Balibrea J L, Altimiras J, Larruzea I, Gómez-Outes A, Martínez-González J, Rocha E
Department of Surgery, School of Medicine, Universidad Complutense, Madrid, Spain.
Int J Surg. 2007 Apr;5(2):114-9. doi: 10.1016/j.ijsu.2006.07.005. Epub 2006 Nov 7.
Low-molecular-weight heparins are drugs of first choice for thromboprophylaxis in cancer surgery. We sought to determine the optimal use of bemiparin in cancer surgery in standard clinical practice.
A retrospective, multicentre audit on the use of bemiparin in patients undergoing cancer surgery and given prophylaxis with bemiparin was undertaken. Surgeons' assessment of venous thromboembolic (VTE) risk (moderate or high) was compared to the criteria of current Consensus Guidelines for VTE management. We assessed the incidence of documented symptomatic VTE, bleeding events, thrombocytopenia, deaths and total events related to VTE or bemiparin prophylaxis (i.e. bleeding, thrombocytopenia). The potential economic impact of postoperative vs. preoperative bemiparin was also analysed.
Clinical records from 197 patients from 5 Spanish centres were checked. Prophylaxis was started postoperatively in 45 patients (22.8%). According to the surgeons' criteria, 73 (37.1%) patients were at high VTE risk and received bemiparin 3500 IU/d. However, according to the criteria of current Guidelines, 189 (95.9%) patients were at high risk of VTE (heterogeneity P-value<0.0001). Three (1.5%) patients, all of them receiving bemiparin 2500 IU/d, developed a symptomatic confirmed VTE. There were 4 major and 5 minor bleeding events during bemiparin prophylaxis. A lower incidence of bleeding (2.2% vs. 5.3%; P=0.48) and total events (2.2% vs. 9.9%; P=0.11) was seen with bemiparin started postoperatively as compared to preoperative bemiparin. Bleeding rates did not significantly differ between patients given low or high bemiparin prophylactic doses (4.0% vs. 5.5%; P=0.72). Two patients died due to cardio-respiratory failure and sepsis, respectively. Postoperative bemiparin provided net cost savings of 909 euro per patient compared to preoperative start of prophylaxis due to shorter hospital stays (9 vs. 11 days) and lower incidence of complications in the postoperative bemiparin group.
Many cancer patients are still poorly assessed for risk of VTE. Bemiparin 3500 IU/d is associated with a lower incidence of VTE without significant increase in complications as compared with bemiparin 2500 IU/d. Postoperative bemiparin prophylaxis seems to be as effective and safer than preoperative start of prophylaxis. Further prospective clinical studies are needed to fully address this issue.
低分子量肝素是癌症手术中血栓预防的首选药物。我们试图确定在标准临床实践中贝米肝素在癌症手术中的最佳用法。
对接受癌症手术并使用贝米肝素进行预防的患者使用贝米肝素的情况进行了一项回顾性多中心审计。将外科医生对静脉血栓栓塞（VTE）风险（中度或高度）的评估与当前VTE管理共识指南的标准进行比较。我们评估了有记录的症状性VTE、出血事件、血小板减少症、死亡以及与VTE或贝米肝素预防相关的总事件（即出血、血小板减少症）的发生率。还分析了术后与术前使用贝米肝素的潜在经济影响。
检查了来自5个西班牙中心的197例患者的临床记录。45例患者（22.8%）术后开始预防。根据外科医生的标准，73例（37.1%）患者VTE风险高，接受3500 IU/d的贝米肝素治疗。然而，根据当前指南的标准，189例（95.9%）患者VTE风险高（异质性P值<0.0001）。3例（1.5%）患者发生了症状性确诊VTE，他们均接受2500 IU/d的贝米肝素治疗。在贝米肝素预防期间发生了4例大出血和5例小出血事件。与术前使用贝米肝素相比，术后开始使用贝米肝素时出血发生率较低（2.2%对5.3%；P = 0.48），总事件发生率也较低（2.2%对9.9%；P = 0.11）。给予低剂量或高剂量贝米肝素预防的患者出血率无显著差异（4.0%对5.5%；P = 0.72）。2例患者分别因心肺功能衰竭和败血症死亡。与术前开始预防相比，术后使用贝米肝素每位患者可节省净成本909欧元，原因是住院时间缩短（9天对11天）且术后贝米肝素组并发症发生率较低。
许多癌症患者的VTE风险仍未得到充分评估。与2500 IU/d的贝米肝素相比，3500 IU/d的贝米肝素VTE发生率较低，且并发症无显著增加。术后使用贝米肝素预防似乎与术前开始预防一样有效且更安全。需要进一步的前瞻性临床研究来全面解决这个问题。
