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Acta Phlebologica 2000 December;1(2):63-7


language: English

Safety and feasibility of an individually tailored prophylaxis against venous thromboembolism in a Rehabilitation Unit

Arpaia G. 1, Vigoreli P. 1, Gussoni C. 1, D’Agostino B. 1, Cimminiello C. 2

1 Rehabilitation Unit, San Carlo Borromeo General Hospital, Milan; 2 2nd Medical Department, Vimercate General Hospital, Milan, Italy


BACKGROUND: Non-sur­gi­cal ­patients—“med­i­cal” cas­es—­often suf­fer ­venous throm­boem­bo­lism (VTE) and a ­fair pro­por­tion ­require pro­phy­lax­is. However, ­there are no sol­id fig­ures on the fre­quen­cy of VTE in med­i­cal ­patients under­go­ing reha­bil­i­ta­tion pro­grams, or on the effi­ca­cy and safe­ty of pro­phy­lac­tic reg­i­mens, ­which ­have obvi­ous­ly to be ­long-­term in ­these ­patients. To ­assess pros­pec­tive­ly the effi­ca­cy and safe­ty, as ­regards bleed­ing, of pro­phy­lac­tic reg­i­mens adapt­ed to ­take ­account of ­each ­patient's ­risk, in a pop­u­la­tion admit­ted to a Reha­bil­i­ta­tion ­Unit ­after a “med­i­cal” dis­ease.
METHODS: Ninety-five con­sec­u­tive ­patients (50 wom­en and 45 men, ­mean age 76.2±12 ­years), fol­low­ing a reha­bil­i­ta­tion pro­gram ­after a med­i­cal dis­ease, ­were strat­i­fied in rela­tion to the ­risk of VTE ­using the 1992 TFR Consensus Group cri­te­ria, mod­i­fied. Patients ­able to ­walk ­were not giv­en pro­phy­lax­is; ­those at medi­um ­risk ­were giv­en low-molec­u­lar ­weight (LMW) hep­ar­in, enox­ap­ar­in 2000 ­anti-Xa ­units/day s.c., and ­wore elas­tic sup­port ­hose; ­high-­risk ­patients ­received 4000 ­anti-Xa ­units/day of enox­ap­ar­in. Patients at ­high ­risk ­also of hemor­rhag­ic com­pli­ca­tions ­used sup­port stock­ings only. Patients ­were inel­i­gible for the ­study if a Doppler ultra­sound exam­ina­tion of the leg ­veins, ­with com­pres­sion, had ­shown ­deep ­venous throm­bo­sis (DVT) at admis­sion. Patients sched­uled for treat­ment ­received it through­out ­their hos­pi­tal ­stay. The ­study end­points ­were symp­toms of VTE and any hemor­rhag­ic com­pli­ca­tions.
RESULTS: The ­risk assess­ment was ­done for all the ­study ­patients so ­that 19 of ­them ­were con­sid­ered at medi­um throm­bot­ic ­risk and 76 at ­high ­risk. Of the ­whole ­initial ­cohort 20 sub­jects ­were walk­ing and ­received no treat­ment. Sixteen ­patients result­ed affect­ed by DVT at the ­entry Dop­pler-ultra­sound screen­ing and ­were treat­ed ­with ther­a­peu­tic anti­co­ag­u­la­tion. The remain­ing 59 sub­jects ­were giv­en a pro­phy­lac­tic reg­i­men: 12 at medi­um ­risk ­with 2000 U/day enox­ap­ar­in ­plus sup­port stock­ings; of the ­high ­risk pop­u­la­tion, 33 ­patients ­received 4000 U/day enox­ap­ar­in and 14 ­were giv­en ­only sup­port ­hose ­since ­they had con­tra­in­di­ca­tions to hep­ar­in. There ­were ­four ­major ­bleeds, one in a ­patient treat­ed for DVT at admis­sion, and ­three dur­ing ­high-­dose enox­ap­ar­in pro­phy­lax­is. There was ­only one def­i­nite symp­to­mat­ic epi­sode of VTE dur­ing reha­bil­i­ta­tion and ­three ­patients ­died: two sud­den­ly, ­with a clin­i­cal sus­pi­cion of ­fatal pul­mo­nary embo­lism, ­although ­this was not con­firmed by autop­sy, and one ­because of grad­u­al dete­ri­ora­tion of gen­er­al con­di­tions: ­this lat­ter ­patient ­also ­showed the ­only ­case of symp­to­mat­ic bila­teral DVT.
CONCLUSIONS: Prophylaxis of VTE can be "per­son­al­ly-tail­ored" in rela­tion to indi­vid­u­al ­risk in ­patients fol­low­ing a reha­bil­i­ta­tion pro­gram ­after a med­i­cal dis­ease. This pre­ven­tion ­must obvi­ous­ly be ­long-­term, and is cer­tain­ly ­safe; how­ev­er, ran­dom­ized con­trolled ­trials are need­ed to con­firm its effi­ca­cy.

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