Jeanne Barre

Epidemiology of venous thromboembolism after lower limb arthroplasty: the FOTO study.

Summary.  Background: In view of recent substantial changes in the management of orthopedic surgery patients, a study was performed in order to update data on the epidemiology of venous thromboembolism (VTE) in patients undergoing lower limb arthroplasty according to contemporary practise. Methods: We performed a prospective observational study of a cohort of consecutive patients hospitalized for total hip or knee replacement in June 2003. The primary study outcome was the incidence of symptomatic VTE at 3 months. All events were adjudicated by an independent critical event committee. Results: Data from 1080 patients (mean age 68.0 years) were available; 63.2% were undergoing total hip replacement and 36.8% total knee replacement. Pharmacological thromboprophylaxis was administered for a mean time of 36 days. Injectable antithrombotics were used in more than 99% of patients, irrespective of the type of surgery. The incidence of the primary study outcome was 1.8% (20 events; 95% CI: 1.0–2.6%). The incidences were 1.3% and 2.8% in hip and knee surgery patients, respectively. There were two pulmonary embolisms, both in knee surgery patients; neither was fatal. Thirty‐five per cent of VTEs occurred after hospital discharge. An age of at least 75 years and the absence of ambulation before hospital discharge were the only significant (P < 0.05) predictors of VTE. The rate of clinically significant bleeding was 1.0% and the rate of death was 0.9%. Conclusions: The incidence of symptomatic VTE after lower limb arthroplasty is low, even if there is still a need to improve thromboprophylaxis, notably in patients undergoing knee arthroplasty.

Two injections of erythropoietin correct moderate anemia in most patients awaiting orthopedic surgery.

BackgroundThe primary objective of this study was to assess the number of erythropoietin (EPO) injections required to reach a hematocrit (Ht) of 40% in moderately anemic patients. The secondary objective was to compare this strategy with autologous blood donation (ABD) in elective orthopedic surgery in terms of red blood cell (RBC) production.Study design and methods93 patients with a baseline Ht between 30 and 39% were randomized into two groups the day of the preoperative assessment. In the EPO group, patients received 40,000 UI/week sc until they reached a maximal Ht of 40%. In the ABD group, a RBC pack was collected every week as long as the Ht was above 33%.ResultsTwo EPO injections were necessary to reach a 40% Ht in 63% of the patients. It was possible to collect two RBC packs in 45% of the patients in the ABD group. Volume of RBC production was significantly higher in the EPO group: 268 ± 142 mL vs 141 ± 129 (P = 0.0001). In the EPO group, Ht was significantly higher on days one and three after surgery and at discharge. The energy score was better in the EPO group. In the ABD group, 12.6% patients vs 6.5% in the EPO group received allogeneic transfusion (ns).ConclusionOnly two EPO injections were sufficient to reach a Ht of 40% in the majority of patients. Therefore, to improve cost/effectiveness, the number of EPO injections should be related to baseline Ht instead of the four injections recommended in the product monograph.RésuméObjectifÉvaluer le nombre d’injections d’érythropoïétine (EPO) nécessaires pour atteindre un hématocrite (Ht) de 40% chez des patients modérément anémiques. Aussi, comparer cette stratégie avec le don de sang autologue (DSA) en chirurgie orthopédique réglée en termes de production de globules rouges (GR).MéthodeDes patients (n = 93) présentant un Ht de base de 30 à 39% ont été répartis en deux groupes le jour de l’évaluation préopératoire. Ceux du groupe EPO ont reçu 40,000 UI/semaine sc jusqu’à ce qu’ils présentent un Ht maximal de 40%. Dans le groupe DSA, un culot globulaire a été prélevé chaque semaine tant que l’Ht était au-dessus de 33%.RésultatsIl a fallu deux injections d’EPO pour atteindre un Ht de 40% chez 63% des patients. Il a été possible de prélever deux culots chez 45% des patients du groupe DSA. Le volume de production de GR a été significativement plus élevé chez ceux du groupe EPO: 268 ± 142mL vs 141 ± 129 (P = 0,0001). Dans le groupe EPO, l’Ht a été significativement plus élevé aux jours un et trois après l’opération et au moment du congé. Le score d’asthénie était moins prononcé dans le groupe EPO. Une transfusion allogénique a été faite chez 12,6% des patients du groupe DSA vs 6,5% du groupe EPO (ns).ConclusionIl a suffi de deux injections d’EPO seulement pour atteindre un Ht de 40% chez la majorité des patients. Donc, pour améliorer l’efficacité des coûts, il faudrait relier le nombre d’injection d’EPO à l’Ht de base plutôt que de faire les quatre injections recommandées dans la monographie du produit.

