By Cathy Saunders
Venous thromboembolism causes more deaths in Australia each year than road trauma, but preventive measures in patients undergoing surgery are often neglected because the issue is not seen as "sexy", experts say.
While attention has focused on so-called 'economy class syndrome' - deep vein thrombosis and pulmonary embolism in recent air travellers - a study in the Archives of Internal Medicine last week drew attention to the post-surgery risk of venous thromboembolism (VTE). Post-operative patients' risk of VTE was 35 times higher in the first month after surgery than in matched controls.
An editorial in the BMJ last week suggested VTE killed about 60,000 people in the UK each year, with autopsy data indicating about 10% of deaths in hospital were due to pulmonary embolism. Only 20% of at-risk patients received appropriate pharmacological treatment, the authors said.
New Australian 'Stop the Clot' guidelines released by the National Institute of Clinical Studies last week said about 30,000 people were hospitalised with VTE in this country each year and about 2000 died as a result.
Dr Martin Gallagher, chairman of the institute's VTE prevention advisory group, said the risk of deep vein thrombosis and pulmonary embolism were generally underestimated.
"There is a widespread lack of recognition of the problem because it is not sexy or cutting-edge medicine," he said, calling on hospitals to include a VTE prophylaxis regimen in discharge plans for a patient's GP.
"With the early discharge of increasingly sick patients from hospital, the burden of preventive work is likely to fall on GPs," he said. "So they do need to be more conscious of the risk in the acutely sick patient, especially those who are immobile or slow to recover and spending a lot of time in bed at home."
Haematologist Professor Alexander Gallus, from Flinders Medical Centre in SA, said clear guidelines were needed to ensure patients discharged from hospital on VTE prophylaxis saw their GP within a specified time.
Dr Jerry Koutts, head of haematology at Sydney's Westmead Hospital, said DVT and pulmonary embolism were underdiagnosed despite being preventable in more than two-thirds of cases.
Prophylactic heparins such as enoxaparin (Clexane) or dalteparin (Fragmin) should be given to high-risk surgical patients, including those aged over 40 years who had procedures lasting more than 30 minutes under general anaesthetic. Other high-risk patients would be those with cancer, heart failure, chronic lung disease, infective or inflammatory conditions, a previous history of DVT or pulmonary embolism, and those who were immobilised or had traumatic injuries.
The Archives of Internal Medicine study identified various risk factors for presentation of DVT in primary care, including a recent fracture (18-fold increase in risk), and varicose veins and inflammatory bowel disease, both of which were associated with a doubling of risk.
BMJ 2007; 334:1017-18.
Stop the Clot guidelines: www.nhmrc.gov.au/nics
Archives of Internal Medicine 2007; 167:935-43.
Reproduced with permission from Australian Doctor, 24th May 2007