safety of perioperative subcutaenous heparin for prophylaxis of

8/7/2019 Safety of Perioperative Subcutaenous Heparin for Prophylaxis of

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Safety of Perioperative Subcutaenous HeparinSafety of Perioperative Subcutaenous Heparin

for Prophylaxis of Venous Thrombosembolismfor Prophylaxis of Venous Thrombosembolism

in Patients Undergoing Craniotomyin Patients Undergoing Craniotomy

McDonald RL et alMcDonald RL et al

Neurosurgery 45(2); 245Neurosurgery 45(2); 245 252, 1999252, 1999

UCMC, Chicago, IllinoisUCMC, Chicago, Illinois


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Give or not to give?Give or not to give?Bleeding vs clottingBleeding vs clotting


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ObjectiveObjective

11stst: To determine whether perioperative: To determine whether perioperativesubcutaneous heparin is safe to use forsubcutaneous heparin is safe to use forpatients undergoing craniotomy and topatients undergoing craniotomy and to

determine the incidence of venousdetermine the incidence of venousthromboembolism in patients undergoingthromboembolism in patients undergoingcraniotomy.craniotomy.

22ndnd

: To determine the risk of DVT and PE: To determine the risk of DVT and PEin patients undergoing craniotomy who arein patients undergoing craniotomy who aretreated with heparintreated with heparin


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IntroductionIntroductionIncidence of DVT in patient undergoingIncidence of DVT in patient undergoing

neurosurgery: 19neurosurgery: 19 50 %50 %PredisposePredispose

Age, HF, previous DVT/PE, malignancy, OCP,Age, HF, previous DVT/PE, malignancy, OCP,pregnancy, defiency antithrombin III, proteinpregnancy, defiency antithrombin III, proteinC&S, factor V Leiden mutationC&S, factor V Leiden mutation

PreventionPrevention

Mobilizing the patient ASAPMobilizing the patient ASAP

MechanicalMechanical -- pneumatic compression (provenpneumatic compression (provenby radiolabeled fibrinogen technique);by radiolabeled fibrinogen technique);compression stockingscompression stockings

PharmacoPharmaco heparin; LMWHheparin; LMWH


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MethodMethodProspective, observational study of heparin for preventionProspective, observational study of heparin for prevention

of thromboembolic complication in patient undergoingof thromboembolic complication in patient undergoingcraniotomy for brain neoplasm, including transphenoidalcraniotomy for brain neoplasm, including transphenoidalsurgery, intracranial aneurysm, vascular malformation orsurgery, intracranial aneurysm, vascular malformation orinfection, spontaneous intracranial haematoma, closedinfection, spontaneous intracranial haematoma, closedhead injury, cortical resection for epilepsyhead injury, cortical resection for epilepsy

Inclusion criteriaInclusion criteria Subject > 18 yrs oldSubject > 18 yrs old

No evidence of deep vein thrombosis (DVT) preoperatively onNo evidence of deep vein thrombosis (DVT) preoperatively onlower limb duplex ultrasoundlower limb duplex ultrasound

Exclusion criteriaExclusion criteria duplex evidence of DVTduplex evidence of DVT

clinical evidence of pulmonary embolus (PE) preoperativelyclinical evidence of pulmonary embolus (PE) preoperatively

hypersensitivity to heparin; heparin induced thrombocytopeniahypersensitivity to heparin; heparin induced thrombocytopenia

Thrombocytopenia, abnormal PT,Thrombocytopenia, abnormal PT, aPTTaPTT, BT, BT

sustained a penetrating head injurysustained a penetrating head injury


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106 eligible patients were entered the study106 eligible patients were entered the study

Study group (106): S/C Heparin 5000U BD, immediateStudy group (106): S/C Heparin 5000U BD, immediatebefore craniotomy and continuing postoperatively for 7/7before craniotomy and continuing postoperatively for 7/7until patient was ambulatoryuntil patient was ambulatory

NONNON--study group (68): refused informed consent, nostudy group (68): refused informed consent, nopreop S/c heparin administered but subsequently S/cpreop S/c heparin administered but subsequently S/cheparin post operativelyheparin post operatively

All patients were treated gradual compression stockingsAll patients were treated gradual compression stockingsand pneumatic compressions devicesand pneumatic compressions devices

Parameters for comparisonParameters for comparison Evidence of DVT/PE clincally and radiological on duplex ultrasoundEvidence of DVT/PE clincally and radiological on duplex ultrasound

and VP Scanand VP Scan

Baseline blood and post operative blood count and coagulationBaseline blood and post operative blood count and coagulationprofile studiesprofile studies

