School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
S Afr Med J. 2020 Feb 26;110(3):235-242. doi: 10.7196/SAMJ.2020.v110i3.14279.
Venous thromboembolism (VTE) complicates a significant proportion of medical admissions. As well as increasing patient morbidity, pulmonary embolism is one of the commonest preventable causes of in-hospital death. An increase in the use of pharmacological preventive measures has been advocated in recent years. South African (SA) and international guidelines have been published in an effort to promote the safe use of VTE prophylaxis.
To describe adherence to both local and international recommendations for VTE prophylaxis in an SA hospital with regard to appropriateness of the decision to prescribe or withhold low-molecular-weight heparin (LMWH), and to observe the practice of dose adjustment in special population groups.
This was a prospective, observational study, and data were collected from consenting adults admitted to the medical wards. We assessed the patients' VTE risk, bleeding risk and the presence of contraindications at the time of LMWH prescription as well as the dose prescribed, specifically taking into consideration adjustment for renal dysfunction and obesity.
Three hundred and fifty-two patients were enrolled, of whom 51.4% were male and 58.5% received LMWH. Primary outcomes. The appropriate overall decision according to both SA and international guidelines was made in 254 cases (72.2%). The inappropriate decision according to both guidelines was made in 79 cases (22.4%) and the appropriate decision according to one guideline only was made in 18 cases (5.1%), while 1 case (0.3%) was not categorised. Contraindications to VTE prophylaxis were present in 35 patients (9.9%), but 9 of these patients nevertheless received LMWH. An incorrect dose was prescribed in 36 cases (17.5%), the most common reason being an inappropriate reduction in the dose in mild renal dysfunction.
Other medications that may have increased bleeding risk were prescribed in 46 patients who received LMWH (22.3%). Mechanical prophylaxis was indicated in 25 (7.1%) of the total sample; however, none received this.
Overall adherence to published guidelines for VTE prophylaxis has improved compared with other published reviews on the topic, but documentation of patients' VTE risk in files is poor. Overuse in low-risk patients may be an unintended consequence of the widespread advocacy of LMWH use in hospital, highlighting the importance of adequate VTE risk stratification. Incorrect dosing in special population groups is an issue that needs to be addressed, as is non-utilisation of mechanical prophylaxis methods.
静脉血栓栓塞症（VTE）在很大比例的内科住院患者中很常见。肺栓塞不仅会增加患者的发病率，还是院内死亡的最常见可预防原因之一。近年来，人们提倡更多地使用药物预防措施。南非（SA）和国际指南已经发布，以促进 VTE 预防的安全使用。
描述南非一家医院在决定开具或不开具低分子肝素（LMWH）时，对 VTE 预防的当地和国际建议的遵循情况，观察特殊人群中剂量调整的情况。
这是一项前瞻性观察性研究，从同意入住内科病房的成年患者中收集数据。我们评估了患者在开具 LMWH 时的 VTE 风险、出血风险和禁忌症，以及开具的剂量，特别是考虑到对肾功能不全和肥胖的剂量调整。
共纳入 352 例患者，其中 51.4%为男性，58.5%接受了 LMWH。主要结局：根据 SA 和国际指南，254 例（72.2%）做出了适当的总体决策。根据两个指南，79 例（22.4%）的决策不适当，根据一个指南，18 例（5.1%）的决策适当，而 1 例（0.3%）无法分类。35 例（9.9%）存在 VTE 预防的禁忌症，但其中 9 例仍接受了 LMWH。36 例（17.5%）开具了不正确的剂量，最常见的原因是在轻度肾功能不全时不适当的剂量减少。
接受 LMWH 的 46 例患者（22.3%）开具了可能增加出血风险的其他药物。总样本中有 25 例（7.1%）需要机械预防，但均未接受。
与其他关于该主题的已发表综述相比，VTE 预防的发布指南的总体遵循情况有所改善，但文件中患者 VTE 风险的记录很差。在低风险患者中的过度使用可能是医院广泛提倡使用 LMWH 的意外后果，突出了充分进行 VTE 风险分层的重要性。特殊人群中不正确的剂量是一个需要解决的问题，还有非使用机械预防方法的问题。
