Warfarin should not be used for thromboprohylaxis in elective major orthopaedic surgery: a Croatian perspective

Kolundžić, Robert and Šimić Jovičić, Marijana and Đinkić, Maja and Petrović, Tadija and Crnković, Tomislav and Trkulja, Vladimir (2017) Warfarin should not be used for thromboprohylaxis in elective major orthopaedic surgery: a Croatian perspective. Medicinski glasnik, 14 (2). pp. 244-249. ISSN 1840-0132

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Abstract

Aim: To identify modes of venous thromboembolism (VTE) prophylaxis in patients undergoing elective major orthopaedic surgery (total hip or knee arthroplasty, THA/TKA) at a single university-associated hospital in Croatia. ----- Methods: A retrospective analysis of consecutive patients subjected to THA or TKA over a two-year period (2014-2015) with a focus on anticoagulation during the first 15 post-surgical days (period of highest VTE risk). ----- Results: Of 603 identified patients three (0.5%) were not anticoagulated (haemophilia) and others received perioperative doses of low molecular weight heparins (LMWH). Overall, 228 (37.8%) patients received prophylaxis not involving warfarin, and 372 continued with short-term LMWH with switching to warfarin. They contributed a total of 1218 international normalized ratio (INR) values (median=3, range=1-8). These were consistently below the target INR range across the observed period. Between post-surgical days 6 and 15 (after the initial titration), 438 values were taken in patients treated with LMWH+warfarin and 92.7% were below, and only 6.8% within the target range; 580 values were taken in patients already switched to warfarin, 74% were below and only 25% within the range. ----- Conclusion: The prevailing mode of VTE prophylaxis was in a clear contrast to (then) actual professional guidelines, with inadequate monitoring and poor anticoagulation. There is no reason to expect a substantially different situation at other institutions across the country. The prevailing practice of VTE prophylaxis in major orthopaedic surgery in Croatia should be promptly abandoned and up-dated in agreement with the current state of the art.

Abstract in Croatian

Cilj: Identificirati modalitete prevencije venskog tromboembolizma (VTE) u bolesnika podvrgnutih elektivnim velikim ortopedskim zahvatima (totalna artroplastika kuka ili koljena) u jednom sveučilišnom medicinskom centru u Hrvatskoj. ----- Metode: Retrospektivna analiza podataka o uzastopnim bolesnicima, podvrgnutim totalnoj artroplastici kuka ili koljena, tijekom dvije godine (2014-2015), s fokusom na antikoagulacijsko liječenje tijekom prvih 15 postoperativnih dana (razdoblje najvišeg rizika za VTE). ----- Rezultati: Od ukupno 603 bolesnika, troje (0.5%) nisu bili antikoagulirani (hemofilija), dok su ostali primili preoperativne doze niskomolekularnog heparina (LMWH). U ukupno 228 (37.8%) bolesnika antikoagulacijski tretman nije uključivao varfarin, dok su 372 bolesnika tretirana kratkotrajnom primjenom LMWH-a s prijelazom na varfarin. Tijekom promatranog razdoblja ukupno je izmjereno 1.218 vrijednosti internacionalnog normaliziranog omjera (INR) (medijan=3, raspon= 1-8, po bolesniku). Vrijednosti su konzistentno bile ispod terapijskog INR-raspona. U razdoblju između šestog i petnaestog postoperativnog dana (nakon početne titracije), ukupno je izmjereno 438 INR-vrijednosti u bolesnika koji su primali i LMWH i varfarin, te je 92.7% njih bilo ispod terapijskog raspona, a samo 6.8% vrijednosti bilo je u terapijskom rasponu. Istodobno, izmjereno je ukupno 580 INR-vrijednosti u bolesnika koji su već bili prebačeni na varfarin – 74% vrijednosti bilo je ispod, a samo 25% vrijednosti bilo je u terapijskom rasponu. ----- Zaključak: Opaženi dominantni oblik VTE profilakse u izravnoj je suprotnosti s profesionalnim smjernicama, s neadekvatnim nadzorom i nedostatnom antikoagulacijom. Nema razloga očekivati da je stanje bitno drugačije u ostalim institucijama u zemlji. Taj predominantni oblik VTE profilakse u velikim ortopedskim zahvatima u Hrvatskoj treba što prije napustiti i uvesti postupke u skladu s trenutno važećim standardima dobre kliničke prakse.

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