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Once- vs Twice-Daily Enoxaparin: #PRSJournal July 2018

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In this episode of the Award-winning PRS Journal Club Podcast, 2018 Resident Ambassadors to the PRS Editorial Board – Francesco Egro, Nicole Phillips, and Ira Savetsky – and special guest William Hoffman, MD discuss the following articles from the July 2018 issue:

I’d like to walk you me to this edition of the award-winning prs journal club podcast with your hosts doctors francesco agro nikki philips and ira svet ski enjoy hello all and welcome back to another edition of the prs monthly journal club podcast for july 2018 i’m nikki philips resident ambassador from the harvard plastic surgery program and i am joined as always

By my co resident ambassadors francesco agro from the university of pittsburgh and i receive etske from nyu this month we are incredibly lucky to have dr. william hoffman as our guest moderator dr. hoffman is professor in chief of plastic surgery and vice chair of the department of surgery at the university of california san francisco dr. hoffman thank you so

Much for joining us today thank you for having me before we begin just a quick reminder to our listeners that this article along with every selected prs journal club article is available for free online you can find them on the prs website along with the article and video pairings selected to further enhance these discussions the article we will discussing next

Is entitled the impact of once versus twice-daily in aqsa peron prophylaxis on risk for venous thromboembolism and clinically relevant bleeding this article is a follow-up study out of the university of utah and stanford groups with dr. christopher panucci as the first author this group has really focused on the important question of the appropriate prophylactic

Regimen against venous thromboembolism which as we all know as a leading cause of morbidity and mortality among plastic surgery patients outcomes of vte events can be devastating and the leaders of our plastic surgery societies have declared this topic worthy of significant attention and funding the study being discussed today was in fact funded by the plastic

Surgery foundation as well as the agency for healthcare and research quality so the central question of this study is the appropriate dosage and timing of chemo prophylaxis against venous thromboembolism within the plastic surgery population the authors have previously presented two studies which are compared head-to-head here and the outcomes of these studies

Are presented as the basis for future research in the first study conducted between march 2015 and march 2016 94 post-op plastic surgery patients were treated with a knock pairen 40 milligrams once daily for vte prophylaxis in a second study conducted the following year 118 post-operative plastic surgery patients were treated with an ox oparin 40 milligrams twice

Daily for vte prophylaxis although previous large multicenter studies have shown a significant decrease in vte events with the administration of once-daily and knox oparin 40 milligrams the rate of venous thromboembolism events did not drop to zero in fact there was still a 4.5% breakthrough rate of vte events among high-risk patients defined as those with capri

Knee scores greater than 8 these findings were upheld in the first arm of the study and so the author’s really wanted to find an objective means of measuring therapeutic effectiveness they examined anti factor 10a levels as a test for blood thinness and found that over 50% of patients had an inadequate anti factor 10 a level while on the once daily dosing of

Lovenox significantly these were also the patients who were found to be at high risk for vte events in the subsequent study with patients receiving twice daily doses of an ox apparent 40 milligrams less than 10 percent were found to have inadequate levels of anti factor 10a however there was evidence that some of these patients were over anticoagulated on this

Regimen so when comparing outcomes between groups there was a significant decrease in vte events among the twice daily dose in cohort 0 events at 90 days compared with 5 events at 90 days and the once daily dose in court but there was also a statistically insignificant but clinically relevant increase in post-operative bleeding events 8 vs. 3 the author’s proposed

That the results of these studies when taken together suggest that there may not be an ideal standardized chemo prophylaxis regimen for all patients rather a weight-based dosing strategy may be more appropriate to minimize risk for both inadequate and over anticoagulation they suggest a dose of 0.4 to 0.5 mig’s per kick twice daily as a potentially optimum regimen

And point towards this as an area for ongoing research and study so i’d like to open up our discussion to the rest of the crew here one of the notable aspects of the study design in my opinion was the lack of consensus regarding how long to continue chemo prophylaxis following discharge i think this is an important question it’s certainly one that’s been closely

Examined among the staff here in boston dr. hoffman i was wondering what is your post discharge routine with regards to anticoagulation and how do you think we should monitor these patients in the outpatient setting excellent question i’m not sure we have a standard approach in patients that don’t have a history and are up walking by the time they go home we do

Not send them home on enoxaparin although we may send them home on aspirin or something oral it’s hard to know what the end point is even though they were talking about 90-day events i think most of the events occur in the first few days pease may occur a little later but the clot and the legs probably occurs early even during induction as a lot of people feel

