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International Angiology 1999 September;18(3):210-9


lingua: Inglese

Duplex screening as a method of quality assurance of perioperative thromboembolism prophylaxis

Van Den Berg E., Bathgate B., Panagakos E., Lambrechts R. *, Hani M. *, Meissner A. *, Schroder M. **

From the Angiology Section, Medical Department I, Department of Trauma, Restorative, Hand and Plastic Surgery * Surgery Center and ** Quality Management, Krefeld Hospital, Krefeld, Germany


Back­ground. Improve­ments in throm­bo­sis pro­phy­lax­is in both the oper­a­tive and non-oper­a­tive ­fields aim to ­reduce fur­ther the not incon­sid­er­able resid­u­al risk of suf­fer­ing a deep vein throm­bo­sis or embo­lism. The goal of the study was to estab­lish the part ­played in a qual­ity assu­rance strat­e­gy by early diag­no­sis of a throm­bo­sis and by knowl­edge of the ­hospital's inter­nal ­patient-risk pro­file in order to coun­ter the unpre­dict­abil­ity of throm­boem­bol­ic com­pli­ca­tions and make ration­al deci­sions about throm­boem­bo­lism pro­phy­lax­is.
Meth­ods. ­Duplex ultra­so­nog­ra­phy has been used rou­tine­ly in trau­ma sur­gi­cal ­patients in Kre­feld Hos­pi­tal since Sep­tem­ber 1991 as a screen­ing meth­od for diag­nos­ing deep leg and pel­vic vein throm­bo­sis prior to mobil­isa­tion of the ­patients. 778 ­patients were inves­ti­gat­ed up to March 1997. In the peri­od from Sep­tem­ber 1991 to Sep­tem­ber 1994, ­patients ­received stan­dar­dised low-dose pro­phy­lax­is with unfrac­tion­at­ed hep­ar­in (UFH). In Octo­ber 1994, the pro­phy­lax­is reg­i­men was mod­i­fied by chang­ing the anti-embo­lism stock­ings from bidi­rec­tion­al elas­tic stock­ings to trans­verse elas­tic grad­u­at­ed com­pres­sion stock­ings (TED®) and by adapt­ing the dos­age of the hep­ar­in pro­phy­lax­is to ­patient risk, with the use of low molec­u­lar ­weight hep­ar­in (LMWH) Cer­top­ar­in (Mono-Embol­ex® NM) since April 1995. All ­patients with a deep vein throm­bo­sis were treat­ed imme­di­ate­ly with APTT-mon­i­tored full hep­a­rin­isa­tion and immo­bil­isa­tion.
­Results. In the peri­od from Sep­tem­ber 1991 to March 1997, an asymp­to­mat­ic deep vein throm­bo­sis of the lower limbs was diag­nosed in 68 cases (8.7%) out of 778 trau­ma sur­gi­cal ­patients by means of rou­tine ­duplex ultra­sound. Using a strat­e­gy of ­duplex screen­ing and imme­di­ate anti­co­ag­u­la­tion/immo­bil­isa­tion, no clin­i­cal­ly sig­nif­i­cant pul­mo­nary embo­li ­occurred in this peri­od. At the same time, the anti­throm­bot­ic effi­ca­cy of the pro­phy­lax­is could be ­improved and ­assessed objec­tive­ly by means of ­duplex screen­ing: with opti­mal com­pres­sion stock­ings and con­sis­tent use of risk-adapt­ed UFH pro­phy­lax­is, it was pos­sible to ­reduce the resid­u­al throm­bo­sis rate, which was 11.5% (95% CI 7.7-15.2%) with stan­dard UFH pro­phy­lax­is, to 8.7 % (95% CI 4.5-12.9%) and ulti­mate­ly, using the com­bi­na­tion of opti­mal anti-embo­lism stock­ings and LMWH pro­phy­lax­is, to 6.0% (95% CI 3.0-8.9%) which was sig­nif­i­cant (p<0.05). The cost-effec­tive­ness anal­y­sis result­ed in a cost-rela­tion per suc­cess­ful­ly treat­ed ­patient of about 1:100 for the diag­no­sis of a deep vein throm­bo­sis using ­duplex ultra­sound and sub­se­quent hep­ar­in treat­ment com­pared to the diag­no­sis and inten­sive care treat­ment of a mas­sive pul­mo­nary embo­lism.
Con­clu­sions. ­Duplex ultra­sound screen­ing for asymp­to­mat­ic deep vein throm­bo­sis thus ­proves to be a suit­able instru­ment for inter­nal hos­pi­tal qual­ity con­trol in throm­bo­sis pro­phy­lax­is. Its rou­tine use can be rec­om­mend­ed at least in high-risk ­patients, not only from the med­i­co­le­gal ­aspect but also from the pure­ly eco­nom­ic ­aspect.

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