Coagulation Profile Changes Due to Thromboprophylaxis and Platelets in Trauma Patients at High-Risk for Venous Thromboembolism

2015 ◽  
Vol 81 (7) ◽  
pp. 663-668 ◽  
Author(s):  
Casey J. Allen ◽  
Clark R. Murray ◽  
Jonathan P. Meizoso ◽  
Juliet J. Ray ◽  
Laura F. Teisch ◽  
...  
Keyword(s):  
Risk Assessment ◽  
Venous Thromboembolism ◽  
High Risk ◽  
Trauma Patients ◽  
Clotting Time ◽  
Coagulation Profile ◽  
Profile Score ◽  
Risk Patients ◽  
Profile Changes

We hypothesize there are coagulation profile changes associated both with initiation of thromboporphylaxis (TPX) and with change in platelet levels in trauma patients at high-risk for venous thromboembolism (VTE). A total of 1203 trauma intensive care unit patients were screened with a VTE risk assessment profile. In all, 302 high-risk patients (risk assessment profile score ≥ 10) were consented for weekly thromboelastography. TPX was initiated between initial and follow-up thromboelastography. Seventy-four patients were analyzed. Upon admission, 87 per cent were hypercoagulable, and 81 per cent remained hypercoagulable by Day 7 ( P = 0.504). TPX was initiated 3.4 ± 1.4 days after admission; 68 per cent received unfractionated heparin and 32 per cent received low-molecular-weight heparin. The VTE rate was 18 per cent, length of stay 38 (25–37) days, and mortality of 17.6 per cent. In all, 76 per cent had a rapid clotting time at admission versus 39 per cent at Day 7 ( P < 0.001); correcting from 7.75 (6.45–8.90) minutes to 10.45 (7.90–15.25) minutes ( P < 0.001). At admission, 41 per cent had an elevated maximum clot formation (MCF) and 85 per cent had at Day 7 ( P < 0.001); increasing from 61(55–65) mm to 75(69–80) mm ( P < 0.001). Platelets positively correlated with MCF at admission (r = 0.308, R2 = 0.095, P = 0.008) and at Day 7 (r = 0.516, R2 = 0.266, P < 0.001). Change in platelet levels correlated with change in MCF (r = 0.332, R2 = 0.110, P = 0.005). In conclusion, hypercoagulability persists despite the use of TPX. Although clotting time normalizes, MCF increases in correlation with platelet levels. As platelet function is a dominant contributor to sustained trauma-evoked hypercoagulability, antiplatelet therapy may be indicated in the management of severely injured trauma patients.

scholarly journals Successful Model for Guideline Implementation to Prevent Cancer-Associated Thrombosis: Venous Thromboembolism Prevention in the Ambulatory Cancer Clinic

2020 ◽  
Vol 16 (9) ◽  
pp. e868-e874 ◽  
Author(s):  
Chris E. Holmes ◽  
Steven Ades ◽  
Susan Gilchrist ◽  
Daniel Douce ◽  
Karen Libby ◽  
...  
Keyword(s):  
Risk Assessment ◽  
Venous Thromboembolism ◽  
High Risk ◽  
Assessment Tool ◽  
Guideline Implementation ◽  
Vte Prophylaxis ◽  
Successful Model ◽  
Venous Thromboembolism Prevention ◽  
Risk Patients ◽  
Cancer Associated Thrombosis

