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Fear of bleeding complications fuels controversy on chemoprophylaxis use

Article-Fear of bleeding complications fuels controversy on chemoprophylaxis use

Key iconKey Points

  • Hospitals are targeting VTE prevention as priority in agendas to improve patient care
  • Plastic surgeons should establish formal protocols to assess VTE risk, address prevention, an expert says

Dr. Venturi
Despite appreciation that the risk of venous thromboembolism (VTE) following many plastic surgery procedures is real, use of chemoprophylaxis remains controversial within the plastic surgery community because of fear of bleeding complications, according to Mark L. Venturi, M.D., who spoke at Plastic Surgery 2010 in September.

Review of available literature indicates that the risks of not prescribing chemoprophylaxis for VTE in appropriate plastic surgery patients are far greater than the risks associated with its use. Hospitals are targeting VTE prevention as a priority in their agendas to improve patient care, and plastic surgeons need to overcome unwarranted concerns about chemoprophylaxis and use it when indicated based on risk stratification, Dr. Venturi says.

"Concern that VTE chemoprophylaxis greatly increases the likelihood for postoperative hematoma is not substantiated in the plastic surgery literature. However, the evidence does show that if hematoma occurs, it is a manageable event," says Dr. Venturi, clinical assistant professor, department of plastic surgery, Georgetown University Medical Center, Washington.

"For their own protection and the protection of their patients, plastic surgeons should have a formal protocol for assessing VTE risk and addressing its prevention, and document that they are applying appropriate guidelines," he adds.

CURRENT GUIDELINES In the past, an absence of VTE prophylaxis guidelines specific to plastic surgery may have contributed to surgeons' failure to adopt routine prophylaxis treatment. The American College of Chest Physicians (ACCP) issues guidelines on VTE prevention and updates its recommendations every four years based on review of the published literature and committee consensus. Although the ACCP guidelines are widely considered the definitive source in this area, they do not address plastic surgery procedures specifically. Furthermore, the most recent edition of the ACCP guidelines eliminates the use of risk-assessment models that incorporate patient-specific risk factors. Instead, it assigns patients to risk groups based almost entirely on the procedure, Dr. Venturi says.

Plastic surgery procedures are not addressed at all in the ACCP guidelines, and certain procedures, such as abdominoplasty and other major body-contouring procedures, carry a particularly high risk of VTE. In addition, abandoning risk-assessment models may be particularly questionable when determining appropriate VTE prophylaxis for the plastic surgery population, as certain VTE risk factors are common in this group.

"For example, the population is dominated by white females who are more likely than any other demographic group to carry the gene for the most common hereditary hypercoagulable disorder. Other features representing risk factors for VTE are also common among patients undergoing plastic and reconstructive surgery procedures, including obesity, cancer, immobility, age greater than 40 years, and estrogen use (oral contraceptives and hormone replacement therapy). Travel is another common, relevant risk factor, as patients may have sought out expertise at distant centers for both reconstructive and aesthetic procedures," Dr. Venturi says.

In response to the limitations of the ACCP guidelines and to encourage appropriate use of VTE prophylaxis in the plastic surgery community, Dr. Venturi and colleagues published guidelines and recommendations for the prevention of VTE in the plastic surgery patient (Venturi ML, Davison SP, Caprini JA. Aesthet Surg J. 2009;29(5):421-428). The information is the product of integrating the recommendations of the ACCP guidelines with published data in the plastic surgery literature.

"Our recommendations in no way contradict the ACCP recommendations, but rather are inclusive of them and broader, with specific applicability to the needs of plastic surgery," Dr. Venturi says.

CHANGING ATTITUDES Resistance to the use of VTE chemoprophylaxis among plastic surgeons appears to be slowly dissipating. Having taught a course on the topic of VTE prevention at the American Society of Plastic Surgeons annual meeting for the past five years, Dr. Venturi says he is noticing greater acceptance among his colleagues that chemoprophylaxis, when appropriate, is something that needs to be done for the benefit of patients.

"As hospital safety councils have made prevention of VTE a priority, the message may be filtering through to the plastic surgery community, and hopefully we are also getting the word out through various educational courses and published articles," Dr. Venturi says.

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