Reuters Health – 21/10/2020 – Ultrasound screening enabled identification and early treatment of extremity deep vein thrombosis (DVT), thereby preventing symptomatic pulmonary embolism (PE) in a single center trial.
“The results of this study have already led to changing practice patterns at a number of high-volume pancreas institutions,” Dr. Nicholas Zyromski of the Indiana University Department of Surgery in Indianapolis told Reuters Health by email. “We would encourage all clinicians caring for necrotizing pancreatitis patients to consider screening for VT.”
“Any patient with necrotizing pancreatitis is appropriate for screening,” he noted. “If VT is detected, institution of full anticoagulation should be at the discretion of the treating physician, considering additional underlying medical problems including bleeding risk.”
Results were reported in the Journal of the American College of Surgeons and presented virtually at the American College of Surgeons 106th Annual Clinical Congress, Scientific Forum.
Eighty-five NP patients (means age, 53; 71% men) were enrolled in the study. The most common NP etiologies were biliary (33%) and alcohol (33%), and the most common comorbidities were hypertension (59%), hyperlipidemia (44%), tobacco use (36%), and diabetes mellitus (26%).
VTE developed in 65% of patients, including splanchnic VT in 48% of affected patients and extremity DVT in 38%. Extremity DVT was diagnosed a mean of 44 days after NP onset. The diagnosis was made prior to any necrosis intervention in 47% of VTE patients, during necrosis evacuation in 44%, and after completion of necrosis debridement in 9%.
DVT incidence was lowest in patients treated successfully with an endoscopic approach or with medical treatment alone; it was highest in patients who required surgical debridement
No individual demographic factor was associated with an increased risk of DVT. Clinical risk factors included any organ failure, respiratory failure, cardiovascular failure, and infected necrosis.
Symptomatic PE was prevented in all patients diagnosed with DVT with no contraindication to anticoagulation. The authors note, “Perhaps the most important finding of this study relates to inadequacy of chemical VTE prophylaxis. Prophylactic range peak anti-Xa concentrations were achieved in only 21% of NP patients. The remaining 79% … received inadequate chemical VTE prophylaxis and perhaps not surprisingly all (extremity) DVT were diagnosed in this group.”
Dr. Zyromski said “The current research effort is directed towards understanding more clearly the mechanisms underlying (DVT development), which will potentially identify specific patients at high risk, as well as inform individualized prophylactic measures.”
Gastroenterologist Dr. Christopher DiMaio, a professor at the Icahn School of Medicine at Mount Sinai in New York City and Director of Interventional Endoscopy at Mount Sinai Health System, told Reuters Health by email, “Patients suffering from necrotizing pancreatitis can be among the most ill and challenging patients to manage.”
“The investigators concluded that fixed dose prophylactic anticoagulation is insufficient for this patient population,” he said. “This implies that for some patients, higher doses of anticoagulation may be required to lower the risk of DVT development.”
“The caveat to this is that while no study patient on full coagulation developed bleeding complications, it is unclear if higher doses of anticoagulation will lead to increased bleeding risk,” he noted. “Bleeding is a known risk for patients with necrotizing pancreatitis and can be fatal in some circumstances. So further, investigation into this may be necessary.”
“Bedside ultrasound is readily available in most medical wards and ICUs,” he added. “It is unclear what the resource utilization would be in order to perform more frequent screening of patients.”
By Marilynn Larkin
SOURCE: https://bit.ly/3kit83q Journal of the American College of Surgeons, online October 8, 2020.
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