PURPOSE: Guidelines recommend venous thromboembolism (VTE) risk assessment in outpatients with cancer and pharmacologic thromboprophylaxis in selected patients at high risk for VTE. Although validated risk stratification tools are available, < 10% of oncologists use a risk assessment tool, and rates of VTE prophylaxis in high-risk patients are low in practice. We hypothesized that implementation of a systems-based program that uses the electronic health record (EHR) and offers personalized VTE prophylaxis recommendations would increase VTE risk assessment rates in patients initiating outpatient chemotherapy. PATIENTS AND METHODS: Venous Thromboembolism Prevention in the Ambulatory Cancer Clinic (VTEPACC) was a multidisciplinary program implemented by nurses, oncologists, pharmacists, hematologists, advanced practice providers, and quality partners. We prospectively identified high-risk patients using the Khorana and Protecht scores (≥ 3 points) via an EHR-based risk assessment tool. Patients with a predicted high risk of VTE during treatment were offered a hematology consultation to consider VTE prophylaxis. Results of the consultation were communicated to the treating oncologist, and clinical outcomes were tracked. RESULTS: A total of 918 outpatients with cancer initiating cancer-directed therapy were evaluated. VTE monthly education rates increased from < 5% before VTEPACC to 81.6% (standard deviation [SD], 11.9; range, 63.6%-97.7%) during the implementation phase and 94.7% (SD, 4.9; range, 82.1%-100%) for the full 2-year postimplementation phase. In the postimplementation phase, 213 patients (23.2%) were identified as being at high risk for developing a VTE. Referrals to hematology were offered to 151 patients (71%), with 141 patients (93%) being assessed and 93.8% receiving VTE prophylaxis. CONCLUSION: VTEPACC is a successful model for guideline implementation to provide VTE risk assessment and prophylaxis to prevent cancer-associated thrombosis in outpatients. Methods applied can readily translate into practice and overcome the current implementation gaps between guidelines and clinical practice.

Comparison of outcome prediction in node-negative breast cancer based on biomarkers uPA/PAI-1 or Adjuvant Online using the 10-year follow-up of the randomized multicenter Chemo N0 trial

2006 ◽  
Vol 24 (18_suppl) ◽  
pp. 534-534 ◽  
Author(s):  
U. Euler ◽  
C. Meisner ◽  
C. Friedel ◽  
M. Schmidt ◽  
M. Untch ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Risk Assessment ◽  
Clinical Trial ◽  
High Risk ◽  
Adjuvant Therapy ◽  
Computer Program ◽  
Risk Patients ◽  
The Individual ◽  
Pai 1

534 Background: Chemo N0 was the first multicenter randomized clinical trial in breast cancer using biomarkers uPA/PAI-1 for risk stratification and chemotherapy selection. Chemo N0 validated uPA/PAI-1 as clinically relevant parameters for risk assessment in N0 breast cancer. About 50% of N0 patients have low uPA/PAI-1 in their primary tumor with excellent 5-year OS (>95%), even without adjuvant therapy. Patients with high uPA/PAI-1 benefit from adjuvant chemotherapy. We evaluated whether biomarkers can predict outcome more accurately than a computer-program. Methods: In Chemo N0, patients (n=689, 1993–98) were stratified according to uPA/PAI-1: High-risk patients were randomized (6x CMF vs. observation), low-risk patients observed. Retrospectively, we divided recruited patients into two groups (chemotherapy vs. no adjuvant therapy) and stratified using uPA/PAI-1 (low vs. high). Individual 10-year OS was calculated by www.adjuvantonline.org (Version 7.0); these estimated values were compared to the observed 10-year OS in Chemo N0. Results: 81/151 patients with already available complete follow-up data 10 years after trial start have 10-year OS results. Median 10-year OS estimated by Adjuvant Online was 77.1% (median 78.6%) taking into account administered adjuvant therapy. 10-year Chemo N0 follow-up revealed an observed 10-year OS of 66.7% (27/81 deceased). 64/81 did not receive chemotherapy: In high-risk untreated patients (n=22), 10-year OS was 54.6% vs. estimated 75.0%. In CMF-treated patients (all high-risk, n=17), observed OS was 58.8% vs. estimated 74.6%. Conclusions: For the first time, risk assessment by novel biomarkers is compared to that by Adjuvant Online in data from a randomized clinical trial. In patients with high uPA/PAI-1, the individual 10-year OS calculated by Adjuvant Online seems to be underestimated compared to observed patient outcome. Further follow-up data will show whether uPA/PAI-1 can predict the individual course of disease more precisely than a computer-program based on large clinical data sets. Final Chemo N0 10-year follow-up is currently being completed. No significant financial relationships to disclose.