Prevention of postoperative venous thromboembolism. Risk assessment and methods of prophylaxis.

Purpose To describe risk assessment models that have been developed to stratify patients into different risk levels of postoperative venous thromboembolism (VTE) and then to review the different methods of prophylaxis and to outline the evidence supporting their effectiveness and safety.Purpose: To describe risk assessment models that have been developed to stratify patients into different risk levels of postoperative venous thromboembolism (VTE) and then to review the different methods of prophylaxis and to outline the evidence supporting their effectiveness and safety. Source: Our review of the literature is focused on consensus documents, recent large randomized trials and meta-analyses. Principal findings: The risk of VTE is determined by the type of surgery and underlying patient factors. Risk assessment models are useful in stratifying patients into different VTE risk levels. However, multiple risk factors are often present in the same patient and in practice the evaluation of their relative contribution to the overall risk remains difficult. A variety of prophylactic strategies including physical and pharmacological methods have been shown to be effective in different patient groups. Patients with a moderate or high risk of VTE should receive prophylaxis consisting of an antithrombotic agent, unless contraindicated, used alone or in combination with a mechanical method. Recommendations concerning which prophylaxis to use and how intensive it should be are based mainly on data from trials using surrogate endpoints, and do not translate easily into practical decisions aiming to reduce the incidence of symptomatic events. Conclusion: Although risk assessment models and recommendations provided by consensus documents are of practical assistance, a decision concerning any patient is best made by combining recommendations of the literature with clinical judgment, including individual patient risk factors for thrombosis and bleeding. Objectif : Decrire les modeles d’evaluation du risque developpes pour classer les patients selon differents niveaux de risque de thromboembolie veineuse postoperatoire (TEV) et ensuite, revoir les methodes de prophylaxie et ebaucher la preuve de leur efficacite et de leur securite.PurposeTo describe risk assessment models that have been developed to stratify patients into different risk levels of postoperative venous thromboembolism (VTE) and then to review the different methods of prophylaxis and to outline the evidence supporting their effectiveness and safety.SourceOur review of the literature is focused on consensus documents, recent large randomized trials and meta-analyses.Principal findingsThe risk of VTE is determined by the type of surgery and underlying patient factors. Risk assessment models are useful in stratifying patients into different VTE risk levels. However, multiple risk factors are often present in the same patient and in practice the evaluation of their relative contribution to the overall risk remains difficult. A variety of prophylactic strategies including physical and pharmacological methods have been shown to be effective in different patient groups. Patients with a moderate or high risk of VTE should receive prophylaxis consisting of an antithrombotic agent, unless contraindicated, used alone or in combination with a mechanical method. Recommendations concerning which prophylaxis to use and how intensive it should be are based mainly on data from trials using surrogate endpoints, and do not translate easily into practical decisions aiming to reduce the incidence of symptomatic events.ConclusionAlthough risk assessment models and recommendations provided by consensus documents are of practical assistance, a decision concerning any patient is best made by combining recommendations of the literature with clinical judgment, including individual patient risk factors for thrombosis and bleeding.ObjectifDêcrire les modèles ďêvaluation du risque dêveloppês pour classer les patients selon diffêrents niveaux de risque de thromboembolie veineuse postopêratoire (TEV) et ensuite, revoir les mêthodes de prophylaxie et êbaucher la preuve de leur efficacitê et de leur sêcuritê.SourceNotre revue de la littêrature est centrêe sur des documents de consensus, de rêcentes grandes êtudes randomisêes et mêta-analyses.Constatations principalesLe risque de TEV dêpend du type de chirurgie et de facteurs sous-jacents reliês au patient. Les modèles ďêvaluation du risque sont utiles pour classer les patients selon diffêrents niveaux de risque de TEV. Cependant, de multiples facteurs de risque sont souvent prêsents chez le même patient et, en pratique, ľêvaluation de leur contribution relative au risque global demeure difficile. Diverses stratêgies prophylactiques, dont des mêthodes physiques et pharmacologiques, se sont rêvêlêes efficaces auprès de diffêrents groupes de patients. Les patients à risque modêrê ou êlevê de TEV devraient recevoir une thêrapie prêventive avec des antithrombotiques, à moins de contre-indication, utilisês seuls ou en combinaison avec une mêthode mêcanique. Les recommandations sur le choix de la prophylaxie à utiliser et sur son importance sont fondêes principalement sur les donnêes ďessais qui utilisent des paramètres indirects et ne se traduisent pas facilement en dêcisions pratiques visant à rêduire ľincidence ďêvênements symptomatiques.ConclusionMême si les modèles ďêvaluation du risque et les recommandations fournies par les documents de consensus sont pratiques, toute dêcision concernant un patient est plus juste si on combine recommandations de la littêrature et jugement clinique, comprenant les facteurs de risque individuels de thrombose et ďhêmorragie.

