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Surgeon discusses indications for prophylaxis in arthroscopic surgery
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WAILEA, Hawaii — As arthroscopic surgery has a low risk for venous thromboembolic events, a patient’s family history plays a key role in determining whether surgeons should administer prophylaxis to the patient, according to a speaker at Orthopedics Today Hawaii.
“Arthroscopic surgery is low risk for developing venous thromboembolism; therefore, I look at the patient and consider whether the patient has risk factors,” speaker Peter R. Kurzweil, MD, of Southern California Center for Sports Medicine in Long Beach, said. “It is the only time I ask for family history. If so, I do use thromboprophylaxis in these high-risk patients.”
Prophylaxis not for everyone
It is not necessary to give every patient blood thinners, according to Kurzweil. Whether major or minor surgery, Kurzweil noted that most studies in the literature report a similar venous thromboembolism (VTE) rate of 0.5% or less.
Peter R. Kurzweil
The risk of a major bleed is small in minor surgery like arthroscopy, according to the American College of Chest Physicians (ACCP); nevertheless, the risk of bleeding is 1.5% or greater in patients who are on blood thinners, making these patients high risk for major bleeding during surgery, according to Kurzweil.
“That is why you do not provide prophylactic treatment for everybody, particularly patients who have a high risk of bleeding,” he said. “There is at least a three times higher risk of a major bleed with thromboprophylaxis than there is [for] developing a blood clot.”
Consider patient history
Kurzweil recommended instead weighing patient history of VTE with risk of major bleeding. The ACCP released guidelines in 2012 that said if a patient has a history of prior blood clot or risk factors for deep vein thrombosis or pulmonary embolism, such as obesity, varicose veins, cancer, smoking or hormone replacement, then that patient should be given thromboprophylaxis. Conversely, if the patient will have prolonged protected weight-bearing, such as after meniscus repair, the ACCP guidelines suggest no thromboprophylaxis because the risk of bleeding is greater than the risk of a blood clot.
“The American College of Chest Physicians said, ‘Know your patient,’” Kurzweil said. “If they had a prior blood clot, maybe you should consider prophylaxis.”
The cost of readmission may be higher for patients that have major bleeding during surgery, according to Kurzweil. He cited a study by James A. Keeney, MD, presented at the Current Concepts in Joint Replacement 2013 Winter Meeting in which researchers found a 3% VTE rate among 2,221 total knee arthroplasty procedures. The readmission rate was 5.4%, and 10% of those patients readmitted to the hospital had bleeding complications. Furthermore, the cost to manage bleeding exceeded the cost of readmission, according to the researchers. Kurzweil recommended aspirin as an alternative to thromboprophylaxis.
“Aspirin is now considered an acceptable form of thromboprophylaxis, even with total knee replacements, as of 2012,” he said. – by Renee Blisard Buddle