Venous thromboembolism prevention in medical patients: a framework for improving practice

2011 ◽  
Vol 26 (2) ◽  
pp. 62-68 ◽  
Author(s):  
P G Vaughan-Shaw ◽  
C Cannon
Keyword(s):  
Risk Assessment ◽  
Venous Thromboembolism ◽  
High Risk ◽  
Clinical Excellence ◽  
Medical Patients ◽  
High Risk Patients ◽  
Venous Thromboembolism Prevention ◽  
Risk Patients ◽  
A Prospective Study ◽  
Pharmacological Thromboprophylaxis

Objective Medical inpatients have been shown to be at risk of venous thromboembolism (VTE) including fatal pulmonary emboli. Several studies have shown that pharmacological thromboprophylaxis significantly reduces the rates of VTE, yet studies published to date have shown a considerable underuse of thromboprophylaxis in medical patients. This study assesses the current use of thromboprophylaxis in medical patients at our institution and aims to identify simple strategies to improve practice. Design A prospective study of thromboprophylaxis prescription was undertaken on three occasions over a 12-month period. Patients were stratified according to the number of risk factors and standards of thromboprophylaxis assessed according to risk. After the first round of data collection, results were presented, a local guideline was developed and a risk assessment was added to the clerking pro forma. Results There were 122 patients in the first round, 101 in the second and 163 in the third. Eligible moderate and high-risk patients receiving a low molecular weight heparin (LMWH) increased from 31% to 63% ( P < 0.005) over the study period. Prescription of thromboembolic deterrent (TED) stockings in those contraindicated to LMWH increased from 23% to 35% although this was not statistically significant ( P = 0.08), and the percentage of high-risk patients correctly receiving LMWH, TED stockings or both increased from 22% to 62% ( P < 0.0005). Documentation of contraindications to thromboprophylaxis increased from 0% to 59% ( P < 0.0005). Conclusion This paper demonstrates an initial rate of thromboprophylaxis use considerably less than the ENDORSE trial. However the strategies employed following initial audit resulted in a significant increase in the prescription of both mechanical and pharmacological thromboprophylaxis. This example demonstrates the role of audit education and a risk assessment in stimulating change. Such strategies could be used to ensure compliance to recently published National Institute of Clinical Excellence VTE guidelines. Furthermore this example could be generalized to improve other aspects of care.

scholarly journals Improving Rates of Venous Thromboembolism Prophylaxis in Multiple Myeloma Patients on Immunomodulatory Drugs

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 2235-2235
Author(s):  
Houry Leblebjian ◽  
Joanna Hamilton ◽  
Sydney Smith ◽  
Jacob Laubach ◽  
Nancy Berliner ◽  
...  
Keyword(s):  
Risk Factors ◽  
Risk Assessment ◽  
Multiple Myeloma ◽  
Venous Thromboembolism ◽  
High Risk ◽  
Low Risk ◽  
Immunomodulatory Drugs ◽  
Vte Prophylaxis ◽  
Nccn Guidelines ◽  
Risk Patients

Abstract BACKGROUND: Multiple myeloma patients who receive immunomodulatory drugs (IMiDs: lenalidomide, thalidomide, and pomalidomide) have an increased risk of developing venous thromboembolism (VTE). Guidelines for thromboprophylaxis are based on additional patient and disease characteristics. We describe our single-institution experience with VTE prophylaxis and an intervention to improve VTE risk assessment and prophylaxis. METHODS: A retrospective review using an internal patient database assessed VTE in multiple myeloma patients being treated with IMiDs from 2000-2016. VTE risk factors for each patient were assessed to determine alignment with thromboprophylaxis guidelines. A Quality Improvement (QI) phase from April 1, 2017 to December 31, 2017 added pharmacy oversight to perform an independent VTE risk assessment. Every patient started on an IMiD during this period underwent a separate VTE risk assessment by a pharmacist or hematologist. Each patient was categorized as high or low VTE risk based on NCCN guidelines. The results and recommendations for VTE prophylaxis were given to the myeloma provider. Results: In the initial retrospective review, 107 patients were identified who developed VTE during treatment of multiple myeloma with an IMiD despite thromboprophylaxis in 91 patients (85% of total; 78% on aspirin). The most common VTE risk factors per NCCN guidelines included cardiac disease (n=70), obesity (n=32), chronic kidney disease (n=27), and prior history of VTE (n=18). Eight patients received anticoagulant-based thromboprophylaxis. In the QI phase, 39 multiple myeloma patients were started on IMiDs. The risk assessment classified 17 as low-risk and 22 as high-risk. Of the high-risk patients, 14 (64%) were placed on an anticoagulant for thromboprophylaxis. Eleven (79%) of the anticoagulants used were direct oral anticoagulants (DOACs), 2 (14%) were a low-molecular weight heparin, one (7%) warfarin. The number of thromboembolic events that occurred were 6 (15%): 4 were high-risk on aspirin and 2 were low-risk on aspirin. The 2 low-risk patients who developed VTE had additional provoking factors (active infection, central line placement, smoking, a long driving trip). Eight high-risk patients were given aspirin. Out of the 8, 3 patients developed VTE and were then switched to anticoagulation. One high-risk patient received aspirin because of moderate thrombocytopenia and subsequently developed a VTE. No patients on anticoagulation developed a VTE. The number of complications attributed to thromboprophylaxis were 2 (5%). Two minor bleeding events occurred in patients who were on DOACs (1 epistaxis and 1 grade 1 GI bleed). Both patients continued DOAC anticoagulation after the event resolved. Conclusions: This two-phase QI study showed that multiple myeloma patients at high risk for VTE benefit from guideline-based thromboprophylaxis facilitated through a pharmacy-based system. DOAC's ease of use offer patients and providers an agreeable option that may improve compliance of VTE guidelines. However, prospective studies with DOACs in multiple myeloma are urgently needed to support this. Figure. Figure. Disclosures No relevant conflicts of interest to declare.