Blood transfusionBlood transfusion

Evidence of bleeding GIT, Genitourinary, and intracranialEvidence of bleeding GIT, Genitourinary, and intracranialhaemorrhage documentedhaemorrhage documented


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Factor Study (106) Non study (68)

Age 49 + 16 47 + 17

Sex

Male /Female 51/55 23/45

Diagnosis

Brain tumour 58 23

Aneurysm 26 18

Vascular

malformation 9 3

Infection 3 12

Subdural/intracereb

ral haemorrhage 3 1

Other 7 9


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Factor Study (106) Non study (68)

DVT / PE 7 / 1 (7.55%) 3 / 1 (5.8%)

Haemorrhage 4 out of 106 (3.8%) 2 of 68 (2.9%)

4 haemorrhage4 haemorrhage -- all intraoperativeall intraoperative

haemorrhageshaemorrhages 3 resulted from3 resulted fromintraoperative aneurysm rupture; 1 duringintraoperative aneurysm rupture; 1 duringresection of an arteriovenousresection of an arteriovenousmalformation.malformation.

There were no intracranial haemorrhageThere were no intracranial haemorrhagenoted on routine post operative CT scansnoted on routine post operative CT scansor MRI scansor MRI scans


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ResultResult

No signifcant difference between hemorrhageNo signifcant difference between hemorrhagerate in study patients and nonrate in study patients and non--study patientsstudy patients

There were no differences between groups inThere were no differences between groups inintraoperative blood loss, transfusionintraoperative blood loss, transfusionrequirements, or postoperative platelet countsrequirements, or postoperative platelet counts

Four clinically significant hemorrhages occurredFour clinically significant hemorrhages occurredduring surgery in patients receiving heparin.during surgery in patients receiving heparin.Three resulted from intraoperative aneurysmThree resulted from intraoperative aneurysm

rupture and one from intraventricular bleedingrupture and one from intraventricular bleedingduring resection of an arteriovenousduring resection of an arteriovenousmalformation. These events were believed to bemalformation. These events were believed to berelated to known complications of theserelated to known complications of theseoperations, not to heparinoperations, not to heparin


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Other studiesOther studies

Ruff and PosnerRuff and Posner 87% DVT occurred with 2/12 of87% DVT occurred with 2/12 ofsurgery from glioma inpatient who received nosurgery from glioma inpatient who received noprophylaxisprophylaxis

Ceratto et alCeratto et al randomized 100 craniotomy and studiesrandomized 100 craniotomy and studies

show heparin decreased DVT from 34% to 6%show heparin decreased DVT from 34% to 6%Bostrom et alBostrom et al randomized 122 patientsrandomized 122 patients no differenceno differencein rate of bleeding and DVTin rate of bleeding and DVT

Dulken&ThomeerDulken&Thomeer only one out of 983 patientsonly one out of 983 patientsundergoing neurosurgery develop postoperativeundergoing neurosurgery develop postoperativehaematoma and no venous thromboembolichaematoma and no venous thromboemboliccomplicationcomplication

ConstantiniConstantini randomized 103randomized 103 no evidence of bleedingno evidence of bleedingassociated with heparin treatmentassociated with heparin treatment


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DiscussionDiscussion

HeparinHeparin 5000 U every 8 or 12 hr. we chose the5000 U every 8 or 12 hr. we chose the

lower dosage because theoretically lower risk oflower dosage because theoretically lower risk of

bleedingbleeding

No conclusion could be drawn as whether heparinNo conclusion could be drawn as whether heparinshould be better given preshould be better given pre--operatively, inductionoperatively, induction

of anaesthesia, or post operatively.of anaesthesia, or post operatively.

Agnelli et al (1998)Agnelli et al (1998) significant reduced risk ofsignificant reduced risk ofDVT from 32%DVT from 32% 17%, without increase risk of17%, without increase risk of

intracranial bleedingintracranial bleeding


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ConclusionConclusion

S/c heparin 5000 U BD is safe in patientS/c heparin 5000 U BD is safe in patient

undergoing routine neurosurgicalundergoing routine neurosurgical

procedures. Larger randomized studiesprocedures. Larger randomized studies

are necessary to determine efficacy andare necessary to determine efficacy and

optimal duration of treatmentoptimal duration of treatment

Risk of DVT/PE is about 7Risk of DVT/PE is about 7--8% despite8% despite

having prophylaxis s/c heparin preop inhaving prophylaxis s/c heparin preop inpatient undergoing craniotomypatient undergoing craniotomy

safety of perioperative subcutaenous heparin for prophylaxis of

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