Postoperative venous thromboembolic disease prevention in the neurosurgery population

1. Postoperative venous thromboembolic disease prevention in the neurosurgery population Ahmad Khaldi, M.D. 1 Michael Wall, PharmD 2 T.C. Origitano, M.D., Ph.D.1 1Department of Neurosurgery 2 Center for Clinical Effectiveness Confidential- For Quality Improvement Purposes Only

2. VTE in Neurosurgery • Neurosurgical inpatients have increased immobility and are at an increased risk of VTE • DVT development can be as high as 29%-43% in following cranial/spinal surgery (no prophylaxis). * • The rate of “clinically evident DVT” in craniotomy patients is around 2-4%. • PE occurs between 0.8%-2% in patients undergoing craniotomy with mortality rate between 9-59%. * Farray, D., Carman, T., Fernandez, B. The treatment and prevention of deep vein thrombosis in the preoperative management of patients who have neurologic disease. Neurological Clin N Am (2004), 22: 423-439. Confidential- For Quality Improvement Purposes Only

3. Objective Reduce the rate of post-operative VTE in neurosurgical patients through increased use of pharmacologic prophylaxis Confidential- For Quality Improvement Purposes Only

4. Duplex Study Patients (n=555) • All patients received mechanical DVT prophylaxis (both compression stocking and sequential compression device) • Patients had a surveillance ultra-sound (duplex) of the lower extremities (twice a week, Monday and Thursday) • During their ICU stay or • If they are deemed to have a high risk of developing DVT while they were on the floor • Patients who developed clinical sign or symptoms of DVT (calf swelling, tenderness along deep venous system, pitting edema) prompted an immediate ultra-sound Confidential- For Quality Improvement Purposes Only

5. VTE develop soon after neurosurgery • * First Duplex (hospital day 1-4) • * Second Duplex (hospital day 2-7) • * Third Duplex (hospital day 7-11) Confidential- For Quality Improvement Purposes Only

6. Longer duration of surgery increases chance for DVT Confidential- For Quality Improvement Purposes Only

7. Effect of Pharmacologic Prophylaxis of DVT • The use of pharmacological subcutaneous heparin at 5000 units every 12 hours was inconsistent in neurosurgical patients prior to March 2007 • As of March of 2007, the compliance for early (POD1) increased to 62% (55 to 85) after the implementation of standard pharmacological prophylaxis to the order set. Confidential- For Quality Improvement Purposes Only

8. Compliance with heparin administration within 24 hours increased significantly 62% Compliance Confidential- For Quality Improvement Purposes Only

9. * * Confidential- For Quality Improvement Purposes Only *<0.005

10. Confidential- For Quality Improvement Purposes Only

11. Conclusions • Increased compliance of early subcutaneous heparin within 24 hours resulted a 43% risk reduction of developing DVT (from 16% to 9%). • There is a direct relationship between heparin prophylaxis and reduction in DVT in neurosurgical inpatients • There was a correlation between the duration of surgery and DVT development. Confidential- For Quality Improvement Purposes Only

12. Future work • Include analyzing the data for complication (rate of hemorrhage) with and without pharmacological DVT prophylaxis (POD 0, POD1 and POD 2) • Preoperative surveillance duplex to rule out pre-existing DVT (high risk patients) • Assessing the usefulness of starting pharmacological DVT prophylaxis intra-operatively in reducing the rate of VTE Confidential- For Quality Improvement Purposes Only