scholarly journals Risk Assessment for Venous Thromboembolism in Patients With Neuroepithelial Tumors: Pretreatment Score to Identify High Risk Patients

2013 ◽  
Vol 53 (7) ◽  
pp. 467-473 ◽  
Author(s):  
Tomohiro KAWAGUCHI ◽  
Toshihiro KUMABE ◽  
Masayuki KANAMORI ◽  
Ryuta SAITO ◽  
Yoji YAMASHITA ◽  
...  
Keyword(s):  
Risk Assessment ◽  
Venous Thromboembolism ◽  
High Risk ◽  
Neuroepithelial Tumors ◽  
High Risk Patients ◽  
Risk Patients ◽  
Pretreatment Score

scholarly journals Risk assessment in precapillary pulmonary hypertension: a comparative analysis

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Thomas Sonnweber ◽  
Eva-Maria Schneider ◽  
Manfred Nairz ◽  
Igor Theurl ◽  
Günter Weiss ◽  
...  
Keyword(s):  
Risk Assessment ◽  
Pulmonary Hypertension ◽  
High Risk ◽  
Risk Stratification ◽  
Risk Prediction ◽  
Mortality Risk ◽  
Assessment Tool ◽  
Risk Models ◽  
Non Invasive

Abstract Background Risk stratification is essential to assess mortality risk and guide treatment in patients with precapillary pulmonary hypertension (PH). We herein compared the accuracy of different currently used PH risk stratification tools and evaluated the significance of particular risk parameters. Methods We conducted a retrospective longitudinal observational cohort study evaluating seven different risk assessment approaches according to the current PH guidelines. A comprehensive assessment including multi-parametric risk stratification was performed at baseline and 4 yearly follow-up time-points. Multi-step Cox hazard analysis was used to analyse and refine risk prediction. Results Various available risk models effectively predicted mortality in patients with precapillary pulmonary hypertension. Right-heart catheter parameters were not essential for risk prediction. Contrary, non-invasive follow-up re-evaluations significantly improved the accuracy of risk estimations. A lack of accuracy of various risk models was found in the intermediate- and high-risk classes. For these patients, an additional evaluation step including assessment of age and right atrium area improved risk prediction significantly. Discussion Currently used abbreviated versions of the ESC/ERS risk assessment tool, as well as the REVEAL 2.0 and REVEAL Lite 2 based risk stratification, lack accuracy to predict mortality in intermediate- and high-risk precapillary pulmonary hypertension patients. An expanded non-invasive evaluation improves mortality risk prediction in these individuals.

scholarly journals Accuracy of upper endoscopies with random biopsies to identify patients with gastric premalignant lesions who can safely be exempt from surveillance

