Beruflich Dokumente
Kultur Dokumente
KEYWORDS
Deep vein thrombosis Patient safety Postoperative complications
Postoperative risk assessment Pulmonary emboli Venous thromboembolism
KEY POINTS
Deep vein thrombosis and its possible sequela of pulmonary embolism are a major risk for plastic
surgery patients.
Patients undergoing an abdominoplasty are at a significant risk of death due to pulmonary emboli.
Risk assessment is the basis for prevention of thromboembolic phenomena.
Measures to prevent deep venous thrombosis must be taken based on risk stratification.
Early diagnosis and treatment of deep venous thrombosis or pulmonary emboli are essential to
decrease the risks of these serious sequelae.
both DVT prophylaxis and risk management, start- documented by Rigg30 and by Reinisch and col-
ing with a 1999 article by Noel McDevitt.5 The leagues31 in 1998, and still remain an important
a
Stanford University Medical School, Palo Alto, CA, USA; b American Association for the Accreditation of
Surgical Facilities, IL, USA; c Ronald E. Iverson, MD, FACS, The Plastic Surgery Center, 1387 Santa Rita Road,
Pleasanton, CA 94566, USA
* Corresponding author. The Plastic Surgery Center, 1387 Santa Rita Road, Pleasanton, CA 94566, USA.
E-mail address: reiversonmd@sbcglobal.net
topic, as pointed out in the article by Abboushi and with a significant number of other procedures; 5 in
colleagues32 in 2012. The facelift procedures that facelift and blepharoplasty, 5 with liposuction, 2
were complicated by postoperative DVT were per- with buttocks/thigh extremity lift, and 2 with breast
formed under both local anesthesia with sedation surgery.
and general anesthesia, continuing a long discus-
sion as to whether avoidance of general anes- Risk Assessment
thesia can decrease or eliminate DVT/PE.3337
Plastic surgery continues to emphasize risk
Hoefflin38 countered by reporting no major compli-
assessment and risk-stratifying models for DVT
cations in 23,000 cases under general anesthesia.
as a basis for prevention and avoidance.2,5,7
Many patient characteristics, behaviors, and
AMERICAN ASSOCIATION FOR THE medical histories identify increased risks for post-
ACCREDITATION OF SURGICAL FACILITIES operative DVT. Obstetric history is important and
Peer Review Data: September 2012 frequently overlooked.23 Past obstetric complica-
tions including a still birth, miscarriage, or prema-
The American Association for the Accreditation of
ture birth with toxemia may indicate a serious
Surgical Facilities (AAAASF), through its quality
thrombophilia defect. Postmenopausal hormone
assurance and peer review process, has previ-
therapy and selective estrogen-receptor modula-
ously reported on significant issues in ambulatory
tors (tamoxifen and raloxifene) are associated
surgery.14,15 The latest data are shown in Table 1
with 2-fold to 3-fold increased risk of venous
and confirm the many reports that DVT/PE is a
thrombosis.39 The factors that predisposed a pa-
major problem for patients having plastic surgery.
tient to thrombosis or embolism in 2002 formed a
Of the 3,922,202 plastic surgery cases, there were
limited list.7 It has not only been expanded but
215 DVTs and 264 PEs for a total of 479. This is an
better defined by Caprini and others.2224,40
incidence by case of 0.01222% or 1 in every 8188
The 2005 Caprini Risk Assessment Model
cases. The largest number of venous thromboem-
(Fig. 1) and its subsequent, more developed,
bolism (VTE), 308, occurred with abdominoplas-
version, the 2010 Caprini Risk Assessment Model
ties. The abdominoplasty procedures performed
(Fig. 2), are thorough, noting common risk factors
alone were 98; abdominoplasties plus 1 additional
for DVT and PE. Each factor is weighted 1, 2, 3, or
procedure were 137; plus 2 additional procedures,
5 points, depending on its significance for risk. An
58; and plus 3 additional procedures, 15, which is
overall total risk category score is then assigned
an incidence of 0.0666% or 1 in every 1502 cases.
(Table 2). A correlation between the total risk
Total abdominoplasties that were associated with
score and proven VTE incidents in surgical pa-
a PE were 185, with an incidence of 0.04% or 1 in
tients has been reported.24,41,42
every 2500 cases. The distribution of PE cases
The assessment of postoperative VTE risk in
associated with abdominoplasty alone or abdom-
patients having plastic surgery, using both the
inoplasties with multiple procedures is similar to
2005 and 2010 Caprini Risk Assessment Models,
the data for patients having VTE/PE. There is no
was studied by Pannucci and colleagues.43 Their
significant statistical difference for VTE or PE
conclusion identified the 2005 Caprini model as a
whether the abdominoplasty is performed alone
more appropriate method for risk stratification of
or with multiple other procedures. It has been re-
patients having plastic surgery than the 2010
ported in the literature that performing multiple
model.
procedures at the same time increases the risk
Although the Caprini assessment models do not
of complications, such as VTE. These peer-
include smoking as a risk factor, the presence of
reviewed data do not support that conclusion.
