Tromboprofilaxis en cirugía ortopédica

Tipo de anestesia, la seguridad y eficacia de tromboprofilaxis con enoxaparina o etexilato de dabigatran en cirugía ortopédica mayor: análisis combinado de tres estudios controlados.  Type of anaesthesia and the safety and efficacy of thromboprophylaxis with enoxaparin or dabigatran etexilate in major orthopaedic surgery: pooled analysis of three randomized controlled trials. Rosencher N, Noack H, Feuring M, Clemens A, Friedman RJ, Eriksson BI. Staff Anaesthesiologist, Department of Anaesthesiology and Intensive Care, Paris Descartes University, Cochin Hospital (AP HP), rue du Faubourg Saint-Jacques, 75014, Paris, France.nadia.rosencher@cch.aphp.fr. Thromb J. 2012 Jun 18;10(1):9. ABSTRACT: BACKGROUND: There has been a shift towards greater use of neuraxial over general anaesthesia for patients undergoing total hip or knee arthroplasty. Furthermore, suggestions that peripheral nerve block may reduce adverse effects have recently been put forward. Although older studies showed a reduction in venous thromboembolism (VTE) with neuraxial compared with general anaesthesia, this difference has not been confirmed in studies using effective current thromboprophylaxis. We used a large data set to investigate the pattern of anaesthesia usage, and whether anaesthesia type affects efficacy and bleeding outcomes of thromboprophylaxis overall, within each treatment group, or for the novel oral anticoagulant dabigatran etexilate versus enoxaparin. CONCLUSIONS: Anaesthesia type did not greatly affect efficacy and safety outcomes in the pooled population of all three treatment groups. The efficacy and safety of dabigatran etexilate was comparable with enoxaparin, regardless of type of anaesthesia. TRIAL REGISTRATION: ClinicalTrials.gov identifiers: NCT00168805, NCT00168818, NCT00152971.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3444414/pdf/1477-9560-10-9.pdf   Dabigatran, rivaroxaban, o apixaban versus enoxaparina para tromboprofilaxis después de remplazo total de cadera o de rodilla: revisión sistemática, meta análisis y comparaciones indirectas de tratamiento  Dabigatran, rivaroxaban, or apixaban versus enoxaparin for thromboprophylaxis after total hip or knee replacement: systematic review, meta-analysis, and indirect treatment comparisons. Gómez-Outes A, Terleira-Fernández AI, Suárez-Gea ML, Vargas-Castrillón E. Division of Pharmacology and Clinical Evaluation, Medicines for Human Use, Spanish Agency for Medicines and Medical Devices, Parque Empresarial Las Mercedes, Madrid, Spain. agomezo@aemps.es BMJ. 2012 Jun 14;344:e3675. doi: 10.1136/bmj.e3675. Abstract OBJECTIVE: To analyse clinical outcomes with new oral anticoagulants for prophylaxis against venous thromboembolism after total hip or knee replacement. DESIGN: Systematic review, meta-analysis, and indirect treatment comparisons. DATA SOURCES: Medline and CENTRAL (up to April 2011), clinical trials registers, conference proceedings, and websites of regulatory agencies. STUDY SELECTION: Randomised controlled trials of rivaroxaban, dabigatran, or apixaban compared with enoxaparin for prophylaxis against venous thromboembolism after total hip or knee replacement. Two investigators independently extracted data. Relative risks of symptomatic venous thromboembolism, clinically relevant bleeding, deaths, and a net clinical endpoint (composite of symptomatic venous thromboembolism, major bleeding, and death) were estimated using a random effect meta-analysis. RevMan and ITC software were used for direct and indirect comparisons, respectively. RESULTS: 16 trials in 38,747 patients were included. Compared with enoxaparin, the risk of symptomatic venous thromboembolism was lower with rivaroxaban (relative risk 0.48, 95% confidence interval 0.31 to 0.75) and similar with dabigatran (0.71, 0.23 to 2.12) and apixaban (0.82, 0.41 to 1.64). Compared with enoxaparin, the relative risk of clinically relevant bleeding was higher with rivaroxaban (1.25, 1.05 to 1.49), similar with dabigatran (1.12, 0.94 to 1.35), and lower with apixaban (0.82, 0.69 to 0.98). The treatments did not differ on the net clinical endpoint in direct or indirect comparisons. CONCLUSIONS: A higher efficacy of new anticoagulants was generally associated with a higher bleeding tendency. The new anticoagulants did not differ significantly for efficacy and safety. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3375207/pdf/bmj.e3675.pdf Tromboprofilaxis en cirugía de columna: una revisión Thromboprophylaxis in spinal surgery: a survey. Bryson DJ, Uzoigwe CE, Braybrooke J. Department of Trauma and Orthopaedics, Leicester Royal Infirmary, Infirmary Square, Leicester, LE1 5WW, UK. davidjbryson@hotmail.com J Orthop Surg Res. 2012 Mar 29;7:14. Abstract BACKGROUND: Venous Thromboembolism (VTE) is the most common complication following major joint surgery. While attention has been focused upon the incidence of thromboembolic disease following total hip or knee arthroplasty or emergency surgery for hip fracture, there exists a gap in the medical literature examining the incidence of VTE in spinal surgery. Evidence suggests that the prevalence of DVT after spinal surgery is higher than generally recognized but with a shortage of epidemiological data, guidelines for optimal prophylaxis are limited. This survey, of individuals attending the 2009 British Association of Spinal Surgeons Annual Meeting, sought to examine prevailing trends in VTE thromboprophylaxis in spinal surgery, adherence to guideline outlined by the National Institute for Health and Clinical Excellence (NICE) and to compare selections made by orthopaedic and neurosurgeons. METHODS: We developed a questionnaire with eight clinical scenarios. Participants were asked to supply details on their specialty and to select which method(s) of thromboprophylaxis they would employ for each scenario. Chi squared analysis was used for statistical comparison of the questionnaire responses. RESULTS: 73% of neurosurgical respondents' and 31% of orthopaedic surgeons employed low molecular weight heparin (p < 0.001). Neurosurgeons also selected anti-embolism stockings more frequently (79% v 50%) while orthopaedic surgeons preferred mechanical prophylaxis (26% v 9%). There was no significant difference between trauma and non-trauma scenarios (p = 0.05). CONCLUSION: There is no clear consensus in thromboprophylaxis in spinal surgery. There was a significant difference in selections across surgical disciplines with neurosurgeons more closely adhering to national guidelines. Further research examining the epidemiology of venous thromboembolism in spinal surgery and the risks-benefit relationship of thromboprophylaxis is warranted. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3349591/pdf/1749-799X-7-14.pdf

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