2021 ◽  
Vol 24 (3) ◽  
pp. 680-690
Author(s):  
Michiel C. Mommersteeg ◽  
Stella A. V. Nieuwenburg ◽  
Wouter J. den Hollander ◽  
Lisanne Holster ◽  
Caroline M. den Hoed ◽  
...  
Keyword(s):  
Gastric Cancer ◽  
High Risk ◽  
Low Risk ◽  
Premalignant Lesions ◽  
High Risk Patients ◽  
European Guidelines ◽  
Progression Of Disease ◽  
Risk Patients ◽  
Progression Risk

Abstract Introduction Guidelines recommend endoscopy with biopsies to stratify patients with gastric premalignant lesions (GPL) to high and low progression risk. High-risk patients are recommended to undergo surveillance. We aimed to assess the accuracy of guideline recommendations to identify low-risk patients, who can safely be discharged from surveillance. Methods This study includes patients with GPL. Patients underwent at least two endoscopies with an interval of 1–6 years. Patients were defined ‘low risk’ if they fulfilled requirements for discharge, and ‘high risk’ if they fulfilled requirements for surveillance, according to European guidelines (MAPS-2012, updated MAPS-2019, BSG). Patients defined ‘low risk’ with progression of disease during follow-up (FU) were considered ‘misclassified’ as low risk. Results 334 patients (median age 60 years IQR11; 48.7% male) were included and followed for a median of 48 months. At baseline, 181/334 (54%) patients were defined low risk. Of these, 32.6% were ‘misclassified’, showing progression of disease during FU. If MAPS-2019 were followed, 169/334 (51%) patients were defined low risk, of which 32.5% were ‘misclassified’. If BSG were followed, 174/334 (51%) patients were defined low risk, of which 32.2% were ‘misclassified’. Seven patients developed gastric cancer (GC) or dysplasia, four patients were ‘misclassified’ based on MAPS-2012 and three on MAPS-2019 and BSG. By performing one additional endoscopy 72.9% (95% CI 62.4–83.3) of high-risk patients and all patients who developed GC or dysplasia were identified. Conclusion One-third of patients that would have been discharged from GC surveillance, appeared to be ‘misclassified’ as low risk. One additional endoscopy will reduce this risk by 70%.

scholarly journals Implementation of the acutely presenting older patient (APOP) screening program in routine emergency department care

2021 ◽  
Author(s):  
Laura C. Blomaard ◽  
Bas de Groot ◽  
Jacinta A. Lucke ◽  
Jelle de Gelder ◽  
Anja M. Booijen ◽  
...  
Keyword(s):  
Emergency Department ◽  
High Risk ◽  
Older Patients ◽  
Screening Program ◽  
Admission Rate ◽  
Older Patient ◽  
Hospital Admission Rate ◽  
High Risk Patients ◽  
Risk Patients

Abstract Objective The aim of this study was to evaluate the effects of implementation of the acutely presenting older patient (APOP) screening program for older patients in routine emergency department (ED) care shortly after implementation. Methods We conducted an implementation study with before-after design, using the plan-do-study-act (PDSA) model for quality improvement, in the ED of a Dutch academic hospital. All consecutive patients ≥ 70 years during 2 months before and after implementation were included. The APOP program comprises screening for risk of functional decline, mortality and cognitive impairment, targeted interventions for high-risk patients and education of professionals. Outcome measures were compliance with interventions and impact on ED process, length of stay (LOS) and hospital admission rate. Results Two comparable groups of patients (median age 77 years) were included before (n = 920) and after (n = 953) implementation. After implementation 560 (59%) patients were screened of which 190 (34%) were high-risk patients. Some of the program interventions for high-risk patients in the ED were adhered to, some were not. More hospitalized patients received comprehensive geriatric assessment (CGA) after implementation (21% before vs. 31% after; p = 0.002). In 89% of high-risk patients who were discharged to home, telephone follow-up was initiated. Implementation did not influence median ED LOS (202 min before vs. 196 min after; p = 0.152) or hospital admission rate (40% before vs. 39% after; p = 0.410). Conclusion Implementation of the APOP screening program in routine ED care did not negatively impact the ED process and resulted in an increase of CGA and telephone follow-up in older patients. Future studies should investigate whether sustainable changes in management and patient outcomes occur after more PDSA cycles.

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