Do we know how to prescribe venous thromboembolism prophylaxis to hospitalized patients?

Lopes, Bruno Abdala Candido; Teixeira, Isabela Pizzatto; Souza, Taynara Dantas de; Tafarel, Jean Rodrigo

doi:10.1590/1677-5449.008516

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ORIGINAL ARTICLES • J. Vasc. Bras. 16 (3) • Jul-Sep 2017 • https://doi.org/10.1590/1677-5449.008516 linkcopy

Do we know how to prescribe venous thromboembolism prophylaxis to hospitalized patients?

Authorship SCIMAGO INSTITUTIONS RANKINGS

Background Although prophylaxis to prevent venous thromboembolism is recommended, it is rarely systematically performed in hospitalized patients.

Objective To investigate whether hospitalized patients are given the correct VTE prophylaxis prescription by the physician responsible for them while in hospital, analyzed by risk category.

Methods This was a cross-sectional study based on analysis of medical records for patients admitted to the Hospital Santa Casa de Misericórdia, Curitiba, PR, Brazil, from March 20 to May 25, 2015. Patients on anticoagulants or with active bleeding were excluded. The following variables were analyzed: sex, age, type of healthcare coverage, specialty responsible for the patient, and patients’ risk factors to classify them as at high, moderate, or low risk of VTE. Use or not of prophylaxis was compared across prescriptions made by clinical and surgical specialties, between patients treated on the Brazilian National Health Service (SUS - Sistema Único de Saúde) and private health insurance, and according to patients’ risk of VTE.

Results Eight of the 78 patients assessed met exclusion criteria. The remaining 70 eligible patients had a mean age of 56.9 years, 41 were male, 62 were treated on the SUS, 31 were treated by clinicians, and 39 were treated by surgeons. Just 46 (65.71%) patients were given prophylaxis for VTE. Among the clinical patients, 29 (93.5%) were given prophylaxis, against 17 (43.6%) in the surgical group (p < 0.001). Moderate and high risk clinical patients were more likely to be given prophylaxis than surgical patients (p < 0.001 and p = 0.002). There were no differences with relation to type of healthcare coverage (SUS vs. private healthcare).

Conclusions At the Hospital Santa Casa de Misericórdia in Curitiba, surgical patients are less well protected from thromboembolic events than clinical patients.

Keywords:
venous thromboembolism; thromboembolic prophylaxis; pulmonary embolism

Clinical factors	Surgical factors	Medications
Age	Surgical procedure	Oral contraception
Malignant neoplasm	Trauma	Hormone replacement therapy
Central and SG catheters	Type of surgery	Chemotherapy
IID	Type of anesthesia	Hormone therapy
Severe respiratory disease	Major burns	Infection
Rheumatological disease	Immobilization	Arterial or venous insufficiency
Thrombophilia	Major amputations	ICU admission
Stroke	Prior history of VTE	LL paresis or paralysis
Pregnancy	AMI	Nephrotic syndrome
Postpartum status	NYHA class III or IV HF	Varicose veins

Low risk	Moderate risk	High risk
Operations on patients less than 40 years old without risk factors;	Major surgery (general, urological, or gynecological) in patients aged 40 to 60 years, without additional risk factors;	General surgery in patients over 60 years old;
Minor operations (duration of less than 30 minutes and with no need for prolonged rest) in patients over 40 years old without additional risk factors other than age;	Surgery in patients less than 40 years old who are taking estrogens	General surgery in patients aged 40-60 years with additional risk factors;
Minor trauma		Major surgery in patients with a previous history of DVT or PTE or thrombophilia;
		Major amputations;
		Major orthopedic surgery;
		Major surgery in patients with malignant neoplasms;
		Major surgery in patients with other hypercoagulable states;
		Multiple traumas with fractures of pelvis, hips, or lower limbs

Low risk	Moderate risk	High risk
Any patient.	Patients over the age of 65 years, bedridden by clinical diseases, but with no other risk factors.	Any disease combined with previous DVT or PTE; Any disease combined with thrombophilia; Myocardial infarction; Diseases associated with other risk factors for DVT; Stroke; Spinal cord injury; Patients in ICU.

Prescription of prophylaxis	Clinical patients	Surgical patients
Prophylaxis prescribed	30 (96.8%)	17 (43.6%)
Prophylaxis not prescribed	1 (3.2%)	22 (56.4%)
Total	31	39

Prescription of prophylaxis	SUS	Private
Prophylaxis prescribed	42 (67.7%)	4 (50%)
Prophylaxis not prescribed	20 (32.3%)	4 (50%)
Total	62	8

Prescription of prophylaxis	Clinical	Surgical
Prophylaxis prescribed at correct dosage	24 (82.8%)	12 (70.6%)
Prophylaxis prescribed at incorrect dosage	5 (17.2%)	5 (29.4%)
Total	29	17

Prescription of prophylaxis	Clinical
Prophylaxis prescribed	3	2
Prophylaxis not prescribed	1	2
Total	4	4

Prescription of prophylaxis	Clinical	Surgical
Prophylaxis prescribed	10	2
Prophylaxis not prescribed	0	11
Total	10	13

Prescription of prophylaxis	Clinical	Surgical
Prophylaxis prescribed	17	13
Prophylaxis not prescribed	0	9
Total	17	22

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Sociedade Brasileira de Angiologia e de Cirurgia Vascular (SBACV) Rua Estela, 515, bloco E, conj. 21, Vila Mariana, CEP04011-002 - São Paulo, SP, Tel.: (11) 5084.3482 / 5084.2853 - Porto Alegre - RS - Brazil
E-mail: secretaria@sbacv.org.br

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[1] SG: Swan-Ganz; IID: inflammatory intestinal disease; VTE: venous thromboembolism; AMI: acute myocardial infarction; NYHA: New York Health Association; HF: heart failure; ICU: intensive care unit; LL: lower limbs.