280 Évaluation de la prise en charge et de l’incidence des événements thromboemboliques veineux après chirurgie de la jambe et du pied. Incidence de l’obésité (Étude ENVOL)

Introduction L’incidence de la thrombose veineuse postoperatoire apres chirurgie reglee ou non de la jambe et du pied est mal connue. Le role de l’obesite comme facteur de risque est mal precise mais il justifie portant le recours frequent a des posologies d’HBPM augmentees lors d’un traitement preventif. L’objectif de cette etude est de decrire et comparer les strategies de prise en charge (prophylaxie antithrombotique periet postoperatoire) chez des patients obeses (BMI > 30) et nonobeses devant subir une intervention chirurgicale a la jambe ou au pied. Methodes L’etude ENVOL est une etude de cohorte, observationnelle, longitudinale, multicentrique, effectuee en France a partir de decembre 2006 et incluant 2400 patients.- 45 % obeses et 55 % non obeses. La prophylaxie thromboembolique a ete laissee libre selon les protocoles des differents investigateurs. Les donnees pre, peri et postoperatoires ont ete relevees jusqu’a la 12 e semaines + 3, comportant notamment le type de chirurgie, le type d’immobilisation eventuelle, le type et la duree du traitement prophylactique, la survenue de complications thromboemboliques, d’infarctus du myocarde, d’angor instable, d’AVC et de complications chirurgicales precoces. Les complications thromboemboliques ont ete validees par un comite d’experts independants. Resultats 2400 patients ont ete inclus (fractures de jambe et de cheville, chirurgie de l’arriere pied et de l’avant pied). L’analyse est en cours et apportera les reponses concernant la pertinence des differentes strategies de prise en charge (absence ou non, duree) en fonction des parametres chirurgicaux et de l’obesite. L’incidence des evenements thromboemboliques sera rapportee et d’eventuels facteurs predictifs de survenue seront identifies.

La prêvention de la thromboembolie veineuse postopêratoire. Évaluation du risque et mêthodes de prophylaxie

