaceutical and mechanical methods of prophylaxis against VTE are effective, their application has been uneven and insufficient. The purpose of this audit was to assess junior physicians working in general surgery, regarding their adherence to local and NICE guidelines regarding the pharmacological VTE prophylaxis practice as well as the mechanical prophylaxis Methodology Pre-intervention audit took place for two weeks. Throughout the course, it covered every adult general surgical emergency inpatient admission at conquest hospital who were deemed indicated for VTE prophylaxis. Each evening while the patients were still in the hospital, data was collected using the prescription charts, nursing and medical notes. The proforma used for data collection detailed the characteristics of VTE risk, the prophylactic medication prescribed for each patient, TED stockings and whether or not this aligned with the NICE clinical guideline (CG) 46,6.8. Post intervention took place for two weeks after teaching of junior doctors and the same as above was carried out, using the new proforma Results Pre-intervention showed that 87% of patients had the proforma filled in and 100% of patients received the appropriate dose of pharmaceutical prophylaxis. However, less than 40% of patients received the appropriate mechanical prophylaxis. Therefore, intervention was made in the form of a new proforma and teaching to junior. Post intervention data is currently being carried out Conclusion Implementation was necessary to ensure that at-risk patients receive appropriate prophylaxis.

Venous Thromboembolism in Plastic Surgery: Where Are We Now?

Optimal timing of pharmacologic venous thromboembolism (VTE) prophylaxis after spontaneous intracerebral hemorrhage (ICH) remains uncertain due to concerns regarding hematoma expansion. Prior studies have primarily relied on arbitrary time thresholds rather than physiological markers of hemorrhage stability. To summarize the literature on the safety and efficacy of pharmacologic VTE prophylaxis initiated after radiographic confirmation of hematoma stability in patients with spontaneous ICH. We conducted a systematic review and meta-analysis of studies assessing heparinoids prophylaxis following repeat neuroimaging demonstrating hemorrhage stability. Three databases were searched: PubMed, Embase, Cochrane Central. The meta-analysis was registered in PROSPERO (CRD420261282903). The primary outcome was new or worsening intracranial hemorrhage, including hematoma expansion or new bleeding. Secondary outcomes included deep vein thrombosis and pulmonary embolism. Random-effects models were applied. P value was set at 0.05. Four observational studies comprising 935 patients met inclusion criteria. Comparative meta-analysis demonstrated no significant association between pharmacologic prophylaxis after radiographic stability and intracranial bleeding risk (OR: 1.24, 95% CI: 0.80-1.94, P = 0.33), with negligible heterogeneity (I2 = 0%). Sensitivity analysis restricted to parenchymal hematoma expansion showed similar results (OR 2.37, 95% CI: 0.42-13.43, P = 0.33). Thromboembolic outcomes trended in favor of pharmacological prophylaxis without reaching statistical significance (OR: 0.63, 95% CI: 0.33-1.22, P = 0.17). Pharmacologic VTE prophylaxis initiated after radiographic confirmation of hematoma stability does not increase intracranial hemorrhage risk and may reduce thromboembolic complications. These findings support further investigation into imaging-guided, individualized strategies for pharmacologic VTE prophylaxis after ICH.

Predicting length of stay for trauma and emergency general surgery patients

# 01. The future of general surgery training: a Canadian resident nationwide Delphi consensus statement {#article-title-2} Various pedagogical models have been introduced in an attempt to improve and restructure surgical training, but significant obstacles remain. Before implementing national