Schiff Renée L, Kahn Susan R, Shrier Ian, Strulovitch Carla, Hammouda Wahbi, Cohen Eva, Zukor David
Department of Medicine, McGill University, Montreal, QC, Canada.
Chest. 2005 Nov;128(5):3364-71. doi: 10.1378/chest.128.5.3364.
To evaluate risk factors for venous thromboembolism (VTE) despite thromboprophylaxis in major orthopedic surgery patients at a tertiary care hospital.
Charts from consecutive patients who underwent total hip replacement (THR), total knee replacement (TKR), or hip fracture surgery (HFS) [hip pinning or hemiarthroplasty] from August 1, 1999, to April 30, 2000, at a large Canadian teaching hospital were abstracted using standardized case report forms. Data were collected on patient characteristics, surgical characteristics, and thromboprophylaxis regimen. Results of tests performed for suspected VTE were documented. Associations between characteristics of interest and objectively confirmed VTE were examined in multivariate analysis.
Over the study period, 310 patients underwent major orthopedic surgery and received standard thromboprophylaxis with either dalteparin or enoxaparin (mean duration of prophylaxis, 7 days). Of these, 34% underwent THR, 30% underwent TKR, and 36% underwent HFS. Of 83 suspected cases of VTE, 44 cases (7 proximal and 37 distal deep venous thrombosis [DVT]); 14% of study population) were confirmed with objective testing. Multivariate analyses revealed that knee surgery (odds ratio [OR], 4.8; 95% confidence interval [CI], 2.3 to 10.1) and type of low molecular weight heparin (LMWH) [enoxaparin (more protective): OR, 0.39; 95% CI, 0.20 to 0.80] independently predicted VTE. No patient characteristics (including previous VTE, malignancy, hormonal therapy, postoperative complications) were associated with VTE.
Despite standard thromboprophylaxis, symptomatic breakthrough VTE, primarily distal DVT, developed in 14% of patients undergoing major orthopedic surgery. Factors that independently predicted VTE in our population were TKR surgery and type of LMWH. TKR patients may warrant more aggressive postoperative physiotherapy and ambulation and adjunctive prophylactic measures such as pneumatic compression. Due to the heterogeneity of different LMWH compounds, direct comparison of the effectiveness of enoxaparin with dalteparin for orthopedic prophylaxis in prospective, randomized trials seems warranted.
评估在一家三级护理医院接受大骨科手术的患者中，尽管采取了血栓预防措施，但发生静脉血栓栓塞（VTE）的风险因素。
使用标准化病例报告表，提取1999年8月1日至2000年4月30日在加拿大一家大型教学医院连续接受全髋关节置换术（THR）、全膝关节置换术（TKR）或髋部骨折手术（HFS）[髋部固定或半关节置换术]的患者的病历。收集患者特征、手术特征和血栓预防方案的数据。记录对疑似VTE进行检测的结果。在多变量分析中检查感兴趣的特征与客观确认的VTE之间的关联。
在研究期间，310例患者接受了大骨科手术，并接受了达肝素或依诺肝素的标准血栓预防（平均预防持续时间为7天）。其中，34%接受了THR，30%接受了TKR，36%接受了HFS。在83例疑似VTE病例中，44例（7例近端和37例远端深静脉血栓形成[DVT]；占研究人群的14%）经客观检测得到确认。多变量分析显示，膝关节手术（比值比[OR]，4.8；95%置信区间[CI]，2.3至10.1）和低分子量肝素（LMWH）的类型[依诺肝素（更具保护作用）：OR，0.39；95%CI，0.20至0.80]独立预测VTE。没有患者特征（包括既往VTE、恶性肿瘤、激素治疗、术后并发症）与VTE相关。
尽管采取了标准的血栓预防措施，但在接受大骨科手术的患者中，仍有14%发生了有症状的突破性VTE，主要是远端DVT。在我们的人群中独立预测VTE的因素是TKR手术和LMWH的类型。TKR患者可能需要更积极的术后物理治疗和活动，以及辅助预防措施，如气压治疗。由于不同LMWH化合物的异质性，在前瞻性随机试验中对依诺肝素和达肝素在骨科预防中的有效性进行直接比较似乎很有必要。