Purpose To describe risk assessment models that have been developed to stratify patients into different risk levels of postoperative venous thromboembolism (VTE) and then to review the different methods of prophylaxis and to outline the evidence supporting their effectiveness and safety.Purpose: To describe risk assessment models that have been developed to stratify patients into different risk levels of postoperative venous thromboembolism (VTE) and then to review the different methods of prophylaxis and to outline the evidence supporting their effectiveness and safety. Source: Our review of the literature is focused on consensus documents, recent large randomized trials and meta-analyses. Principal findings: The risk of VTE is determined by the type of surgery and underlying patient factors. Risk assessment models are useful in stratifying patients into different VTE risk levels. However, multiple risk factors are often present in the same patient and in practice the evaluation of their relative contribution to the overall risk remains difficult. A variety of prophylactic strategies including physical and pharmacological methods have been shown to be effective in different patient groups. Patients with a moderate or high risk of VTE should receive prophylaxis consisting of an antithrombotic agent, unless contraindicated, used alone or in combination with a mechanical method. Recommendations concerning which prophylaxis to use and how intensive it should be are based mainly on data from trials using surrogate endpoints, and do not translate easily into practical decisions aiming to reduce the incidence of symptomatic events. Conclusion: Although risk assessment models and recommendations provided by consensus documents are of practical assistance, a decision concerning any patient is best made by combining recommendations of the literature with clinical judgment, including individual patient risk factors for thrombosis and bleeding. Objectif : Decrire les modeles d’evaluation du risque developpes pour classer les patients selon differents niveaux de risque de thromboembolie veineuse postoperatoire (TEV) et ensuite, revoir les methodes de prophylaxie et ebaucher la preuve de leur efficacite et de leur securite.PurposeTo describe risk assessment models that have been developed to stratify patients into different risk levels of postoperative venous thromboembolism (VTE) and then to review the different methods of prophylaxis and to outline the evidence supporting their effectiveness and safety.SourceOur review of the literature is focused on consensus documents, recent large randomized trials and meta-analyses.Principal findingsThe risk of VTE is determined by the type of surgery and underlying patient factors. Risk assessment models are useful in stratifying patients into different VTE risk levels. However, multiple risk factors are often present in the same patient and in practice the evaluation of their relative contribution to the overall risk remains difficult. A variety of prophylactic strategies including physical and pharmacological methods have been shown to be effective in different patient groups. Patients with a moderate or high risk of VTE should receive prophylaxis consisting of an antithrombotic agent, unless contraindicated, used alone or in combination with a mechanical method. Recommendations concerning which prophylaxis to use and how intensive it should be are based mainly on data from trials using surrogate endpoints, and do not translate easily into practical decisions aiming to reduce the incidence of symptomatic events.ConclusionAlthough risk assessment models and recommendations provided by consensus documents are of practical assistance, a decision concerning any patient is best made by combining recommendations of the literature with clinical judgment, including individual patient risk factors for thrombosis and bleeding.ObjectifDêcrire les modèles ďêvaluation du risque dêveloppês pour classer les patients selon diffêrents niveaux de risque de thromboembolie veineuse postopêratoire (TEV) et ensuite, revoir les mêthodes de prophylaxie et êbaucher la preuve de leur efficacitê et de leur sêcuritê.SourceNotre revue de la littêrature est centrêe sur des documents de consensus, de rêcentes grandes êtudes randomisêes et mêta-analyses.Constatations principalesLe risque de TEV dêpend du type de chirurgie et de facteurs sous-jacents reliês au patient. Les modèles ďêvaluation du risque sont utiles pour classer les patients selon diffêrents niveaux de risque de TEV. Cependant, de multiples facteurs de risque sont souvent prêsents chez le même patient et, en pratique, ľêvaluation de leur contribution relative au risque global demeure difficile. Diverses stratêgies prophylactiques, dont des mêthodes physiques et pharmacologiques, se sont rêvêlêes efficaces auprès de diffêrents groupes de patients. Les patients à risque modêrê ou êlevê de TEV devraient recevoir une thêrapie prêventive avec des antithrombotiques, à moins de contre-indication, utilisês seuls ou en combinaison avec une mêthode mêcanique. Les recommandations sur le choix de la prophylaxie à utiliser et sur son importance sont fondêes principalement sur les donnêes ďessais qui utilisent des paramètres indirects et ne se traduisent pas facilement en dêcisions pratiques visant à rêduire ľincidence ďêvênements symptomatiques.ConclusionMême si les modèles ďêvaluation du risque et les recommandations fournies par les documents de consensus sont pratiques, toute dêcision concernant un patient est plus juste si on combine recommandations de la littêrature et jugement clinique, comprenant les facteurs de risque individuels de thrombose et ďhêmorragie.

Prevention of postoperative venous thromboembo- lism. Risk assessment and methods of prophylaxis (La prévention de la thromboembolie veineuse postopératoire. Évaluation du ris- que et méthodes de prophylaxie)