That’s like the most important part of the procedure so i don’t think we have a standardized approach and in terms of my personal practice i do almost only facial stuff and two-thirds of my practice is kids so i haven’t seen a thrombotic event in a long time we honestly haven’t had very many that have been reported through our qi process because these are pretty

High numbers that they’re saying here where they’re talking about five or six percent thrombosis events and in fact when they’re talking about it they’re talking about symptomatic events where in fact we know that at least half of clots and the legs at least are silent so the number is probably higher than what they actually are measuring i think dr. hoffman to

That point if you don’t mind me jumping in i mean it’s very hard to know exactly what cases they’re talking about because i’ll be comparing cosmetic aids to micro surgical cases we might be comparing apples to oranges they have a table that looked at risk factors and actually one of the things i noticed was that surgery greater than 45 minutes was significantly

Higher in the twice-daily group compared to the once-daily group and so in anything the bias was towards more events in the twice-daily group and in fact they had zero so but they don’t actually tell you what kind of surgery it was you’re right yeah exactly and do you feel that because of this should the interpretation of these results be taking with a pinch

Of salt given that as you said we don’t know what procedures were included in these trials i think absolutely and that would be helpful information for sure they state that they were comparable groups but they didn’t really in the discussion i think but somewhere in the article they said that they were comparable groups but i think they were just taking all

Comers that had higher capri knee scores since they were kind of randomly selected i think it probably is comparable but it would be helpful to have that information in the paper absolutely absolutely ira what did you think about the paper i enjoyed this paper you know i think overall it was pretty well designed comparing the two prospective clinical trials but

I certainly agree it would be nice to know what type of surgeries the patients were undergoing nonetheless i think the evidence is compelling and you know thromboembolism in pulmonary embolism certainly one of the most dreaded fears especially you know we’re talking about cosmetic surgery and typically when we think of this or when i think of it i’m thinking you

Know patients undergo abdominoplasty and they’re not moving around they’re not walking but certainly weighing the risk benefit in each patient is critical dr. hoffman i want to hear your thoughts about sure of the increasing use of expert or liposomal bupivacaine it’s being used more and more in tap box we’ve been using it in our abdominal plastic patients more

And more and i think it’s somewhat of a game changer that these patients are really up in walking and ambulating more i’m curious your thoughts about whether or not this will potentially have an impact that may be lowering being a strombel embolism and potentially pulmonary embolism i would think it would help certainly we know that walking and you know moving

Around or conversely not moving around as a high risk factor for vtes and i would think that the sooner they’re walking the better i was actually thinking when we were talking about abdominoplasty is that i miss the days of the real surgical nurses because they knew that they had to get patients out of bed and now the nurses they’re much nicer now maybe but they

Feel bad for the patients they don’t want to hurt them getting out of that and a lot of times you have to encourage everyone you have to encourage everyone in some way that the patients have to get out of bed and that there’s a nurses job to help them do that my wife just had her knee replaced a couple days ago and they had her out of bed that afternoon because

In orthopedics especially with knees hips they have a high rate of thromboembolic events and they know how important it is so they’re kicking people’s butts like right away and i think that’s critical to trying to prevent these events also yeah i think it is interesting yeah the orthopedic hospitals you know a lot of things that orthopedic surgeons do instead of

Their management there’s a lot to learn i think a lot of it they work so closely with physical therapists that really get them going quickly for us it’s pretty easy at bellevue we don’t rely on the nurses we sort of beat on the interns to get these patients out of bed twice a day zero but yeah certainly it would be nice if there was more attention from nursing and

Really getting them going quickly nikki any additional thoughts that you may have this has been a great discussion i think it’s pointing to some of the challenges of this question or really you know the plastic surgery patient population is such a varied patient population i mean there’s no cookie cutter or plastic surgery patient and so i think it’s a really

Important question i think the authors are clearly doing very good work bringing our attention to it but i think we’re gonna need to continue developing algorithms and guidelines that are very specific to each different type of surgery ambulatory surgery and different risk factors associated with you know the patients and with the surgery themselves with that

I think we’ll probably wrap up this discussion i want to thank everyone for a really great conversation before we sign off just a brief reminder to our listeners please be sure to check out the other two july 2018 prs journal club podcasts and if you like what you hear share us with your colleagues and rate us in the apple itunes store if you haven’t already go

Ahead and like the prs facebook page and please join us for our monthly facebook journal club you can interact with each month’s featured authors in real time and thank you again dr. hoffman for joining us today thank you

Transcribed from video
Once- vs Twice-Daily Enoxaparin: #PRSJournal July 2018 By PRSJournal