coagulation abnormalities associated with smok-
There were 94 deaths associated with plastic
ing44 may further increase the risk for DVT/PE. To-
surgery, or an incidence of 0.0024% or 1 in every
bacco smoking has been associated with
41,726 cases. The incidence of death in plastic sur-
increased serum homocysteine, representing a
gery procedures is 0.0017% or 1 in every 58,779
3-point risk factor in the model. The interrelation-
procedures. The death rate in plastic surgery by
ship between smoking, its procoagulant mech-
case or procedure is less than when all specialties
anisms, and VTE awaits further therapeutic
are combined; the number of deaths related to PE
studies. The importance of evidence-based medi-
in the plastic surgery cases was 40 of 94, or 43%. It
cine in these areas mandates further research.4547
is significant that, of the 40 deaths in plastic surgery
procedures, an incidence of 0.0010% or 1 in every
Prevention
98,055 cases, 26 occurred with abdominoplasties
for an incidence of 0.0056% or 1 in every 17,791 The strategies for prevention of DVT/PE are exten-
cases. The data also reveal that PEs have occurred sive and most often based on preoperative risk
Deep Venous Thrombosis 391
Table 1
American association for the accreditation of surgical facilities, plastic surgery data for VTE, PE, and
deaths (September 2012)
Fig. 1. The 2005 Caprini Risk Assessment Model. COPD, chronic obstructive pulmonary disease. (Adapted from
Caprini JA. Thrombosis risk assessment as a guide to quality patient care. Dis Mon 2005;51:708; with permission.)
Deep Venous Thrombosis 393
Fig. 2. The 2010 Caprini Risk Assessment Model. BMI, body mass index; DVT/PE, deep venous thrombosis/pulmo-
nary embolus; SVT, superficial venous thrombophlebitis. (Adapted from Caprini JA. Risk assessment as a guide to
thrombosis prophylaxis. Curr Opin Pulm Med 2010;16:44852; with permission.)
Hemoptysis
Box 3 Transient or orthostatic hypotension
Manifestations of DVT or PE that may elicit calls
to the office Transient hypoxemia
Unexplained decrease in level of
Chest pain consciousness
Fainting Suspected postoperative myocardial
Feeling dizzy, or faint leg color change infarction
Leg pain Postoperative nonhemorrhagic stroke
Leg swelling Postoperative pneumonia
Leg tenderness Unexplained sudden death
Shortness of breath or tachypnea Venous engorgement of the leg
396 Iverson & Gomez
can be used as an alternative to venography. problem. It seems from all current information
Patients suspected of DVT may choose treatment that DVT/PE problems will never be eliminated.
rather than venography. The level of awareness of DVT/PE as a major
cause of mortality in ambulatory surgery has
Treatment dramatically increased over the past 10 years.
There are many strategies for the prevention and
Once the diagnosis of DVT is made, the surgeon
treatment of DVT/PE. It is only through both
must immediately consider a consultation with
patients and surgeons being informed about the
the appropriate medical physician specialist and
dangers and realities of DVT that the incidence of
possibly a vascular surgeon. Without appropriate
the problem can be decreased. It is imperative
treatment, 20% of calf vein thrombi propagate
that plastic surgeons continue their efforts for
proximately to where they pose a serious threat.
increased public awareness and patient education
At least 50% of proximal DVTs are associated
related to the risk factors and symptoms of DVT.
with a PE or recurrent DVT, 10% were immediately
Plastic surgeons must routinely incorporate pre-
fatal with PE, and 5% caused death later as a
operative DVT risk assessment models for all pa-
result of right ventricular dysfunction and/or pul-
tients who are to undergo surgery as well as
monary hypertension.10 The other major problem
apply a renewed vigilance on patient selection.
following a DVT is postthrombotic syndrome
The prevention protocol should be based on risk
(PTS).25,26 PTS is clinically associated with leg
assessment and all appropriate recommended
pain, swelling of the leg, and varicose veins.
perioperative and postoperative modalities for
The protocol for antithrombotic therapy is
prevention must be used. Surgeon and their staff
covered in the 2012 The American College of
must be trained to identify and diagnose a DVT
Chest Physicians Evidence-based Clinical Practice
for when prevention fails. If a DVT is suspected,
Guidelines,51 summarizing bodies of evidence to
appropriate treatment using a specialist medical
offer 600 recommendations for diagnosing, pre-
consultation is a necessity and should be insti-
venting, and treating DVT. The guidelines suggest
tuted immediately.
that the initial anticoagulation for acute DVT be a
When these approaches are used by all plastics
parenteral anticoagulation low-molecular-weight
surgeons, a significant improvement in patient
heparin (Enoxaparin), fondaparinux (Arixtra), intra-
safety and surgical outcomes should be seen.
venous unfractionated heparin, or subcutaneous
The overall safety of performing surgery in an
heparin. This protocol is also indicated for patients
ambulatory setting is well documented. Continued
with a high suspicion of acute VTE. Any patient
vigilance is essential for all safety issues in the
who has been identified as high risk for bleeding
surgery suite, but those precautions for DVT/PE
dyscrasias requires special evaluation before insti-
prevention should be foremost because those dis-
tuting initial anticoagulation.
eases are frequently associated with a patients
Catheter-directed thrombolysis must be consid-
disability and even death.
ered because of the benefit for the prevention of
the PTS. Catheter-assisted thrombus removal is
also a consideration as a method of decreasing
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