Purpose To describe risk assessment models that have been developed to stratify patients into different risk levels of postoperative venous thromboembolism (VTE) and then to review the different methods of prophylaxis and to outline the evidence supporting their effectiveness and safety.Purpose: To describe risk assessment models that have been developed to stratify patients into different risk levels of postoperative venous thromboembolism (VTE) and then to review the different methods of prophylaxis and to outline the evidence supporting their effectiveness and safety. Source: Our review of the literature is focused on consensus documents, recent large randomized trials and meta-analyses. Principal findings: The risk of VTE is determined by the type of surgery and underlying patient factors. Risk assessment models are useful in stratifying patients into different VTE risk levels. However, multiple risk factors are often present in the same patient and in practice the evaluation of their relative contribution to the overall risk remains difficult. A variety of prophylactic strategies including physical and pharmacological methods have been shown to be effective in different patient groups. Patients with a moderate or high risk of VTE should receive prophylaxis consisting of an antithrombotic agent, unless contraindicated, used alone or in combination with a mechanical method. Recommendations concerning which prophylaxis to use and how intensive it should be are based mainly on data from trials using surrogate endpoints, and do not translate easily into practical decisions aiming to reduce the incidence of symptomatic events. Conclusion: Although risk assessment models and recommendations provided by consensus documents are of practical assistance, a decision concerning any patient is best made by combining recommendations of the literature with clinical judgment, including individual patient risk factors for thrombosis and bleeding. Objectif : Decrire les modeles d’evaluation du risque developpes pour classer les patients selon differents niveaux de risque de thromboembolie veineuse postoperatoire (TEV) et ensuite, revoir les methodes de prophylaxie et ebaucher la preuve de leur efficacite et de leur securite.PurposeTo describe risk assessment models that have been developed to stratify patients into different risk levels of postoperative venous thromboembolism (VTE) and then to review the different methods of prophylaxis and to outline the evidence supporting their effectiveness and safety.SourceOur review of the literature is focused on consensus documents, recent large randomized trials and meta-analyses.Principal findingsThe risk of VTE is determined by the type of surgery and underlying patient factors. Risk assessment models are useful in stratifying patients into different VTE risk levels. However, multiple risk factors are often present in the same patient and in practice the evaluation of their relative contribution to the overall risk remains difficult. A variety of prophylactic strategies including physical and pharmacological methods have been shown to be effective in different patient groups. Patients with a moderate or high risk of VTE should receive prophylaxis consisting of an antithrombotic agent, unless contraindicated, used alone or in combination with a mechanical method. Recommendations concerning which prophylaxis to use and how intensive it should be are based mainly on data from trials using surrogate endpoints, and do not translate easily into practical decisions aiming to reduce the incidence of symptomatic events.ConclusionAlthough risk assessment models and recommendations provided by consensus documents are of practical assistance, a decision concerning any patient is best made by combining recommendations of the literature with clinical judgment, including individual patient risk factors for thrombosis and bleeding.ObjectifDêcrire les modèles ďêvaluation du risque dêveloppês pour classer les patients selon diffêrents niveaux de risque de thromboembolie veineuse postopêratoire (TEV) et ensuite, revoir les mêthodes de prophylaxie et êbaucher la preuve de leur efficacitê et de leur sêcuritê.SourceNotre revue de la littêrature est centrêe sur des documents de consensus, de rêcentes grandes êtudes randomisêes et mêta-analyses.Constatations principalesLe risque de TEV dêpend du type de chirurgie et de facteurs sous-jacents reliês au patient. Les modèles ďêvaluation du risque sont utiles pour classer les patients selon diffêrents niveaux de risque de TEV. Cependant, de multiples facteurs de risque sont souvent prêsents chez le même patient et, en pratique, ľêvaluation de leur contribution relative au risque global demeure difficile. Diverses stratêgies prophylactiques, dont des mêthodes physiques et pharmacologiques, se sont rêvêlêes efficaces auprès de diffêrents groupes de patients. Les patients à risque modêrê ou êlevê de TEV devraient recevoir une thêrapie prêventive avec des antithrombotiques, à moins de contre-indication, utilisês seuls ou en combinaison avec une mêthode mêcanique. Les recommandations sur le choix de la prophylaxie à utiliser et sur son importance sont fondêes principalement sur les donnêes ďessais qui utilisent des paramètres indirects et ne se traduisent pas facilement en dêcisions pratiques visant à rêduire ľincidence ďêvênements symptomatiques.ConclusionMême si les modèles ďêvaluation du risque et les recommandations fournies par les documents de consensus sont pratiques, toute dêcision concernant un patient est plus juste si on combine recommandations de la littêrature et jugement clinique, comprenant les facteurs de risque individuels de thrombose et ďhêmorragie.